Strong cohesive relationships will significantly enhance the success of your clinical documentation improvement (CDI) program.
Henry Ford's famous quote: “Coming together is the beginning, keeping together is progress, working together is success” epitomises how clinical documentation specialists (CDSs) and health information managers (HIMs) can work together to deliver a successful CDI program.
Coming together is the beginning: Planning
The planning phase is when the CDI team comes together to establish the objectives and philosophy of a CDI program.
If you are developing a CDI program, your objectives are likely to be:
During the planning phase, it is important to ensure the CDS training includes the HIM, clinical coders, any CDS trainees and other key stakeholders. This collaborative approach ensures that the program’s purpose and objectives are clear from the outset.
Making sure staff feel included and part of the process forms a common ground on which effective social and working relationships can be built.
The planning phase is also when you define the roles of the CDS and HIM within the CDI program. Both roles need a clear scope within their position description, as both exercise a unique set of interrelated skill sets.
For the planning stage to be effective, each position must work to their strengths while understanding and respecting their work scope and boundaries.
Keeping together is progress: Implementation
The implementation phase is the mutual commitment phase. At this stage, you have established the CDI team, and the key stakeholders are coming together for a common purpose. The point of this stage is to sustain the program’s momentum and fuel the high-level team performance.
Organising hospital-wide clinician education sessions that include coders and HIMs provide an opportunity to lift the profile of HIMs and coding team.
During this phase, the HIM and CDS continue to support each other.
The HIM supports the CDS’ education and development by providing coding advice and updates, informing about contract rules and documentation requirements, and helping to improve classification and data integrity.
The HIM can also help identify common conditions poorly documented or deficient in detail and address structure and content of documentation queries.
Conversely, the CDS has the clinical expertise and clinician engagement experience to facilitate effective clinical discussions that encourage behavioural change and keep key stakeholders on board with the program.
Working together is success: Post Implementation & Development - Sustained CDI
After you have implemented your CDI program, and conducted training and hospital wide education, the program is on the way to becoming a sustainable, embedded practice.
Working together requires various levels of communication that, when facilitated properly, produce forward action and positive results. Developing more effective communication begins with the idea of “one.” Shared contribution is the art of working as one – and that one is the vision of CDI.
To enhance collaboration in the future, you will need regular joint meetings and combined education opportunities in both clinical education and coding.
Don’t forget feedback
Feedback is essential to the success of any program, and CDI is no exception.
Feedback from the HIM and coding team to the CDS(s), when a strong relationship exists, will support more efficient and effective coding. This ultimately improves job satisfaction, employee engagement and CDI program buy-in.
Finally, remember that a disconnect between the two roles will likely lead to poor outcomes of your CDI program.
The disconnect can materialise in different ways, including if:
Effective CDI programs foster a close symbiotic relationship between the HIM and the CDS, who:
CDI is a journey that succeeds when the two roles work together. If you need to develop better relationships between your HIM and CDS, or if you’re looking for more support in your CDI program, contact us today.
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.