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Reorganization adds staff and improvements
Potential financial gain outweighs cost of staff
After working with a consultant to determine how to improve clinical documentation, the care coordination department at Wake Forest Baptist Medical Center in Winston-Salem, NC, revamped its clinical documentation program, adding more staff and shifting the team from unit-based to service-based.
"We had the program in place for 12 years, and the administration felt it would benefit the whole institution to re-educate the physicians, the reviewers, and the coders. With ICD-10 coming along in two more years, the documentation is going to have to be more specific to fit the codes. We brought in a consultant in January 2011 to look for opportunities for improvement and to help us revamp the program," says Tamara A. Hicks, RN, BSN, CCS, CCDS, ACM, manager of care coordination at the 885-bed academic medical center.
At Wake Forest Baptist, the clinical documentation improvement is handled by BSN-prepared nurses who are called clinical documentation consultants. Before the reorganization, the department had 11 clinical documentation consultants with one supervisor covering the entire hospital. Based on the recommendations of the consultants, the hospital now has an additional four clinical documentation consultants.
"The consultants looked at the actual records and identified opportunities for improvement. They were able to estimate the potential financial gains we'd have from improving documentation and concluded that the potential additional reimbursement was far more than the cost of adding additional staff," Hicks says.
The clinical documentation staff members were unit-based before the reorganization. Now they are assigned by service and work as a team with the case managers and other members of the multidisciplinary team on the service.
"This arrangement makes it easier for the clinical documentation consultants to track cases and collaborate with the case managers. The case managers have a close working relationship with the physicians and are able to assist with documentation," Hicks says.
The goal is for the clinical documentation consultants to review all patients, regardless of payer. "We are still bringing the new staff on board and haven't gotten to that point yet. The priority right now is to review Medicare, Medicare Advantage, and Medicaid patients first," Hicks says. "We don't have productivity measures for this staff, in terms of the number of records they have to review each day. We want to give them the time they need to make a thorough review of the documentation."
Another initiative is for the clinical documentation consultants to become more compliant with American Health Information Management Association (AHIMA) recommendations for language used in clinical documentation improvement queries to physicians. "We are trying very hard to learn how to phrase the query so we aren't leading physicians or putting words in their mouths. For instance, we can't ask a physician if the patient has pneumonia. We can ask only for more information about the significance of the evidence on the X-ray," Hicks says.
A team that included Hicks and other members of the department leadership reviewed several vendors and what they offered, listed the pros and cons of each, and worked with the hospital's chief financial officer to choose a vendor. The consultants were on site for a week completing the assessment, and they spent an additional four weeks training the staff. Pediatrics was one area where the consultants recommended improvement. "The staff was trying to cover all payers, and the volume was getting to the point that the clinical documentation consultants were not able to manage the workload and stopped reviewing the pediatric patient charts," she says.
The coders and clinical documentation consultants spent three weeks in the classroom. In addition, the clinical documentation consultants spent clinical time with the consultants working on actual cases. "Reviewing the documentation process was very helpful to the staff. We had gotten stale and weren't being as thorough as possible.We gave them more resources and urged them to slow down," Hicks says.
The consultant team included a physician who presented in-service education to more than 600 physicians who admit patients to the hospital. "They showed them the difference that documentation can make in severity of illness, why it matters, and how it affects the hospital and the physician profiles," Hicks says.
Several of the clinical documentation staff have achieved the certification of certified clinical documentation specialist (CCDS).
"I encourage the staff to take the test to achieve their certification," says Hicks who worked with the Association of Clinical Documentation Improvement Specialists to develop the certification test.