Webinar: Quality and Clinical Documentation Improvement (CDI): Elevating Healthcare Accuracy and Completeness

Linnea: Good afternoon and welcome to today’s program titled Quality and Clinical Documentation Improvement Elevating Healthcare Accuracy and Completeness.

I’m Linnea Archibald, the Associate Editorial Director for ACDIS and I will be your host for

today’s webinar. Our program today will be 60 minutes in length. Do note that an on-demand version of the program will be available approximately one day after the completion of the webinar. Details on how to access the on-demand recording will be sent via email within 24 hours following the live webinar.Today’s program is sponsored by Tendo.

Thank you to our sponsor and to everyone in our audience for giving us your time and attention this afternoon.Before we get started, we do have just a few housekeeping details for you all.

First, to ensure that you can see all the content for the event, please go ahead and maximize your event window and be sure to adjust your computer volume settings and or your PC speakers for optimal sound quality.

Second, at the bottom of your console are multiple widgets you can use. To submit a question, click on the Q &A widget. You may submit questions at any time during the presentation.

However, do note that it’s likely we won’t get to them until the designated Q&A portion of the Program. Also, please note that there is no slide deck available for today’s program. It will be largely a panel discussion, so most of what you’re going to need to pay attention to will be spoken out loud anyway.

Finally, today’s program is approved for one ACDIS continuing education credit, but only for those of you who attend our program today, June 25th, 2024, so please stay tuned for all the instructions about obtaining your certificate at the end of our program. And now it’s my pleasure to introduce our speakers for today’s webinar.

Aimee VanBellen, MBA, HA, BSN, RN, CCDS, is the Senior Manager of CDI at Brigham and Women’s Hospital in Boston.

Lena Wilson, MHI, RHIA, CCS, CCDS, is the Revenue Cycle Systems Manager, HIM Clinical Operations at Indiana University Health, formerly Clarion Health in the Chicago area. And I’m sorry, in the Indianapolis area. I got ahead of myself there.

And finally, we have Christine Green, who is in Chicago, MSN RN, Vice President of CDI at NorthWestern Medicine.

Our panel today will be moderated by Deb Jones, MSN RN, who is the Senior Director of Insights at Tendo.

Thank you all for taking the time to talk with us today. And with that, I will hand it over to all of our wonderful speakers to begin the presentation.

Deb: Thank you, Linnea. And on behalf of Tendo, I’d like to thank Linnea and the ACDIS team for allowing us this platform today.And thank you to everyone who has joined this webinar.

Since joining Tendo a few months ago, I’ve had a lot of like fun firsts and a few months ago, I got the opportunity at the ACDIS conference to have my first experience on the other side of the booth, so to speak.

And today it’s really exciting to have the opportunity to be on the other side of the microphone, which may or may not be kind of dangerous for all of you if you know, burst into song at any moment, which would be dangerous.Anyhow, I would just like to go into a little bit more detail about our talented panel today.

So first, Christine Green.Christine is the Vice President of Clinical Documentation at Northwestern Memorial Healthcare. Northwestern Memorial Hospital is the only Illinois hospital that is nationally ranked in the US News World Report 2023-24 and has been on that ranking for the past 12 years straight. Prior to her current role, Christine served as the Director of Clinical Documentation and the Director of Quality Utilization.I’m wondering if that was at the same time, and I hope not for your sake. During her time at Northwestern, Christine has been able to align clinical documentation as a system function and integrated clinical documentation nurses with physicians and advanced practice providers, which is a great model through in-person rounding and experiences to drive measurable improvements in accuracy and expected outcomes. She is also a member of the Actus CDI Leadership Council.

Next we have Aimee Van Ballen.Aimee is an experienced documentation specialist with 15 years of CDI experience, who serves as the senior manager of CDI at Brigham and Women’s Hospital and Brigham and Women’s Faulkner Hospital in Boston, Massachusetts.She has recently completed her MBA with a focus in healthcare administration.Congratulations, Aimee. Very happy for you. She’s also certified in her field and has a vast knowledge in CDI with a passion for capturing accuracy and medical record documentation to reflect the true severity of illness and risk of mortality of the patients.

In previous roles, Aimee has focused on mortality risk adjustment capture and vizient data

benchmarking, as well as provider and CDI education. She has successfully expanded her career through volunteerism and mentoring within the CDI community as many of us know, she has served as the co-chair of the Massachusetts ACDIS chapter, as well as recently completing her four-year term on the ACDIS advisory board, where she served as a subject matter expert and contributed to industry-driven papers.

And finally, we have Lena Wilson. Lena is the manager of CDI at Indiana University Health in Indianapolis. Lena has a bachelor’s in HAM, as well as a master’s in health informatics, both from Indiana University. She holds credentials in CCS and CCDS. And she has spent the last 16 years at IU and during her tenure has worked in various supporting roles for the CDI team from direct leadership and program oversight to solely focusing on physician documentation, education leading up to the ICD-10 code set conversion. She has worked to support the implementation of computer assistance CDI tools, as well as computer quality monitoring programs.

Thank you, all of you, for agreeing to share with us today.

Today’s discussion will focus primarily around quality documentation and how these three CDI leaders from prominent institutions are addressing the impact that quality documentation has on many CDI programs.

Specifically, what I hope to cover today is thinking about, for the three of you, what is your quality true north? And by that, I mean, at the end of the day, what do you hope to achieve? What goals are you striving for? And then in light of these goals, how are these programs prioritizing their work in their CDI workflows?What changes or adaptations to traditional CDI workflows have you had to implement, if any, successful or otherwise to address the increased work? And then lastly, what does success look like for you?What outcomes are you measuring, and how and why? And then we’ll also leave some time for questions. And I’ll just frame for all of you in the audience today what I mean by the term of quality documentation, because it may mean different things for different people.

For me and for this discussion, I’m referring to documentation of conditions that play a role in the measurement of quality outcomes, quality rankings and ratings, whether that CMS STAR ratings, Vizient, US News, LeapFrog, all of our value-based measures.These are all designed to evaluate and compare the quality of care at different institutions, and that is something that all our organizations, large and small, want to accurately demonstrate.Not only do they want to highlight their excellent work, it is also important in attracting new and recruiting top talent.

For CDI teams, addressing quality documentation can come in the form of identifying that a condition is or is not present on admission, reviewing PSIs for inclusion or exclusion criteria,validating that the most appropriate principal diagnosis is reflected to ensure that your mortality is attributed to the most accurate service line or identifying the presence of conditions that may positively or negatively impact the risk adjustment for a particular measure or a particular patient population.

So before we dive in any further, I’d like to share that this is a topic that I am very passionate about.For me, it was when I was first leading the CDI program at Brigham Women’s Hospital and that program was and still does dock into quality.

It was there that I learned that aside from capturing SOI and ROM, there was so much more impact that documentation had on quality outcomes. And it was there that I learned that for organizations to accurately demonstrate the quality of care that they provide, they first have to ensure that the data that informs those measures is accurate and reliable. And that data comes directly from hospital claims.And as this group surely knows, that relies on provider documentation.

So when I realized all of that, it was like a light switch for me at that point, that our roles as CDSs really had such a broader impact on organizational success than I had ever previously realized.

And then since leaving Brigham, And working on the vendor side past year, what I have realized as well is that across the country and across organizations, the variability in documentation from one organization to another is really very, very significant, more so than I ever realized. In fact, I’d go so far as to say that most hospitals’ quality of care is probably pretty similar, and it’s really the variability in the documentation from one organization to another that really kind of skews that outcome data.

So with all that being said, let’s start by meeting our panelists.

So I’ll ask if each of you could just share a little bit about your organization, your specific role and the scope of your CDI program. Lena, maybe we could start with you and then Christine and then Aimee.

Lena: Normally I’m the last one with Wilson is my last name but I’ll go first. We can do it in reverse order today. So as you’ve already heard my name is Lena Wilson. I am the manager of the CDI program at Indiana University Health. For those of you that aren’t aware of IU Health we are a hospital system spread across the entire state of Indiana.

We’re affiliated with the IU School of Medicine, so we consist of academic medical centers, we have community hospitals, a freestanding pediatric facility, as well as critical access hospitals. So quite a large footprint across the state. So in terms of our CDI program, our scope right now is just our nine acute care facilities, so those are going to be the adult and the pediatric facilities. we’ve suspended operations currently on our critical access hospitals just to about do some additional evaluation and that may come back up in scope later on.So in terms of my team and the volume, I’ve got 20 team members whose sole responsibility is to do normal day-to-day concurrent reviews, their concurrent operations, and then I have two in the quality space.

So the two that are in the quality space, one of them is responsible for our post-discharge queries,so we’re unique from maybe some other programs and some of the other listeners out there that we actually triage all post discharge queries from our coding team, and they funnel through my staff, we review them, we send back anything that we don’t feel is appropriate, whether it doesn’t meet criteria from a compliant query standpoint, or maybe the documentation is already there, and then we send out whatever we feel is appropriate, so that one team member responsible for that.

And then the other team member is part-time and assists me with different audits and mortality

reviews.So one of the last things you talked about Deb was in terms of different rankings and things that we look at for goals.Our organization is a vizient shop, so like a lot of people out there on the call, we do use that as a driver so that quality and accountability study. We also look at our U.S. news rankings as well.

So some of the goals that we have from our organizational level down to our CDI team is looking at that mortality index and length of stay index.So when we look at those values, we’ve got that observed over expected, and we know

documentation can really help to drive that expected bucket. So that’s one of the goals that our organization has from a CDI perspective is to increase that expected value when it looks at those indices.So, and I’ll let you tag in whoever you want to go next.

Christine:

Hi, everyone. I’m Christine Green, Vice President of Clinical Documentation for Northwestern Medicine. We are anchored by Northwestern Memorial Hospital, which is our academic medical center and affiliated with the Feinberg School of Medicine.We do have 10 other hospitals within our system.Most are acute care hospitals, but we also have a rehab hospital and a critical access hospital. And we do support, in CBI, 10 of the 11.We just do not support the critical access hospital at this time.Something interesting about Northwestern that you may not know is we’re really well known for

our transplants.Very well known for our lung transplants, especially post-pandemic. But then we also just celebrated our 10 ,000th abdominal transplant, being in the kidney, liver,

pancreas arena. And we also just had the first ever kidney transplant while the patient was awake, which you can actually probably Google that and see the news coverage of that.

So we are an honor roll hospital, a magnet hospital. And I’ve been with the organization for over 26 years now.As far as our CDI team goes, we do have inpatient rehab and ambulatory CDI.

We’ve got about 100 CDI nurses that cover the inpatient arena across the hospital or the system.And then we’ve got about 24 on the ambulatory side. And we’re ever growing.

We also do in the last year, oh, I guess it’s two years, we’ve expanded into Mom Baby.

So we have an arm of our team that covers Mom Baby.Also interesting is that NMH, Northwestern Memorial Hospital, is one of the largest birthing

centers in the United States.

We’ve got about 11,000 to 12,000 deliveries each year, and so we have to strategically approach that because we’re not going to be able to cover all of those deliveries.Our True North messaging is for a complete and accurate medical record. We message this all the way from our CEO to our CDI nurses that are out rounding and working with our teams.

And then our true north for measurement is Vizian for a host of reasons, mostly because this is a great way to be able to real-time benchmark with our peer organizations as well as compare and monitor our internal performance and understand where we’re doing really well and where we have opportunities to improve.Aimee: And I’m Aimee.I am the senior manager at Brigham and Faulkner and took over from Deb who had already set

the stage for us.So, Brigham just recently became MGB, which is a partnership with Mass General and 16 other hospitals.So, of two hospitals, Brigham is the academic medical center, level one trauma, high acuity. We have about 800 beds there Faulkner, on the other hand, is a community hospital. It’s small, 162 beds, so very different scope on CDI and on quality.I would say MGB is focused on quality patient outcomes.That’s the underlying or overlying arching focus for everything that we do in CDI and throughout MGB.So, you know, we do focus on U.S.News and World Report, but the truth overall is patient, you know, patient safety.Deb:Great. Thank you, all of you.And it’s interesting that the panel that we brought together today, and just by chance, really, you

all have community hospitals and academics hospitals under your purview.So, I think that everything that we share today should resonate across all of our ACDIS

memberships. So, I really appreciate that. So, we kind of touched on this, but in a deeper sense, when thinking about quality and CDI, I mentioned this, quality true north or overarching goals.And what are those and how do you think about those in terms of measurement? So if you’re reviewing PSIs, what is the end goal of that?Is it CMS STARS, is it LeapFrog, is it Vizient?

And if you’re reviewing risk adjustment, what does that look like?Is that for Vizion, is it for US News, is it for, are you trying to impact your PSI expected rates or denominator?I’ll just pick on Christine to start this one and if you could just elaborate a little bit about that.

Christine:

Yeah, and I’d say all of the above.We focus on all of those things, but really our message is what’s complete, what’s accurate,what’s going to best represent the patient and how they presented to us and what we treated them for and diagnosed them with.And so it’s really about a complete and accurate medical record, and then all else follows.

So whoever is evaluating us from an external lens, there’s not a lot we can control, but we can

control what goes out our door and make sure it’s accurate.So that’s really our messaging to our physicians and APPs is accuracy.And of course, we do a lot to make that happen, right, behind the scenes and in cleaning up the

claims to make sure they’re accurate.But that’s our messaging.And then we do look at Viziant.We do look at US News and World Report and CMS. We know that if we’re accurate, at least we’ll be evaluated fairly in anyone that ranks them race up.

Aimee:

Yeah, I’ll jump in there and just say, you know, I think if you’re doing a complete and thorough

chart review, you will hit all of those denominators, right? So it’s hard when there’s proprietary data and every risk adjustment is a little bit different. I will say capturing as much risk adjustment as possible, even the small diagnosis, has a big impact overall. So, you know, at Brigham, we do use Vizient as well, but, we focus on ODE. When you’re reviewing the charts, concurrently, the CDIs will try to capture any risk adjustment that they know of, and will flag the PSIs or HACs working on developing.

We just hired quality liaison for the hospitals and she will be reviewing, you know, the Medicare

mortality and the PSIs and then we will have frontline CDI concurrent staff following behind

her.Deb: Lena, anything?Lena:I was just gonna, yeah, just jump in and say, you know, kind of like what Christine said, we focus on all the things, everything that you listed and just as Christine and Aimee said, I definitely would agree and echo that you know I’m a firm believer that if we’ve got all of that quality

documentation in place we’ve got that accurate complete record everything is going to follow

appropriately even even ultimately the reimbursement that we’re supposed to receive.In terms of our organization we really focus on again like I mentioned earlier the Vizient Q &A

that’s also going to include the PSIs that roll up to the Vizient Q &A study and then also our All

of our facilities are, you know, available and there to be ranked, but we’re really doing a lot of

focus on our academic medical center now in downtown Indianapolis.But one of the things that I did want to also say is there’s a significant amount of overlap.

So it may seem very daunting when you’re when, you know, you’ve got all of these different

quality rankings and different quality metrics and which one do you follow.But there is such a significant overlap between whether you’re looking at if you’re a vizient shop

or you’re looking at Elix Hauser variables for US News a lot of the common queries that we’re

sending out every single day are going to be those same Conditions that are popping or bubbling up to the top for vizient for US News And some of the things that we are working on is to just increase the capture of those conditions So, we’ve started to select a smaller group of them and really working to hone in on how do we address those, how do we increase the capture of those conditions, and once we feel like those are mastered, then we’ll move on to another set of those.

Deb: So, it may seem daunting, but as long as you’re looking at it from, you know, where you can maximize your work effort, it’s definitely achievable. I agree with that.

just say you can also use your benchmarking data to hone in your education for your frontline

CDIs and where there is potential opportunity based on your rankings.That’s kind of a great segue into my next question, which is how do you prioritize the work?

How with all of these different methodologies out there and all of these different priorities that

CDI is kind of like a laundry list now of things that we need to capture in the record, how do you

prioritize that?I know I heard mention of nurses that are strictly assigned to review PSIs or quality outcomes,

but maybe each of you could elaborate a little bit on that.And since Aimee, I haven’t picked on you to go first, this will be your turn.

Aimee: As a manager, I review a lot of PSIs currently while the new quality liaison gets up and running.So I work very closely with coding and quality and reviewing those records.

I would send the queries on any PSI currently.You know, I think it’s hard because CDI is in the chart, right? CDI in general are some of the most capable people I’ve ever met. They can handle anything that is further away.

So I do think it’s important to be realistic about how much we can really do in each day.

So I think there are a lot of overlapping diagnoses, and if you focus on the most common ones

for your full staff, then you can have additional staff hone in on more specific details.Because I think at the end of the day, right, we still need to be doing concurrent CDI work,

querying for CCMCC capture rate to change, you know, PBX and to clarify the record.And so it’s a hard balance between quality.Deb:And, you know, I’ll just ask you, since some of our audience may not be familiar with all of the risk adjustment conditions, I mean, maybe you could elaborate a little bit on like, what are some of those conditions?Aimee: So there’s so many risk adjustment diagnoses, but the good part is that a lot of them are chronic conditions, right? Or, you know, fairly basic conditions.So your fluid and electrolyte, your BMI over 40 or under 19, your malnutrition, your CHF, your

hypertension, your CKD, AKI. There’s a lot of just very everyday CDI diagnoses that impacts risk adjustment hugely.

So dehydration, for example, you wouldn’t think has a huge impact, but it actually does.

So, you know, kind of those main top 10 diagnoses, I think they’re probably things you guys already turn for.Deb:So it’s just an additional awareness that like these also impact quality. Thank you.And Lena, anything you want to add about how the work is prioritized at your organization?Lena: So we have software that prioritizes our workflow through our concurrent operations.So it’s gonna bring to the team’s attention to those charts that they need to address and kind of

funnel out those that are maybe lower in priority or the documentation is already set and we don’t need to necessarily review those.That’s at least to optimize that concurrent workflow like Aimee was talking about. And a lot of these things we are addressing while the patient’s in-house. We in particular do not differentiate between queries that are maybe DRG impact versus quality impacts.I know that was one of the things that you wanted us to elaborate a little bit more on here.

So if a query’s been identified or a needs been identified to improve documentation, then the

query needs to be sent, regardless of whatever type of impact it makes.And I mean, we may think initially that it might have a DRG impact, but through the rest of the

course of the patient stay, there might be additional things that have happened, and then maybe

our DRG changing query that we sent in the beginning, there might be an additional MCC and

maybe there wasn’t the only MCC on the account that helped to change the DRG.

So I’m just kind of looking at it holistically there.Deb:And I’ll just ask one follow-up question to that before I ask Christine the same question, but is there a point where you just say enough is enough?Lena:I mean, we can go on.I’m a firm believer that there’s always opportunity.

Right, there’s always going to be opportunity. I really do think that you have to know the priorities of your own individual organization.So there may be a point where, you know, if you’ve got to make a decision between sepsis and something else, then you’re gonna lead more towards that, you know, that in organ failure, you’re gonna lean more towards querying for sepsis.But we do, like I mentioned earlier, we have those top conditions, so we do try to focus on those

But you’re exactly right, Deb.I mean, there is a point I think it even calls it out in the query practice brief that you know.We we can’t query for everything.We can’t query for every gap in the documentation So you really do have to come up with your

own standards to say, you know How are we going to prioritize and at what point are we going to say?We’re not going to proceed with this with this additional query that for specificity when it might

not make an actual impact Even from a quality perspective.I mean there are codes that are included And, you know, even with Vizient and NUS News for

the ELIX Houser codes, that they do accept unspecified.I know we don’t like unspecifieds, but I mean, they do take unspecified codes in some situations.So that might also come into play in that decision.Deb: Very true.Thank you for that.Aimee anything to add on that topic of how the work is prioritized in your organization?Aimee: Yeah, so I’m going to answer this question differently than what I would have answered just about a few years ago.We used to prioritize within the role and within each nurse and kind of change up priorities

during the day and have a schematic around that.And in reflecting on that, what I realized is that not everyone responds well to that type of daily structure.And even those that do don’t like it.And so, for a host of reasons, we really changed the structure and approach of our team over the last few years and built out different roles to create a laser focus on certain things and have people really own things and have more of a streamlined day.We still prioritize everything that’s on the screen, but we do it differently today, really by

building out different roles.And the host of reasons includes not only getting the job done and doing a good job, but also employee satisfaction and having the nurses really enjoy what they do.Deb:I think that’s so important, especially in a role like CDI when we can just be in front of the

computer all day long, and that kind of segues into my next question, which Christine, I’ll just go back to you, I’ll just ask you if you could elaborate a little bit more about the different roles within the department.My question specifically was, are you functioning differently in order to incorporate all of this

increased demand on CDI?So my question really to you is, could you elaborate on some of those different roles within your

team and different workflows that you might be performing?Chrisitne: Yeah. So, for years, we’ve had a mortality review team.So, we continue to have that, although we’ve expanded it across the system just because of the

amount of time required to work on these cases and the sort of intricate workflow that we have with the physicians on the frontline in mortality.But what we’ve also done is build out what I would call an external rankings arm of those that

are really focused on certain conditions like Elex Hauser and other items that we’ve billed pre-

bill holds for through our EPIC work queues.I think this part is important because as for a number of reasons, one, because we need to focus

on that and what we realize is by focusing on it differently, we’re doing a job.But it’s also important to remember to go back and see what capabilities you have today versus

maybe when you last looked. So as an example, we’re an Epic medical record.And what we’ve learned is going back today to see what capabilities exist are much different

than, say, five years ago, because our IT team has advanced and the services that Epic offers has advanced.And so, I’d encourage the leaders out there to go back and see what else you might be able to do that years ago you couldn’t.And so, we’ve really leveraged technology to be able to do different things to bring out

comorbidities and the documentation of comorbidities and the identification of those within our

Team. So, we built out this external rankings team. We also have denials.So our DRG downgrade requests at our AMC have gone up 200% trending from our fiscal year

2020 through 2023. And so as we started to realize that trajectory back in 22, we built out a role for that.And so we have someone that owns that and partners with not only our NM sort of denials team

as a CDI expert, but also we have a physician partnering to do that as well.And so that is just a few examples of how we built it out on the inpatient side. And then on the outpatient side, definitely population health and HCCs, we have a whole arm of our team now that that’s all they do, that’s all they’re focused on.They’re out in the clinic working and building relationships with primary care and other

specialties to make sure that, again, complete and accurate medical record extends into the

ambulatory space as well.So, that is just a couple of examples of what we’ve done differently over the last few years is

really build out specialty roles and be laser focused on certain areas.Deb: Awesome answer. Thank you so much.And Lena, I know you kind of touched on before but anything anything more to add on on how

the work is prioritized for you?Yeah so kind of to add on a little bit to what Christine just said I steal an analogy from our CMIO

he talks about a toolbox and using using all the tools in your toolbox so like Christine mentioned

you know using your EMR and leveraging that technology that you have to support the provider

so not all of this burden necessarily needs to follow on CDI from a concurrent perspective But

ideally and it’s a satisfier for not only the team but the providers as well push that work up more

real-time So as the providers are documenting they’re get they’re getting prompts if your EMR

can support something like that So we don’t have to send those queries for those abnormal

electrolytes or CKD stage or anemia anymore You know, we refer to it as the the low-hanging

fruit But but honestly, I feel like that’s kind of the fruit that’s on the ground at this point because

those are those common queries that We don’t want to send anymore and the docs don’t want to get it.So let’s push it up more real time You know, let’s make it a little bit easier for them to to be able

to document that and get that prompt and reminder Um, one of the other things that we’re doing

so not only those prompts we’re investigating those a little bit further but also um Looking at

different ways that providers can use.Um, I’m a cerner shop So we have um global auto text and dot phrases.I’m sure there’s a an epic analogy or you know a comparable component for that but they’re

basically just little macros that they can put in the EMR so we’ve been working to create some

additional things to help capture our comorbid conditions and not only that but also partnering

with other areas as well.So we’ve got one that we have the concept approved for sepsis.The global autotext there has information related to CDI, so these common queries that we’re sending.Sepsis is one of our number one query that we actually send across our system.

So we’ve not only baked in the CDI components, but we’ve also baked in the information related to the CMS Sepsis bundle.

So it’s kind of a one-stop shop.It’s got your CDI pieces.It’s got your CMS abstraction for the Sepsis bundle.And hopefully we’re really optimistic that that’s gonna reduce the need for the CDI query burden

related to Sepsis.So that’s definitely something that we’re looking for.And then also something else that I thought of was, make sure that things that you think are

working, kind of like Christine was saying, things that weren’t available five years ago.Well, maybe we’ve gotten information in our notes that auto-import from other areas within our

EMR.So is that BMI actually calculating on all of the progress notes like it’s supposed to?Is that nutrition note information that says the patient has severe malnutrition, importing where

it’s supposed to in the provider’s documentation or wound care notes.And if it’s not, maybe that’s another area of opportunity that you can investigate to ensure that

information is being imported in the provider’s note so that we can reduce, again, reduce that

query burden.We want to make sure that we are actually, you know, sending what we need to send, but also

equipping the providers and the other documenters, aid the APPs as well with that information

real time. So yeah, I think that was all I had to add.Deb: That’s phenomenal. I’m a huge proponent of, you know, getting the documentation right up front. And Aimee, you might hate me for this because I’m going to put you on the spot.I didn’t tell you I was going to ask this, but I know that recently there was some work done at

Brigham around pairing CDI nurses with providers to kind of prompt that education.Can you elaborate a little bit on that for our viewers?Aimee: Yeah, sure.I mean, we’ve also developed a tool to try to frontline, get that low hanging fruit that Lena was talking about.So we have a similar.cd tool that the providers can use and it will bring up like certain diagnoses

that based on the labs and the AI and EMR, they might have to eliminate some of those queries,

But additionally, we have some just a few CDIs who are service line based and specifically in

neurology and neurosurgery.They formed quite a strong relationship and they worked with one of the residents who is now in

attending on really changing their notes, changing the way that they document, educating them

on, like, why are these silly little diagnoses important on this patient?And so, I think the understanding of, like, why helps a lot in capturing the quality.I also think that we’ve utilized our physician advisor for additional help and support.And so, you know, based on, like, Vizient and our stats following those service lines, we’ve seen

huge improvements in their ODE expected.And so, you know, I think it’s a great tool to potentially partner specific people, like Kristen said.I will tag onto her comment that these reviews, they do take longer, right?So as leaders and managers, we need to be understanding in our expectations that these mortality reviews or these HAC-DSI reviews, they just take longer to get them right, so yeah.Deb: Thank you..So anyhow, I’ll move on to my final question, because I’m just like glanced at the clock and it’s

almost a quarter after, so we have to leave some time for questions.This went much faster than I thought it would.Just my final question really is, how do you measure success?So what types of things are you looking at as far as outcomes?Traditionally, we looked at CCC, MCC, MCC-capture rate.Oh, by the way, full transparency, I had a nurse moment around 3 a.m. when I woke up out of the blue and thought, oh my God, I forgot to put CMI on that slide.And then I fell back to sleep because it wasn’t like a patient was dying or something in the old

Days. Anyhow, what are the things that you’re looking at now measuring maybe differently than you would have measured them in the past?Lena?Lena: All right.I would say kind of to summarize everything I already said earlier, you can’t really, you can’t boil

the ocean.So, you know, I’d recommend just starting, finding a few key topics to start with, look for things that overlap, kind of that biggest bang for your buck.So making sure that you’re optimizing the workflow that you have. Also, look at the pocket

guide.There are a lot of conditions that are in the pocket guide that are going to impact from a quality perspective, whether it be Vizient, whether it be ElixHouser, even HCCs as well.So, I mean, definitely take look at those tools that we have and those resources.

Again, leveraging your EMR, anything to help kind of spread that workload off of your staff and

kind of spread it, push it up forward to the providers real time, I think are all good things.And just as you master a topic, move on, find something else that you might identify as a gap,

and then try not to tackle everything at once, but just work on a few things at a time.Deb:And then from the three of you, any tips, tricks?

I know Lena just offered a few, but any last-minute advice for CDI teams before we open it up to

questions?Christine?

Chrsitne:I have one area.You know, I think we push so hard to document better and do better and do more and ask that of the team members that we work with, so physicians, APPs, or even dietitians.And I think sometimes you have to give pause to see, look instead at what are some of the

Barriers? You know, maybe what is some of the friction that’s occurring out there, and how could we look at it differently?So real quick, in a recent example, we really have been working over the last couple years with

our dietary team in looking at what are their barriers to success for our clinical nutrition staff.And what we realized is they’re not able to always get to all of their consults, and if they are,

sometimes they’re not able at some of our locations to always go and do an in-person assessment.And that takes time to figure that out, and we’ve actually helped to help drive in CDI some

business cases to help bring this forth.This is going to, you can’t always keep saying document better, do more if you don’t have the

right approach on the other end.And so through our lens, we’ve been able to help build some business cases for and on behalf of

the clinical nutrition team.Really important to get those dietitians in the room and do a physical exam, as many of you are

very well aware. So look, look elsewhere, look at what the barriers are.Deb:

That’s just a great example, because it kind of just like brings everything full circle of how, you

know, our work really just impacts the organization in ways that go way beyond what we, you

know, naturally think off the top of our heads.Aimee, anything to add?Aimee: Yeah, I actually, to tag onto Christine, I actually think in addition to not just focusing on the

barriers and what we can’t do, to focus on what we do do great, and recognition I think goes a

long way.Part of why I love the Brigham team is because there is a very positive, supportive team.And recently at a CMO meeting, CDI was applauded for our work in mortality in the ODE

index.And I think the staff love that.They respond to that, right?So I think just recognizing how hard that they’re working each day for all of these different

measures and to see that upper management is noticing and appreciating their efforts I think goes a long way.Deb:I love that because for so long I think probably across the country CDI coding very much under the radar just doing our thing minding our own business and it’s just been in the last I don’t know. I feel like six or seven years or maybe a little bit less or more depending where you are that CDI has kind of come out of the shadows a bit and we’re starting to get recognized more for the impact that we have.Aimee: Just to add to that I mean we have a vested interest in the success as well so I mean even though we’re behind the scenes even though you know we we might be sitting in our homes or in an office and you know kind of in the basement in a hospital or something we still have a best

interest in the success of our organizations and our quality outcomes.Deb: Yep, absolutely.Thank you guys so much.This has been so much fun. I can’t believe how fast it’s gone.We have 13 minutes.So Linnea, any questions?Linnea: We do have questions already, which is exciting.Thank you all for the excellent discussion today.I always enjoy listening to all of you.I actually know all of the panelists this time prior to this, which is always exciting for me.This does bring us to the Q &A portion of the program.So if you have questions for our panelists, click on the Q &A widget in the GoToWebinar

platform.Your question will remain anonymous and it will not be viewable to other audience members.And we did have a few come in as you all were chatting.So I will just jump right in.Our first question is, do you measure impact separately for quality reviews versus your typical or

more traditional inpatient CDI reviews.Aimee: We do not.So we don’t separate it.We have started doing that for our second level reviews and our HAC PSIs.Previously, it was all in one bucket, but I think as teens delineate, it will be important to capture

them separately.Linnea: Lena, anything different?Lena:No, we lump all of ours together, so.Linnea: And Christine, same?Christine: Yeah, we do not separate it out.Deb:I know at one time, I’ll just add a little flavor, at Brigham, when I was leading the team, there

was a period of time where we would just measure queries that impacted reimbursement

compared to queries that impacted quality, and we used that kind of very loosely, so it was kind

of like, if it didn’t impact finance, then we assumed that there was some quality impact.And it was remarkable of the ratio where we would see that the queries that were for quality

were much, much higher in volume than queries that impacted our reimbursement.Linnea: Awesome, thank you all.The next question asks if any of you are covering outpatient CDI at all and if you’re involved in

the quality reviews for that space as well.I know.Christine:I think it depends on the definition of outpatient.We do not cover any outpatient hospital departments, such as charging capture or outpatient

ambulatory surgeries, but we do cover what we consider ambulatory CDI, focusing on HCC

capture and RAS score.Linnea: Christine, is that primarily like in the primary care space?Christine: Correct.Primary care and then expanding into specialties as well, so cardiology, oncology. We’ve grown our practice there as well.Linnea: And then, so I think that the question was, are you measuring, are you doing anything to measure quality for that?So I’m thinking specifically like out of quality or outpatient ambulatory outcome measures.

Is there anything that your CDI program is involved with from that aspect or is it primarily

focused on RAF?Christine: Primarily focused on RAF, although we’re very much partnered up with our ambulatory quality team in helping to measure and look at some the things that they’re looking at there.And also areas of exclusion.

And so that part is just building up, I would say for us this next year.Linnea:Great, well, we might wanna revisit and hear more about the ambulatory CDI program.

Always things we can come back to, right? And especially in the outpatient space, I feel like it’ll change so much and the next couple of years over the next year, just because of the nature of how fast it’s evolving that we could have the conversation all over again.Awesome, thank you all.

Our next question also kind of gets at the metric conversation. Someone is asking what the KPIs are that you’re using specifically for your teams.I can go first.Lena: So like I mentioned earlier, we’re looking at the expected value for So, when we look at length of stay and mortality, so that’s an overarching goal.When we’re getting down to looking at query volumes, are we sending a higher volume of

particular queries, and then that’s, I can’t remember if Christine said it or Aimee said it earlier,

that’s where you’re looking to maybe provide education back out to certain individuals or certain

service lines on particular queries, just so you can address those, maybe bring those down or find other opportunities to address that proactively so CDI isn’t involved.So, but mainly that the expected and then also looking at the capture of the different conditions

that we’re looking at.Christine: The same as Lena, our main focus is O to E mortality and raising the expected.Yeah, I’d also add that I’m a big fan of using that expected mortality as an outcome measure.And it’s, you know, when you think about the O over E and what we can impact, obviously, we’re

not, as CDI nurses, city health offices, impacting the observed in any way, but we can certainly

really impact the expected.And I think that’s where, you know, when I started this conversation, I thought, like, what do I

get excited about?Like, it’s, like, being able to that expected move is pretty pretty impactful.

We know that we’re really representing the acuity of our patients appropriately.Linnea: Awesome. Thank you all.

This next question is specifically for Christine in relation to the specialty teams.

So this person asks whether you separate or assign the workflow by certain diagnoses or DRGs

or based on geographical location.Christine: Yes.So, our nurses across the system are locally deployed to their different hospitals and our clinics.So, our ambulatory CDI nurse teams are assigned specific clinics, so they build a relationship there.But within the inpatient setting, while they’re locally deployed, we also further distribute by

Specialty. And so they’re someone assigned to the thoracic team or to the MICU or to our cardiac surgery team.So we do it specialty-based throughout our program.Linnea: Awesome, thank you for that.Our next question, let me see here, is about social determinants of health.So this person is asking if you can share some examples of SDOH that you’re capturing specifically for quality purposes?Lena: Well, obviously the homelessness codes have changed.They’ve been now upgraded to CCs.It appears that they’re going to expand out that whole Z-59 code category to allow all of those to

be CCs.But outside of that, I mean, we’re really looking at anything that’s going to be applicable for the patient.There are several, when back to the vizient shops, there are several CATIC risk variables that are specifically related to SDOH code.So we just wanna make sure that if they are appropriate for the patients that we are actually

capturing those.So we do get that complexity there in the documentation.CATIC also has recently put out like a social determinant of health wheel that the nurses fill out llike on admission. And a lot of times you can capture diagnoses from there.So like homelessness, lack of ability to pay for medication, lack of support, there’s a whole

wealth of them.And language barrier is a really heavy hitter as well.Linnea: Awesome, thank you all. And we are just about at time here, so that is all the time we have for questions today.But thank you all so much for answering those on the fly.

I know you never know what you’re gonna get with Q &A, so thank you all for being gracious

with your expertise today.As I mentioned in the introduction for today’s program, this webinar is approved for one ACDIS

Continuing Education credit, but only for those of you who attend our program today, June 25th,

2024.To obtain the certificate for today’s program, simply click on the link that will be included in

your post webinar email that will go out within the next 24 hours. Be on the lookout for that.It will have information about the on-demand recording as well as the link to that evaluation.And finally, I would just like to thank our audience for participating today and of course to

Tendo for sponsoring the program and to our speakers for sharing their expertise.We hope that and will join us for a future program, and this will conclude our presentation today.So I hope you all have a wonderful day. Thank you.