acdis day2-8 track2-6 pres 0517-gafford-f · title: microsoft powerpoint -...

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Janie Gafford, RN, BSN, MBA, CCDS, CDIPCDI QI Auditor

Cedars‐Sinai Medical CenterLos Angeles, CA

Auditing CDI Staff: Developing a CDI Quality Improvement Program at Cedars‐Sinai Medical Center

With thanks to Susan Tiffany, RN, CCDS

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Learning Objectives

• At the completion of this educational activity, the learner will be able to:

– Define the role of the Cedars‐Sinai CDI QI Program

– Identify the Cedars‐Sinai CDI QI Program goals

– Describe how the Cedars‐Sinai CDI QI Program was designed to meet CDI goals

– Discuss challenges and successes of the Cedars‐Sinai CDI QI Program

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2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.

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Polling Question #1

• Do you have a CDI QI (quality improvement) process at your facility?

– Yes

– No

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The Role of the Cedars‐Sinai CDI QI Program

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The Role of the Cedars‐Sinai CDI QI ProgramCDI Leadership

Thea Campbell

Executive Dir. of Health Information Management

Thea Campbell

Executive Dir. of Health Information Management

Colleen Stalvey

Associate Dir. of Revenue Cycle Services

Colleen Stalvey

Associate Dir. of Revenue Cycle Services

Laura Hardy

Health System Manager

Laura Hardy

Health System Manager

Mark LeBlanc

CDI Consultant


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Angie YoungbloodShelli Wolenetz Adrienne Youngblood

Marie Boone

Mark Tajon

Elana GilmanAileen Factora

Zelia Paulo

Michael Kevorkian

Jill WeberArly Vitello Donna Wheeler

Olga Mendez

Paula Williams

Maeghan Sulin

Nancy Wright

The Role of the Cedars‐Sinai CDI QI ProgramCDI Staff

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CDIStaffCDIStaff

HIDHID

CDIMgmtCDI

Mgmt

CDI Consultants

CDI Consultants

QI Auditors

QI Auditors

Coding AuditorsCoding Auditors

PhysicianAdvocatesPhysicianAdvocates

The Role of the Cedars‐Sinai CDI QI ProgramCDI Resources

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Two Key Responsibilities

Evaluate Quality of CDI Reviews

Provide CDI Education

The Role of the Cedars‐Sinai CDI QI ProgramKey Responsibilities


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CODING

TECHNOLOGY

MENTORING

ATTENTION TO DETAIL

FLEXIBILITY

CLINICAL

CDI

The Role of the Cedars‐Sinai CDI QI ProgramCriteria for Ideal CDI QI Auditors

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Cedars‐Sinai CDI QI Program Goals

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Improve compliance and uniformity of

queries

Improve coding knowledge

Improve clinical knowledge

Identify staff opportunity

Identify MD opportunity

Improve physician response

rate

Ensure data quality

Improve consistency of follow‐up

Identify coding opportunity

Improve CDI/physician engagement

Cedars‐Sinai CDI QI Program GoalsFour Tiers


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Cedars‐Sinai CDI QI Program GoalsTwo Main Aspects of Cedars‐Sinai CDI QI Methodology

• Queries

• Encounter reviews

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Cedars‐Sinai CDI QI Program GoalsAuditing Queries

1. Compliance– Query needed

– Non‐leading

2. Format– Three‐legged stool methodology

– Follows query template format

– Concise and succinct

3. Clinical validity– Clinical indicators uses industry‐specific definitions

4. Data entry– Field entry was appropriate

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Query QI Elements TotalPossible Points

Case#1

Case#2

Case #3

Case #4

Query compliance 2 2 2 2 2

Three‐legged stool format 2 2 2 2 2

Sent to appropriate MD 2 2 2 2 0

Query follow‐up timely 2 2 2 2 2

Data entry 2 2 0 2 2

TOTAL POINTS 10 10 8 10 8

PERCENTAGE SCORE 100% 100% 80% 100% 80% 90%

Cedars‐Sinai CDI QI Program GoalsQuery Audit Example


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Cedars‐Sinai CDI QI Program GoalsAuditing Encounter Reviews

1. Principal diagnosis

2. Secondary diagnosis

3. Principal procedure

4. Query opportunity

5. Data entry

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Review QI Elements TotalPossible Points

Case#1

Case#2

Case #3

Case #4

PDX assigned appropriately 2 2 2 2 2

Secondary diagnoses identified

2 2 2 2 2

Principal procedure 2 2 2 2 0

Query opportunity identified 2 2 2 2 2

Data entry 2 2 2 2 2

TOTAL POINTS 10 10 10 10 8

PERCENTAGE SCORE 100% 100% 100% 100% 80% 95%

Cedars‐Sinai CDI QI Program GoalsEncounter Review Audit Example

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Designing the Cedars‐Sinai CDI QI Program


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Designing the Cedars‐Sinai CDI QI Program 6 Basic Foundations

Establish Query Standards

Select QI Elements

Decide on CDI/QI Database

Establish QI Role in the CDI/Coding Workflow

Sampling and FTE

Education Plan

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Treatment/Monitoring

Three‐Legged StoolMethodology

Treatment/Monitoring

Three‐Legged StoolMethodology

Establish Query Standards1


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Queries: QI element examples

• Was the query non‐leading?

• Was the query format appropriate?

• Was timely follow‐up performed?

• Was the appropriate physician response assigned?

Full case reviews: QI element examples

• Was the appropriate PDX picked?

• Were the appropriate SDXs assigned?

• Was a query opportunity recognized?

• Was the appropriate principal procedure assigned?

• Was the case followed up according to CDI policy?

Select QI Elements2



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• Software – Data collection system

– CAC

– Spreadsheet

• Build dictionary list– Physician responses

– Type of query

– Query subject

• Create and generate reports– Report of CDI queries (discharged)

– Report of CDI reviews (discharged)

Decide on CDI/QI Database3


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Establish QI Role in CDI/Coding Workflow4

CDIValidates or rejects codes

CODINGAccepts or

rejects codes

BILLINGReports generated – QI extracts report from

final coded cases for QI

QI identifies CDI opportunity– QI auditor gives feedback to CDI– CDI agrees or gives evidence for rebuttal– QI returns points, upholds, or escalates

to the rest of the QI team

QI identifies coding opportunity– QI auditor requests review

from coding auditor – If agreed, coding auditor will

give feedback to coder

QI gives ongoing support– QI auditors provide

educational resource


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• Average encounters per day

– 10 (encounters) x 16 (staff) = 160 encounters

– 5 (queries) x 16 (staff) = 80 queries

• QI audit reviews for staff of 16

– 18 encounters (month) x 16 staff = 288

– 18 queries (month) x 16 staff = 288

– 288/20 workdays in a month = 14.4

– Queries = 14.4/day are QI’d (2 FTEs)

– Encounters = 14.4/day are QI’d (2 FTEs)

Sampling and FTE5



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Type of Review

# QI Reviews # Staff Reviews % Auditedfor QI

Queries 14.4 80 18%

Encounters 14.4 160 9%

Sampling and FTE5

Sample size: Percentage audited by 2 FTEs


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Education Plan6

Data Analysis

Staff OpportunitiesPhysician Trends

Educational Resources

NewsletterRemindersResearchPresentationsMD BootcampCDI Staff Bootcamp

Ongoing Staff Feedback

MonthlyConcurrent

QI


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Lessons Learned


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Lessons LearnedChallenges

ChallengeObsolete QI Elements

MitigationQuarterly Evaluation of QI Elements

QI tool can become less useful because staff has achieved proficiency in a specific QI element

• QI element “Query sent to appropriate MD” removed because of 100% score

• QI element “MD follow‐up performed” reestablished due to decrease in physician response rate

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ChallengeInconsistency of Auditors

MitigationFrequent Communication and Collaboration

Different auditors may have inconsistent levels of application of the QI tool and apply points differently

• Biweekly QI team meetings • All‐or‐nothing element scoring

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ChallengePunitive vs. Constructive

MitigationEmphasize the Educational advantage of QI Tool

QI feedback could be misconstrued by staff as punitive

•Approach QI tool as a constructive tool for education rather than punitive

•QI Auditors are evaluated based on how many points are overturned


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Lessons LearnedSuccesses: QI Tool Is Effective Over Time

92%

96%

94% 94%

95%

97%

96% 96%

97%

95%

93%

94%

96% 96%

98% 98%

96%

97%

89%

90%

91%

92%

93%

94%

95%

96%

97%

98%

99%

QI Query

88%

92%

94%95%

96% 96%95%

96%97%

95%94%

96% 96% 96% 96% 96%95%

94%

82%

84%

86%

88%

90%

92%

94%

96%

98%

QI Review

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Increased Consistency

Increased CDI Skills

Easily Identify Opportunities

Use QI Scores to Quantify Quality

Recognized by Governing Agency

• Query• Reviews

• Coding • Clinical

• QI program endorsed by CMS

• Staff • MD

• Use benchmark as goal for quality• Use QI scores for annual evaluation

Lessons LearnedSuccesses

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Summary

• Role of the Cedars‐Sinai CDI QI Program

• Cedars‐Sinai CDI QI Program goals

• Designing the Cedars‐Sinai CDI QI Program

• Lessons learned in implementing the Cedars‐Sinai CDI QI Program


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Thank you. Questions?

[email protected]

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide.


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acdis day2-8 track2-6 pres 0517-gafford-f · title: microsoft powerpoint -...

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