1. Believe it or not…… CDI metrics tell the whole story SC ADCIS Sept 5, 2014 Kay Blue, RN, BSN, ACM Director, CDI-Carolinas Healthcare System Charlotte, NC

2. Objectives After this presentation, the participant will be able to: 1. Identify at least 3 metrics for measuring the success of a CDI program 2. Identify 1 factor that can alter or affect change in overall facility CMI 3. Identify 1 critical success factor for optimization of a CDI program

3. Monitoring CDI Program Define the Metrics to measure Define the target population for the measurements (Medicare, All payers, DRG payers) Collect, Track & Trend Data Perform Analysis of the Data Interpreting the Data Share the Data -Management/Administrative Teams - Your own CDI Team Perform trending analysis with Peer Group or Med Par Identify any areas for process improvement

4. Metrics…. It’s what you are missing Beware of vanity metrics. Vanity metrics are metrics that make you feel really good–like everything is working. But in fact, they mean nothing. Data from multiple sources- It’s very important to keep all metrics related to your program in one central database. This makes it easy to analyze and compare your strategic efforts Bottom line Are you getting a ROI? Bang for your buck? Are you measuring the right thing?

5. Importance of Metrics Make everything measurable Don’t report data just to report the #’s Your data should be actionable Good metrics will allow you to drill down and identify your most effective operational strategies.

7. Provide Meaningful Data If Data is meant to drive your CDI program, it must be collected consistently, communicated with all involved, be relevant to everyday practice. Timeliness of data collection, feedback targeted to specific diagnoses, staff, physicians can definitely lead to future success of the CDI program.

8. Program Metrics 1. Staff productivity- # of reviews performed –Initial & Concurrent –DRG impact (how many cases did the CDIS shift the actual DRG?) 2. % of overall cases reviewed 3. Query rate 4. Physician response rate 5. Agreement rate 6. CDI/Coder mismatch rate 7. Financial Impact/Reimbursement 8. SOI/ROM 9. CC/MCC capture 10. LOS 11. CMI- Overall, Medical, Surgical, Service Line

9. Program Benchmarks Average Statistics: 1800-1900 annual discharges per 1 FTE 150-160 monthly discharges per 1 FTE Review rate > 80-90% monthly discharges Overall Query rate (40-50%) Physician Response rate > 90% Physician Agreement rate > 75% (Caution- Is this the actual opinion of the provider or is it driven by demand for query response?)

10. Considerations for Staff Productivity Measure apples to apples: Hours worked, complexity of the cases (ICU vs medical or surgical cases) Hours worked / FT/PT status /PTO/Education Expertise- Years of CDI experience New vs follow-up reviews Quality of reviews (accuracy, completeness) Queries posted (audit for compliance, DRG impact vs SOI/ROM, timing of query)

12. Consistency in the data Actual value of the query Possible/Potential financial impact- Thoughts??? Scenario 1: CDI posts a query for MCC. Physician rounds and documents another diagnosis that = MCC. The CDI query is no longer capturable in the data for financial impact. Granted, it may affect SOI/ROM Scenario 2:CDI posts a concurrent query. MD does not respond. Coding reposts exact same query. Who takes credit for the query impact? CDI or coding.

13. Thoughts for taking credit for Query Productivity: It takes time, effort for CDIS to pose the query content, document the query & submit it. Daily follow up for query response Additional communication & time spent to get the response. Bottom line- CDI did the original work to post the queries, should you get credit for the work you do? Standardization/Consistency in the data collection & reporting of response rates

14. Consistency in the data Query response rates: Agree or Disagree? -Physician responds & provides the desired answer to the query = Agree -Physician responds, but provides another diagnosis /Alternate response = ? Agree or Disagree -Physician responds- Unable to determine = ? Agree or Disagree *** Query Leary: too many queries posted to MD’s, Is the query sound, credible?, MD response just to prevent further communications/messages/queries

15. Calculations Query Rate = # of charts with Queries Total # of Cases Reviewed (In this case, multiple queries on a record does not increase Query Percentage) Query Rate = Total # of Queries Posted Total # of Cases Reviewed MD response % = # Responses x 100 Total # Queries Agreement % =# Agrees Total # Queries

17. Is CDI only for financial impact? It is true, we must see a ROI for the CDI program –Justifies FTE’s –Justifies the importance of the actual work you do –Does the work performed in record reviews equate to effectiveness & quality or only dollars? On the Other Hand True value & Importance of CDI program –Actual documentation improvement benefits quality and reporting statistics and supports the integrity of the medical record –“Getting credit for the care that is delivered & the utilization of resources provided “ –

18. Looking beyond the revenue Compliance- doing the right thing regardless of the financial impact (positive or negative) Assignment of the most appropriate PDX, DRG for accuracy in coding LOS goals- Observed to expected Affects Quality reporting VBP (reward for excellence based on quality measures/performance)

19. CHF Documentation Excellence DRGMD DocumentationGLOSRelative Weight Documentation293Acute CHF exacerbation, arrhythmia and shortness of breath 2.2 Days0.6756 Increased Acuity & Accuracy of Clinical Findings 292Acute Systolic CHF, A-flutter and hypoxemia 3.8 Days1.0214 Increased Specificity 291Acute Systolic CHF, Acute Respiratory Failure 4.7 Days1.510

20. Tracking/Monitoring SOI/ROM No financial impact or reimbursement. With Healthcare Reform, Quality Indicators, Value Base Purchasing, & Bundled payment initiatives constantly in the forefront for performance measures, it is important for complete & accurate documentation to reflect the true clinical picture of the patient’s condition

21. Mortality Index Scores Additional Co-morbid conditions added as secondary diagnoses will increase the ROM, showing that the patient has a higher probability of dying The expected mortality rate is a calculation grouped by DRG including the principal diagnosis, all of their secondary diagnoses/co-morbidities, procedures along with adjustments factored in based on age, race, & gender. A score of 1.0 = hospital survival rate is expected in relation to the patient’s SOI/injuries A score < 1.0 & lower means that the hospital is providing top quality care in a safe manner with less expected risk of mortality

22. Overall CMI change as performance metric?? It is true that change to CMI can be a direct reflection of the CDI program. However….. Consider volume/census changes Increase or decrease in surgical volumes Has anyone seen their CMI decrease due to increase in lower relative weight DRGs traditionally OBS cases now being IP cases based on the 2 midnight rule? Be careful when measuring facilities against each other for CMI (Differ based on services provided, DRG relative weights, medical/surgical mix, blended rates)

23. External factors to monitor PEPPER Report ( comparative data at state & national levels to monitor CC/MCC capture rates for specific DRGs – pair & triplets to identify potential overcoding/undercoding) Quality reports- PSI’s, HAC’s, Complications, Mortality index RAC audits, other payers Hospital compare reports Physician Profiles Revenue cycle for the organization Denials management

25. Internal monitoring of additional elements for success Top Conditions/Diagnoses that require the most additional or specific documentation Top physicians queried Patient care specialties that are most often queried ( ex: cardiology, general surgery, etc.) Employee & Physician engagement/ Buy in CDI Education provided to medical staff Documentation changes/trends/ decrease in queries for a specific diagnosis as a direct result of the CDI program

26. Key Drivers/Success of CDI program To perform medical record reviews with the focus on capturing the most accurate & complete documentation in the medical record to assist with the most appropriate DRG assignment. Goal is to reflect the severity of illness with the highest level of specificity to provide a snapshot of the quality of care delivered Once you have these two drivers met…… the revenue component will follow.

27. Critical Factors for Success Do you have an engaged medical staff who understand the importance of the CDI program? Is the overall organization focused on meeting quality initiatives and LOS goals? Do you have the right CDI players? Do you have goals/targets set? Have the goals been communicated? Use data to identify opportunities for improvement

28. The Message Excellence in clinical documentation will improve performance in multiple areas: -Communication -Capture of SOI- all the comorbid conditions which require ongoing treatment -Validation of the quality of care provided -Compliance with quality/safety -Get credit for the care that is delivered - Benefits physician & hospital profiling - Promotes accurate coding practices

29. References AHIMA: American Health Information Management Association, http://www.ahima.orghttp://www.ahima.org ACDIS: Association of Cinical Documentation Improvement Specialists, http://www.hcpro.com/ACDIS/http://www.hcpro.com/ACDIS/ CCDS Exam Study Guide, Fran Jurcak; 2012 3M & JA Thomas Guides for Program Success

30. Questions????