Redesigning Clinical Documentation Maximizes Revenue

The client

This multi-hospital, 800-bed system needed to partner with their physicians to succeed in this Clinical Documentation Improvement initiative.

The challenge

To maximize reimbursement and deliver outstanding patient care, our client needed to redesign their clinical documentation processes. They also recognized the need to educate physicians and staff in order to align their CDI with industry best practices.

“Through education, process improvements, scheduling changes and measurement, our client improved their clinical documentation, revenue stream and quality of care,” says Dr. Patricia Hines, Managing Director and Care Management Transformation Practice Lead of Novia Strategies. “They continue to make strides in their CDI initiative.”

The approach

Forming a CDI Workgroup enabled us to guide a client through designing new CDI processes, procedures and tools. But what truly made the difference was education – both for the CDI specialists as well as for the physicians.

  • Championing the project: Inviting a respected care management physician advisor to assume the role of CDI physician advisor gave the team a champion who worked 1:1 with medical staff to break down barriers and secure engagement. He also helped create educational material and tools to improve documentation.
  • Creating electronic query templates: Developing, testing and implementing concurrent and retrospective query templates enabled physicians to see and respond to queries in a more timely fashion.
  • Revamping scheduling: Assigning CDI Specialists to patient care units by specialty and adjusting start times to match physician rounding patterns provided an opportunity for impromptu education and resolution of queries.
  • Measuring results: Creating and publishing a weekly CDI scorecard kept the team informed of their performance versus the targets for charts reviewed, queries created, physician response rate and Case Mix Index (CMI).

The results

Outcomes

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