Coming Together at Essentia Health: Part I

EDITOR’S NOTE: This the first in a two-part series on the clinical documentation integrity department at Essentia Health, a health system that serves Minnesota, Wisconsin, North Dakota, and Idaho.

Previously, Essentia Health’s clinical documentation improvement (CDI) department consisted of three segregated, separated, regional teams. Employees had minimal interaction with each other. There were three segregated markets, two separate managers, and three physician advisors. Each region also had different workflows, policies, and processes. Coming together as one was important and necessary.

Presently, Essentia Health’s inpatient CDI department has one department consisting of one system manager, a physician adviser, an analyst, 13 CDI specialists, and four coders. This team covers 75 clinics and six acute-care hospitals that span two states. Essentia overall consists of 15 hospitals, 75 clinics, six long-term care facilities, two assisted living facilities, four independent living facilities, five ambulance services, and one research institute. We are “One Essentia.”

Throughout the journey to become “One Essentia,” we have implemented impactful changes that strengthened our team and improved our value to the organization. Here are a few examples:

• One Team: Teambuilding retreats, goal-setting, and creating an environment to foster change was vital. One physician advisor now supports and trains other advisors, creating consistency with education on CDI concepts and goals. The CDI team works both on-site and remotely, enhancing and embracing technology. Communication among staff continues through weekly huddles and web telecommunications. Respectful working relationships have been fostered among all staff. Additional educational opportunities and conference attendance is offered, and all staff is CCDS-credentialed.
• One Policy: Instead of three different workflows, policies, and processes, all staff began using a single inpatient worklist. With input from all the CDI specialist staff and solicited input from each clinical specialty, a standard clinical definition set was developed. A unified query template and escalation policy for no responses on queries was created. A one-stop location for policies now exists. A productivity board tracks time spent on cases, education, and other tasks. A leadership dashboard now reports physician response rate, CDI query rates, and information about case mix index (CMI), query impact, and more.
• One Focus: Risk-adjusted focus on Hierarchical Condition Categories (HCCs), mortality, readmissions, and the monitoring of patient safety indicators (PSIs), quality measures, and metrics are part of the daily chart review. Our focus is to maintain complete, accurate, and compliant documentation.

To potentially elevate your own inpatient CDI program: 

• Strengthen education for all CDI staff
• Increase staff interaction and elevate department exposure within the organization
• Send delegates to the Association of Clinical Documentation Improvement Specialists (ACDIS) national conference (to avoid the appearance of being preferential, perhaps say “send delegates to a national conference on coding”
• Build a stronger coding and CDI relationship
  • Hold combined CDI and coding roundtable meetings, collaboration, and education
  • Build a universal query template set for both CDI and coding
• Develop a system-wide standard clinical definition set
  • Obtain approval from each clinical specialty to become system policy
• Be aware of future opportunities in the industry
  • Collaborate with other departments such as compliance, quality, dietitians, case management, etc.
  • Analyze the potential and logistics of expanding to outpatient services

To increase diversity and impact, Essentia Health launched an outpatient CDI program in June 2017. This new division of the CDI team consists of one system physician advisor, five inpatient CDI registered nurses (RNs), and four coders. The primary goal of this new team is to work with medical practitioners within the Accountable Care Organization (ACO) membership who have been identified as having the opportunity to improve performance with risk adjustment within their clinic patient population. To aid in the outpatient CDI workflow, two outpatient electronic medical record (EMR) work queues have been established. These queues represent prospective and retrospective encounters divided by payor, visit, and target physicians. The outpatient CDI team reviews more than 500 patient visits per week. Utilizing an internal system, it maintains a consistency within the notes, as well as tracking queries and monitoring future opportunities.

Each review consists of the following: 

• HCC opportunity
• Clinical integrity of medical professionals’ notes
• Review of current codes selected by medical professionals
• Add/remove diagnosis codes, per MEAT (monitor, evaluate, assess, and treat) guidelines

An innovative function of this new team is utilizing and integrating the outpatient and inpatient CDI staff. Five RNs from the inpatient team now work and collaborate with the outpatient team to optimize each patient’s problem list, per coding guidelines, and maintain the clinical integrity of each patient.

Another key component to the success of the outpatient program is education. An established coding quality and education team collaborates with the system physician advisor to conduct meaningful education sessions. To date, this team has presented more than 15 such sessions and also conducts one-on-one educational sessions for individual physicians seeking documentation improvement opportunities. 

All teams, across all markets, are unified and working toward one goal: One Mission, One Essentia.