High-functioning clinical documentation integrity (CDI) programs are taking on a more significant role—delivering tremendous impact on both clinical quality and the patient and provider experience.
At their core, successful CDI programs ensure the accuracy and completeness of medical record documentation and provide clinically valid records to substantiate payments. But these programs also hold tremendous potential to enable high reliability care and drive strong performance in rankings and ratings programs.
In addition to supporting improved outcomes in real time, they ensure accuracy of records so patients can see their full medical care and have the convenience and peace of mind that come with that. Providers are also more equipped to focus on providing high-quality care and can spend less time on administrative tasks.
By capturing and reporting quality indicators like mortality, readmissions, patient safety indicators, and length of stay (LOS), CDI programs can facilitate clinical improvements in care. That, in turn, leads to stronger performance in payment models and ratings and rankings programs. Organizations that receive Leapfrog A, CMS 5 star, and US News and World Report Best Hospitals ratings most often have a fully optimized CDI program—one that knows how to flex to provide maximum impact for both revenue and quality.
The four elements of a CDI program that drive quality improvement
The good news is that most organizations already have a CDI program. They can transform existing programs from basic to advanced practice by building a strong foundation. In our experience, these four elements are essential for a successful CDI program:
- Governance structure
- People and processes
- Technology and tools
- Measurement
1. Implement an integrated governance structure
CDI program success depends on a governance structure that engages both administrative and clinical leadership. Integrated leadership is crucial to establish organizational alignment on the CDI program’s vision and approach. It also provides an infrastructure that holds the right leaders accountable for executing and sustaining priority initiatives. Whether the organization adopts an enterprise- or an entity-specific approach, CDI governance structures should include the following:
- Executive sponsorship by the chief financial officer (CFO) and chief medical or quality officer (CMO/CQO) to provide joint oversight, direction, and support for new initiatives, technologies, and expansion opportunities. According to a recent survey, only half of CDI programs believe their executive leadership is providing the support they need.
- Broad stakeholder representation from CDI, coding, case management, quality, and provider teams to ensure alignment and support for CDI programmatic goals. This also includes clear delineation of roles and responsibilities across key stakeholder groups to promote accountability.
- Regular meeting cadence to review and evaluate progress on quality key performance indicators (KPIs) such as mortality, readmissions, LOS, and patient safety indicators (PSIs). These meetings should also measure impacts on rankings and ratings platforms (e.g., CMS Stars, Leapfrog, US News and World Report, Benchmarking platform) in addition to metrics that show financial impact.
Establishing supportive governance sets up the CDI team for success.
For instance, one health system advanced the role of its CDI program by establishing an interdisciplinary steering committee that facilitated teaming and communication among CDI specialists, coders, clinical quality reviewers, case managers, physicians, finance team members, and C-suite executives. The committee led ongoing assessment of CDI services and technology, which enabled better clinical outcomes, ratings and rankings, and reimbursement.
2. Invest in the right people and processes to increase experience and provider engagement
Organizations that want to increase the care quality value of their CDI program need to invest in more robust workforce education. Critically, staff need to know how to capture the clinical outcome variables that risk-adjustment models use. They also need to optimize the related processes and workflows so they are capturing these variables efficiently and accurately. Additional training could include education sessions on quality risk adjustment for pay-for-performance contracts, benchmarking platforms, and other reputational ranking agencies.
Once the organization has a skilled team, leaders should keep in mind that CDI professionals with experience in clinical quality improvement are in demand. High turnover rates, work-life balance, professional development, and a sense of purpose all impact recruitment and retention. Fostering opportunities for CDI professionals to grow in the clinical quality improvement arena will increase their overall experience, supporting staff retention and program strength. Roles to consider developing include:
- CDI educator: Ensures efficiency by keeping the CDI team up to date on risk model and performance ranking methodology changes as well as best-practice treatment plans.
- Clinical quality outcomes validation specialist: Ensures accurate performance data by reviewing medical records prior to bill drop, validating that they have provided evidenced-based care, and optimally captured clinical quality outcomes risk-model variables.
- Service line liaison: Facilitates increased provider engagement by partnering with physician champions across high-profile service lines. The liaison reduces unnecessary query volume by discussing quality outcomes documentation trends, providing risk-variable education at faculty meetings, and participating in patient rounds to address questions and concerns in real time.
3. Leverage the right technology and tools to optimize efficiency, consistency, and predictive capability
The goals and vision of the CDI program should drive technology investment decisions. Other decision factors should include budget, ease of use, ability to interface with other solutions (such as the electronic health record), degree and type of artificial intelligence (AI) used to predict opportunities and prioritize cases for review, and the ability to retrieve and report outcomes data.
A variety of software tools can help CDI professionals and key stakeholders (i.e., providers, case managers, and quality improvement specialists) get on the same page while the patient is receiving care. These tools create visibility into documentation and care plans in real time. In turn, that facilitates communication about the accuracy of clinical documentation, the appropriateness of codes, and the right level of care and follow-up services that will support optimal patient outcomes, including length of stay and mortality.
Among the quality indicators these software tools can predict or display in real time are geometric mean LOS, severity of illness (SOI), risk of mortality (ROM), and comorbid risk variable capture (e.g., Elixhauser comorbid conditions).
For example, during a CDI program redesign, a large academic health system incorporated machine learning to prioritize review. This technology created efficiencies by predetermining cases for review based on the highest likelihood of quality and financial opportunity. It also eliminated cases for which CDI would make a limited impact. In turn, the intervention reduced the CDI case review rate by 20%. At the same time, it increased reimbursement and quality.
4. Measure what matters to reduce quality variability and increase ratings and rankings performance
The maxim “if you can’t measure it, you can’t improve it” is especially true for CDI program success. While KPIs focused on reimbursement and risk mitigation are well-established for CDI programs, few clinical quality metrics exist.
The most successful quality measurement strategy starts with acknowledging what matters most to the organization (e.g., CMS Stars, Leapfrog, US News and World Report, and benchmarking platforms) and developing CDI metrics aligned with that vision as “true north.”
For instance, an organization might trend the expected values for mortality and LOS as a percentage. The organization can then visualize the impact of the CDI program on the overall observed-to-expected ratio. It also allows the organization to monitor the capture rate of key risk variables or metrics (e.g., Elixhauser, SOI, ROM, and PSIs) used in value-based incentive, ratings, and rankings programs. By comparing top decile performance and its baseline performance, the organization can proactively target areas for improvement.
Once the organization has defined its quality KPIs, it must routinely monitor, report, and share performance with executive and clinical leaders. Doing so can hold stakeholders accountable, drive action, and spur improvement.
A health system in the Northeast, for example, dramatically improved the accuracy of its expected mortality rate. From a baseline of 2.1%, the program exceeded benchmarks and reached 6.1%, leading to better Vizient rankings as well as sustained performance in US News and World Report and Leapfrog.
Fuel organizational success with a CDI program optimized for quality outcomes
Laying this foundation for your CDI program will deliver value across the organization. Optimizing a CDI program for quality improves outcomes, supports more timely and appropriate reimbursement, and improves ratings and rankings—all of which drive organizational success.
Additional contributors to this article: LaTonya O’Neal, Partner, Financial Transformation
