Clinical Documentation Improvement (CDI) has grown into an important part of both the public and private healthcare system. Over the past several years, I’ve had the opportunity to work as a Clinical Documentation Specialist (CDS) in hospitals in each of these systems. The benefit provided by CDI to public and private hospitals are the same – better documentation leading to better communication, data, and appropriate renumeration – however the day-to-day realities of working as a CDS in these systems can look quite different. In this article I’ll explore my experience navigating each of these systems and reflect on how CDI work changes and stays the same in each setting.
Common Ground: What Stays the Same
CDI fundamentals
The fundamental tenants of CDI work stay the same regardless of the system. Clear communication for patient safety, data integrity and accuracy, and appropriate renumeration remain guiding principles of the work. As we all know, better documentation leads to better communication between clinicians, and this is essential to providing safe and quality patient care. Between public and private services this remains the most powerful argument for CDI work, especially when engaging clinicians. Clinicians care about the quality of care their patients receive whether they're salaried employees of a state health department or private practitioners with admitting rights.
Whether public or private, hospital data is collected from patient documentation in largely the same way. While the ICD-10-AM editions that a hospital uses may be different (in private hospitals, different health funds can use different editions), the impact of documentation accuracy and detail on data collection is identical. The uses for this data are also very similar between public and private organisations – the data is still used for hospital benchmarking, decision making, and for use by external organisations such as government departments and healthcare organisations. Appropriate renumeration is important in both public and private hospitals because, ultimately, both are businesses. This is readily recognised in a private hospital setting, where the commercial nature of healthcare is more explicit. However, where a private hospital is run by a private business and funded by health funds, a public hospital is run by the state government and funded by the federal government. This is easy to forget when working in a public setting, but the importance of financial sustainability to allow for the provision of quality care is equally vital in public as it is in private.
The challenges of our work
While the tenants of our work remain the same, so too do the challenges we face. Time-poor clinicians, a limited awareness and understanding of the importance of CDI, and the need for consistent engagement and education are the same across both settings. This is because both public and private hospitals are complex systems, where the professionals working in them face heavy clinical workloads with ever expanding administrative requirements. This means the bandwidth of the clinicians we are engaging with in both settings is similar, making the challenge of engaging clinicians and providing CDI education similar.
The importance of executive engagement
One similarity that has proven particularly important in my experience is the value of executive engagement. Leadership teams in both public and private hospitals become excited about CDI work once they understand its benefits and potential impact. I have also found significant value engaging with the leadership team in both my public and private hospital roles. I have used the expertise of the finance team to identify under-representation in the complexity of data, collaborated with HIM manages to address areas of documentation which are consistently poor, and have had legitimacy added to the CDI program in the eyes of clinicians through the championing of the program by my unit manager or CEO. The relationship with this team is vitally important regardless of the system you are in.
Where the Systems Diverge
While much of the core components of CDI work remain the same between public and private systems, there are significant differences in the day-to-day realities of the role in these two systems.
The Clinician Employment Model
The structure of medical employment creates one of the most noticeable differences in how CDS work differs between public and private hospitals. In public hospitals, senior doctors are typically salaried employees. This means they're around more consistently, often have offices on-site, and consultants are frequently involved with hospital executive teams. This means they are easier to find on-site, easier to organise a discussion with, and (in my experience) have a better appreciation for the importance of CDI given their closer involvement with the business of the hospital.
Private hospitals clinicians operate quite differently. Private physicians come in to see their patients and then leave, often moving between multiple hospitals and their private rooms. This makes them harder to catch for a conversation and means their roles are less embedded into the business of the hospital. This means relying more heavily on written queries and educational materials. To be clear, I have not found private clinicians any more or less willing to engage than public clinicians – but the model of employment means they have different time constraints, availability, and buy-in.
The Pace and Nature of Change
The way in which change is implemented in a public vs private setting is different, and CDI projects are no exception. The public health systems move slowly but consistently. Making change can require navigating multiple layers of bureaucracy, meaning you can forever be waiting for the right meeting or the right person to sign something off. However, once you understand the system – you know the right forms, you’ve built the right relationships, you know the process – you can move a project forward consistently, albeit at a slower pace that you might like. The private space has felt, to me, faster but less predictable. Change can happen more quickly and generally with less bureaucratic overhead. This is fantastic for smaller changes or initiatives. However, for larger changes you can find yourself struggling to know where to go or who to talk to, and it can feel like the path you need to take is less clear than in public, although it is generally faster once you find it.
Siloing
Finally, public hospitals tend to have distinct departments specialising in different areas of medicine, with separate executive teams, wards, and systems for each. In private, everything is more amalgamated and integrated. While specialist wards exist—such as cardiac or post-operative units—the operational processes are the same and leadership structures are typically hospital-wide rather than department-specific. This is likely a result of public hospitals (at least, the public hospital I worked at) being larger than most private hospitals, requiring separation of services. Still, it has a noticeable impact on the ability to facilitate widescale CDI change. In the public space, I found myself needing to customise my education and engagement to the area in which I was working – new stakeholders needed to be engaged with, and new systems understood. However, in the private setting, the degree of change between areas is far less, and so education or change that worked on one ward or in one area is likely to be similarly effective in another area of the hospital.
Conclusion
As you can see, the setting in which CDI is performed – public or private – changes some practical considerations of the role but does not change what CDS do at our core – improve documentation for communication, data integrity, and appropriate renumeration. The knowledge and experience of CDSs is well utilised in both public and private hospitals. If you are considering taking the leap from public to private, or vice versa, I hope this article has demonstrated that while there are differences to be negotiated, they are not insurmountable. You will be better equipped for the role.