Background: The Accreditation Council for Graduate Medical Education (ACGME) includes “Systems Based Practice” as part of its six core competencies for resident education. Clinical documentation is a primary resource of patient safety and quality metrics such as severity of illness (SOI), risk of mortality (ROM) and Medicare Severity DRG (MS-DRG) of a systems based practice. These measures also affect hospital ranking, research, and reimbursement. Studies have shown that although residents acknowledge they are the primary author for clinical documentation, around 40% have little to no knowledge of clinical documentation improvement (CDI) programs. Baseline data at Johns Hopkins All Children’s Hospital (JHACH) indicates that only 18% of resident physicians agree or strongly agree that they have received adequate training on CDI.
Purpose: Our objective was to create a CDI curriculum for pediatric residents on the hospitalist service at JHACH. Our goal was to improve resident satisfaction in documentation education from less than 18% to 50% from October 2018 to March 2019.
Description: Residents employed at JHACH were surveyed to assess both their level of satisfaction with CDI and their knowledge of CDI with a short 10 question pre-test. This test required residents to choose the most accurate clinical diagnosis that corresponded to appropriate coding terminology. In total, 78% (n=72) of residents ranging from PGY 1-4 levels participated in this survey and pre-test. Initial survey results show 93% of residents agree or strongly agree that CDI education is important for their career as physicians. However, despite recognizing the importance of CDI, pre-test data showed no significant difference in correct answers between residents from all PGY levels. The “Take 5” CDI education series was created and monthly lectures were given over a 5 month period at designated education lectures and in nighttime curriculum. This consisted of five lectures covering four systems and one of high yield topics from several systems. Lectures were given as brief 30-60 minute interactive sessions where an audience response system was utilized to facilitate discussion and learning. After these lectures, PowerPoint presentations and CDI Education binders were made available as references for documentation. Once the education series is complete, residents will be surveyed and retested to determine if resident CDI education satisfaction improves, and to see if there is a quantifiable improvement of residents in the course of their training.
Conclusions: Our initial results show there is strong resident interest in CDI. Pre-test data show no significant difference resident’s clinical documentation knowledge from all levels of training. Despite residents being one of the primary physician documenters, there is a lack of CDI education to improve their documentation efforts. We are pending the final results of our project.
To cite this abstract:Maier, C; Simone, C; Baldwin, K; Dees, P; Young, D. ‘TAKE 5’ TO IMPROVE RESIDENT SATISFACTION WITH CDI. Abstract published at Hospital Medicine 2019, March 24-27, National Harbor, Md. Abstract 324. https://www.shmabstracts.com/abstract/take-5-to-improve-resident-satisfaction-with-cdi/. Accessed December 11, 2019.