Innovative program at Bayshore sets standard for other hospitals to follow Bayshore Community Hospital, Holmdel, is proactively setting the standard for a type of program that will soon become essential for all hospitals and medical centers. Clinical Documentation Improvement (CDI) team members at Bayshore Community Hospital, Cathy Egan (l), CDI/coding manager, and Sally Klemm (right), R.N., CDI specialist, recently participated in the second annual Medical Documentation and Coding Process Improvement Conference in Chicago, Ill., where they spoke about how to deliver a successful CDI program like the one established at Bayshore. About a year and a half ago,Bayshore formed a team of professionals with the goal of improving clinical documentation practices within the facility.Physician clinical documentation is required to record a patient's health history,diagnosis, treatment and outcome. It is important that this documentation is legible, timely and comprehensive because the information is then translated into coded data,which is used to describe the patient's hospital encounter and severity of illness.Because the current health-care marketplace is constantly changing the rules for participation, the process of translating a physician's clinical language into regulatory, financial and quality languages requires a diligent and concerted team effort.The administrative leadership team at Bayshore understood the importance of good clinical documentation practices and had the courage and foresight to approve a budget to foster a Clinical Documentation Improvement (CDI) program at the hospital. The Bayshore CDI professional team includes registered nurses, certified coders,health information professionals and physicians.Their mission is a commitment to promoting clinical documentation excellence and data accuracy through innovation, education, communication and by building successful multidisciplinary relationships within the organization. The team is focused on bringing increased awareness about the importance of accurate and precise clinical documentation among physicians and hospital employees.Through improved documentation practices, the hospital is able to report more specific and accurate coded data to the agencies that monitor regulatory compliance and patient outcomes such asThe Department of Health (DOH), Joint Commission on theAccreditation of Healthcare Organizations (JCAHO) and Centers for Medicare and Medicaid Services (CMS). Bayshore hospital is committed to achieving the best scores within these agency ratings. In less than two years, the CDI program has increased the number of Bayshore physicians receiving an internal five-star Documentation Excellence rating by 15 percent. Since physician documentation is also tied to appropriate reimbursement, CDI programs will soon become imperative for all hospitals.This year CMS has proposed many significant changes to the way hospitals and medical centers will be paid.One change involves creating different levels of reimbursement based on the severity of a patient's illness. Therefore,more specific diagnoses will need to be documented to better reflect a patient's condition, a concept already adopted by Bayshore through the CDI program. Bayshore was sought out by the World Research Group to participate in the second annual Medical Documentation and Coding Process Improvement Conference in May in Chicago, Ill., as a model for executing this type of program. Bayshore CDI team members, Cathy Egan,C.C.S.,Clinical Documentation Improvement/coding manager, and Sally Klemm,R.N.,Clinical Documentation Improvement specialist,were asked to give a presentation about how to deliver a successful Clinical Documentation Improvement program like the one established at Bayshore. "We were very pleased to find that large, teaching hospitals such as Beth Israel Deaconess Medical Center [an affiliate of Harvard Medical School] are performing the same type of initiative as our small community hospital. It shows that our program is as good as the best." said Egan."Our commitment to relationship building and teamwork is what has made this program more successful than those attempted at other area hospitals." "Our success with this program would also not be possible without the cooperation of the Bayshore physicians and clinical staff," said Klemm."They realize the importance of accurate and consistent medical documentation and want to help make patient care at Bayshore the best it can possibly be." Cathy and Sally will be delivering an encore presentation on Oct. 27 at the third annual Medical Coding and Billing Conference hosted by Monmouth Ocean AmericanAcademy of Professional Coders at Branches inWest Long Branch. Interested parties can register at www.monmouthnjcoders.org. Bayshore Community Health Services (BCHS) has expanded tremendously over the past 35 years.BCHS has increased the services offered at the main health-care facility,Bayshore Community Hospital in Holmdel, and also operates specialized health-care facilities reaching far into our neighboring communities of Monmouth and Middlesex counties. Treatment options and programs have been expanded to meet the growing needs of the community,delivered by a staff of over 2,000 dedicated physicians, nurses and health-care professionals. Bayshore Health Services is changing, to change your life. Bayshore Community Health Services is affiliated with RobertWood Johnson University Hospital,RobertWood Johnson Health Network andThe Cancer Institute of New Jersey. For more information, visit www.bchs.com.