bsn, rn, ccds - acdis · · 2017-05-23lara faustino, bsn, rn, ccds ... • bmc is a private,...

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Remote CDI: A Panel Discussion

Lara Faustino, BSN, RN, CCDS, Remote CDS Boston Medical Center, Boston, MA

Rebecca Willcutt, BSN, RN, CCS, CCDS, CDIP Director Kara Masucci, MSN, RN, CCDS, Remote CDI Nurse

Cooper University Hospital, Camden, NJ

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Lara Faustino, BSN, RN, CCDS

Boston Medical Center, Boston, MA

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Learning Objectives

• At the completion of this educational activity, the learner will be able to:

– Identify key components necessary for a successful remote CDI program during development and implementation

– Describe some common misconceptions surrounding remote CDI work

– Identify the top benefits achieved as well as barriers and resolutions

– Identify collaborative efforts that support the success of a remote CDI program

2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.

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“Raise Your Hands” Question

1. How many have CDSs who work partially remote now?

2. How many have CDSs who work 100% remote now?

3. How many would like to experience working 100% remote after this conference?

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Oliver!

Hello ACDIS!

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Exceptional Care Without Exception

• BMC is a private, not‐for‐profit, 496‐bed academic medical center

• The primary teaching affiliate for Boston University School of Medicine

• BMC is the busiest level I trauma center in New England

– More than 24,801 admissions and 1,080,766 patient visits in the last year

• 59% are from under‐served populations and rely on government payers

• 31% of patients do not speak English as a primary language


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CDI Remote Transition Timeline

• Program began Oct 2010—floors and laptops—0 battery, limited space– Met resistance with physicians early on—concern for program

interruptions/daily workflow

• May 2011: Team moved to office setting within the hospital• In 2014, Boston Medical Center embarked on an ambitious,

four‐year campus redesign– Hospital merger to become one site by 2018

• 2014: CDI team is moved to the finance building on campus/away from medical floors

• Transition: 2 days remote April 2014 • Transition: 4 days remote January 2015 (sold) • Transition: 5 remote workweek with bimonthly staff meetings

by Spring 2015

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Check the Box

100% electronic EMR

High‐speed internet access

Quality CDI software

Internal hospital messaging

Agreed/approved policy

Productivity expectations

Remote office setting

Motivated CDI team

CONFIDENCE

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Clinical Scenario

• Physician statement:

“Email me –sometimes I don’t write my notes until midnight …”


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Query Response Today in Real Life …

“Sent from my iPhone”

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A Visibly Invisible CDI Team

How does an invisible CDI team remain visible?

Our unique “pop‐up” query process within the EMR ensures visibility across the whole care team in each individual record, thus promoting visibility of an active CDI team.

• Daily communication via the following applications:– Query process in EMR

– Email

– Text paging

– Internal hospital instant messaging system

– Work extensions are forwarded to preferred remote lines

• Promotes privacy of personal home/cell lines

• Physician education:– On‐site as needed per preference of physicians’ platform

• 1:1 meetings, small or large educational speaking engagements

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December 2014 EPIC Go‐Live!

• Implementation of our unique electronic query process

• Created with physician leadership approval

• Allows customizable physician query response

• Real‐time documentation

• Activated/deactivated by CDI team

– Based on query response/policy


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Query “Pop‐Up”

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Query “Pop‐Up” Instructions

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Growing Pains …

Problems

Token sign‐on

IT upgrades

Teleconferencing

Software upgrades

Hospital “downtime”

Power loss

Prevention of unauthorized hospital/patient information

Friday active queries

Solutions

Aruba boxes

Savvy IT remote login

Coaching/practice

Management collaboration

Downtime review policy

Hospital policy for loss of power/internet connection

BMC telecommuter policy

Friday disclosure notice


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Clinical Documentation Specialist (CDS) Telecommuter PolicyHealth Information Management Department

Boston Medical CenterAgreement

By signing below I certify that I have read, understand and voluntarily agree to the terms and conditions of the CDS Telecommuting Program as outlined in the telecommuter document dated ______________.

I will adhere to the duties, obligations, responsibilities and conditions for telecommuters as described in this agreement as well as hospital policies and procedures, as they may be amended from time to time.

I agree that I will maintain my remote workspace in a safe manner, employing appropriate telecommuting security measures to protect information and systems. I will take all the necessary precautions as outlined in the departmental policies regarding confidentiality and necessary precautions to secure proprietary information at my home workspace to prevent unauthorized access to any hospital and/or patient information.

I understand that telecommuting to provide services to the hospital is a voluntary program and a privilege. I may stop telecommuting by providing notice to my supervisor. I also understand that the hospital may, at any time, change any or all of the conditions for which I am permitted or not permitted to telecommute.

__________________________ _______________________

Employee Signature: Date:

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Clinical Documentation

Please be aware that any active queries without a response noted in EPIC by 2 p.m. on Fridays will remain open in EPIC and

re-addressed Monday morning.

Thank you and we apologize for the inconvenience!

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Achievements

• Creative communication streamlines:

– CDIS productivity/quality review

– Most often real‐time physician query resolution• Queries “pop‐up”/documentation is clarified or deactivated (hours)

• Optimized collaborative efforts/physician engagement

• Vested in query response even when off service (if query escalated)

• Documentation best practice physician education:

– Optimally timed for the physician

– Applied documentation best practice to all records


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Common Misconceptions vs. Reality

• Online shopping

• Cooking

• Cleaning

• Child/senior care

• Coffee shop

• Under the radar

• Time management

• Availability

• Accountability

• Protocols

• Internal IM system

• Exceed productivity

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Tips for Successful Remote Days!

• Routine

• Gym/yoga

• Shower

• Day clothes (not pajamas!)

• Connect with colleagues

• Self‐education if any downtime

– ACDIS website

• Take a walk

• Take a trip after work

– Even if it’s just to the grocery store!

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#GOALS

Current state

Physician education

MS/APR‐DRG reviews

Variety service line reviews

Quality collaboration

Future state

Physician champion

CDI ladder/team lead

Grow/expand CDI team

Variable shifts

Outpatient CDI

NICU/obstetrics/GYN

Per diem CDI


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The Bottom Line …

• This program positively impacts the organization on both a departmental and individual level, while supporting Boston Medical Center’s vision of a positive work/life balance for its employees.

• A full‐time remote CDI program CAN be successful after a well‐established CDI program is proven within an organization.

• The remote office setting has proven to impact overall health and well‐being, as evidenced by employee satisfaction, respected physician relationships, and meeting metric goals.

• The organization benefits with staff retention—all employees hired into the department are still with the department!

• Organization saves on real estate, resources, and utilities.

• Employees do not occupy parking spaces, making more available for patients/families.

• Attractive role for quality CDI candidates (autonomy/critical thinking).

• If you have tried before and failed … try again!

How can our model help your organization?

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Rebecca Willcutt, BSN, RN, CCS, CCDSKara Masucci, MSN, RN, CCDS

Cooper University Hospital, Camden, NJ

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z

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ATTRIBUTES & ONBOARDING

TEAM BUILDING

BARRIERS

BEST PRACTICE AND METRICS

BENEFITS

• Identify key attributes for new hires and successful onboarding of remote CDI staff

• Discuss successful strategies to implement a hybrid program and build a cohesive team

• Explain barriers affecting the efficiency and effectiveness of a hybrid program

• Define best practices and list metrics of a hybrid program

• Predict the benefits to the hospital, staff, and practitioners

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Daily census

416Admissions

29,473Hospital beds

635

Cooper University Health Care

in Camden, NJ, operates an

academic, tertiary (specialist)

care hospital; a leading cancer

center; a children’s hospital;

three urgent care centers; and

more than 100 outpatient

offices throughout South Jersey

and Pennsylvania.

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z

z


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Clinical Documentation ImprovementProgram (CDIP) Team

• Falls under quality & operational excellence department

• Institute (service line) model – CDS team on‐site

– CDS remote

• 100% PSI and HAC review pre‐bill – Remote CDS & director

• Hybrid staff – 3 on‐site CDS RNs

– 8 remote CDS RNs

– 1 remote CDS director

– 1 on‐site lead CDS RN

– 1 on‐site medical director (trauma surgeon)

Beth Gsell RN, BSN, CCDSOnsite CDSMount Holly, New Jersey

Kara Masucci RN, MSN, CCDSRemote CDSWhippany, New Jersey

Matthew Durfee RN, CCDS, CCSRemote CDSBoston, MassachusettsSarah LaSource RN, BSN, CCDSRemote CDSBirmingham, Alabama

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Remote CDS Requirements

• RN with Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) credential

• Certified Coding Specialist (CCS) or Certified Risk Adjustment Coder (CRC) credential required within 1 year

• Proficiency with vendor software and hospital EMR

• Knowledge of regulatory environment

• Spirit of excellence

• Problem solving and deductive reasoning skills

• Behavioral‐based review and solid references

• Self‐owned office equipment and computer


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Successful Remote Onboarding

• Ensure access to necessary hospital computer applications– Citrix installed prior to start– Remote connect via VPN – Computer with fast and secure internet– Often the biggest hurdle to onboarding

• First week– IT setup day and mandatory online compliance classes– Preceptor assigned– Full‐staff group WebEx meeting for introduction – CDIP policies, process flow maps, and query format– Complete a few patient reviews with preceptor– No queries posted until okayed

• Communicate expectations– New patient reviews per day– Follow‐up reviews time frame per PFM– Query follow‐up per PFM– Reconciliation of cases– Flexibility is a must; not everyone has the same query opportunity

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Benefits of Hybrid CDI Team

• Immediate return on investment• On‐site CDSs are the face of the program• Less disruptive to the physician’s workflow• Less physically intrusive in the units• Frees up valuable real estate• 100% electronic clarification process• Physicians have full access to the CDSs during business hours

and contact via phone or email

• Less distraction and interruption for the CDSs = greater productivity

• Less distraction and interruption for the physicians = happier physicians

• Flexibility of not having to commute = happier employees

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Barriers Affecting the Efficiency and Effectiveness of a Remote CDI Program

• Rely only on the EMR

– EMR is cumbersome

– EMR contains duplicate information

– Difficult to collaborate with bedside RN

• IT issues, including internet and Citrix downtime

• Increased difficulty in establishing relationship with physicians

• Loss of “ad hoc” education for physicians and continued education for CDSs

• CDSs may feel unsupported in their role


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Growing and Nurturing a Hybrid Team

Plant Trust “Be a good leader, treat people well, motivate them well, and don’t try to second‐guess everything they do.” ‐Richard Branson

Plant Loyalty“Train people well enough so they can leave. Treat them well enough so they don’t want to.” ‐Richard Branson

Plant Joy“Happiness inspires productivity.” ‐Shawn Anchor

96% Employee Satisfaction/Engagement Score96% Employee Satisfaction/Engagement Score

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Open Virtual Door & Relationships

• Maintain open lines of communication– Daily group instant messaging is key

– Out of sight is NOT out of mind

– Over‐communication

– Group emails

– Emojis and GIFs

• Attitude, attitude, attitude• Humor and laughter• Get to know each other on a personal

level to mitigate feelings of isolation• Ask for and give help• Encourage small talk and IM chitchat• Bring entire team together annually

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Servant Leadership• Your team is your #1 customer—don’t pull rank

• Believe the best about each team member; give benefit of doubt

• Work should bring happiness, satisfaction, and psychological safety

• Lead by example

• Please & thank you, smiles, honesty, transparency, admitting mistakes, and the Golden Rule

• Know birthdays, names of spouses, children, and pets

• Encourage high, strong emotional engagement

• Friendly rapport builds morale, productivity, and job satisfaction

• Family comes first

• Turn weakness into strength

• Give affirmation, appreciation, and kudos

• Empowerment is contagious—spread it

• Talk each other up

• Trust, trust, trust

• Empathy: Never humiliate or devalue

• Believe in the power of autonomy and a long leash

• Give credit when credit is due

• Have their backs

Servant Mindset

Get to Know Them

Build Confidence

Loyalty


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Clarification Process

• CDS enters clarification as a “short note” in electronic medical record

• CDS tags the physician and it travels to his/her inbox

• CDS follows the escalation process

• Physician responds to the clarification and signs the note

• Once signed by the physician, it becomes part of the permanent record

Clarification Response

Rate = 100%


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Sample Clarificatio

n

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Escalation for Unanswered Clarifications

72 Hours After Clarification Written

Escalation #1 Contact physician

48 Hours After Escalation #1

Escalation #2 Contact physician and CDIP MD director

48 Hours After Escalation #2

Escalation #3Contact physician, CDIP MD director, and

department head

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CDIP Team Metrics

• CDS individual– Initial reviews per CDS

– Subsequent reviews

– Impact clarification rate

– Non‐impact clarification rate (i.e., severity, HCC, PSI, etc.)

– Audit of clarification compliance

• CDIP team– 100% PSI review completed

– 100% HAC review completed

– 100% Medicare and Managed Medicare review completed

– CMI

– Expected mortality

– Physician response rate

– Physician congruent rate

– Flexibility is a must; not everyone has the same query opportunity


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Thank you. Questions? [email protected]‐[email protected]‐[email protected]

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide.


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bsn, rn, ccds - acdis · · 2017-05-23lara faustino, bsn, rn, ccds ... • bmc is a private,...

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