Recruitment, Selection, and Orientation for CDI Specialists

A strong clinical documentation improvement (CDI) program begins with the proper recruitment, careful selection, and adequate orientation of CDI specialists. The purpose of a CDI program is to initiate concurrent and retrospective reviews of health records for conflicting, incomplete, or nonspecific provider documentation. These reviews usually occur on the patient care units. The goal is to identify accurate clinical indicators to ensure that the diagnosis and procedures are supported by ICD-9-CM codes.

These efforts result in greater integrity of the documentation, coding, reimbursement, severity of illness, and risk of mortality classifications. Defining the goals of the CDI program as well as the purpose of the CDI specialist's role within the organization will assist providers in developing a process designed to consistently hire quality staff.

Individuals qualified to serve as a CDI specialist include, but are not limited to, health information management (HIM) professionals, coding professionals, physicians, nurses, and other professionals with a clinical and/or coding background. In this diverse population of possible candidates, having an appropriate knowledge base is just one piece of the overall process and does not alone guarantee success. This practice brief will provide guidelines for the ideal successful recruitment, selection, and orientation processes for CDI specialists in the development of a sustainable and high quality CDI program.

Recruitment Best Practices

Hiring and retaining the best talent in healthcare is as tough as it's ever been. According to a study by the National Association of State Auditors, Comptrollers and Treasurers, for the first time in US history the number of young workers entering the labor market will not be enough to replace an aging workforce. Recruiting experienced professionals for CDI programs has become an important skill for managers today.

In March of 1999, the Cecil G. Sheps Center for Health Services Research (Sheps Center) at the University of North Carolina at Chapel Hill presented a proposal to the Council for Allied Health in North Carolina to establish advisory panels that examine the allied health workforce. In 2002, the Technical Panel of the council met to further discuss HIM workforce trends. The panel determined that the HIM workforce has undergone numerous changes over the last 50 years. The profession, once limited to medical records management, has expanded and is now closely linked to new initiatives and regulations surrounding increased financial pressures, quality initiatives, scrutiny of fraud and abuse, and a continued shift to the outpatient care delivery system. These factors will necessitate a need for a skilled and specialized workforce.

Researchers agree the best way to recruit top talent is to create a culture where great employees want to work. Many times the organization that has the best culture does not have the highest pay grade. Compensating for salaries by offering a positive work environment is a significant component of the job search for many new hires. Creating a culture in which staff is treated with respect and consideration is a move in the right direction. Good recruitment begins with the hiring manager and is enhanced by the right staff. A strong organizational culture, competitive compensation, and engaged employees can provide managers with recruitment opportunities. One way to maximize highly engaged CDI specialists is by placing them in positions of influence within the organization itself.

Managers can seek opportunities to add a CDI specialist to a standing committee, or to leverage specialists as contributing writers for the CDI newsletter. Developing increasingly influential roles for existing staff may assist in recruiting for the organization as current staff communicate the value of their own roles within the organization and demonstrate the rewarding nature of the program. Opportunities to learn and grow professionally will cascade from current employees to peers who may be seeking to make a job change. These individuals can also add value to the interview process, allowing them to more easily identify applicants who fit with the team and thus enhance the selection process.

Finding the right individuals does not end with acknowledging experience. Successful CDI programs also consider cultural compatibility, leadership skills, and intellectual ability to excel in a complex healthcare environment. The recruitment process can take several months, and should not be a process that is rushed or neglected.

Recruitment often goes well beyond a traditional candidate search, newspaper ads, and word of mouth in order to find the right fit. Furthermore, many organizations lack the infrastructure and processes for recruiting CDI specialists because of a focus on internal talent development. Internal talent development is always a preferred method for growth and development, but it is not the only recruitment option available.

Recruiting Internally

There are advantages to recruiting internally, or hiring from within the organization. These candidates are already ingrained in the organizational culture and thus knowledgeable of the organizational goals and needs as well as the focus of the CDI program. Internal candidates often approach the new position with a positive outlook and knowledge of how they can make a difference.

When recruiting internally for CDI positions there are many potential candidate streams. Internal candidates can be located from within the HIM, coding, quality, nursing, or case management departments. These candidates often require additional skill or knowledge development if the CDI position is outside their current scope. For example, if a unit coordinator has completed their associate's degree, is credentialed as a registered health information technician (RHIT), and demonstrates the skills to advance into a CDI position, additional training on the specifics of CDI may be needed.

There are also some disadvantages to recruiting internally. Recruiting solely from internal candidates may produce organizational cultural complacency, restrict the candidate pool, perpetuate poor performers, and constrain creative ideas. Many organizations also utilize external recruitment as a balance to internal recruitment activities.

Recruiting Externally

Recruiting external candidates facilitates new ideas and brings fresh candidates into the organization. It allows the organization to choose from a larger pool of candidates and can lead to a more experienced and diverse workforce. In fact, hiring a more experienced and diverse workforce can decrease training costs because the candidate comes into the organization with the skills and knowledge required for the job with little or no development needed.

For example, if an external candidate holding the RHIT, CCS, and clinical documentation improvement professional (CDIP) credentials applies for a position as a clinical documentation specialist (CDS), they will come into the organization with the specific knowledge required. Another example of such a candidate may be a registered nurse with a certified clinical documentation specialist (CCDS) credential and case management experience.

Organizations should also consider the disadvantages of hiring externally. Recruiting externally is much more of an unknown for the organization. Even with a solid recruitment, selection, and orientation process the new candidate is still relatively unknown and how they will fit with the other staff members and react in certain situations is difficult to identify. These misplacements can cost the organization time and financial resources.

Recruitment Tips

Employees are the life blood of an organization, but finding the right "needle in the haystack" can often be overwhelming. Additional tips for expanding the pool of candidates includes:

• Recruiting both internally and externally
• Starting an internship program with local universities
• Advertising in professional journals or magazines
• Posting openings at trade association meetings
• Asking current employees to assist in recruitment efforts
• Looking for key behaviors and plan on developing skills
• Utilizing job shadowing for internal candidates
• Rotating nursing and HIM students through the CDI program

Selecting the Right Employee

While recruitment cultivates a large number of candidates, selection is the next step in the process. The hiring manager must work with the data pool of applicants to match the right employee to the right job-a task that requires having effective processes in place that will match applicants with the needs of the organization.

Effective candidate selection has the potential to decrease absenteeism and employee turnover-ultimately helping to provide a positive boost to overall organization and program culture. In addition, successful selection will save organizations time and money during the orientation and training process.

Throughout the process of hiring a new employee, remember to carefully assess the applicant's fit with the team and physicians. Utilizing experience and intellectual capabilities alone will not guarantee an appropriate hire. The ability to fit in sync with the team and to interact effectively with physicians is a strong indication of how well the CDI specialist will integrate into the organization. To that end, it is important to ensure that final hiring decisions remain under the hiring manager's authority.

Staying flexible is also important when making a hiring decision. Candidates that are a good organizational fit may be extremely difficult to find. In addition, creating the right culture, maximizing the best workers, and staying involved during the hiring process may not fill every open position. In some instances the right choice is not the person with long-term experience, but the person that fits best into the team and the culture of the organization. Finding the right fit for the team and organization may mean hiring someone with less experience and spending some time developing the skill set.

Preliminary Selection

Selection begins with a preliminary application review and screening interview, usually conducted over the phone. This process eliminates candidates who do not meet the minimum eligibility criteria established by the organization. This process should include a thorough review of the candidate's application or resume, skill set, academic background, certifications, and work history.

When evaluating a potential CDS candidate this process may include identifying three to five years of healthcare experience, prior experience in coding or other related work, and the CDIP credential. Failure to meet these required criteria could exclude the candidate from moving forward in the hiring process.

The next step in the selection process may include specific questions that further narrow down the pool of candidates. This may be completed by either human resources staff or the hiring manager. These questions may focus on items such as:

1. Any blanks in the application: "Can you tell me why the education section is blank?"
2. Additional qualifications: "Do you have any additional certifications or qualifications you would like me to know?"
3. Probing questions around experience: "Your application indicates two years of healthcare experience, can you explain other experience that may be relevant?"
4. Selection requirements: "This position requires a CDIP credential, which you do not currently have. Would you be willing to obtain the credential within six months of employment?"

Testing the Candidates

An additional possible step to include in the selection process may be to administer a written test. The test can focus on aptitude, intelligence, reasoning, or personality. These tests should be used to objectively assess the potential candidate, and should not be biased. Questions should be open ended, requiring a thoughtful response by the candidate rather than a simple yes/no answer. These tests are usually given by the hiring manager and can be weighted for importance. Sample questions include:

1. Why do you feel that CDI is important to the organization's revenue cycle?
2. Explain what principal and secondary diagnoses are.
3. How would you interact with a negative person?
4. When working on a team, what role do you usually take and why?
5. What is an example of how you have communicated a difficult decision?

Interview Tips

The final step in the selection process is the actual employment interview. This can be an individual interview with the hiring manager, a team interview, or a combination of the two. It is important to include key stakeholders, such as:

• Hiring manager
• Departmental director
• Members of the CDI team
• Coding professionals
• Nursing
• Physician advisor

Employment interview questions can be developed to further gauge the candidate's behavior and skill set. Behavior questions to consider include:

• How do you handle a challenge?
• What motivates you?
• Share an example of how you have motivated others?
• Tell me about a time you have worked effectively under pressure?

Once the candidate has been chosen an acceptance letter can be sent and an official start date established.

Plan an Organizational Orientation

CDI programs require structure to ensure success and sustainability. When considering CDI positions, the organization must address staffing and management of the program within current organizational dynamics. The orientation process must likewise be tailored to fit those needs. No two programs will be exactly alike, and ideally orientation will be focused on the current efforts of the program along with an annual education plan.

Similar to staffing models and job descriptions, orientation programs will vary widely from organization to organization. The best and most successful programs share many common components. Orientation begins upon making a job offer. Notify the new staff member prior to their first day of work of all orientation details, schedules, and other pertinent information. Most CDS staff will first attend organization-specific orientation before reporting to the hiring manager.

The best orientation program does not end after the hospital's general orientation. It continues with a comprehensive department-specific training phase with clear objectives for training. These training periods can last from 90 days to up to one year. The level of competencies that the new hire should have at the end of the orientation phase should be clearly outlined at the beginning and progress monitored throughout the process.

In order to monitor progress, regular follow-up sessions should be scheduled with the new staff member. Although much of the feedback for a CDI specialist may occur on the floor as they directly interact with clinical care providers, it is still important for their immediate supervisor/manager to meet with them and inform them of their progress, identify learning needs, and check off items that are completed or closed.

The final step in the orientation process should be a complete evaluation of the CDI professional's performance. Throughout the orientation process notes should be taken, measurements made, and progress noted. At the end of orientation, the manager/preceptor should fill out a complete evaluation of the new hire's performance. During orientation, nurse managers and supervisors should measure new hire success and progress toward clinical competence. During the interview process, the process of receiving feedback-as well as how often that feedback will be provided-should be discussed.

The orientation program should continually be evaluated by new hires and changes made accordingly. Feedback should include an evaluation of both the formal organization-wide and department-specific programs.

Common Orientation Mistakes

Orientation can be a make-or-break for the organization and the CDI program. At its best, the CDI new hire orientation will be the same for both internal and external staff hired. The orientation will solidify the CDI staff member's place on the team, and the relationship they have within the organization. This is the best time to fuel enthusiasm for the CDI profession, goals of the program, and the impact the staff member will have on patient care, as well as prepare new hires for a long career with the organization.

Make the first day count. New CDI staff members can begin questioning their decision by the end of the first day. Their anxiety can be fueled by common orientation missteps such as:

1. Piling too much information into one day
2. Focusing too heavily on "not allowed" items
3. Failing to reach out prior to orientation with important information such as parking details, orientation schedules, or contact numbers
4. Failing to welcome them

Orientation Tips

Employee orientation can be overwhelming and complex. Consider the experience from the employee's perspective. Make orientation fun, exciting, and as simple as possible. Some tips for successful orientation include:

1. Don't jam everything into one day
2. Intertwine paperwork with interactions with key stakeholders
3. Assign work buddies
4. Identify key organizational members such as the CEO, CFO, CNO, Chief of Staff

CDI Program Orientation Details

Following organizational orientation, CDI specialists should complete a department-specific orientation process. The departmental orientation may cover up to five days of additional learning for the new staff member. Departmental orientation is the most critical step of the CDI process, as it sets the stage for employee success, department success, and organization success.

Clear and concise departmental orientation will expedite the CDI specialist's ability to perform and contribute to the success of the program. This will lead to other program benefits such as strengthening the CDI program, encouraging strong performance, providing clear communication on expectations, and understanding the important impact CDI has on the organization.

The success of the CDI program hinges upon the behavior of the new staff member. A happy staff member will feel at ease, interact in a positive manner, support the program, and be productive. By educating the CDI specialist clearly and consistently, the new staff member will know who to contact for follow-up questions, how to place appropriate queries, how to interact with clinical care providers, and where to seek out answers. See Appendix A: Employee Department Orientation Checklist, for a sample CDI departmental checklist.

Hiring the right CDI specialist is a tough decision. With workforce trends indicating shortfalls in traditional health information management careers and many clinical professionals looking for a career change, the talent pool may be larger than expected. It will take time and effort to locate the right CDI specialist for the organization, and spending time on the front end processes will go a long way in securing the right individual for the position.

For more detailed information on recruitment, selection, and orientation of CDI specialists, refer to the AHIMA CDI Toolkit available in AHIMA's HIM Body of Knowledge.^TM

Appendix A

Employee Department Orientation Checklist

Employee Name:______________________________________________________________

Start Date:_________________________ Trainer:___________________________________

Time and Attendance

• Time clocks
• Work schedule
• Reporting time
• Requesting vacation
• Calling in sick
• Breaks/lunch
• Holidays
• Overtime
• Pay days

Department Guidelines

• Personal calls
• Personal copies
• Personal e-mail
• Internet usage
• Taking pictures with cell phone
• Desk
• Storing personal items
• Copy of job description

Safety

• Fire safety
• Fire exits
• Overhead page notifications
• Emergency plan
• Emergency exits

Getting Started

• User ID and password
• System access training
• System policies and procedures
• E-mail account
• Telephone
• Keys
• Copy of organizational chart
• Departmental organizational chart
• CDI organizational chart
• Name of trainer
• Name of buddy
• Copy of CDI goals
• Copy of CDI policies

Processes

• Customer service standards
• Telephone etiquette
• Voicemail standards
• Emails standards
• Email response time
• Dress code
• Obtaining supplies

Meetings

• Organization meetings
• Department meetings
• Section meetings
• Other meetings to attend

Appendix B

Clinical Documentation Improvement Job-Specific Training
(to be completed within 30 days of hire) Overview of CDI Program

1. What is the Hospital CDI program?
   1. Program structure
   2. List key stakeholders
2. Clinical Documentation Improvement Program Purpose
   1. Benefits of the program
   2. Reasons for the program
      1. Quality
      2. Reimbursement
      3. Compliance
   3. CDI role
      1. Business impact
      2. Role impact
   4. How the program is measured
      1. Benchmarking
      2. Program dashboard
      3. Productivity
      4. Queries placed

Medicare Severity Diagnosis-Related Groups

1. Why MS-DRGs
   1. Volumes
   2. Potential financial impact
   3. Potential quality impact
   4. Potential compliance impact
2. Understanding MS-DRGs
   1. What is MS-DRG
   2. What is POA
   3. What is HAC
3. Use of CC/MCC
   1. What is a CC
   2. What is a MCC
   3. Impact on MS-DRG
   4. Impact on profiles

Review of Top 10 MS-DRGs for Organization

1. Review Top 10
2. Review those without CC or MCC

How to Read Documentation

1. Review chart order
2. Review paper record location
3. Review electronic modules
4. Review EHR screen shots for:
   1. Demographic information
   2. History and physician
   3. Consultations
   4. Operative notes
   5. Progress notes
   6. Physician orders
   7. Laboratory
   8. Radiology
   9. Other ancillary
      1. Respiratory therapy
      2. Wound therapy
      3. Nursing education
      4. Other
   10. Problem List
   11. Medication Administration Flow Sheet (MAR)
   12. Flow sheets
   13. Emergency department

Documentation Roles

1. Physicians
   1. Problem list
   2. ED notes
   3. History and physical
   4. Progress notes
   5. Orders
   6. Procedure notes
   7. Discharge notes
2. Administrative/hospital staff
   1. Patient demographics
   2. Guarantee account
   3. Coverage/payer information
   4. Financial counseling
3. Clinical Hospital Staff
   1. Intake notes
   2. Medication administration
   3. Flow sheets
   4. Dietician notes
   5. Ancillary notes
   6. Wound care notes
   7. Social services/case management
   8. Spiritual care
   9. Laboratory
   10. Radiology
4. Clinical Documentation Improvement Staff
   1. Physician queries
5. Coding staff
   1. Physician queries
   2. Coding

Documentation Used for Clinical Code Assignment

1. Face sheet:
   1. Code diagnoses and complications appearing on the face sheet. Patient face sheets in an EHR are easier to use now to get the information you need for coding. A face sheet in an EHR is one convenient location to see both chronic and acute diagnoses, prescriptions, and drug allergies for each patient.
2. Progress notes:
   1. To detect complications and/or secondary diagnoses for which the patient was treated and/or procedures performed.
3. History and physical:
   1. To identify any additional conditions, such as history of cancer or a pacemaker in situ.
4. Discharge summary:
   1. Read if available and compare listed diagnoses with face sheet.
   2. Code diagnoses and procedures are listed on discharge summary but not specified on face sheet.
5. Consultation report:
   1. To detect additional diagnoses or complications for which the patient was treated.
6. Operative reports:
   1. Scan to identify additional procedures requiring coding.
7. Pathology reports:
   1. Review to confirm or obtain more detail (note: coder must continue to verify and obtain confirmation of any diagnoses from this clinical documentation with the attending physician).
8. Laboratory:
   1. Use reports as guides to identify diagnoses (i.e., types of infections) or more detail (note: coder must continue to verify and obtain confirmation of any diagnoses from this clinical documentation with the attending physician).
9. Radiology:
   1. Use reports as guides to identify diagnoses or more detail (i.e., type of fracture) (note: coder must continue to verify and obtain confirmation of any diagnoses from this clinical documentation with the attending physician).
10. Physician's orders:
    1. To detect treatment for unlisted diagnoses, the administration of insulin, antibiotics, sulfonamides (may indicate treatment of diabetes), and respiratory or urinary infections that should be confirmed by the coder.
11. Nutritional assessments

Review Common MS-DRG Trends

1. Sepsis, SIRS, Shock, UTI
   1. Clinical Definition
   2. Body System
   3. Clinical Indicators
   4. Coding Guidelines
2. Cancer and Metastatic Cancer
   1. Clinical Definition
   2. Body System
   3. Clinical Indicators
   4. Coding Guidelines
3. Anemia
   1. Clinical Definition
   2. Body System
   3. Clinical Indicators
   4. Coding Guidelines
4. Diabetes and Manifestations
   1. Clinical Definition
   2. Body System
   3. Clinical Indicators
   4. Coding Guidelines
5. Gastrointestinal System
   1. Clinical Definition
   2. Body System
   3. Clinical Indicators
   4. Coding Guidelines
6. Protein Calorie Malnutrition
   1. Clinical Definition
   2. Body System
   3. Clinical Indicators
   4. Coding Guidelines
7. Respiratory Failure
   1. Clinical Definition
   2. Body System
   3. Clinical Indicators
   4. Coding Guidelines
8. Renal Failure
   1. Clinical Definition
   2. Body System
   3. Clinical Indicators
   4. Coding Guidelines

Physician Queries

1. Managing an effective concurrent querying process
   1. Overview of query process
   2. Completeness
   3. Clarity
   4. Consistency
   5. Precision and content
   6. Concurrent versus Retrospective
2. Guidelines for querying the physician
   1. When to query a physician
   2. When NOT to query a physician
   3. Compliance guidelines
   4. Verbal versus written queries
3. Writing a physician query
   1. General guidelines
   2. Template format
   3. Communicating to the physician
   4. Reviewing physician response, comments
4. Query management
   1. Managing physician responses
   2. Managing queries not answered at discharge
   3. Review query follow up process

CDI Metrics

1. Identify program metrics
   1. Productivity rate
   2. Query rate
   3. Query response rate
   4. Query validation rate
   5. Need for retrospective queries

Prepared by

Gloryanne Bryant, RHIA, CCS, CDIP, CCDS
Sheila Burgess, RHIA, CDIP, RN, HIT PRO-CP
Martin Conroy, RHIA
Nancy Lero, RN, BSN, CCDS, CDIP, CBCS
Ranae Race, RHIT
Carla Serrano, RHIT, CDIP, CCS, CCDS, CPC
Sheryl Theno, RHIT, CDIP
Lou Ann Wiedemann, MS, RHIA, CDIP, CPEHR, FAHIMA

The information contained in this practice brief reflects the consensus opinion of the professionals who developed it. It has not been validated through scientific research.