CDI & Quality: Pair Up to Drive Change
At the heart of every hospital’s mission is a commitment to delivering excellent patient care. When things don’t go as planned, it’s an opportunity for us to learn and improve. Accurate documentation is often where improvement starts—it’s about capturing the patient’s story in a way that truly reflects the care they receive.
With a deep commitment to optimizing Clinical Documentation Improvement (CDI) and quality processes, I’ve witnessed how accurate documentation not only enhances quality scores but also builds trust among teams and with our patients. Ensuring we focus on real opportunities for improvement, rather than false problems created by poor documentation, is where the collaboration between CDI and Quality teams truly makes a difference.
Getting the Documentation Right
Consider Central Line-Associated Bloodstream Infections (CLABSIs). These play a crucial role in hospital quality metrics, and even small improvements in documentation can lead to significant positive outcomes. Midlines and PICC lines might look similar, but they’re not the same. By ensuring we accurately differentiate and document these, we help maintain the integrity of our quality scores.
Occasionally, CLABSIs might be inadvertently coded due to documentation mix-ups, but with the right processes in place, we can catch these early and ensure our data accurately reflects the exceptional care provided.
Key Questions to Ask
In my experience, asking the right questions is key to continuing our improvement efforts:
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? Is the CDI team making sure the correct type of line is documented?
? Does the quality leader fully understand which cases are being coded as CLABSI?
? Are we double-checking Hospital-Acquired Conditions (HAC) and Patient Safety Indicator (PSI) cases before billing to ensure accuracy?
By continuing to enhance our reconciliation process and reviewing these cases together, CDI and Quality teams can prevent errors, protect our quality metrics, and ensure that our data truly reflects the high standard of care we deliver.
Moving Forward Together
As we continue to collaborate, let’s focus on ensuring that accurate documentation is more than just a way to avoid penalties—it’s about keeping the clinical truth front and center. While I may no longer be directly involved in these reviews, my commitment to advancing accurate documentation and quality care remains unwavering. I’m confident that through continued collaboration, our patients will receive the best care, our documentation will stay precise, and our healthcare system will continue to thrive.
Registered Nurse Certified in Clinical Documentation Improvement
6 个月Great article! I’ve witnessed both - collaborative teams and siloed teams. With the evolution of OP CDI I’ve seen a shift towards multidisciplinary collaboration. We truly work better together, and improved patient outcomes and quality is the result. Our patients move about throughout the entire health system, from ambulatory to inpatient, ED, etc. and with greater collaboration, efficient internal processes, and the right EHR/AI tools we can optimize patient care across the continuum and close the loop.
Clinical Documentation Integrity Specialist Advocate for Quality Healthcare Care Management|Compliance Board Chair - Nonprofit Audit
6 个月Great advice
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6 个月Collaboration is key! Great article highlighting the value CDI brings to an organization and the impact on Quality and Patient Outcomes.
Director of Clinical Patient Safety
6 个月Great article! Your work and collaboration is invaluable.
MBA, BSN, RN, TCRN, CFRN
6 个月Well done!