CDI and Quality Improvement

Quality metrics and measurements are a crucial and prominent feature of CDI work. Because claims data is increasingly used to determine performance metrics on quality measures, and because the clinical criteria for the inclusion or exclusion of a given patient are determined by the accuracy of the medical documentation, CDI specialists and departments must pay scrupulous attention to quality improvement during reviews.

Facilitating effective collaboration between departments and tracking benchmark information cultivated from databases are also integral aspects of CDI and quality improvement.

In partnership with 3M, the Association of Clinical Documentation Integrity Specialists (ACDIS) CDI Leadership Council asked several of its members to evaluate the results of a nationwide survey exploring the current state of CDI quality reviews, the use of external databases for benchmarking, tracking quality-related impact, reviewing mortalities for risk adjustment and severity of illness (SOI)/risk of mortality (ROM) capture, and collaborating with other departments on quality concerns.

In this industry report, readers get a full inside look at the ways leaders approach quality reviews.

Three biggest talking points:

• According to survey respondents, the top three quality measures reviewed by CDI departments are present on admission (POA) indicators (reviewed by 88.05% of respondents), Patient Safety Indicators (PSI) (77.69%), and hospital-acquired conditions (HAC) (77.29%).

• According to the survey, the top three methods to measure quality-related impact are categorizing types of impact in CDI software (38.25%), manually tracking impact using a spreadsheet (22.71%), and using an external vendor service to track and monitor impact (11.95%). Additionally, 18.33% said they do not track quality-related impact at all.

• The most popular method for collaborating with quality is to have the leadership from each department attend the other’s meetings (74.10%), and the most popular method when collaborating with the coding department and the clinical care team is to collaborate as needed when a concern comes up (65.34% and 43.43%, respectively).