Meetings rotate among hospitals in Northern Illinois

As seen in Hospital Case Management
Published July, 2009

When the RN clinical documentation improvement specialists at Central DuPage Hospital set up a networking meeting with their peers from other hospitals in northern Illinois, they never dreamed that their efforts would lead to the formation of a new organization with regular meetings.

"We never thought the group would grow the way it has. Since there aren't a lot of nurses who perform clinical documentation review, we thought it would be helpful to network with documentation specialists at other area hospitals and exchange information. The idea caught on, and the group has gotten bigger and better as people from other hospitals hear about our network and want to join," says Nancy Sikorski, RN, BA, clinical documentation improvement specialist at the Winfield, IL, hospital.

Since that first meeting hosted by Central DuPage Hospital in April 2008, the Northern Illinois Clinical Documentation Specialists Network's membership has grown from clinical documentation improvement specialists at seven hospitals to representatives from more than a dozen hospitals in the northern Illinois area. The organization has been contacted by clinical documentation improvement specialists from other areas who want to either join the organization or develop their own.

"When we started the group, we were interested in finding out how the program was working at other hospitals and to get tips for improving our program. Everybody thought they learned a lot at the initial meeting, so we decided to continue to meet. We decided on a name for our group at the second meeting," she says.

The hospitals take turns hosting the organization's quarterly meetings, which typically include an educational program from an expert, along with the information exchange and brainstorming session.

At one meeting, the hospital brought in one of its renal specialists to educate the group on kidney failure. At the most recent meeting, the group participated in a teleconference from a physician who is an expert on documentation and serves on the advisory board for the Association for Clinical Documentation Improvement Specialists, a national organization.

The organization has a question-and-answer section on its web site where clinical documentation specialists can ask about MS-DRGs and how they apply to specific symptoms and specific patient populations. The northern Illinois organization concentrates on other areas, such as how to create closer working relationships with physicians, coders, and other staff members.

"When we get together, we offer tips and strategies that have worked for us. We talk about what has and has not worked for us and get ideas of how we can solve our problems," Sikorski reports.

"Generally, we have talked about communication challenges that come up day to day in between the coding nurses, physicians, and the coding staff," she says.

One of the biggest areas of concern among the nurses was how to get physician cooperation as they clarify the documentation.

"Most of the doctors are very cooperative and anxious to learn, but a few are challenging. We brainstorm on how we can better educate our physicians on what we are trying to do and what
works in getting the documentation we need," says Sikorski.

The Central DuPage Hospital clinical documentation specialists shared their strategy of treating physicians to movie tickets and coupons from Starbucks as rewards for clarifying the documentation.

"It's our way of thanking them. This has worked very well," she says.

Representatives from some other hospitals pointed out that they could not adopt the strategy because hospital policy forbids giving physicians gifts.

Another hospital presented its physician education program to the group and shared the posters and other tools they use to get physician buy-in for the documentation efforts.

"We brainstorm on how we can better educate our physicians on what we are trying to do and what works in getting the documentation we need," Sikorski adds.

When participants discuss their unsuccessful efforts to get physicians to improve documentation in the chart, their peers can identify with the situation.

"We can do only so much. They are the physicians and they are responsible for what they document or don't document. We all are in the same situation, and it helps to share our experiences, even when we aren't successful," she says.

The members discuss their relationship with the coders and how the clinical documentation system works at each hospital.

"We collaborate on how to work with the coders and share our expertise so we can make sure that everything is documented and coded correctly," she says.

At most of the hospitals, the RN clinical documentation specialists work with coders and share their expertise, Sikorski says.

"At our hospital, both disciplines respect each other and work closely together. I don't know all the coding rules, and the coders are not nurses. It is a collaborative effort between the two," she says.

At Central DuPage Hospital, the coders depend on the clinical documentation improvement specialists to ensure that the clinical information indicates the correct diagnosis so they can assign the right code, she says.

"If the patient is in the hospital with pneumonia, the clinical documentation improvement specialist can look at the documentation and see that he or she may be debilitated and may have had a stroke.

We can identify complications and comorbidities that reflect the accurate acuity of the patient and query the physician as needed for a more specific diagnosis, such as aspiration pneumonia," she says.

The clinical documentation improvement specialists have an advantage over coders when it comes to ensuring proper documentation because they are working with the charts on a daily basis and have an opportunity to interact with the physicians in real time, Sikorski says.

Nurses, coders, should collaborate

Based on her experiences and those of other RNs in the organization, Sikorski recommends that nurses and coders work together on documentation.

"If I see that a patient has an abnormal lab and the documentation doesn't reflect it, I can discuss it with the doctor. Coders don't have that opportunity," she says.

The clinical documentation specialists have brainstormed on how to ensure that all of the conditions that are present on admission are fully documented in the chart.

"We are all concerned about the present on admission requirements because the hospital won't be reimbursed if certain conditions develop after admission," Sikorski says.

Other topics for discussion have included the number of charts each nurse reviews every day, how frequently the charts are reviewed, and how the process works at each hospital.

Clinical documentation specialists at some hospitals report that they need to come in for half a day on Saturday or Sunday to review the charts, particularly if the hospital has a large Medicare population, she says.

"They found that there were patients who were being admitted on Friday and discharged on Sunday before the clinical documentation specialists could review the charts. They come in over the weekend to capture some documentation that otherwise might be missed," she says.

Clinical documentation improvement is increasing in importance as payers and the Centers for Medicare & Medicaid Services more closely scrutinize hospital claims, she says.

"If the documentation isn't complete on the front end, it's more difficult for the coders to code on the back end," she says.

Based on her experience and that of her peers at other hospitals, Sikorski recommends that dedicated staff handle clinical documentation improvement.

At Central DuPage Hospital, the clinical documentation improvement specialists are RNs who occasionally fill in if the case managers need help.

"When this happens, it's difficult to do justice to either program. If I help with utilization review, I can review only about 10 charts. Otherwise, in a typical day, I look at 22 or 23 charts," she says.

"If a case manager is assigned to both tasks, the clinical documentation improvement duties are likely to fall by the wayside," she says.

Launching new organization takes time and effort

It took Nancy Sikorski, RN, BA, nearly four months of research, telephone calls, and e-mails to bring together some of the RN clinical documentation improvement specialists in northern Illinois for a meeting.

"We are all so busy that it took a long time for everyone to connect. I had to leave telephone messages or e-mail messages to get in touch with the nurses and they had to get back in touch with me," recalls Sikorski, clinical documentation improvement specialist at Central DuPage Hospital in Winfield, IL.

Since that first meeting of the Northern Illinois Clinical Documentation Improvement Specialists Network in April 2008, the organization has grown as more RN clinical documentation specialists learn about it and join.

Sikorski suggests that clinicians who want to set up a similar organization in their area start by compiling a list of all the hospitals they want to include and contacting them to get the names of the clinical documentation improvement specialists.

"This is challenging because, depending on the hospital, the clinical documentation specialists may be located in the finance department, medical records, or nursing," she says.

Since the hospital operators may not be familiar with the clinical documentation improvement specialist position, it may take a few telephone calls to locate the right people, she says.

Often the medical records staff can steer you in the right direction, she adds.

Once she identified the right people at each hospital, Sikorski asked them what they would like to discuss and set an agenda for the meeting.

"We invited everyone who was interested to our hospital and provided refreshments. The meeting lasted about three hours, and everybody learned so much, we decided to continue," she says.

"Since that first meeting, we have been building a networking resource for each other in this unique and very exciting field," Sikorski says.