The implementation of clinical documentation improvement software definitely requires good planning to ensure success on all levels. There are several steps you can take to ensure that CDI is introduced successfully to your care team. One of the first steps is to carefully analyze the areas that need improvement. Every setting can have its own plan when it comes to CDI implementation.
For example, some clinical settings have excellent results in maximizing patient throughput (the process describing the movement of patients from arrival and up to discharge). However, the same hospital or clinic encounters some difficulties on keeping up with accurate coding. Therefore, more planning and focus is needed in the accurate coding sector. Or, some physicians have managed to standardize their documentation process, but another part of the staff (the nurses for example) encounter difficulties in this specific sector. In order to successfully introduce clinical documentation improvement software it is important to analyze expenses and revenue, plan and compare and see which are those areas where revenue is lost.
Another important step is the designation of clinical documentation improvement leaders. Many settings opt for an OR manager for example, who is capable of coordinating and planning such a program. Also, doctors will need guidance and help in adapting to the new changes brought by the implementation. Besides a general staff leader, a physician leader is also a good idea. Things will start working better and much faster if there is someone available at the top of the pyramid to coordinate everything and plan accordingly.
Clinical documentation improvement program implementation is not a simple process, but once you get everything rolling it will make everyone’s job so much easier. Establishing employee training programs is yet another important step in achieving success within the shortest possible time. Offer support to the employees and invest efforts into creating quality training programs.
Reviewing your CDI progress frequently is also important. The best way to review is to conduct short interviews with the staff and come up with ways in which they can improve their jobs and tasks on a day to day basis. Taking a step by step approach will bring results faster.