How CDI Programs Contribute To Waste In Healthcare
There is no doubt that healthcare is rife with waste: Processes that do not directly contribute to patient care and outcomes and that interfere with our work, can be, according to LEAN principles, considered waste.
Depending on who you speak to, one can make the argument that the CDI function interferes with a physician’s workflow, and hence, can be considered “waste”. I am hoping that if you are reading this blog post, you already have a firm understanding of how CDI contributes to patient outcomes and quality data, hence making it a necessity (in the absence more efficient alternatives).
While this short post is by no means written to give you a crash course in LEAN principles and its implementation in healthcare, it is worth noting from Mark Graban’s book ‘LEAN Hospitals’ where he writes: “Lean is about improving quality and productivity. Lean is also about fixing problems permanently instead of hiding them or working around them.”
Identifying waste in CDI can take on many forms, ranging from CDS workflow processes to how a physician answers a query. I do believe that there is one approach that is widely adopted by many organizations that contributes to significant waste in the CDI function.
An All Too Familiar Scenario
An organization has had a CDI program in place for a long time and, despite this, the CFO is approached by vendors in the industry who claim that, based on their data, there is still significant room for improvement in clinical documentation. Depending on the CFO, they may ignore the claim, or might decide to dig a little deeper. The vendor, usually a consulting firm, goes to work on analyzing data and possibly conducting chart review to identify if anything is being “left on the table”. Lo and behold, they do identify opportunities, despite the organization having a robust program in place for many years.
This is perceived as the CDI program not being able to pick up these opportunities on the front end, and then a viable solution could be to re-evaluate staff, or even increase the number of eyes on the charts. While it is true that it is important for our documentation specialists to be competent and for the program to be adequately staffed, I believe that many of the opportunities could be picked up very economically if the program’s focus shifted just a bit to the physician’s role in those missed opportunities.
If you follow my posts, you know by now that one of my pet peeves is the fact that we end up submitting the same queries to the same physicians on the same diagnoses month in and month out. While I never expect our physicians to become subject matter experts in CDI, the role of CDI in healthcare behooves us to, at least, get familiar with what is required to accurately and compliantly document commonly encountered diagnoses.
Case in point: The number one query for many organizations is still for the acuity of heart failure.
In the meantime, the CDS queries until a shift in the DRG is noted and then moves on, unable to capture the full extent of the patient diagnoses in that chart, which may be some of the “missed opportunities” identified initially. CDSs are acutely aware of avoiding “query fatigue”, especially when their performance is sometimes measured by query response rates.
How The Solution Contributes To Waste
To solve the issue, organizations sometimes believe that having more eyes on the charts is an attractive solution and increases staffing levels, along with CDS training and education. As mentioned earlier, having these two areas covered is crucial to a high-functioning CDI program, but completely ignoring the physician component is what contributes to waste in CDI.
More eyes on charts very often means more queries generated on common diagnoses, with no learned behavior on the part of the physician. This approach, where the physician component is ignored, stymies the contributions of the competent CDS and has them functioning at a level where they just have to meet a quota – a frustrating situation at best!
This is also, by no means, fixing the problem permanently, according to LEAN principles. I believe that creating an environment where the physicians have started to rely on the program as a crutch rather than as a safety net is an environment that contributes to waste in healthcare. Ironically, the more competent the CDI function, the more likely the physicians may use them as a crutch.
The fix is simple, but not necessarily easy. Historically, we have protected physicians from the thought of having them change their documentation behavior and patterns on even a few diagnoses, but I am advocating for a shift in the industry.
In the end, it all comes down to accountability: Holding physicians accountable to clinical leadership. It is something worth taking on if you want to change the documentation culture of your organization.
“Lean thinking is lean, because it provides a way to do more and more with less and less – less human effort, less equipment, less time and less space…”
– From ‘Lean Thinking’ by James P. Womack and Daniel T. Jones