A group of cardiac surgeons were looking for ways to improve their Society of Thoracic Surgeons (STS) rating from a two-star facility to a three-star. They were delivering excellent care, their patients were recovering quickly without readmission, and by all accounts, their care was reflective of the standards by which the STS holds three-star facilities. So, what was holding them back from achieving this level of success and reaping the rewards of a glowing reputation?

To help them understand their clinical data and find the solutions they needed, they turned to Sarah Devereaux, a Senior Manager of Client Operations at Q-Centrix, and her dedicated team of clinical data experts. What they discovered was that the facility’s struggles had nothing to do with the quality of care, but rather discrepancies in their clinical documentation.

“We looked at the facility’s fallouts for prolonged ventilation and realized that while their surgeons were extubating patients within the appropriate time frame following surgery, the care team just wasn’t documenting those times appropriately which made it appear that their patients were staying intubated longer than medically necessary. We worked with the respiratory team, the physicians, and the surgical P.A.s to help them find a way to report their data more accurately. Ultimately, we helped create a template they could scan directly into their EMR, making the process as standardized as possible. Within six months, and before the next STS national submission deadline, we were able to change their rating just by improving the way they documented this clinical data.”

This type of story isn’t something hospitals typically relate to clinical documentation improvement work, but it’s just the beginning of what’s possible when clinical documentation is prioritized. 

What is clinical documentation improvement?  

“We’re only as good as the data we collect.”

The above quote from Sarah underscores a key idea when understanding the importance of clinical documentation improvement.  

CDI refers to the practice of ensuring any documentation collected in medical records is complete and accurate. It involves a collaborative effort between healthcare providers, CDI specialists, and coding professionals to ensure the recorded data adequately captures and reflects the patient’s condition, the services provided, and the healthcare outcomes.  

As we saw in the example above, these data are the only tool hospitals have to understand the quality of their care across departments, where improvements can be made, and to ensure they are meeting the requirements needed for accreditations and CMS reimbursements. 

In this way, skilled clinical data experts supporting documentation improvement efforts go beyond the important function of ensuring the integrity and completeness of medical records. They’re doing the work necessary to: 

Improve patient outcomes 

Clear documentation enables providers to have an unimpeded understanding of the patient’s condition, history, and needs, facilitating better coordination of care and reducing the risk of medical errors. Arguably, the most important goal of CDI is to improve care giving.  

Increase physician trust and engagement with their data 

Thorough and precise documentation gives physicians more confidence in the accuracy and completeness of the data at their disposal, facilitating their reliance on data to inform targeted, personalized care decisions. CDI empowers physicians by providing them with reliable and trustworthy data, fostering a sense of ownership and accountability for their data and increased trust in the entire documentation process. 

Enhance reputations and communication 

Accurate and comprehensive documentation reflects the organization’s commitment to quality care and patient safety. When healthcare organizations prioritize CDI, it demonstrates their dedication to maintaining high standards and adhering to regulatory requirements.  

Clear and detailed documentation also facilitates effective communication among healthcare teams, ensuring that crucial information is accurately conveyed, shared, and understood. Improved documentation allows for seamless transitions of care and enhances interdisciplinary collaboration, fostering better coordination and continuity of care.  

Enable comprehensive data analysis 

With reliable and comprehensive clinical data, healthcare organizations can conduct meaningful research, drive quality initiatives, and identify opportunities for optimizing care delivery. CDI establishes the necessary data integrity and consistency, enabling healthcare organizations to harness the power of data analysis to improve patient care and outcomes. 

Support positive financial impact through appropriate reimbursements 

By providing a comprehensive and accurate picture of the patient’s clinical story, CDI facilitates appropriate coding and billing. Proper documentation enables healthcare organizations to accurately reflect the complexity and acuity of patient cases, which in turn leads to proper reimbursement for services provided. CDI helps mitigate the risk of under-coding or incomplete documentation, which can result in missed revenue opportunities. Moreover, by improving the accuracy of clinical documentation, healthcare organizations can minimize claim denials and audits, reducing the administrative burden and associated costs. 

As reimbursements for registry participation continue to develop across service lines, the significance of these clinical documentation improvement benefits cannot be overstated.

The growing desire for high-quality data and registry participation 

Sarah has witnessed significant changes in the importance of clinical data reporting and registry participation throughout her career. Recently, she’s witnessed a growing desire for high-quality data and registry involvement, particularly due to the increasing number of reimbursement-related programs implemented by registries each year.  

Many physicians initially participate in registries for reimbursement purposes, but they soon recognize the potential of this data to enhance patient care and, as a result, increase their engagement in that data. Sarah emphasizes the critical role of documentation in registry participation, stating,  

“Whichever side of participation you are on, the documentation has got to be there, or you don’t get anything out of it.”

Amidst the current financial challenges faced by hospitals, the benefits of registry participation and the effort required to unlock this value have become even more vital. Sarah notes that historically, vascular registries have had lower rates of engagement compared to nationally mandated and publicly reported cardiac options. However, anticipation of CMS (Centers for Medicare and Medicaid Services) creating reimbursement systems for vascular sites has driven more attention to these areas and pushed more facilities to step up their participation.  

“By mid 2024, I’m willing to bet we will see many more vascular hospitals wanting to participate at a high level. In time, we may see registries for other service lines follow suit.”

How does the improvement process work? 

Sarah’s team at Q-Centrix collaborates with hospitals nationwide, engaging in various case types to improve clinical documentation. Their process involves collecting data obtained from the hospital’s electronic medical records and submitting it to national registries on their behalf. Once the data is aggregated and analyzed by managers, comprehensive reports are shared with the facilities. The objective is to foster meaningful conversations about enhancing documentation practices. 

“The most valuable discussions occur when we’re able to exchange insights with partners. They share their progress, and we pull relevant data to demonstrate the impact of their efforts.”

Together, Sarah’s team and hospital teams address the identified gaps, explore performance trends among physicians, and collaborate on finding solutions. The willingness of facilities to actively engage in these conversations significantly influences the quality of their data.  

While the specific content of these discussions depends on the unique needs of each health system or facility, various topics can be explored. These may include: 

• • Optimizing the structure of the electronic medical record 
  • Addressing instances of missing documentation 
  • Strategies for increasing physician engagement 
  • Exploring vendor tool options and utilization 
  • Identifying opportunities for improved collaboration between the teams at Q-Centrix and the facility. 

“Ultimately, our purpose for having these tailored discussions is to empower our partners in achieving improved data quality and enhancing the overall value they receive from a collaboration with our team.”

Who does clinical documentation improvement work? 

With the right training and support, individuals from various backgrounds can excel in clinical documentation improvement work. The Q-Centrix Institute has achieved remarkable success in nurturing and harnessing a diverse talent pool, resulting in the production of a substantial number of highly skilled clinical professionals. However, there are several key players in the documentation improvement process.  

Dedicated clinical documentation specialists collaborate with physicians and other providers to clarify documentation queries, address gaps, and improve the overall quality and integrity of clinical data.  

Medical coders provide in-depth knowledge of coding systems, ensuring accurate coding for reimbursement, research, and data analysis purposes.  

Health information management professionals oversee the organization and retrieval of medical records and health information, ensuring compliance with regulatory requirements, privacy laws, and data security measures.  

Lastly, physician champions, often specialists or subject matter experts, play a crucial role in driving CDI initiatives. They actively engage in improving documentation practices, educate fellow physicians, and serve as advocates for accurate and detailed documentation. Physician champions bridge the gap between CDI specialists and clinical staff, fostering a culture of collaboration and continuous improvement.  

What are the challenges with clinical documentation improvement? 

Engaging physicians 

One of the main challenges in clinical documentation improvement (CDI) is getting physicians actively engaged in the process. However, finding a single champion within the physician community can be a catalyst for success. This champion serves as a role model and advocate for the benefits of accurate documentation. Once the positive impact of CDI is demonstrated through the champion’s involvement, it often sparks a domino effect, encouraging other physicians to join the movement.  

Time and resources to leverage the data 

Another key challenge is a lack of sufficient time and resources to devote to the task of CDI. The demands of providing patient care and managing day-to-day operations often leave limited capacity for in-depth data analysis and utilization.  

However, partnering with organizations like Q-Centrix can alleviate this burden by providing hospitals with the necessary data and information to drive impactful work. Collaborating with a dedicated team is akin to having an additional workforce focused on data management and analysis, ready to adapt to the hospital’s specific needs. This partnership allows hospitals to leverage the expertise and resources of external professionals, relieving the strain on internal teams and enabling them to maximize the value derived from their data. 

Challenging preconceptions

Shifting mindsets from a focus on checking data collection off the to-do list, to a broader perspective of continuous improvement is a significant challenge in healthcare. Heightened competition and more discerning patients willing to travel for care demands a change in approach.  

Embracing a mindset centered on improvement opens doors to unexplored possibilities and enables healthcare organizations to naturally become more competitive. By prioritizing the enhancement of patient care, hospitals can differentiate themselves and build a reputation for providing exceptional services. As the focus shifts towards consistently improving care outcomes, patients themselves begin to recognize the commitment to excellence, fostering trust and loyalty. This transformation in mindset not only propels healthcare organizations to higher levels of performance but also serves the greater purpose of advancing patient care and well-being. 

How to prioritize your clinical documentation improvement efforts 

A fantastic way to prioritize clinical documentation improvement efforts most effectively is to conduct an enterprise assessment. An assessment provides hospitals with valuable insights into identifying the individuals and programs within their team best suited to leverage and maximize the potential impact of CDI initiatives. By evaluating factors such as engagement levels, expertise, and data utilization preferences, hospitals can strategically allocate resources for optimal return on investment.  

Prioritizing efforts based on this assessment ensures that the highest-skilled and most engaged members of the team are empowered to deliver the highest quality of data. This approach not only fosters buy-in and success within specific registries, but also extends its benefits across the entire health system or facility. The resulting positive outcomes serve as compelling evidence that encourages other surgeons and stakeholders to join the CDI efforts. 

Connecting the dots between participation, reimbursement, and better outcomes 

Clinical documentation improvement programs play a pivotal role in connecting the dots between registry participation and improved care for healthcare facilities. While some hospitals may initially engage in registry work solely for reimbursement or to fulfill mandated reporting requirements, CDI goes beyond these motivations to yield compelling best practices everyone across the hospital or system can use.  

The relationship between data integrity, utilization, and clinical documentation improvement is inseparable. As Sarah emphasizes,  

“The goal and fundamental reason for all these efforts is to improve the standard of care delivered to patients. We do this work because the better the documentation, the better the data. The better the data, the better the standards. Those standards and best practices are what help every hospital across the nation improve the quality of health care delivered to the people they serve.”