Clinical Documentation Improvement (CDI) Health System Regulation

Situation

SwedishAmerican Hospital (Swedish), a 333-bed, full-service, nonprofit hospital located in Rockford, Illinois, provides over forty different specialties, as well as outpatient, wellness, and education programs, to the greater Rockford region, northern Illinois, and southern Wisconsin. Leadership wanted to ensure that the hospital’s clinical documentation integrity (CDI) program, which had been in place for several years, performed at best practice standards. The organization collaborated with BRG’s CDI experts to evaluate and revitalize Swedish’s program.

Solution

BRG professionals launched a comprehensive review of Swedish’s CDI program and implemented improvements to capture missed opportunities for complete and accurate physician documentation and to improve severity of illness (SOI) and risk of mortality (ROM) scores. The effort centered on education for clinical documentation specialists (CDSs), coding professionals, and physicians; performance development; process improvement; and monitoring metrics.

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