How to build your CDI program around quality

Disclaimer: Described video not needed. The visuals in this video only support what is spoken. The visuals do not provide additional information Lisa: Good afternoon and thank you for joining another CDI innovation webinar, where we have our guests today, Mark LeBlanc and Dr. Jason Hom from Stanford, where they are going to be discussing how to build your CDI program around quality. Before I hand it over to them, just a couple housekeeping items. If you do have any issues with your sound, there is a sound dropdown in your dashboard. Click on that, just to make sure you're either using your computer speakers. If the audio is still not working, you can always call in with your phone using the passcodes that are in there in the dial-in information. We do encourage questions during this presentation, that we'll try to get to as many as we can at the end. Also, that is located in your dashboard in the questions drop-down. We are recording today, so you will get an archive of this recording and presentation after. Lisa: Also, if you are interested in looking at the presentation and following along separately, that is in the handout section of your dashboard, where you can download that directly. And there's also some other information, fact sheets, as well, if you're interested to hear more or read more about our products and solutions. You are going to get a certificate of attendance today that, if you'd like to submit to AHIMA or ACDIS to apply for CEUs, you can. And then we also have a survey at the end, that we would really appreciate your feedback just to know how we did today. So to make sure we have as much time as we can for the actual presentation, I am going to go ahead and pass it over to you, Mark. Mark LeBlanc: All right, thank you. Good morning, or afternoon, or wherever you are depending on what time zone. Welcome to our presentation. I'm Mark LeBlanc. I am the manager for the Stanford CDI program. I've been here at Stanford since about 2018. I'm a nurse by background and I've been a nurse for 40 years. That's scary. And I've been in CDI for over 15 years. Jason? Jason Hom: Hi, everyone. My name is Jason Hom. I'm one of the hospital medicine attendings here. Greatly enjoy working with Mark and the rest of the CDI team as the physician advisor and look forward to chatting with you all today. Mark LeBlanc: We do have some learning objectives, so we definitely have posted those up here and hopefully we will be able to accomplish those today. Tell you a little bit about Stanford. If you don't know, Stanford Healthcare located in Palo Alto, California. That's where our main campus is. We have a secondary campus at ValleyCare, which I'll get to, as well, but is Stanford Medicine at Stanford University, the school of medicine. You can see that we are a level one trauma center. We're the only one between San Francisco and San Jose, which is an interesting fact. And we do a lot of different types of care here. Our ValleyCare office is in what we call the East Bay and it is a community based hospital that has been onboarded since 2015. And a lot of their providers are now going between both facilities. Mark LeBlanc: So overall, Stanford Health Care opened a new hospital back in 2019. It is across the street from our old hospital and it is a very large state-of-the-art facility that we're very proud of. And we are now working diligently to turn the 300P, which was the original hospital, into the same state-of-the-art facility with a lot of remodeling and things going on. Our mission at Stanford is to care, to educate, and to discover. Our vision is healing humanity through science and compassion one patient at a time. And I think as we talk about the quality initiatives in our quality care for every patient, so we're committed to provide clear, accurate, and honest information about the quality of care we offer all our patients. So we really are striving to make sure that the data, the information, and everything that goes out is accurate, and complete, and paints an accurate picture. Mark LeBlanc: Our CDI program here at Stanford, to talk about our journey, I think our chart helps to describe how we look at CDI here at Stanford Health Care. So we have an upside down org chart. So if you're looking to my name, you have to look more towards the bottom because that's where I am and Jason's down there with me. So we are here to support the CDI specialists who do all of the work for us on the front lines. And in between the specialists we have a career ladder, so we have some quality and outcomes leads who you'll hear more and more about as we continue our discussion. We have education leads that actually are responsible for all the education for both provider driven as well as the staff education. And then we have service line leads who help to support that educational efforts at the service line level. And then the specialists do our daily work. Mark LeBlanc: (silence) Mark LeBlanc: So we've been doing multi-disciplinary reviews since 2015 as all potential PSIs in house and we haven't involved both CDI, the clinical partners as well as coding and quality partners. So the scope includes the mortality case, that we look at every mortality case from a multidisciplinary perspective. And we also have focus reviews that we do periodically, where I think we're in the middle of doing a substance focus review. We've done some orthopedic focus reviews and we didn't really look at them on a monthly basis to see what it is. We've done a COVID focus review. And then sometimes when there's documentation or coding capture guidelines we'll do focus reviews to make sure that we're keeping those at the full slot. We also have a very large Vizient expertise and engagement from the CDI. And so we do risk model analysis and we've been doing this since 2017. Mark LeBlanc: And we have a tool that we created, which is called the .RCC tool and it is a tool that is embedded in the provider's documentation that they can use to identify conditions present on admission or even conditions not present on admission. It was mainly developed for our Vizient model and making sure that we're capturing all of those diagnoses, but it also helps to alleviate or helps to keep our query rates lower because, if physicians or certain groups have a lot of queries in one area, then we try to incorporate that into the tool. That tool also is managed twice a year. So if Vizient comes up when they redo their models, we go back in and redo our tools. And we also encourage from an organizational standpoint, we encourage providers to use it in their HMP and their discharge summary, but we also encourage it in their progress notes [inaudible 00:08:46] seeing use of it there. We have a fairly high rate of use of the tool and so it's really been prudent. And, Jason, do you have anything you wanted to add from a provider standpoint? Jason Hom: Not too much. Yeah, .RCC stands for relevant conditions and comorbidities. And, as Mark mentioned, it's fired within the HMP and the discharge summary. If you're wondering about how much time it takes providers to fill out, it really depends on the complexity of the patient, length of stay, and other factors. Probably if it's done meaningfully, a few minutes to fill out. Mark LeBlanc: Thanks. I think that's probably the biggest. When we developed them is that in the beginning a lot of the providers wanted everything listed on the .RCC. And it became such a huge, overwhelming tool that we've learned and we've gotten to really start to hone in on the actual ... There's no reason to put certain diagnoses on certain ones if the provider's always documented and it's part of their practice. And so there's no reason to remind them, so we try to make sure we take those out of the .RCC so that it really becomes a little bit more efficient for them to fill out. We did do a CDI collaborative project this year and we have been looking a lot at our CC/MCC capture rates. And we're honing in on the fact that sometimes the data, even though against our peers we may show that we're not as high a level of capture, but if certain elective or short stays can negatively impact that. And so as long as you're able to talk to those and so we spend a lot of time around that as well. Mark LeBlanc: (silence) Mark LeBlanc: So we really wanted to do a collaborative approach when we look at our CDI program. So we consider ourselves part of coding quality and CDI as a core, supporting the clinical provider and compliance is out there, as well, helping us in the periphery. So we really wanted to make sure that we weren't siloed. We wanted to make sure that we allow providers who wanted us to look at certain cases to make sure that the documentation and the code capture was accurate. We've created a way for them to do that. And we've made sure that we try to make sure that we have a strong partnership. That's really what we're always trying to achieve between all the departments. Back in 2013, they started looking at PSI 15, or the accidental puncture and laceration, and they wanted to make sure that we had an accuracy in capturing the complication. And we wanted to make sure that we improved the patient experience and outcomes and we wanted to have an honest review of the cases and reflection of the clinical practice. Mark LeBlanc: And then we started doing all the PSI 90 cases back in 2015, so we've been doing a quality of focus and we continue to grow that focus and to make the program even stronger than it was in the previous years. So just to give you a little idea of how we do stuff here at Stanford, so the CDI specialists do concurrent reviews and queries for all of the inpatients and usually with length of stays greater than two days. And then they follow the cases as needed. When the system fires at PSI or HAC, there is a second level review that is done by our CDI quality and outcomes specialists. And then pre-bill, coding, and queries happen and then there's another review. If there's still a final coded PSI or HAC at that point, then we do another multidisciplinary review. And this includes CDI, coding, and quality. And quality is looking at it to see if there was a patient or a clinical issue that needs to be brought back to the clinical team. Mark LeBlanc: (silence) Mark LeBlanc: We also do pre-bill reviews and queries for any focused non-maximized DRGs. We do multidisciplinary clinical reviews, like I talked about before, for certain focus areas. And we do look at all of our mortality cases as a multidisciplinary team. Mark LeBlanc: (silence) Mark LeBlanc: So, like I said, we use the 3M software. And when it flags a case concurrently and/or by coding, then it flags for additional reviews. Mark LeBlanc: (silence) Mark LeBlanc: Let's see. And we do submit all of our queries. Everybody works cohesively to make sure that we're getting the documentation accurately to reflect the PSI, if it needs to be there, or to get the documentation that will help to negate that PSI. Mark LeBlanc: (silence) Mark LeBlanc: Everything that we do is around the patient and patient focused and I think that's key for making sure that your quality initiatives are accurate. And so we are looking at the documentation codings, looking at the code accuracy, and quality is there to help when all of those pieces are finalized and validated, that they are looking at it from the quality patient experience and if there's something to take back to the clinical teams to work on improvements from the clinical side. And so we include nursing, clinical providers, and compliance are all part of this relationship that we have going forward. Our CDI teams, they have a coding knowledge that they really are looking at the documentation and making sure that you have the documentation to capture these codes as well as writing the queries when we don't. And making sure that we're providing education to the providers around the accuracy of the documentation and why we need certain things documented. Mark LeBlanc: And all of our work is done around making sure that all of our publicly reported data is accurate. Our coding team are the ones who were out there making sure at the end that the codes are accurately reflected and captured. They make sure that we get all of our POAs done correctly. And then, like I said, the quality team is very vital to the fact that they ensure that the messaging back to providers around what it is that we are identifying from a code perspective, that impacts the PSI and the data reporting. Anything you want to add, Jason, from that perspective? Jason Hom: Just to highlight the collaborative approach that you mentioned. I think there's a lot of crosstalk on the backend, so there's swim lanes within the 3M 360 program and different experts, whether it's from CDI, coding, or quality are oftentimes looking at the same cases and talking on the backend. And then the more provider facing end there's a lot of crosstalk as well. So, for example, a lot of times the CDI specialist will present at the quality meetings to talk about transmitting or transfer regarding PSIs or those types of things. So a lot of collaboration, both visible within the organization at meetings, and also on the backend. Mark LeBlanc: Yeah, that's a great point because a lot of times CDI, coding, and quality are all reviewing at the same time and going back and forth around answering questions for each other and providing more information. Mark LeBlanc: (silence) Mark LeBlanc: Part of the process, I think, as you start to look at these types of enhancing your programs around quality is to make sure you break down walls, make sure you don't have silos, make sure everything's collaborative. You want to make sure that you have the right skillset and making sure that the teams are giving the support that they need to utilize those skills. Takes a lot of team building in order to get everything up and running. In the beginning you have to make sure that it's a collaborative effort. And sometimes that can be really hard because each department has its own workflows and ideas of what they're trying to accomplish. And then trying to make sure that everybody understands the big picture and that we are all trying to accomplish something similar for the organization and the patients. And it's the importance of all of us working together. And then I think finally it's about being honest and having those discussions, making sure that there's chances for enhanced learning, and also just getting lots of feedback from the team and letting them be a part of the process is key as well. Mark LeBlanc: (silence) Mark LeBlanc: So this is just making sure that you have the essential skills on the team to make sure that you can get the output that you want in an efficient manner. So you want to make sure that it's professional, there's interpersonal process and improvement, whatever way you do that, and your data and technology. And obviously the data and technology piece is the key to helping drive the work, but also making sure that you have all the right people at the table. Mark LeBlanc: (silence) Mark LeBlanc: I think it's really important when you do any kind of project or any kind of development within a CDI program that you have a lot of good, clear messaging. You have to have goals set, you have to have an understanding of what the importance of the work is. And so I think it was really important for us as the team and the journey really started for me in 2018 when we began to plan for the implementation of 3M 360. The work had been going on in other formats, probably more technology sporadic, or Excel spreadsheets, and emails, and all kinds of forms. And we really saw an opportunity and we wanted to make sure that we harness the software to do this work. And so that's really where we started to pull all these teams together to start to talk about what a collaborative effort could look like, understand where in the process each team would come in, what the expectations were, make sure that everybody felt comfortable in the roles that they were playing. Mark LeBlanc: And then also to understand how we would recognize those successes and make sure that those were brought out and the reporting and our baseline metrics. Mark LeBlanc: (silence) Mark LeBlanc: So we also involved providers and the service lines. We have physician champions in each service line that Jason works with and we wanted to make sure that we understood what they were using for benchmarks. So it's really important that you understand not only what does the organization [inaudible 00:22:43] organization says Vizient's our benchmark or our CMS or something, however they want to do it, but you also need to understand that there are other individual benchmarks as each service line or different one, like NSQIP, or different providers have different things or different groups. We want to make sure that we work with them very closely. We wanted to make sure that of the ones that we chose and that they use, that we became experts in the methodology and figure out ways to mitigate those risks around documentation. And I think that's key as well. And a lot of times it was the quality departments that had a lot of this knowledge base and we would tap into that, as well, and help us to learn more about the quality initiative. Mark LeBlanc: And then we wanted to make sure that we had a good process for reporting and we want to be able to have our previous parent and a comparison data. So it was to make sure that we had some performance metrics that we could make sure that we were watching and keeping track of. And then we wanted to make sure that we communicated them. Anything you wanted to add, Jason? Jason Hom: Yeah, I think very well said. I think there's a lot of different routes for two way communication that's mutually beneficial. So I'll give us your examples. I think the CDI website, anyone, whether it's a professional from quality, provider from any service line, can submit a case if they want to review it because they have a question about the coding or a documentation related issue. We have oftentimes found that just multidisciplinary discussion of one case can lead to a whole slew of really fruitful conversation. Sometimes we'll have big topics that get discussed at division meetings, at quality meetings. Sometimes when I'm on service, I'm going back on service next week, a provider will just stop me in the hallway and ask about a case or about a particular topic. Sometimes those hallway conversations are very fruitful, as well, so I think the key, as Mark highlighted, is just really respectful and consistent communication with all the relevant stakeholders. Mark LeBlanc: Thanks, Jason. Yeah, so then it's setting your expectations and accountability. So I think one of the overarching expectations, like I've said over and over again, is patients is the focus of the work. And it's definitely our goal is to improve patient outcomes. So when you can try to clear out the documentation issues and the code capture issues, then you can definitely hone in on the clinical issues and allow the organization to really be able to start to say this is a clinical issue and this is where we need to place them, some resources on trying to improve that piece of it. And I don't know how it is at other places, but I know when I first got here that there was a lot of questions about our documentation and coding. And so every time there was a blip in some sort of quality outcome, it was always there's something wrong with the documentation and the code capture. Mark LeBlanc: And so it took a lot of work and a lot of time and partnering to make sure that we got the word out, that, no, we're really doing a lot of backend work around ensuring that the documentation is there and the code capture is there. And we'll continue to do that because that's what we're here to do, but then to try to help to promote our quality partners. Okay, we need to go back and say, no, this is a clinical issue and we need to start to talk about it. What can we do on the clinical side to help improve these outcomes? And so that's really been a key thing that's come out of all of this work? Yeah. I mean, you have to make sure that people understand what's in it for them. And as any other thing that we do in CDI, and probably in any business, you need your senior clinical leadership as well as your senior administrative leadership supporting the efforts. And you definitely need to have report out. Mark LeBlanc: And, as Jason talked about, our website also has tons of dashboards, and progress reports, and different things that we developed for all the different service lines around a lot of different metrics as well as quality metrics. And it's there for anybody. They can see it at any time and anybody who has access to our internet can see it as well. So it's very transparent and it's out there for all to see. Anything else you wanted to add there, Jason? Jason Hom: No, I don't think so. Mark LeBlanc: Okay. And then to continue on around expectations, we attend a lot of meetings. And I think that's key to making it, like Jason said, we'll present. We've been getting more and more time and a lot of what we've been presenting lately is just the process that we use because there were so many people in the organization that didn't realize how much work that quality CDI and coding did behind the scenes from the time that patients admitted until when the bill goes out the door. So just having them understand that piece and starting to trust that we're doing all the things. We're doing peer reviews, we're doing lots of audits of the work and spot checking, and making sure that we continue to have a high accuracy rate within all the work that we do. So I think that's been a real key for us. Mark LeBlanc: Yeah, I think that's all I have there. So this just talks a little bit about our focus review process, which Jason is a huge part of. And so we usually will come up with some sort of potential opportunity identified. We'll focus on internal clinical review and it includes both CDI and coding quality. We give feedback to our partners around it. This is also part of what Jason said, when somebody wants a chart review or multiple chart reviews, that they can put in a request for us to look at, all of that stuff. And so the goal of all of this work is, like I said, making sure that we have accurate medical records for our patients and that we're reflecting the outcomes from Stanford's work that we do every day. Mark LeBlanc: (silence) Mark LeBlanc: So as anything else we do, if you don't have the clinicians on board, it's not going to be very successful. So we really wanted to have one of our strategies as engaging the clinician. And it was an all around respect and collaboration. So we definitely wanted that to be the driving factors that we use when we engage. And, like I said, we had the luxury of having provider champions from all the service lines that we could tap into as well as the senior clinical leadership have been supportive as well. Mark LeBlanc: (silence) Mark LeBlanc: So I think some of the things that we came away with is that I think recognizing that everyone wanted to do the right thing and that we're all on the same chain was one of the things that you just have to have as an assumption and base your work off of that. And I think that's come true from what I've seen in our work that we've done to date. And we need to recognize that they're super busy and they have a lot of expertise. And, as Jason said, we built the .RCC. I mean, it does take time and so we're asking them to spend that time. And so we want to assure that when they spend the time it's fruitful and that it pays off for both the, the patient, and our organization. And so that's why we put so much energy and efforts into maintaining it, and updating it, and keeping it front and center. Mark LeBlanc: And we want to make sure that we target our conversations because a lot of times here at Stanford the APPs and the residents are doing a lot of the documentation and the attendings are there to co-sign and monitor and maintain it. So we definitely learned sometimes certain topics and target audiences can be very good when you're engaging with them and they can include all of them as well. And, like I said earlier, you want to make sure that you share that the analysis, which we do mostly with all of our service lines. And we not only create the dashboard, but we give them a synopsis of what we're seeing and where we see potential opportunities for improvement and collaboration and working with them to help educate and do other things as well. Did you want to add anything, Jason? Jason Hom: Yeah, I think as you nicely highlighted, we're very grateful for how engaged and supportive all the clinical staff here are, whether it's APPs, or residents, or attendings. And everyone's very busy, our censuses are quite high now, even though COVID thankfully has abated, but overall query response rate in Palo Alto hovers around 99.99%. A meaningful response rate, which includes the agrees and disagrees, is currently somewhere around in the mid 90s. We're very grateful about that. And just in terms of the meetings, and Mark and I both highlighted, when you go to provider focused meetings, like division meetings, we found it's very helpful to ask providers what are you interested in seeing. And oftentimes people say I'm curious about this data or that data and that gives you a really natural way to say I don't have that level of granularity that you want. I'd love to prepare it for you and then you get an invitation to the next meeting. So it creates a positive cycle so that your interactions at meetings with providers aren't simply just one-off. Mark LeBlanc: Yeah, that's a great point. And I think the service line leads, having a consistent person working with the service lines also helps because they develop that relationship as well. And sometimes in between maybe they'll be asked to provide some data for something, a different type of meeting that someone's going to. So it's really great. Sometimes we get invited to meetings that we never thought, didn't really realize they were happening. And now we're like this is great because we really need to be at the table here. Mark LeBlanc: (silence) Mark LeBlanc: Yeah, I think this just comes from it, is making sure that we're partnering with them and making sure that they understand that we do have some expertise and that we do provide value for them and can help them to improve some of these outcomes that they're being tasked to work on. And that when they are working on them, that it is truly a clinical issue that they're trying to take on from their side. And the misconception that it's purely financial still is out there after 15 plus years. And I was thinking this morning, I'll digress just a hair, but when I started back we didn't really talk about quality so much in the early days. We just looked for that one CC or MCC and then we moved on. And we were purely financially motivated and that's how CDI got its start for people who may not really realize that has been later. And so to turn that around sometimes can be very hard, especially if you've had a program for a very long time and you have providers who've been around for a very long time. Mark LeBlanc: It's hard to get them to see that and so making sure that you have those conversations and them understanding all the work that we're doing and that they're doing is really around the quality issues. And making sure that our quality outcomes are accurately reported. Mark LeBlanc: (silence) Mark LeBlanc: Yeah, and so we do have some, like Jason said. We want to make sure that we bring the right stuff to the right meetings. We want to make sure that, like you said, we're tracking it, we're trending it for them. We're giving them the details when they wanted and not providing a bunch of details when they don't want it. So I think that's really a key piece of learning how to be sure that you're attending a meeting and bringing the right stuff to that meeting and being able to ask questions. And also being comfortable saying, like Jason said, I don't have it, or I can get it for you, or let me find some other people who can answer those questions for you. They're becoming the person who may not just be the expert in certain areas, but also you can find other resources for them. Did you want to add anything, Jason? Jason Hom: No. Mark LeBlanc: No? Okay. All right, so I think it's all about, like I said, we've been talking a lot about going beyond traditional quality efforts, which is a lot of times just looking at PSIs and validating those, but the creating of .RCC, making sure that you're creating tools to help make things more efficient as well as improving quality of time. Right now we've just finished a whole project around admission status because there was so much just differencing of that process and the process of applying it. And admission status does have a huge outcome around quality metrics and so making sure that you get that right is important. And making sure that you understand what the guidelines are around it. Here at Stanford we have a provider experience group that is trying to help make the provider experience better, so it's around technology optimization, so trying to reduce their burden. Mark LeBlanc: And then we are also looking at a lot of CMS advocacy, so Jason does a lot of work around that and trying to get some work at CMS to think about changing some of their rules and guidelines around capturing of codes. Did you want to elaborate any for them? Maybe we can get some people on board to help us with that. Jason Hom: Yeah, I know. Maybe I could use the help since I've been pretty unsuccessful so far, but one example would be, I think as many of you probably have experienced at your institutions as well, one of the most common retro queries to surgical providers is about pathology reports since the past report typically takes a while to come back as the pathologists are very thoughtful. And oftentimes doesn't come back until post-discharge. And countless surgeons have asked this seems clinically like a logical system that I have to confirm the pathologist's findings when the reason I send them the biopsy is to get their expertise because pathology is the gold standard. So they do have an advocacy project regarding that. We do have another advocacy project regarding pressure injury diagnoses, too. That's a relatively common query here based on the [inaudible 00:39:45] nurse's documentation. So CMS does have a specific group about reducing documentation burden and that's the group that we've been reaching out to. Mark LeBlanc: Thanks. And I think we'll talk a little bit about, as well, some more information. And then PSI 12, the fact that you can't really determine and/or query for the POA status. So there's some talk around clinically doing a lower extremity ultrasound screening on transfers and our high risk admissions so that we can substantiate that there is no clot [inaudible 00:40:29] at that time. So, like I said, the data analysis and validation is a big part of quality and the initiatives that we do, goals and messaging, alignment. So making sure that we align our goals with the organizational goals and the service line goals and making sure that we're all working towards the same sort of goals and with the patient center and mission-minded. And then we talked a lot about transparency of performance, so making sure that we have some sort of dashboard and that it is transparent and out there for all to see. And, as Jason said, there's a whole advocacy around thinking big. Mark LeBlanc: And so CMS has an initiative called Patients Over Paperwork and they want to reduce unnecessary regulatory burden to allow providers to concentrate on their primary mission, improving patient health outcomes. So, like we said, why do we need to have the doctor write a pathologist? We should be able to code directly from the pathology report. Why do we need to have the doctor the wound care nurses there, the experts? Why can't we just code directly from wound care? And you can take it to a lot of things. Most medical schools don't teach malnutrition or any kind of nutritional type stuff now, so providers are reliant on the dietary departments to go in and do those assessments and do those diagnoses. And so why do we need to get them to write it? Why can't we look at patient care as we do in the hospitals and as a multidisciplinary team? And we should be able to use the team member's documentation that's pertinent to that type of work to capture codes from and show the outcome because they are part of the quality, and the outcomes, and the patient experience. Mark LeBlanc: So that's a biggie that we're working on. Anything you wanted to add, Jason, there? Okay, cool. Let's see. So some high points, just make sure that you take a collaborative approach. We feel like that's really the best way to review PSIs. And make sure you keep your patients at the center of the work. It's always good when you have multidisciplinary teams and even just all teams and all peers. And just make sure you acknowledge, appreciate, and leverage all the skill sets. Make sure you have clear and manageable processes, make sure you use data. As we all know, data is key for everything now and making sure that you can monitor that and to show your program's success or areas for improvement. Make sure you are always taking feedback and everybody that's part of the group should be able to feel confident that they can give feedback, and that they can ask questions, and be able to be part of the team and just celebrate the success. That's a key that I try to do all the time with every little thing. Mark LeBlanc: And we do it in our daily huddles, we talk about personal successes, team successes. And so I think that's key. Anything you want to add there? Okay. So for us, some of the things that we're continuing to work on is our data validation, which we're continuing to do, socializing our actual efforts. I think that's been a big thing for me in the last few meetings where we've developed some slides similar to the one I showed earlier on around what is a documentation review. What does that mean? Who are the people looking at your documentation? How many times? Why are they writing queries? And then all the work that goes on behind the scenes, the second level reviews, and then these multidisciplinary reviews, and the focus reviews. And I think that as more and more of the organization understand all the work, I think that they become very appreciative and become less questioning of the accuracy of the coding and the data. And willing to start talking about other clinical issues, as well, at that point. Mark LeBlanc: And then we are looking at readmissions and population health outcomes this year. That's part of some of our quality initiatives that we're going to be adding to our plate in FY22. And that's it for our presentation. I think the next one is a quick poll. Lisa: Great. Well, thank you both. That was a ton of information and fantastic information. We have a lot of questions that we're going to try to get to as many as we can. I am going to launch just a quick poll as we start getting into these questions. If you are interested in getting information about quality, best practices, and metrics, let us know. Let us know here and we will send you an email about this. So let's just go ahead and get into these questions. We had several around the actual tool within Vizient and just generally what tools you are using. Can you go into a little bit more detail around the Vizient tool and how that works with the process and system? Mark LeBlanc: Yeah, so the .RCC is actually an electronic health record tool, but it's a smart phrase or it's built within the electronic health record. So they fired this smart tool and it gives them a dropdown menu. So if people are familiar, like for Jason, would fire the medicine one and then it might say one of the first categories might be electrolytes. And then there might be choices, like hyponatremia. And then so as he's clicking, it's a click functionality. So you click on the diagnosis, then it gives you another. Sometimes if it's more acuity, it may be acute or chronic. And then it clicks all the way down to whether it's TLA or not TLA. And every category and every diagnosis also has free texts because you can't just limit the providers to just the pre-populated one. So they have to have the ability to free text as well. And so we built categories based off of Vizient models. And within those categories we have the diagnoses identified. And then each service line we work with them individually to decide which of the ... Mark LeBlanc: We may have 30 categories and they may only want three categories because their models that they are based off of it only includes four of those categories. So they only want four. And others may want 10, so that's how we built it and how we manage it. Do you want to add something, Jason, that might ... I don't know if I'm making sense. Jason Hom: Yeah. No, I think that's well said. I think Mark alluded to this previously, but Vizient does change their models periodically. So they have a different multiple linear regression model for mortality, for length of stay, for cost for each DRG. So we do review those model updates periodically to make sure that the tool which is embedded in the admission and discharge templates is periodically updated. In terms of looking at the data, so we not only track did providers fire this tool within their HNP or their discharge summary, but now we're also tracking what we have deemed like a meaningful use of this tool. So we have a crude proxy for that, which is did the provider select at least one diagnosis within this tool? Obviously, I say that's a very crude metric because it could be the case where there were more diagnoses that should have been selected. There are also some times where it probably makes sense not to select any diagnoses within this tool, but we are trying to be as data-driven as possible. Jason Hom: And analyzing the use of the tool to help inform is there a particular service line or a particular provider group that we could chat with some more and provide a little more encouragement for. Mark LeBlanc: Yeah. And the specialists also use some of the Vizient tools that Vizient provides as part of their engagement, that they can go in. And once they identify the working DRG, they can then go in and look at all of the different diagnoses that could impact it. And then look to see if there's an opportunity to query on any of those because a lot of times they're not like your standard CC, or MCC, or SOI, or ROM drivers. Sometimes they can be very on something you hadn't thought of. After we've used all the tools we have, we do also take this tool and look to see if there's other opportunities to improve the quality outcome. Lisa: So a follow-up question with the tool and other tools that you're using, which EMR are you utilizing? Mark LeBlanc: Are we allowed to say? We're in [inaudible 00:51:32] Lisa: Okay. We won't stay on that one too long then. All right, so another question that we got from Chelsea, what does your staffing look like for CDI? How do you determine how many CDIs you need to complete all the work and collaboration? Mark LeBlanc: That's a great question. I can tell you what our current model is. So we have nine specialists who do the reviews on the front end and those nine specialists are supported by four service line specialists who help to support them and the work. And then there's two educators and two quality and outcomes, so that makes up the entire CDI team at this point. Well, we definitely look at our review rate and trying to figure out. I mean, we always are needing more staffing and we'd love more. I think the sweetest spot we have right now is the service line leads. They each have about five or so service lines, five to six. And that seems to be fairly manageable to be able to do all the work that we're doing from that perspective. So that seems to be a good spot for us there. We probably need a few more specialists to get our review rates up, but we definitely are using the 3M tool. And so we use prioritization and I definitely feel like with the staffing we have we're getting to the cases that we need to get to. Mark LeBlanc: And the ones that we aren't getting to I'm monitoring on the back end to see if there's retro query shift and I'm not seeing that happening. And so I feel like we're probably in a good spot from that perspective and that's how I try to make sure that our prioritization is working. Lisa: Okay, great. So another question that we have from Alicia, your program seems highly integrated. Do you work on site or remotely? And do you focus on productivity as much as the quality of the CDI coding? Because communicating with all those involved would appear to take a lot of time, what is the productivity expectation? Mark LeBlanc: So since the pandemic we are fully remote. Prior to that, we were on site with two days a week remote, but now we're fully remote. We're no longer on site. I watch productivity, but I don't look at productivity alone. So I'm looking at people's reviews, their queries. We monitor how many times they interact with providers, the specialists do. They track when they get a call or they call a provider or do any sort of individual education. So I look at it as a whole picture, so I'm really working hard before I leave this profession and retire to try to help set the new standard of what is best practice in CDI. And I definitely think it's more around quality focus than it is review focus, but I don't have the magical answer. I will say that the service line leads, that's really the majority of their time is spent in interactions. And so that is the majority of their work, is just putting together metrics, and dashboards, and meetings, and going and doing presentations. Mark LeBlanc: So the expectation for them is to be less and doing the work. And that they don't do reviews in the system, per se. They do do the escalation of our queries, so they get involved because they're really the ones who have the relationships with providers. So we get more out of their involvement in the escalation process, but other than that they're mainly just doing meetings and presentations. Lisa: Great. I think we have time for one more question. This is from Tara. In your quality strategy, do you take into consideration the payer's criteria of certain diagnoses as it relates to potential DRG denials? For example, recently United Healthcare, which is a big auditor, has put out that they will be using sepsis-3 criteria starting July 1st. Mark LeBlanc: It is not in our current strategy, per se. We are definitely in the next year have some initiatives around what we call the DRG downgrade denial, where they don't actually deny it. They just say we're going to downgrade the DRG from this one to this one, throw out an MCC, or throw out a CC, or change the principal diagnosis altogether. So from that perspective, I think that's where we'll probably get involved with some more of these individual type payer things, but we have not at Stanford been that involved and we've definitely been pushing. And I think FY22 is the year that we will be at the table because we're getting more and more involved from that perspective. And I do see a change in the environment, that we will definitely be there. Lisa: Fantastic. Well, again, the information today has been fantastic and we appreciate you taking the time to answer all the questions that we were able to get to. Just a reminder for those that are on today, if you could complete the survey, we really appreciate your feedback about the content of today's presentation. If you are interested in learning more about any of the 3M products and solutions, there is an opportunity to complete that in the survey, as well, if you'd like some follow up for that. And don't forget, we will be sending out the archive of the presentation as well as the reporting. And within that email you will have the opportunity to register for our next CDI innovation webinar, which will be in August. And, again, we appreciate it. To both Mark and Jason, do you have any closing statements that you would like to make? Mark LeBlanc: Thanks for the opportunity to share. We're always willing to do that. And if people want to reach out afterwards, please give out my email address and you can reach out to me. Lisa: Perfect. Jason Hom: Yeah, likewise. Thanks so much for the opportunity and feel free to reach out. You can email me. Lisa: Absolutely. Well, thank you to you both and we look forward to hosting you the next time. So take care, everyone. Mark LeBlanc: Thank you. Bye-bye. Mark LeBlanc: (silence)