Discover why clinical documentation improvement is a behavioural change process that requires a scientific approach.
If you’re thinking about implementing a clinical documentation improvement (CDI) program at your hospital or health service, it’s essential to adopt a scientific approach grounded in evidence-based behaviour change strategies.
Successfully implementing a CDI program involves changing entrenched habits in systems that, historically, don’t adopt change easily.
Changing human behaviours is a difficult process and, without a holistic scientific approach, behaviour change attempts typically don’t work.
Many hospitals attempting CDI for the first time don’t treat the process like a science.
Over the years, researchers have developed numerous models for effective behavioural change. However, there are several core elements that are consistent themes across all of these models:
Applying these evidence-based elements to your CDI program will give you the best chance of implementing a process that works now and into the future.
CDI is a journey, not a one-time event
At CDIA, we’ve partnered with many hospitals who have previously attempted one-off CDI strategies that haven’t resulted in the desired long-term success.
Some have understood the motivation for change within their organisation, but many have lacked the friction-reducing strategies, reinforcement, and organisational commitment to change required for long-term success.
Others have reasoned that it may be easier to change the minds of the junior doctors than the senior clinicians. However, as a result, the organisational commitment to change is lacking.
Some hospitals have used retrospective queries as a means of improving documentation. The challenge with this approach is that retrospective queries are often completed months after the patient has left the hospital. This means that while retrospective documentation queries may be useful for enhancing data integrity and hospital sustainability, retrospective queries have little to no meaning for the patient.
It’s common for hospitals to think of CDI as a one-off initiative with a distinct endpoint. But one-off attempts don’t work because they don’t have the following core elements of a robust holistic behavioural change program.
Step 1: Communicate the reason for change to get people on board
To effectively changed an entrenched habit, people need to understand the size and nature of the problem. Many clinicians – despite being experts in their fields and working in various hospital systems for decades – often don’t understand the reason for CDI.
Perhaps they have been told they need to write more, or that they aren’t capturing correct data – but they don’t understand the nature of the problem and how it relates to:
For clinicians to want to adopt and embrace CDI, they need to understand the ‘why’ behind the program.
Step 2: Develop friction-reducing strategies to make the change process easier
Friction-reducing strategies are essential to effective behavioural change as they make the change process smoother.
In CDI, a friction-reducing strategy could be to ensure CDI education is provided to all clinicians working within the hospital during program implementation. Identifying key stakeholders including clinical managers and medical advisory committee members for focused education on CDI can also reduce friction.
On the other hand, being told to “write more” is not a friction-reducing strategy, because it doesn’t make life easier for a busy clinician who works long hours and struggles to make it home for dinner with his/her family. The primary focus of a CDI program is to improve the quality of clinical documentation, not to simply increase the volume of it.
Step 3: Reinforce the message
Reinforcement is an essential aspect of behavioural change because humans depend on support for change. In many hospitals, the CDI message is not reinforced to clinicians which can undermine the program’s success, even if they have initially understood the reason for change and have good friction-reducing strategies.
If the message is not reinforced, it is difficult to sustain long-term change. CDI is a journey, not an event. In hospitals around Australia, a lack of reinforcement is the single critical step often hindering effective organisational change.
The reinforcement stage is where the role of the clinical documentation specialist (CDS) comes into play, as they are the central person responsible for reinforcing the CDI message. The hospital needs to invest in people who can ensure that change is occurring in their facility.
Momentum
With the first three elements in place, change starts to occur and bring momentum. You’ll notice a networking-style effect, where clinicians and key stakeholders change their behaviours as they see others changing. By this point, you have overcome the initial inertia and are experiencing self-propagating change.
Step 4: Organisational commitment
Even when change has begun to occur, organisations require an ongoing commitment to the CDI program.
Once the ball is rolling, it’s important to maintain velocity and momentum so your hospital can get to a stage of consolidation, where change is sustainable and entrenched.
Fostering a symbiotic relationship between your CDS and HIM and creating a CDI steering committee are two important steps that will help you achieve organisational commitment.
The final word
Throughout history, medicine has continued to change and evolve. Looking back, it’s clear that change is possible. Practices that were once widely accepted are now not. There was once a time when doctors smoked in operating theatres and handwashing was not common practice.
In the future, we may well reflect on this time, at our documentation culture, with similar thoughts and reactions.
Taking a scientific approach to behavioural change is the best way to implement a successful CDI program
At CDIA, our Pursuit Program adopts an evidence-based approach to behavioural change which is one of the reasons why it delivers consistent results around Australia.
Find out more about how we can help your hospital begin the change process here.
We invite you to share your ideas, experiences, and achievements in CDI by submitting content to the CDIA Community! Contact community@cdia.com.au to learn more.