Teamwork makes clinical documentation management program a success at Kettering Medical Center

Association of Clinical Documentation Improvement Specialists, March 10, 2008

By Peggy Taulbee, RN, BSN, and Teri Sholder, RN, BSN

In 2002, we began a Clinical Documentation Management Program (CDMP) at our acute care facility, Kettering Medical Center in Miamisburg, OH. Over the last five years, we have made significant accomplishments and we attribute them to the collaboration of an outstanding and supportive team.

Success with the CDMP has been a direct result of four key strategic components. These include the following:

  1. Administrative support
  2. Educated and experienced nursing staff
  3. Unit-based documentation specialist assignments
  4. Teamwork with ancillary departments

All of these components are necessary ingredients to support physician queries and encourage physicians to comply with our documentation requirements.

Administrative support has enabled our documentation specialists to have the materials, tools, and education they need to drive a successful program. We require our documentation specialists to have a BSN, and we also prefer them to have a background in critical care. We find that this background helps to establish their credibility with physicians.

We assign clinical documentation specialists to specific units and they become an integral part of the interdisciplinary team to ensure patient quality of care. Their presence on the units for the majority of the day ensures that they have ample opportunity to interact with the same physicians concurrently, and on a routine basis.

In addition, the clinical documentation specialists work as a team with several ancillary departments, and their cooperation with these departments contributes to rapid decision making, accurate DRG assignment, or query opportunities. For example, every day our information systems (IS) department compiles an electronically-generated clinical laboratory report, which details abnormal results indicative of specific disease processes such as heart failure, pneumonia, or AMI. IS distributes these lists electronically to the documentation specialists and other interested personnel. This tool alerts the clinical documentation specialists and allows a deeper investigation of the medical record and generates additional query opportunities.

Ensuring the program's success
It is always difficult to get physicians to comply with a clinical documentation improvement program. However, most physicians respond to our clinical documentation specialists' queries professionally and are open to discussion of appropriate documentation in the medical record.

Our specialists have a database which we use to demonstrate significant improvement in revenue as a result of our daily interventions. Documentation specialists document and track the accomplishments of the team both for quality assurance and financial impact. Since the implementation of the program, our facility has seen a positive impact on our case mix index and a corresponding financial return.

Our clinical documentation program is a recognized presence in the hospital. At the onset of the program, we chose bright chartreuse green for the query sheet. This color has been noted as the most visible color to the human eye so it easily catches the physician's attention. We strategically work on our physician relationships to maintain an open line of communication to discuss documentation issues. We also share supporting documentation and research on evidence based practice standards which further enhances our program's credibility with physicians. This includes justification and support for national quality measures initiatives and nationally accepted best practice standards.

Educating physicians on documentation
Physician education is a daily goal and a continual challenge. We take every opportunity to enlighten the physicians about coding, documentation, and quality of care standards. Some of our successful methods for educating physicians include:

  • Placing access to Web-based education and educational posters in physician lounges
  • Distributing flyers on units that announce upcoming educational opportunities for physicians
  • Providing education on compliant and complete documentation of our patients' severity of illness
  • Stressing the importance of physician and hospital profiles and how their documentation reflects the care that they administer.

Timing is critical when approaching physicians for discussion or scheduling educational sessions, so we always take this into consideration. Our established relationships with our physicians allow us to identify appropriate times to fit this education into their busy schedules; such as offering education in physician lounges during lunch hours.

Recently we added a medical director to our program. The medical director's role is that of a professional liaison between the documentation specialists, coders, case managers, staff nurses, and physicians. This position provides clinical credibility and a connection between documentation integrity and physician accountability.

The medical director's primary objective is to understand and appropriately leverage the political, economic, and personal interests of the medical staff in order to facilitate seamless communication and ease of flow through the clinical documentation integrity process.

The CDMP process continues to bring positive results for our facility. We have begun to hardwire processes that encourage and maintain physician documentation compliance with Medicare guidelines. With the advent of Medicare-Severity DRGs (MS-DRGs) and present on admission criteria, we are helping our physicians navigate through CMS' ever-changing coding rules. We strive to stay up to date with current educational information provided by various external resources.

Throughout this process, our hospital has ensured that we have adequate resources to facilitate the CDMP program. And as we embrace the 2008 fiscal year, we are confident that we will have continued success with the CDMP program.

Editor's note: New e-mail address: You can contact Peggy Taulbee via e-mail at peggy.taulbee@khnetwork.org.  

Do you have an article that you'd like to submit? Send it to ACDIS Director Brian Murphy at bmurphy@hcpro.com.