Developing a hospital-wide steering committee is a key ingredient of a successful CDI program. This example CDI Steering Committee - Terms of Reference is intended as a guide only and may be adapted as required.
CLINICAL DOCUMENTATION IMPROVEMENT (CDI) PROGRAM STEERING COMMITTEE
- TERMS OF REFERENCE
1. Purpose
The CDI Program Steering Committee is a group of hospital stakeholders who meet regularly to discuss the progress and outcomes of the CDI Program. The success and impact of the program will be assessed and strategies for improving the program identified.
The purpose of the CDI Steering Committee is to:
• Create open discussion on the general progress of the CDI program
• Present data on, and results of, the CDI program
• Discuss CDS KPIs and whether these are being met or need to be adjusted
• Provide a forum to support and encourage the CDSs
• Identify challenges facing the CDSs and create strategies for overcoming them
• Identify threats to the success of the CDI Program and create strategies to prevent their eventuation
• Discuss strategies for delivering clinical documentation education to clinical staff
• Explore mechanisms for engaging with clinicians
• Promote collaboration and feedback from all CDI program stakeholders
• Facilitate partnerships and communication amongst members of the committee to enhance learning and improve the CDI program’s activities and education, and
• Facilitate the development of internal policies.
2. Membership
The CDI Steering Committee will be most valuable when a member(s) of the executive team and a broad range of key stakeholders are involved.
Membership should include:
• Clinical Documentation Specialist(s)
• Executive sponsor
• Clinician champions
• Clinical manager representative
• Health information manager
• Clinical coding representative
• Nurse Educator representative
Suggested additional stakeholders to consider:
• Clinical managers
• Allied Health professionals
• Patient advocate
3. Accountability
The CDI Steering Committee should provide regular updates on the progress of the CDI Program to the Hospital Executive.
4. Frequency and time of meetings
In the first six months following the CDI Program’s introduction, meetings are to be held monthly. After this, they are to be held bimonthly. Additional meetings may be held at the discretion of the committee. Meetings will only be conducted when a quorum is present. To be quorate, the Chair and at least one-half of the members of the Committee must be present.
5. Functions and responsibilities
All CDI Program Steering Committee members are to be active participants in meetings and come prepared with feedback on the CDI program.
The CDS(s) will act as conveners of the meeting. Their role includes:
• Preparing data to be presented to the committee,
• Coordinating attendance, and
• Inviting any additional stakeholders to the meeting to facilitate its business.
The committee can choose to nominate a chairperson. The executive sponsor would be a suitable person for this role.
6. Powers of the committee
The CDI Program Steering Committee can troubleshoot problems in the program, respond to feedback, and identify strategies for improvement. They have the authority to adjust the CDI program as they see fit, with the approval of the executive sponsor. Recommendations for significant changes and expansion of the program must be presented to the executive for approval.
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