acompellingcase.com copyright ©2008 the camp method: medical staff training that really works…...

aCompellingCase.com Copyright ©2008

The CAMP Method: Medical Staff Training that Really

Works…and, improves documentation!

2010 WSHIMA Annual MeetingRuthann Russo, PhD, JD, MPH, RHIT

April 15, 2010


Objectives

• Improve understanding of the physician and the medical staff culture

• Describe the benefits of CAMP Method training to administrators to secure support for the training

• Design a training program using the CAMP Method components

• Apply the CAMP Method components in a training program• Assess strengths and weaknesses of my organization’s

current physician training programs• Identify immediate ways to improve current training efforts• Identify ways to use training to improve HIM-Medical Staff

relations


The Biggest CDI Challenge Contest

• CDMatters.com contest• Common themes among contestants• And the winner is….


Biggest CDI Challenge Contest

• How can we permanently modify physician behavior?


Why do we want to permanently modify physician behavior?

• Economic & clinical reasons• Severity DRGs• Medicare Quality Measures• Meaningful Use• EHR implementation• ICD-10


HIMs: The best to modify physician behavior

Physician authority

Physician Hospital

Link

Clinical –Technical Link

HIM Professional


How can we modify physician behavior? Take them CAMPing

• Coaching• Asking• Mastering• Peer Learning


CAMP™ Method

ReproducibleMaterials

ObjectiveCriteria

ConsistentMethodology+ + + =

Sustainable & Compliant HQCD

The Formula for High Quality Clinical Documentation (HQCD)


Physician Training & CDI Metrics

Question: Which best describes your organization’s CDI training for physicians:

1. Sessions are mandatory, less than 1 hour2. Sessions are mandatory, more than one hour3. Sessions are NOT mandatory, less than one hour4. Sessions are NOT mandatory, more than one hour5. We do not currently train physicians on CDI


Physician Training & CDI Metrics

Question: Which best describes your organization’s CDI training for physicians:

1. Sessions are mandatory, less than 1 hour 16%2. Sessions are mandatory, more than one hour 7%3. Sessions are NOT mandatory, less than one hour 45%4. Sessions are NOT mandatory, more than one hour 22%5. We do not currently train physicians on CDI 10%


Background

• The struggle for high quality clinical documentation began over 20 years ago

• Then, it was about how to work around the physicians to get the work done

• Now, it has to be about working through & with physicians

• Clinical documentation management, by its very nature, must be a collaborative effort directed by the hospital and led by the physicians….


What appeals to physicians?

• Validated research findings• Use of the scientific method• Leading a cause• Having an impact


Research shows that…..

Poor quality clinical documentation by physicians – Is present in 10 to 70 percent of patient medical

records– Has been linked to excessive healthcare costs– Has been linked to poor quality of care– May be related to lack of formal training

You can access all of the research in Chapter 2 of Volume 1

Carroll, Tarczy-Hornoch, O’Rielly, & Christakis (2003)Cascio, Wilkens, Ain, Toulson, & Frassica (2005)Mulvehill, Schneider, Cullen, Roaten, Foster, & Porter (2005)Novitski, Sing, Kersher, & Griffo (2005)Rhyne & Gehlbach (1979)Rifkin, Berger, Holmboe, & Sturdevant (2007)Socolar, Raines, Chen-Mok, & Runyan (1998)Stengel, Abauwens, Walter, Kopfer, & Ekkerkamp (2004)Wong, McCarron, & Shaw (1983)


The Research Study

• 3-group blinded interventional research study at The Hospital of the University of Pennsylvania in 2007

• Trained 3 groups of internal medicine residents– One group received CAMP™ Method Training of two

2-hour sessions– One group received limited training of about 1 hour – One group received no training (control group)

• Tests and surveys were given to all study participants before and after the training. These provided the data for our regression models


Research Results – statistical support

• Regression models showed statistical significance with a p value <0.05 and Adj. R-square of .7 and an effect size of .5 for training using the CAMP™ Method over either a limited training program or no training (control group)

• Physicians trained using the CAMP Method produced statistically significant higher quality clinical documentation than physicians who received training similar to that currently provided to physicians


Most important research finding

• CAMP™ Method training group’s self-efficacy improved in addition to their clinical documentation quality

• Improved strong self-efficacy = sustainability of training results

• Self-efficacy [i.e. sustainability of CDI] improved for CAMP

Method trainees, but did not improve for the other groups


Using The CAMP™ Method….applying what we know


CAMP™ Method


ObjectiveCriteria



The Formula for High Quality Clinical Documentation (HQCD)


The Process

HypothesisDesign & Conduct

Study

Publish Results/Peer

Review

Publish Book detailing

training & resources

If physicians are trained in

HQCD, then both quality & sustainability will improve

Academy of Management 2008 paper presented –

Nominated for best theory to practice

award

Blinded 3-group

interventional study at HUP

A Compelling Case for Clinical Documentation Volume 1 & 2


CAMP™ Method Components

• Coaching, involves coaching and encouraging participants about their abilities to perform this function.

• Asking, involves soliciting feedback from the physician participants in a specific manner and at a specific time.

• Mastering, involves practical application of the principles demonstrated and discussed during the training program.

• Peer Learning, involves instruction by a knowledgeable peer, who is trusted by the group.


7 Criteria for High Quality Clinical Documentation

(HQCD)1. Legible2. Timely3. Clear4. Consistent5. Complete6. Precise7. Reliable You will see these criteria defined and then

referenced over and over in the book…..these 7 criteria are the glue that holds the theory of HQCD and the training together


Criteria Documentation example/description

Legibility Handwriting can be deciphered by anyone with an 8th grade education. (Includes the patient) Required by HIPAA, and all government and regulatory agencies

Completeness Comprehensive and complete documentation including whether any abnormal test results are clinically significant (Joint Commission requirement)

Clarity Avoid or clarify vague or ambiguous documentation, especially in the case of a symptom principal diagnosis (chest pain vs. GERD or syncope vs. dehydration)

Consistency Agreement between two or more treating physicians with resolution of any conflicting documentation upon discharge

Precision Diagnoses should be documented with as much precision and detail as possible. If a more specific diagnosis appears to be supported, it should be documented as such (anemia vs. acute or chronic blood loss anemia)

Reliability Document the condition being treated or tested (i.e. Lasix for CHF; KCL administered, hypokalemia documented)


Coaching

• Grooming and encouraging participants about their ability to perform HQCD

• Credible peers should be providing this instruction• Driven by physician responses to the self-efficacy

questionnaire…for example in the study, physicians scored low on their beliefs that they could clearly and completely document the clinical significance of all abnormal test results

• Specific activities and times during the training to deliver coaching for optimal results

Who teaches your CDI training sessions for physicians?

1. A physician2. A physician and an HIM/CDI professional3. An HIM/CDI professional4. Other5. We do not current provide CDI training


Who teaches your CDI training sessions for physicians?

1. A physician 7%2. A physician and an HIM/CDI professional 18%3. An HIM/CDI professional 58% 4. Other 5%5. We do not current provide CDI training 12%


Asking

• Requesting feedback from physician trainees• Addresses the physician’s willingness to participate

and document using HQCD• Ask the question, “What’s bothering you about this?”• Specific times and activities during the training to

“ask” for optimal results…for example, the physicians in the study didn’t believe hospital documentation was related to their own reimbursement


Mastering• Physicians actually document during the session and

receive feedback• The most important component; often the most overlooked• How often do hospitals incorporate the actual practice of

the concept being taught into their physician training?• Sample records are used in training…provided on the

resource disc• In addition, physicians are asked to practice between the 2

training sessionsWhich statement best describes your organization’s use of “mastery”

1. We use sample records in physician CDI training2. We do not use sample records and do not plant to use them3. We do not use sample records, but would like to in the future4. We do not conduct physician CDI training


Which statement best describes your organization’s use of “mastery”

1. We use sample records in physician CDI training 19%2. We do not use sample records and do not plan to use them 15%3. We do not use sample records, but would like to in the future 54%4. We do not conduct physician CDI training 12%


Peer Learning

• Physicians are more likely to learn and retain information when it is delivered by a knowledgeable, credible peer

• Sharing experiences, feedback to trainees, etc• Interaction among the trainees….attendees shared

their between session experiences with the group• Background of the physician trainer

– Professional training – currently licensed MD or DO– Their own clinical documentation training – 40 hrs– Experience in classroom teaching – 40 hrs– Experience in providing practical instruction – 100

hrs


CAMP™ Method


ObjectiveCriteria



The Training Formula for High Quality Clinical Documentation (HQCD)


Compelling Case – Volume 1• Introduces senior managers in the organization to clinical

documentation training and the CAMP™ Method• Explains the research study and the statistics supporting

the training in detail • Ties in the role of CDI in strategy….ultimately goes to the

hospital’s VVMS (values, vision, and mission statement)• Explains how CD can be used to build or strengthen

hospital-physician relationships.• 16 case studies


Compelling Case – Volume 2

• Operational manual for implementing a CAMP™ Method training program

• Details each component of the CAMP method and how it should be rolled out in order to achieve the same results as the original study

• Explaining the use of all of the CAMP™ Method tools….measurement & training (PPT, DVD, case studies)

• Applying the CAMP Method to training for other clinicians

• Time management for physicians


CAMP ™ Method CDI Training For Physicians

Improved quality Of Clinical

documentation

Improved CDI Metrics/ Better Outcomes for Your

Organization

Improved understanding

Of responsibilities

Improved cooperation

From physicians

The Relationship between Training & CDI Metrics


CDI Key Metrics: Strategic & Operational

• Strategic: measure the long term impact of the program

(e.g. CMI, Severity, Quality Indicators ratings; Public report card ratings)

• Operational: measure the day-to-day impact of the program that, over time, will also have long term impact


CDI Key Metrics

• Record review rate• Query rate [concurrent & retrospective]• Response rate [concurrent & retrospective]• Agreement/validation rate [concurrent &

retrospective]

Polling question

Which statement best describes CDI Key metrics collection in your organization?

1. We collect key metrics2. We don’t collect key metrics, but plan to in the future3. We don’t collect key metrics and do not plan to begin


Polling question

Which statement best describes CDI Key metrics collection in your organization?

1. We collect key metrics 57%2. We don’t collect key metrics, but plan to in the future 44%3. We don’t collect key metrics and do not plan to begin 9%


CDI Key Metrics & Target Measurements

[

Data element/measurement Quarter 1 Target%

Achievement

Concurrent: physician query rate: 40% 40% 100%

Physician response rate: 50% 75% 67%

Physician query agreement /validation rate: 70% 80% 88%

Retrospective: physician query rate: 5% 15% 33%

Physician response rate: 60% 100% 60%

Physician query agreement rate: 55% 65% 84%


Sample Summary Assessment Results by Specialty

Specialty % of records with queries

General Medicine 33%

General Surgery 24%

GYN 12%

Cardiology 21%

Orthopedic Surgery 11%

Hematology/Oncology 19%

Finding Concurrent

Query Rate 25%

Secondary Diagnosis Query 37%

Principal Diagnosis Query 63%

Top 5 Queries Pneumonia, Sepsis, Chest PainAbnormal Labs, Abnormal X-ray


The Cost of Physician Non-Response

Service Internal Medicine Cardiology

# Annual discharges 1,280 1,020

# Annual queries 384 357

Average value per query (value reduced for expected negative responses)

$895 $1,700

Value at 95% response rate $327,000 $577,000




Self-assessment

39

Have mandatory initial CDI training sessions for all physicians Y NHave mandatory follow up or regular CDI training sessions for all physicians Y NUse a physician and an HIM/CDI professional to conduct physician CDI training Y NBuild in component of “coaching” (i.e. encouraging physicians that they have the ability to practice high quality clinical documentation) into CDI training

Y N

Begin each training session by asking the physicians about their concerns Y NAre effective at managing physician’s concerns voiced during the training process Y NHave physicians review patient records during training & ID documentation deficiencies

Y N

Collect CDI Metrics Y NShare CDI Metrics with physicians Y NUse CDI metrics to tailor the content of follow up education Y NTotal Points: (Give yourself 10 points for every Y response; 0 for every N)

In my organization, we:


CAMP™ Method Tools

Measurement Tools• Self-Efficacy survey• Attitudes & Opinions questionnaire• Clinical Documentation test• Program evaluation

Training Tools• Training program outline/agenda• PowerPoint presentations• 10 case studies• DVD clip


Resources

• www.cdmatters.com : free downloads of CDI policies, audio-conferences; procedures and other resources; Ruthann’s CDI blog

• www.acompellingcaseforcdi.com : Book website; additional books, resources, CDI toolkits available

• www.cimexhealth.com/learning : web-based learning site• [email protected] (contact information for

Ruthann Russo)– If you would like a free copy of the CDI Resources CD-ROM,

you can request it through my email– If you would like a password to view a sample web-based

learning course, you can request it through my email

http://www.cdmatters.com/

http://www.acompellingcaseforcdi.com/

http://www.cimexhealth.com/learning

mailto:[email protected]

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