Home

Alternative staff schedules offer CDI opportunities

Association of Clinical Documentation Improvement Specialists, August 11, 2010

When the University of Medicine and Dentistry of New Jersey (UMDNJ) hired Melanie Halpern, RN-BC, MBA, CCDS, CCRA, to implement a clinical documentation and coding integrity (CDCI) program, administration allotted three full-time positions to staff the 550-bed academic medical center. Halpern conducted interviews and thought she had found the perfect candidate. There was a catch. The individual lived three hours away, too far of a commute to make the typical nine-to-five, five-days per- week schedule feasible.

So Halpern asked the advice of Atlanta-based FTI Healthcare Consulting, which UMDNJ hired to establish its CDI practice.
 
“At the time, we didn’t have any clients that used an alternative scheduling program,” says Marion Kruse, RN, MBA, director at FTI. So Kruse and Halpern started exploring various options.
 
A sound CDI program can’t be built on the needs of a single staff member, regardless of his or her qualifications, says Kruse. Thus, “you have to build the business case for a flexible schedule based on the program’s overarching needs and the benefit of that role to the facility,” she says.
 
“The question became, ‘Can we break free from the Monday-through-Friday regime and maybe get six days of coverage or find another benefit to help the overall program?’ ” Halpern says.
 
Halpern developed three options to illustrate how the CDI program might function. (ACDIS members can download Halpern’s spreadsheet from the Forms & Tools Library.) These options are as follows:
  • Three full time equivalent (FTE) staff working four 10-hour days
  • Three 12-hour shifts
  • A typical five-day, 7.5-hour-per-day schedule
 
Pros
Fluctuations in census and length of stay made Halpern’s argument for an alternative staffing schedule somewhat easier. Furthermore, she discovered that Tuesdays through Thursdays were the busiest times of the week at the facility.
 
Patients may feel sick over the weekend but wait until Monday to call the doctor, Halpern explains. The patient sees his or her primary care physician on Tuesday and comes to the hospital either Tuesday afternoon or Wednesday. Any observation status cases could complicate that timeline, she says.
 
“That pushes us to Saturday,” says Halpern. “If I have someone there during one of the weekend days, it gives me a big head start when the rest of the staff comes in on its regular Monday routine.”
 
“If you are advocating coverage six days a week, then it would be a no-brainer to go with a 12-hour shift [three days working and four days off],” Kruse says. “There’s a business case to be made for capturing Friday afternoon admissions and surgery cases on Saturday or capturing cases that might otherwise be missed.”
 
Furthermore, a CDI program may decide to employ an alternatively scheduled staff member to, as Kruse describes it, “act as a sweeper on a soccer team” to work the facility’s busiest days and “pick up the cases that the rest of the team can’t get to.”
 
Under such a scenario, a CDI manager or director would need to carefully review the facility’s census patterns and physician rounding habits to accurately determine the department’s needs.
 
Since a 12-hour schedule can be grueling, Halpern suggests breaking up the monotony by diversifying CDI specialists’ tasks to include physician education and assessment of query trends. So rather than review case after case, hour after hour, this person could review cases for eight hours per day and attend to other responsibilities during the remaining time.
 
“They could look through the previous month’s sepsis or congestive heart failure queries, for example, and identify documentation trends or missed query opportunities and bring those back to the team for discussion,” says Halpern.
 
Early morning or evening hours can be ideal times to connect with typically overscheduled staff such as physicians and coders, Halpern says. “You can have a great conversation with a physician at 7 a.m. when it’s quiet in the hospital before he or she gets too busy,” she says.
 
In addition, CDI specialists may find it easier to meet with coding staff during their off hours.
 
Cons
Each staffing model has its drawbacks. For example, in option one (CDI staff working 10-hour shifts four days per week) staff members cover floors every other day, and documentation reviews of short stays could be missed, Kruse says.
 
Additionally, if a CDI specialist submits a query on Monday but does not return to that floor until Wednesday, he or she could miss an opportunity for a beneficial physician interaction or assurance that a query has been answered, Kruse says.
 
On the other hand, this model allows the facility to have a CDI staff member available seven days a week.
 
Under option two (a 12-hour, three-days-per-week schedule), the biggest concern is staff fatigue, Halpern says.
 
“Clinical documentation improvement requires a lot of attention to detail. Specialists need to be able to review a lot of information, analyze what they’ve read, and ask the appropriate questions using the specific clinical indicators to back them up. How can someone be on top of their game after eight hours on duty?” Halpern says.
 
In addition to brain fatigue, Kruse worries about CDI specialists’ ability to complete their work. She advocates for CDI staff to “own” a patient record once they’ve started looking through it to prevent passive diffusion of responsibility.
 
If a specialist were to work a three-day schedule, the other team would have to pick up the specialist’s cases on day four if the patients were still in the facility.
 
“As that [specialist] moves in and out of the facility, do they end up leaving CDI work for the next CDI specialist to cover?” Kruse asks.
 
The answer to that problem may be added monitoring. A CDI manager would need to perform due diligence and be vigilant in conducting regular monitoring of operational and outcome measures.
 
“We’ll have to go back and look at these cases in a more analytical way to make sure that nothing is being missed,” Halpern says.
 
Kruse says that programs choosing this method should pay careful attention to the following warning signs:
  • Decreases in the number of initial and follow-up reviews
  • Increases in the number of cases without a CC or MCC in the face of decreasing query rates
  • Changes in the case assignment to DRGs within the key pairings/triad that the Office of Inspector General has traditionally monitored
  • Decreases in the number of expired cases that do not have a severity of illness and risk of mortality score of three or more
 
“That’s the quickest way to see if your staff is doing a thorough job,” Kruse says.
 
Additional assessments used to determine staff efficiency include:
  • Retrospective query rate (post-bill)
  • Open queries
 
“If staff members working alternative hours fall outside of the expected productivity benchmarks, then you may need to address those concerns one-on-one with the employee,” Kruse says.
 
A manager should retain the right to revoke flexible scheduling or amend schedules if the work isn’t being performed in an acceptable manner, Halpern says.
 
“But I hope that the discussion, that putting the options out there, will help to break the mold,” she says. “It could be a real opportunity under the right circumstances.”

Most Popular