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T practice guidelines for managing health information

PRACTICE BRIEF

THE GOAL OF a strong clinical documentation improvement (CDI) program is to validate that the documentation supports the highest level of specificity based on the clinical evidence provided. An effective CDI program begins with proper recruitment, careful selection, and adequate orientation of CDI professionals, whose purpose is to initiate concurrent and/or retrospective reviews of the health record for clear, consistent, complete, precise, reliable, legible, and timely documentation. CDI reviews can occur in both inpatient and outpatient settings and should include the level of documentation necessary to accurately assign the appropriate International Classification of Diseases, tenth edition, Clinical Modification and Procedural Coding System (ICD-10-CM/PCS) and Current Procedural Terminology (CPT) codes.

These efforts result in greater integrity of the documentation, which supports appropriate reimbursement and accurate quality scores. Defining the goals of the CDI program, as well as the pur- pose of the CDI professional’s role within the organization, will assist providers in developing a process that results in the con- sistent hiring of quality staff.

Individuals qualified to serve as a CDI professional include, but are not limited to:

� Health information management (HIM) professionals � Coding professionals � Physicians � Nurses � Other professionals with a clinical and/or coding background

In this diverse population of possible candidates, having an appropriate knowledge base is one piece of the overall process and does not guarantee success. This Practice Brief will provide guidelines for the ideal successful recruitment, selection, and orientation processes for CDI professionals in the development of a sustainable and high-quality CDI program.

Recruitment Best Practices Researchers agree that the best way to recruit top talent is to cre- ate a culture that promotes a positive work environment,1 which leads to greater job satisfaction and employee retention.2 Creating a culture in which staff members are treated with respect and consideration while compensated with a competitive salary and benefits package will help your organization stand out as a place where people want to work. 3 A positive setting, salaries, and benefits are significant components of a job search for new hires so

it’s important to create a workplace where top talent would want to work.4

Managers can seek opportunities to involve CDI profession- als in committees and/or meetings that promote CDI activi- ties and physician education. Another opportunity would be to leverage CDI professionals as contributing writers for the CDI newsletter. Newsletters can be created specifically for CDI topics and dispersed throughout the organization. This helps promote the benefits of having a CDI program and identify the current docu- mentation topics impacting the organization.5 Developing increas- ingly influential roles for existing staff may assist in recruiting for the organization as current staff communicate the value of their own roles within the organization and demonstrate the rewarding nature of the program. Opportunities to learn and grow profession- ally will cascade from current employees to peers who may be seeking to make a job change. These individuals can also add value to the interview process, allowing them to more easily identify applicants who fit the team and who will enhance the selection process.

Finding the right individuals does not end with acknowledging experience. Successful CDI programs also consider cultural com- patibility, leadership skills, effective communication, and intel- lectual ability to excel in a complex healthcare environment. The recruitment process can take several months and should not be rushed or neglected.

Recruitment often goes beyond traditional candidate search- es, job hiring sites, and word-of-mouth recommendations. Fur- thermore, many organizations lack the infrastructure and process- es for recruiting CDI professionals because of a focus on internal talent development. Internal talent development is always a preferred method for growth and development, but it is not the only recruitment option available.

Recruiting Internally There are advantages to recruiting internally—hiring from within the organization. These candidates are already ingrained in the or- ganizational culture and are knowledgeable of the organizational goals and needs as well as the focus of the CDI program. Internal candidates often approach the new positions with positive out- looks and knowledge of how they can make a difference.

When recruiting internally for CDI positions, there are many po- tential candidate streams. Internal candidates can be located with- in the HIM, coding, quality, nursing, or case management de-

Recruitment, Selection, and Orientation for CDI Professionals

Editor’s Note: This Practice Brief supersedes the July 2013 Practice Brief titled “Recruitment, Selection, and Orientation for CDI Specialists.”

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Practice Brief

partments. These candidates often require an additional skill or knowledge development if the CDI position is outside their current scope. For example, if a unit coordinator has completed their asso- ciate-level degree, is credentialed as a registered health informa- tion technician (RHIT), and demonstrates the skills to advance into a CDI position, they still may need additional training on the specifics of CDI.

There are also potential disadvantages to recruiting internal can- didates, including the promotion of organizational cultural com- placency, restricting the candidate pool, perpetuating poor per- formers, and constraining creative ideas.

Recruiting Externally Many organizations utilize external recruitment as a balance to internal recruitment activities. Recruiting external candidates facilitates new ideas and brings fresh candidates into the organiza- tion. It allows the organization to choose from a larger pool of applicants. It also can lead to a more experienced and diverse workforce, and can decrease training costs because the candi- date comes into the organization with the skills and knowledge required for the job with little or no development needed.

For example, if an external candidate holding the registered health information administrator (RHIA), certified coding spe- cialist (CCS), and certified documentation improvement prac- titioner (CDIP) credentials applies for a position in the CDI department, they will come into the organization with specific, required knowledge. For example, a candidate who is a registered nurse (RN) may already hold a CCS credential and have case management experience.

Organizations should also consider the disadvantages of hiring externally, as it is much more of an unknown for the organization. Even with a solid recruitment effort, selection pool, and orienta- tion process, new candidates are still relatively unknown. It can be difficult to identify how they will fit with other staff members and react in certain situations. External candidates—for example, an experienced CDI professional—may find it difficult to adapt to a new process. Adding in questions during the recruitment phase regarding their comfort level with changes can help identify those individuals who may struggle with the program’s struc- ture. Candidate misplacements can cost the organization time and financial resources.

Selecting the Right Employee Prior to selecting employees for new positions, the organization must decide if it is open to recruiting entry-level professionals without CDI experience or if it prefers professionals with little- to-extensive CDI experience. It is also essential to define the for- mat of the program—for example, in-house/onsite reviews vs. offsite/remote reviews. There has been an upward trend in hy- brid programs which are attractive to many candidates and al- low for flexibility, increase employee satisfaction, and increase productivity. Defining these parameters helps filter the candi- date pool and streamlines the hiring process.

CDI is quickly expanding beyond the adult inpatient scope to include outpatient, psychiatry, pediatrics, rehab, and same- day surgeries/ambulatory care. This expansion is leading to the

need for specialized reviews and a mix of CDI staff who can ca- ter to this growing need.

Recruiters often run into issues like information falsification on resumes. When this occurs, the candidate may appear quali- fied on paper but in reality, isn’t able to offer the expertise re- quired to be successful in the CDI role. Recruiting and selecting the right fit for any CDI program requires a careful and thought- ful analysis of each prospective candidate to ensure the candi- date can perform at the level required for the position.

Generally, to be successful in a CDI role, candidates must have the clinical knowledge required to review a health record, the ability to recognize deficiencies or gaps in documentation, and strong critical/analytical thinking skills. Effective communica- tion skills are of the utmost importance as well, because the person in this role needs to be able to confidently converse with providers and other team members. A candidate that possesses these qualities would be ideal for a CDI program.

Optimal candidate selection has the potential to decrease em- ployee turnover. Ultimately, a strong CDI professional can provide a positive influence on the organization’s culture and program effectiveness. In addition, successful selection will save the or- ganization time and money during the orientation and training process.

Throughout the process of hiring a new employee, remember to carefully assess the applicant’s fit with both the team and physi- cians. Utilizing experience and intellectual capabilities alone will not guarantee an appropriate hire. The ability to seamlessly interact with the team and communicate effectively with physicians is a strong in- dication of how well the CDI professional will integrate into the or- ganization. To that end, it is important to ensure that final hiring decisions remain under the hiring manager’s authority.

Candidates that are a good organizational fit may be extremely difficult to find so staying flexible is important when making hir- ing decisions. Still, creating the right culture, maximizing the best workers, and staying involved during the hiring process may not fill every open position. In some instances, the right choice may not be the person with long-term experience, but the person that fits best with the team and culture of the organization. This may mean hiring someone with less experience and committing to pro- viding the necessary training and education to develop the skill set.

Preliminary Selection Selection begins with a preliminary application review and screen- ing interview, which is usually conducted over the phone. This pro- cess eliminates candidates who do not meet the minimum eligibil- ity criteria established by the organization. This process should include a thorough review of the candidate’s application or re- sume, skill set, academic background, certifications, and work history.

Depending on the goals of the CDI program—whether looking to hire trainees or experienced professionals—evaluation of a poten- tial candidate may include identifying healthcare experience, pri- or experience in coding or other related work, and possession of the CDIP/CCDS credential. Establishing these criteria will help narrow down the pool of candidates.

The next step in the selection process may include specific

44 / Journal of AHIMA September 19

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questions that further narrow down the pool of candidates. This may be completed by either human resources staff or the hiring manager. These questions may focus on items such as:

� Gaps in the application: “Can you tell me why the educa- tion section is blank?”

� Additional qualifications: “Do you have any additional certi- fications or qualifications you would like me to know about?”

� Questions about experience: “Your application indicates two years of healthcare experience; can you explain other expe- rience that may be relevant?”

� Adaptability: “How comfortable are you with change? Can you give me an example of a time when you had to learn a new process and how well you adapted to this change?”

Interview Interviews are conducted after candidates have been chosen through the preliminary selection process. Interviews can take place on site or via Skype or other video conference options for candidates who cannot come to the physical location, allowing for flexibility to en- courage prospective hires. The interview format can be a one-on-one discussion with the hiring manager, a team interview, or a combi- nation of the two. The interview process should be defined in a procedure indicating who will be included and which standard questions will be asked. While the interview format and poten- tial questions should provide a foundation to gain information from each candidate, the format should also be flexible, allowing members of the interview team to introduce new questions based on the interviewee’s responses. To create a flexible interview at- mosphere that is most conducive to candidates, it is important to include key stakeholders in the interview process, including:

� Hiring manager � CDI director/manager � Members of the CDI team � Coding professionals � Nursing specialists � Physician advisor

The interview process can be intimidating for candidates so it is important to make an effort to reduce their anxiety. Allow space for the candidate to talk about their personal experienc- es, which can help the hiring manager gauge the candidate in an informal manner. It can also help the interviewer generate questions based on the information offered by the candidate.

It is very important for interviewers to avoid distractions like checking notes to read questions. This approach takes the sponta- neity out of the interview and may create a restrictive atmosphere that doesn’t allow candidates to better express themselves.

Questions can be asked about candidates’ previous CDI expe- rience, with the potential to identify and articulate connections between their experience and the processes in place at the in- terviewer’s organization.

Plan an Organizational Orientation Organizational Orientation To ensure success and sustainability, a successful CDI program requires structure. Organizations should address staffing and

management of the CDI program within the current human re- source dynamics of the organization. A comprehensive depart- ment-specific training program with clear objectives should be incorporated into an overall training program for the CDI pro- fessional. In addition to organizational training, the CDI profes- sional should have a plan for training specifically geared toward educating the CDI professional.

CDI Program Orientation It is important for organizations to ensure CDI staff are “thor- oughly trained in the principles of high-quality clinical docu- mentation as well as the review of patient records to identify possible deficiencies in documentation.”6 A collaborative train- ing session where nurses, doctors, allied health professionals, and seasoned CDI professionals are present is highly recom- mended in order to give the new CDI professional a well-round- ed view of the program.

Training for CDI staff should include three parts:7 � Training in the theory of high-quality clinical documen-

tation � Training in the physician query process � Training on how to collect and analyze data for the pro-

gram

Training in the theory of high-quality clinical documentation Training in the theory of high-quality clinical documentation should include the fundamentals of coding and reimburse- ment, and should cover how high-quality clinical documen- tation affects the reimbursement process. CDI staff should be knowledgeable of current coding guidelines in order to deter- mine if documentation provided in the health record is suf- ficient to appropriately identify the severity of illness and risk of mortality of the patient being treated. The CDI professional should also be trained on the basics of quality indicators and how inadequate documentation can affect the organization’s quality scores.

Diagnosis Related Group (DRG) Training An important aspect of CDI training and education is un- derstanding the impact of severity diagnoses and its relation to Diagnosis Related Groups. Some organizations provide a specific list of diagnoses to be queried by the CDI profes- sional as ongoing initiatives. This list is usually comprised of commonly occurring severity diagnoses—comorbid con- ditions or major comorbid conditions—while other organi- zations educate their associates on query opportunities per major diagnostic categories. The final group of CDI programs educate CDI professionals on DRGs and coding concepts. For further guidance on educating CDI professionals on understanding DRGs and coding guidelines and practices, please refer to Appendix A, included in the online version of this Practice Brief.

Training in the Physician Query Process Training in the physician query process is a critical component of the clinical documentation improvement process. CDI pro-

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fessionals should be trained on appropriate ways to review a health record to identify documentation deficiencies, when a physician query may be needed, and the parameters for con- structing a compliant query. According to Hess, “The record re- view process should include addressing all components of the patient record as possible sources for query opportunities.”8

In general, physician queries should be constructed to clarify conflicting, ambiguous, or incomplete information, obtain clin- ically relevant information not previously addressed within the current documentation, and clarify present-on-admission indi- cator assignments.9

For more information on constructing a compliant query, reference AHIMA’s 2019 Practice Brief titled “Guidelines for Achieving a Compliant Query Practice” and the AHIMA Inpa- tient Query Toolkit. Both are available online in AHIMA’s HIM Body of Knowledge.

Training On Data Collection and Analysis CDI professionals should be trained on how to collect data, how to analyze the data collected, how to enter information into the program database, and how to formulate and organize the data for a physician query.

The collection of program data should include the identifica- tion of:10

� All cases reviewed � The number of cases with queries � The nature of the query � The physician’s response to the query

Post-Training Evaluation After initial training of CDI staff, a post-training evaluation should be conducted to ensure the appropriate transfer of knowledge has occurred and the CDI professional has a strong grasp on key concepts. Post-training evaluation can also include a “shadowing” program in which more experienced CDI profes- sionals within the organization shadow newer staff in order to ensure an effective training process.

Ongoing Education for CDI staff Ongoing education for CDI staff is crucial to the ultimate suc- cess of the CDI program. Ongoing education can include ad- ditional coursework to obtain credentials such as the Certified Documentation Improvement Practitioner (CDIP). Ongoing training can also include choosing specific cases for review within the CDI group as a learning opportunity to help all staff continue to develop skills.

For more on current and future trends in CDI, please see the extended online-only version of this Practice Brief, available in AHIMA’s HIM Body of Knowledge. ¢

Notes 1. Seppälä, Emma and Kim Cameron. “Proof That Positive

Work Cultures Are More Productive.” Harvard Business Re- view. December 1, 2015. https://hbr.org/2015/12/proof- that-positive-work-cultures-are-more-productive.

2. Ibid.

3. Adler, Howard and Richard Ghiselli. “The Importance of Compensation and Benefits on University Students’ Per- ception of Organization As Potential Employers.” Journal of Management and Strategy 6 (1): 2015. http://www.sciedu. ca/journal/index.php/jms/article/viewFile/6200/3713.

4. Ibid. 5. AHIMA. Clinical Documentation Improvement Toolkit.

Chicago, IL: AHIMA Press, 2016. http://bok.ahima.org/ PdfView?oid=301829.

6. Hess, Pamela Carroll. Clinical Documentation Improve- ment: Principles and Practices. Chicago, IL: AHIMA Press, 2015. p. 157.

7. Ibid. 8. Ibid, p. 162. 9. AHIMA. “Guidelines for Achieving a Compliant Query

Practice (2019 Update).” Journal of AHIMA 90, no. 4 (April 2019): 36-41.http://bok.ahima.org/doc?oid=302674.

10. Hess, Pamela Carroll. Clinical Documentation Improve- ment: Principles and Practices.

Prepared By Tammy Combs, RN, MSN, CDIP, CCS, CCDS Jennifer Daly, RN, MSN, CDIP, CCDS Okemena Ewoterai, CDIP, CCS, CCDS Chinedum Mogbo, MBBS, MsHIM, RHIA, CCDS, CDIP, CCS Daphne I. Willis, MSA, RHIA, CPHQ, CDIP

Prepared By (2013) Gloryanne Bryant, RHIA, CCS, CDIP, CCDS Sheila Burgess, RHIA, CDIP, RN, HIT PRO-CP Martin Conroy, RHIA Nancy Lero, RN, BSN, CCDS, CDIP, CBCS Ranae Race, RHIT Carla Serrano, RHIT, CDIP, CCS, CCDS, CPC Sheryl Theno, RHIT, CDIP Lou Ann Wiedemann, MS, RHIA, CDIP, CPEHR, FAHIMA

Acknowledgements Katherine Kozlowski, RHIA, CCS, CDIP, RMCC Patty Buttner, MBA/HCM, RHIA, CDIP, CHDA, CPHI, CCS,

CICA Donna Rugg, RHIT, CDIP, CCS-P, CICA, CCS Newelle Horn Robyn Stambaugh, MS, RHIA Sandy Bundenthal, RHIA, CCS

Read More Appendices Available Online http://bok.ahima.org There are four appendices available in the online version of

this Practice Brief, available in AHIMA’s HIM Body of Knowledge: • Appendix A: Key Points in Developing a CDI Program • Appendix B: Orientation for New CDI Professionals • Appendix C: Ongoing Education Plan • Appendix D: Qualitative Productivity Tool Example

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