May 23, 2016

Achieving CDI Success from Key Performance Indicator Management Strategies Part I

By
EDITOR’S NOTE: This is the first in a two-part series examining how to manage a CDI program using Key Performance Indicator management strategies.

Managing a clinical documentation improvement (CDI) program is about much more than just coordinating time-off requests, allocating budget items, coordinating meetings and trainings, facilitating the occasional audit, or consulting engagement and pulling some reports for senior leadership.

Those are all fine examples of passive leadership. Passive leaders are plug-and-play and for the most part, often being little more than glorified task managers from 20 years ago with a shiny new presentation style and a set of corporate philosophies meant to increase organizational capabilities. You can take a well-organized passive leader and plug them into any department-specific leadership role and they will employ their advanced management training concepts to the general direction and leadership of the program. In many cases, the results look great. In fact, often the whole thing looks and sounds wonderful even as it slowly falls in mediocrity and ultimately fails.

What more could there be to do? And when would I have the time to do more than that? What would the return on my investment even be for further engaging the staff? If these are your initial responses, prepare for a paradigm shift. Some programs simply require active leadership. They require a subject matter expert who is involved in the day-to-day work of the staff, understands the nuances of the staff’s needs and challenges faced, and proves able to employ the types of subtle performance improvement strategies that actually make for a successful program.  

As a CDI consultation specialist building and molding new programs, I picked up several such strategies to ensure success of various programs. One of my clients had a financial goal of over $800,000 in increased revenue. We doubled that. Another multi-hospital system was probably going to struggle to bring in $2.8 million. We brought in $4.2 million. I could go on and on with examples, but I think you get the point. On average, my clients brought in about 125 percent of the stated return on investment (ROI) goal.   

Right now you may be thinking that citing the above two examples was in bad taste. How dare I talk about financial benefit in a time when the focus on CDI has shifted to overall quality and sound documentation? The same principles of management I employed to achieve those financial goals are the strategies you might employ to increase the level of quality in a record and ensure the overall best health of the patient population. The dollar signs were for illustration only and are inconsequential to the points I am about to outline.

Forget everything you know or think you know about “hands-off” management. A successful program needs constant maintenance. Every employee, every performance metric, every gear in the cog has to be carefully supervised. If the standard, successful hands-off department is a Honda Accord that you can just drive and forget about, only stopping for the occasional fuel-up and bi-yearly oil change, then think of a CDI program as a drag racer. The drag racer requires a look under the hood every quarter mile and constant tweaks. Failure to do so not only might it make it even slower than the Accord, but it likely won’t even run at all after a few miles.  

This is one of the reasons why I think so many CDI programs exhibit mediocre performance and even fail outright. Failure to identify, monitor, and problem-solve performance issues is a common theme among hospitals that have poorly functioning CDI programs. These functions cannot be performed by your consultants and vendors; while those entities will partner with you to make sure you have the tools you need to properly run the program, they cannot actually run the program for you (short of outsourcing the program to the consulting company, of course).

By now you may be wondering what the “magic formula” is. After all, I have given no specifics so far. Let’s address that from a key performance indicator (KPI) approach, with a few basic strategies that are simple to employ. Be warned, however, that these will require a drastic shift in where you spend your time as a CDI solution leader. Ask yourself this: do you want to be thought of as the great leader who appears to say and do all the right things, or do you want to be in charge of a world-class, benchmark-setting program that is both financially successful as well as prepared to hold its own when subject to audit scrutiny? It is possible to achieve both, but if time constraints force you to sacrifice some political tasks in favor of obtaining real results, tough choices will have to be made. Culture and procedure are nice, but results are king.

Production metrics count. However, the conversation does not end there. With so much variability in each organization, for both speed and accessibility of the electronic medical record (EMR) and individual CDI specialist experience levels, we find that performance metrics are often not uniform across the board. When you factor in variation in the review procedure and query process, you get near-unpredictable variability in what the recommended production rates should be, especially in the review rate metric.  

Before you begin goal-setting, however, you first must determine a “par” for your specific facility and staff, to use a golf analogy. Just like every hole is different, every CDI department is unique and will have its own individualized performance metrics. If you are not currently collecting data on productivity in a very specific way, it is time to begin. A thorough review of the review rate requires an overall assessment of what exactly the CDI specialists are doing with their time. You will need to monitor and document factors such as how many times a CDI has to log into a system, and for how long – yes, we are counting key strokes here. You will need to know how much time they spend answering emails, answering phone calls, printing materials, and what other non-CDI duties are required of them, any of which could negatively impact the amount of time available to be spent on the task at hand.

Unfortunately, you are not done with the data collection process after you have done this. Likely there are differences in the production rates of the different units of the hospital. The average time to conduct a record review may be drastically different in an ICU setting versus the floor, for example. One also must take into account the average lengths of stays of each patient population, as well as the medical complexity of the care being provided. This likely will lead not only to a customized “par” for the facility (when all the data is averaged together), but also an individualized “par” for each individual CDI specialist.  

Once these pars are determined, the real management begins. While we will have determined at this point what review rate is currently being achieved, we really still have no data about what review rate is possible. Some employees are faster, some are more thorough. Most, however, still have some untapped and unknown potential. Set an achievable goal for each employee that pushes them to test their capabilities. A 5-percent increase over the current “par” for a three-to-six-month period is not an unreasonable goal to set. If that increase is easily met, you can increase the goal in 2- to 3-percent intervals until the CDI specialists plateau.
Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Allen R. Frady, RN, BSN, CCS, CCDS, AHIMA Approved ICD-10-CM/PCS Trainer

With 20 years in healthcare, Allen R. Frady provides clients assistance in the areas of documentation, program implementation and compliance. His background includes critical care nursing, coding, auditing, utilization review, and documentation improvement.

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