On Sunday, at AHIMA’s CDI Summit, Rachel Mack, RN, MSN, CCDS, CDIP, CCS, CDI, Iodine Software, did something unusual to kick off a conversation about clinical documentation improvement (CDI) audits.
She asked attendees to rise from their seats and hug someone nearby—preferably, someone they didn’t know. The icebreaker was meant to convey a key point of her session, “Journey to the Center of CDI Audits”: that the human touch, essential for individual growth and development, is crucial too for the success of a CDI audit.
The concept of CDI audits is relatively new. Part of a CDI specialist’s job is to audit a doctor’s documentation, code assignment, and other administrative data routinely. Yet, Mack recalled that when she was first hired onto a CDI team as a CDI auditor, her husband, who is a nurse, couldn’t believe no one was auditing the work of CDI specialists themselves. As a clinician, he knew there were several people looking at the charts he worked on every day.
Why Conduct Audits?
CDI departments should conduct regular audits for many reasons. Routine audits, Mack said, send CDI specialists the message that they are being held accountable and their work means something. Auditing CDI specialists also makes it easier for CDI managers to figure out whether documentation problems lie with the CDI specialists or the physicians. Identifying the source can clarify further training and help the education process go more smoothly.
Additionally, just as physicians can be unaware that coding and documentation are tied to reimbursement, Mack learned CDI specialists can be in the same straits. When one health system she worked for had a meeting to vent about the difficult process of aligning CDI programs at seven different sites, one CDI specialist stood up and said, “I didn’t have any idea that CDI was related to finance—nobody told me that.”
This was the exact opposite of what Mack had been taught about CDI, but it showed her that an auditor’s job is to make sure everyone’s goals are aligned.
Tips for Success
Some CDI specialists might dread working with or auditing new CDI specialists, but newbies hold a special place in Mack’s heart, because their relative openness to the process makes it easy to nip bad habits in the bud.
“New staff are so malleable and early on in their career, they are critical, vital audits. If you start auditing them early on, you won’t later hear them say ‘Nobody told me that a condition needed to be documented as present on admission’ or ‘Nobody ever told me that was a patient safety indicator,’” Mack said.
She shared some simple forms that can be completed as part of an audit. They include checklists and point systems that can help CDI specialists take the audit results less personally, since the CDI auditor’s delivery of the results to the specialist can be a delicate process.
“Without a human touch, this can be a very difficult conversation,” Mack cautioned, adding, “even if they rocked it.” In addition, the information should be conveyed in person. And it’s helpful to have the CDI manager in the room, as well as the auditor and the CDI specialist.
“There needs to be a support person for the auditor and the CDI specialist. These conversations can spiral,” said Mack. “Everyone is there to make it as safe a conversation as possible.”