Why "We Have Always Done It This Way" Is Counter Productive

We Have Always Done it This Way- This is indeed the most dangerous phrase in the language, particularly in healthcare and especially in Clinical Documentation Improvement. I was enjoying dinner with a physician colleague Sunday evening and a discussion on what ails the revenue cycle of hospital, prime contributing factors being inefficiencies throughout the revenue cycle abound. Why do these inefficiencies perpetually continue? Mainly due to the pervasive attitude of we have always don't it this way and a resistance to change.

This appears to be the attitude of the CDI profession, continue with the same chase the diagnosis retrospective processes rather than update processes that facilitate actual improvement in documentation through physician engagement. Physician response rate to queries does not equate to or represent physician engagement. Neither does getting physicians to document probable, suspected, likely or possible diagnoses in the discharge summary to allow capture of diagnoses that optimize the DRG. Equipping ourselves with the proper skill sets and core knowledge in documentation improvement, becoming more proficient in techniques of change agent and committing our energies and efforts to expand the breadth and depth of documentation in the medical record, not more documentation, instead more effective documentation, is the foundation for ultimate success in enhancing the communication of patient care. A sound first step in the long journey to CDI effectiveness is to transform our approach of record review from a retrospective to a prospective process, beginning with conducting chart reviews on the day of admission preferably starting in the Emergency Department documentation. The goal in starting the chart review process ED longitudinally following the patient from admission to discharge is to recognize and capitalize upon the opportunity to improve the quality and completeness of the medical record in totality. Securing and capturing a diagnosis at a set time is static in nature, only representing a framed picture as opposed to a stream of logical pictures telling the patient story from beginning to end.

Take a listen to the podcast for December 15th's Finally Friday, bear in mind the first part of the show is about the 340 B drug program, be patient and you will have the opportunity for a candid conversation on concepts to consider in the evolution of CDI.

https://www.freeconferencecall.com/rss/podcast?id=5156049797:485386523