Resident integration with inpatient clinical documentation improvement: a quality improvement project

Clinical documentation improvement (CDI) is an increasing part of health system quality and patient care with clinical documentation integrity specialists (CDIS) expanding into daily physician workflow. This integration can be especially challenging for resident teams due to increased team size, lack of documentation experience, and misunderstanding of both CDIS and CDI purpose.

The University of Kansas Health System Internal Medicine residency programme reported challenges with CDIS and resident workflow integration specifically in navigating and understanding CDIS documentation queries, CDIS interruption of interdisciplinary huddles, and general misunderstanding of CDI and the role of CDIS.

A quality improvement project was undertaken to integrate CDIS more effectively into resident workflow. Combined with a resident debrief session to identify general areas of concern, surveys were administered to internal medicine residents, resident rounding faculty and CDIS team members to identify specific barriers to CDIS-physician integration.

A collective group of CDIS member teams, internal medicine chief residents and faculty physicians was formed. Changes made to the CDI process based on survey feedback included (1) improving formatting of CDIS electronic query templates, (2) standardisation of timing for CDIS verbal queries during interdisciplinary huddles, and (3) development of a resident didactic session focused on the role of CDIS and documentation's impact on quality, safety and outcomes as related to the hospital, provider and patient.

Surveys completed after implementation showed a positive impact on electronic query template changes and perception of CDIS at interdisciplinary huddles. The didactic curriculum was effective in helping residents understand the role and limitations of CDIS and how documentation affects quality of care.

CDIS-physician integration into resident teams can occur through a collaborative focus on specific aspects of physician workflow and improving understanding of the impact of CDI on patient safety and quality of care.