Hospitals have implemented clinical documentation improvement (CDI) platforms to improve their workflow processes. Light Medical Center executives assumed that CDI could not sufficiently support coding and other related functions. Consequently, the executives opted for additional extension of computer-assisted coding (CAC) to support workflow for the CDI environment.
However, Light Medical Center realized that CAC did not facilitate workflow and the focused shifted to coding rather than reinforcing and supporting clinical identification of errors as expected. Further, Light Medical Center failed to capture vital data, missed certain financial data and other critical opportunities. The CDI failed to benefit the facility, and it was restricted by the CAC deployment. In short, technology systems deployed failed to support the workflow, instead they led to more work and several errors in documentation of patient data.
Myths, Misconceptions, and Barriers
Multiple myths, misconceptions, and barriers are responsible for the lack of foresight and/or creativity in the company. Consequently, they hinder innovation at the organization. A widespread belief is that competition is superior to collaboration. Light Medical Center strived to advance CDI and technology adoption, and most departments implemented various IT solutions to support their work. However, creativity suffered most because competition for resources increased while collaboration was ignored. Departments and individuals also competed for recognition. Consequently, there was limited knowledge and information sharing.
Light Medical Center is not endowed with sufficient resources to serve all departments and personnel adequately. This led to a popular narrative that limited resources hindered creativity and that most creative organizations had abundant supply of resources. They claimed that creativity and constraints could not foster innovative solutions at Light Medical Center.
Many employees also believed that creativity emanated from innately creative individuals (Dyer, Gregersen, & Christensen, 2009). That is, some employees are creative, and others are not. Many employees believe this narrative, and leaders tend to support such claims by hiring external consultants, deploying additional resources, or outsourcing some functions.
Some critical barriers have been noted in the company. CDI specialists had limited focus while nurses and physicians who coded information had different objectives. Limited collaborative processes were observed in the organization, which ultimately stifled creativity. CDI differed significantly from coding. While the CDI department could assign some codes to ensure that functional codes were captured, the CDI department-derived codes were not always adopted in the final analysis of bills. The CDI unit focused on identifying possible quality drawbacks, reimbursement, and specific diagnoses instead of every diagnosis.
Light Medical Center understood that CDI specialists would facilitate workflow processes. In this regard, the organization anticipated that physician education would occur when members from various departments interacted and ultimately enhance documentation processes and behaviors. Moreover, much attention was focused on the number of reviews completed. As a result, most CDI specialists had limited time for information and knowledge sharing. Hence, there were multiple missed learning opportunities in the organization.
Light Medical Center also suffered from technology issues. One major complaint among CDI specialists was that they were unable to customize the CDI platform to meet their workflow needs and specific demands. While it is necessary for specialists to develop supporting manual interventions to meet their unique needs, Light Medical Center had opted for CAC, which led to multiple integration issues. Technology is meant to enhance efficiency. However, in this case, the organization had encountered technology barriers to its workflow processes. Moreover, additional CAC required more coding in the workflow.
Divergent and Convergent Thinking
Both divergent and convergent thinking are important for the generation of effective creative solutions. That is, both thinking styles must work together for new solutions to be realized. Some creative solutions without the necessary convergent thinking, for instance, could lead to innovation risks.
The first strategy to accommodate both convergent and divergent thinking styles involves the summation model. In this case, both divergent and convergent thinking styles play joint roles. Divergent thinking provides new ideas to convergent thinking or compensate for the inadequacy identified. The pre-requisite model shows that basic minimum prior convergent thinking involve acquisition of straight, factual knowledge, which is mandatory before any solution can be generated because divergent thinking requires some contents on which it can run.
At the threshold level, the ability to gain information increases through convergent thinking styles and the possibility of divergent thinking advances. That is, both forms of thinking appear correlated. Further, the channel allows the convergent thinking to offer a pathway or channel via which information passes to reach the divergent thinking systems. Hence, the creative individuals will process specific information. Later, the capacity model will control the exact material that goes to the intellectual structure through convergent thinking while divergent thinking will be allowed to work on the available data.
The second approach embraces the style models. Ideas generated using both thinking styles will be recognize as independent and do not have direct influence over each other. The team will be allowed to apply their superior ability to gain new insights, process and capture information, develop abstract concepts, create general relationships, knowledge matrices, systems and other related elements. In this case, thinking abilities will determine whether convergent or divergent thoughts are generated, which reflect new or existing ideas. The difference between these two thinking styles appears as qualitative instead of quantitative. Overall, mental processes can be divergent or convergent.
The final approach is alternation. In this approach, it is observed that divergent thinking is required in some instances and convergent thinking in others while in other cases the two are necessary. The critical notion in this case is that both divergent and convergent thinking styles are necessary for generation of creative solutions. However, they might not be necessarily needed simultaneously in the process, and that the creative team may alternate between the two styles.
These three strategies show that both divergent and convergent thinking styles are necessary for creative solutions. The team will use them to support each other effectively to generate novel ideas and solutions.
Mind Mapping
Technology issues are associated with integration challenges where CAC cannot sufficiently be integrated with CDI. CDI cannot be easily customized to meet specific needs of the Medical Center. In addition, intricacy of ICD-10-PCS shows that most physicians would not document all the required information in the same order as expected for coding purposes. Cases of wrong terminologies also restrict functional outputs. For instance, the CAC system can only identify words found in coding terminologies. However, failure to use the right terminology would mean missed opportunity for CAC.
Physician limitation is associated with limited time to learn, emphasis on the number of documented records, too much documentation, and limited end user training.
Workflow challenges are noted in competition rather than collaboration, CDI specialists’ narrow focus, coding errors, and failure to capture those errors. In this regard, technologies fail to meet their roles for the Medical Center.
Resource availability focuses on lean staff, segmented units and departments, staff competition and system limitations. In this case, creativity suffers significantly at the Medical Center.
Design Thinking
Notable correlation is observed between innovation and design thinking. Precisely, innovation models can be easily accommodated in design thinking principles to enhance capabilities of the design team and processes that facilitate innovation. From the IDEO observation, innovation accounts for three critical elements, including user desirability, business feasibility, and technology practicality. The design processes will be applied to ensure that the Medical Center attains these three elements in problem solving and subsequently finds creative solutions to technology failure to support workflow.
First, the user-centered design will be user focused. That is, system users will be at the center of all processes that focus on problem solving at the Medical Center.
Second, the design process will be based on solid business case. That is, when coding errors, missing documents, incomplete documentation, and conflicting information occur, the Medical Center usually suffers losses and possible significant cost disadvantages associated with the CAC and CDI applications. Hence, a business case to demonstrate feasibility is necessary.
Finally, development, testing, and validation of solutions are important for design thinking processes. Prototypes assist in solution development while testing allows feedback to be obtained for improvement. Solutions are assessed for potential issues before deployment.
While these major principles and others have shown that design thinking can deliver innovative solutions to an organization, one must however recognize that they are insufficient and may not reflect the reality. Hence, innovation may not be realized due to some fundamental barriers that should be addressed.
First, design thinking is known for its individualization and collaboration approaches at various points during solution generation in order to attain the best ideas. However, creativity is a function of individual efforts and thoughts during the initial stages. Later stages usually require collaboration and idea sharing for improvement. It is not clear how competing departments would collaborate to find the best ideas.
Second, design thinking requires sustained processes once started in an organization. There should be a dedicated design team to drive this agenda. In fact, external consultants cannot deliver sustained innovative solutions at all times. Thus, it is necessary for the Medical Center to create an environment that supports innovation in different ways. The right leadership, customized processes, and empowered employees will be required to drive innovation at the Medical Center.
Third, an effective design thinking process starts with a thorough understanding of end users. However, precise scoping of issues to guide processes and strategic business objectives could be difficult to attain. Hence, most design thinking strategies may lack a clear roadmap to guide innovative solution generation. Consequently, it leads to wasted resources and efforts. Further, wrong implementation process intended to deliver the ultimate solution would also hinder progress. As such, it would not be possible to optimize efficiency from a flawed process and poorly developed solutions. This implies that the value and solutions delivered through design thinking are rendered ineffective.
Testing Potential Solutions
Efficiency testing protocol
Efficiency can only be achieved by eliminating CAC in the CDI function because it acts as a barrier rather than a solution. In most instances, the Medical Center has demonstrated that CAC has not failed to address specific needs of the CDI unit. CDI concentrates on missing data identification from disparate sources and pieces of patient data. In all these, CAC has failed to show that it can sufficiently replicate intricate processes for CDI. CAC also shifts attention to coding and fails to support the core function of missing data detection. Hence, CAC does not currently benefit the Medical Center. Instead, it leads to complex workflow processes because of additional coding, failure to detect missing information, and it impairs ability to detect missing information.
Testing processes for this solution should demonstrate effective, improved CDI processes. Further, notable technology limitation would be realized. The CDI technology would be customized to capture data from admission, discharge, and transfer to ensure that the unit can prioritize its goals.
Further, CDI unit will ensure that the CDI is flexible enough to support its workflow. In this case, supplementing manual procedures may be effective for improving processes rather than using CAC.
Learning testing protocol
CDI specialists are not physicians, but they possess immense knowledge in CDI technology application and documentation, which physicians do not have. Thus, learning to enhance documentation practices and behaviors is core to this solution. For instance, CDI specialists should demonstrate the importance of effective documentation, how it is perceived, and related to coding processes with the simplest terminologies.
Results should demonstrate increased learning opportunities for physicians and documentation practices and behaviors.
Collaborative testing protocol
The Medical Center appreciates its lean resources. Hence, staffing constraints usually hinder CDI efforts to deliver reliable information, advance learning, and collaboration. It is noted that once CAC has been dropped and a new, robust CDI platform is implemented, workflow efficiency would improve and reduce demands on few constrained CDI specialists. Consequently, collaboration would increase tremendously.
Learning, information sharing and capture, minimal errors, staff engagement, and improved efficiency would reflect collaborative processes at the Medical Center (Hoever, van Knippenberg, van Ginkel, & Barkema, 2012).
Creativity and Ethics
CDI functions are critical for reimbursement and decision-making in healthcare facilities and in Medicare and Medicaid services. However, ethical issues may emanate during these functions.
CDI specialists may take part in or sustain inappropriate recording tendencies meant to improperly inflate payment, secure insurance policy coverage, and/or distort figures through ways that contradict federal and state laws and regulations and official rules and guidelines of the Medical Center.
Moreover, CDI specialists may engage in unethical practices related to data omission or fail to correct incorrect documentation, and add unsupported procedures and diagnoses with the aim of influencing reimbursement, demonstrate the need for medical attention, and enhance appearance of publicly reported information.
Finally, CDI specialists could fail to protect data confidentiality and gain access to protected health records not necessarily needed for their job-related roles. Such breaches of confidentiality often have severe legal consequences.
The suggested innovative solutions focus on ethical practices (Schumacher & Wasieleski, 2013). By withdrawing CAC platforms, educating staff, and promoting collaborative processes, no ethical issues are expected to arise. Nevertheless, care would be taken to ensure that written policies and procedures, produced collaboratively among CDI specialists, medical personnel, Health Information Management (HIM), quality assurance department, and case management and compliance teams are strictly consistent with the expected federal and state regulations, Medical Center practices, and the industry best practices.
References
Dyer, J. H., Gregersen, H. B., & Christensen, C. M. (2009). The Innovator’s DNA: Mastering the Five Skills of Disruptive Innovators. Harvard Business Review, 2-9.
Hoever, I. J., van Knippenberg, D., van Ginkel, W. P., & Barkema, H. G. (2012). Fostering Team Creativity: Perspective Taking as Key to Unlocking Diversity’s Potential. Journal of Applied Psychology, 97(5), 982–996. doi: 10.1037/a0029159.
Schumacher, E. G., & Wasieleski, D. M. (2013). Institutionalizing Ethical Innovation in Organizations: An Integrated Causal Model of Moral Innovation Decision Processes. Journal of Business Ethics, 113(1), 15–37. doi: 10.1007/s10551-012-1277-7.