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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
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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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
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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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
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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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
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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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
Designing the Cedars‐Sinai CDI QI Program
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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
Designing the Cedars‐Sinai CDI QI Program
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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• 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
Designing the Cedars‐Sinai CDI QI Program
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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
Designing the Cedars‐Sinai CDI QI Program
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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
Designing the Cedars‐Sinai CDI QI Program
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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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
Designing the Cedars‐Sinai CDI QI Program
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Education Plan6
Data Analysis
Staff OpportunitiesPhysician Trends
Educational Resources
NewsletterRemindersResearchPresentationsMD BootcampCDI Staff Bootcamp
Ongoing Staff Feedback
MonthlyConcurrent
QI
Designing the Cedars‐Sinai CDI QI Program
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Lessons Learned
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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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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Lessons LearnedChallenges
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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Lessons LearnedChallenges
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
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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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
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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Thank you. Questions?
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.
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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