Applying the Toyota Way Principles to CDI

The principles focus on continuous improvement.

There have been numerous articles and other materials written promoting the material benefits of implementing some if not all of Toyota’s 14 principles, first outlined by the auto manufacturer in The Toyota Way, published in 2001. These principles have been referred to as “a system designed to provide the tools for people to continually improve their work.” The principles are divided into four sections:

• Long-term philosophy
• The right process will produce the right results
• Add value to the organization by developing your people
• Continuously solving root problems drives organizational learning

Fundamental to the Toyota principles is continuous improvement: not resting on one’s laurels and previous successes, and continuing to anticipate the need for change and process improvement as the market changes. The principles for continuous improvement include establishing a long-term vision, working on challenges, continual innovation, and going to the source of the issue or problem. These same principles can be effectively applied to the clinical documentation integrity (CDI) profession, with tremendous results that are sustainable over time. Let’s take a look at the application of these principles within the confines of the four separate sections.

Long-Term Philosophy

The CDI industry’s present-day state, born 12-plus years ago, has not materially changed to maintain relevance with the need for complete and accurate physician documentation and communication of patient care. Fundamentally, CDI is still operating under the guise of “documentation integrity,” consisting of seeking diagnoses for reimbursement purposes in some form or fashion, whether via quality measures with indirect reimbursement ramifications or direct reimbursement capture through complication and comorbidity/major complication and comorbidity (CC/MCC) documentation. Make no mistake, this is nothing more than a short-term philosophy, imposed at the significant expense of long-term, sustainable, meaningful improvement of physician documentation. So, what should a long-term philosophy of CDI look like?

I have consistently supported and will continue to support CDI subscribing to the philosophy of clinical documentation excellence versus clinical documentation improvement, also referred to as clinical documentation integrity. Clinical documentation integrity refers to achieving complete and accurate physician documentation, working with physicians as colleagues in the name of quality patient care supported by optimal net patient revenue – revenue that the hospital and physician can collect and maintain with reduced compliance risk and recoupment exposure. Complete and accurate physician documentation may be defined as the following:

• All entries in the medical record must be complete. A medical record is considered complete if it contains sufficient information to identify the patient, support the diagnosis/condition, justify the care, treatment, and services; document the course and results of care, treatment, and services; and promote continuity of care among providers.

Developing the Right Philosophy

Working towards complete and accurate physician documentation in all patient records as the underlying philosophy of CDI requires wholesale changes in current CDI processes, predicated upon the almighty query process. The hallmark of CDI has been and continues to the query process, even more so today with CDI consulting companies pushing their software, the likes of which include artificial intelligence, natural language processing, and other iterations, all meant to streamline and weaponize the query process, automatically identifying records with the most potential for documentation improvement (i.e., reimbursement capture that often does not materialize due to lack of clinical information and context to support the diagnoses). Generating more queries unequivocally generates more payor denials, contrary to mainstream thought processes in CDI, perpetuated by consulting companies and taken at face value by the majority of CFOs and CDI leadership.

Moving towards a long-term CDI philosophy of facilitating complete and accurate physician documentation through establishment of strong working partnerships with physicians, physician advisors, case management, and utilization review requires wholesale changes to present-day key performance indicators (KPIs), which are promoted by consulting companies and often viewed as gospel by CDI leadership and hospital administration. These task-based KPIs are without question detrimental to the achievement of complete and accurate documentation, serving merely as check boxes in an environment with reactive and repetitive activities.

The More Effective CDI Processes

Proper, well-designed CDI processes foster best-practice physician documentation learnings and knowledge sharing, allowing physicians to work smarter, not harder. Effective processes of CDI facilitate attainment of positive behavioral patterns of creating physician documentation that supports the right care. The first step in designing reasonable CDI processes that are intended to truly move the needle is to migrate away from (but not totally abandon) the notion of task-based KPIs that perpetuate inefficient processes.

Transforming CDI processes in 2021 – when the need for complete and accurate documentation supportive of quality of care and desperately needed revenue, with the raging COVID-19 pandemic decimating hospital finances – demands that the CDI profession assume accountability for expanding their current knowledge of best-practice standards and principles of documentation. All CDI professionals must recognize the significant knowledge deficits to overcome in addressing our ability to identify documentation insufficiencies in the medical record with the physician. It is simply not enough to refer to ourselves as CDI specialists when our breadth of knowledge in most instances centers around reviewing a record for the purposes of identifying opportunities for diagnosis capture without addressing continued documentation insufficiencies in the record that payors capitalize upon, to either deny payment or recoup payment years later.

Paving the way for CDI

Paving the way for CDI transformation rests squarely on CDI leadership and staffers alike. Business as usual is not a viable option, given the fact that present-day CDI processes are not achieving reasonable return on investment, with continued medical necessity and clinical validation denials – this despite the fact that we are reviewing charts and claiming victory in the form of invalid and unreliable measures of success, again, referred to traditional KPIs. We have just entered a new year, so now is the time to recognize that current CDI processes are in desperate need of updating to address the requirement of complete and accurate documentation, as defined earlier in this article. The CDI profession is at a critical juncture; it must either reinvent itself or ultimately play into the hands of eventual extinction, just like the dinosaurs. In my next article I will discuss several strategies to jump-start an effective initiative to transform CDI for the 21^st century, breaking down silos in the revenue cycle while making a compelling argument for hospital administration to support the profession’s commitment to reinvent itself.

Stay tuned.