A robust clinical documentation integrity (CDI) program is composed of a multifaceted team that often includes a CDI specialist and a CDI nurse advisor/champion. Not all CDI programs have a CDI nurse advisor and, even if they do, they may not always have coding experience. They are often paired with CDI specialists, but it can be challenging to define the CDI nurse advisor’s and CDI specialist’s specific tasks on a daily basis and provide the education they each need to have a successful and trustful program. Refining the relationship between the CDI specialist and CDI nurse advisor is imperative to a mutually respectful and successful CDI program.
The Background of a CDI Specialist
CDI specialists come from a variety of backgrounds, including coding, compliance, nursing, etc. Clinical knowledge is essential for CDI specialists to perform their job successfully, and a CDI specialist who comes from a coding background can achieve strong clinical knowledge through their years of experience, as coding professionals and this clinical knowledge could be almost equal of a CDI nurse advisor. Furthermore, when a CDI specialist works alongside a CDI nurse advisor, they learn from, and gain greater respect for, each other’s experience.
The Role of CDI Nurse Advisor in CDI Program
Each facility has its own requirements or preferences when it comes to hiring members of the CDI team. In the case of the CDI nurse advisor, most facilities require that candidates be Registered Nurses (RN) and prefer them to have coding experience and/or a coding credential. It’s up to management whether they want to hire an experienced RN in coding or train an unexperienced one, but they must take in consideration if they have the staff, needs, resources, and time to opt to train.
For example, the Patient Safety Enhancement Program (PSEP) CDI Guide to Safety Tool (STRIVE) at the University of Michigan states: “Suggested Team Membership: Nurse Champion is responsible for engaging nursing staff in CDI prevention efforts and working to integrate practice into daily nursing workflow. When selecting a nurse champion, consider someone who is well respected and in a position to obtain support from other nurses.”
If the program has a full-time CDI nurse advisor/champion, while the CDI specialist is reviewing charts, sending queries, and preparing education for providers, it’s important to consider what other tasks the CDI nurse advisor should perform. It is important to establish well defined functional statements as to what the CDI specialist will do, what the CDI nurse advisor will do, and how they will work together. The role of the CDI nurse advisor may vary from facility to facility, but common responsibilities include:
- Serve as a clinical liaison between facility CDI specialists and providers to facilitate facility CDI activities.
- Apply expertise in nursing practice to support and grow clinical documentation activities to include the evaluation of data to identify opportunities for the focus of CDI program activities.
- Develop and present education to providers and other healthcare professionals, in collaboration with facility CDI staff on clinical documentation, based on opportunities identified by clinical reviews as well as those identified by facility CDI specialists and coding professionals.
- Prepare reports, and review and evaluate CDI metrics.
- Follow ethical guidelines for clinical documentation improvement activities.
Education Roles of the CDI Specialist and CDI Nurse Advisor
The CDI manager, health information management director, or the respective leader of the section or department where the CDI program lies must carefully determine how to deliver education to providers. Most of the time, the role of educator is shared between the CDI nurse advisor and the CDI specialist. If the nurse advisor does not have coding knowledge or is still in coding training, the CDI specialist will often provide the education, with the involvement of the nurse advisor. As clinical experts, nurse advisors can teach the CDI specialists, but the specialists may already know much of the information. The tasks of the CDI specialist and the CDI nurse advisor must be structured to provide clarity and reduce confusion.
Overcoming Differences, Gaps, and Weaknesses
No matter your role in the CDI program, it’s important to grow together and exchange knowledge and experience to reach the desired goals. To overcome differences, gaps, and weaknesses:
- Implement a manager or director structure. Having a structure in place will make things run in the correct direction, eliminating overlapping efforts. Define the CDI specialist’s daily tasks.
- Identify and recognize your gaps. A new CDI specialist may have little clinical knowledge, or new CDI nurse advisor may have little coding knowledge.
- Set aside your egos. CDI specialists and CDI nurse advisors are experts in their own roles, and there must be reciprocal respect of their backgrounds and experience. Learning from each other and complementing their expertise will give the success you are seeking.
- Be a team player. Acting as the “Lone Ranger” won’t work. Have a teamwork mindset; it takes everybody playing for and with the team to be successful.
In conclusion, we all have strengths and weaknesses. The key to overcome these weaknesses is the discipline to have a teachable spirit, humbleness, and the desire to grow as a team.
Combs, Tammy. “The State of CDI.” Journal of AHIMA 90, no. 4 (April 2019): 18-21. https://bok.ahima.org/doc?oid=302702
Defining the role and responsibilities of the clinical documentation improvement specialist: Position Paper, ACDIS, 2014, www.acdis.org.
The Clinical Documentation Improvement Specialist’s Handbook, Second Edition by Marion Kruse, MBA, RN and Heather Taillon, RHIA, CCDS.
Omar E. Monet Ayala (email@example.com) is a Registered Health Information Technician (RHIT) with an associate’s degree from Huertas College in Caguas, Puerto Rico, and 11 years of experience in the health information management field.