1st Edition

Successful Collaboration in Healthcare A Guide for Physicians, Nurses and Clinical Documentation Specialists

By Colleen Stukenberg Copyright 2010
    136 Pages 12 B/W Illustrations
    by Productivity Press

    This critically acclaimed work makes the case for collaboration and shows that it can be greatly enhanced with conscious understanding and systematic effort. As a healthcare specialist who has worn many hats from direct care giver to case manager to documentation specialist, Colleen Stukenberg is able to –

    • Show how to build trust and communication and demonstrates specific opportunities where collaboration can make all the difference
    • Identify ways that quality of care and financial factors overlap and the advantages that can be garnered through an understanding of this
    • Explain how those in different roles view information through different types of knowledge and how an understanding of each perspective makes it easier to find the best source for important answers
    • Discuss the education and ever-increasing role of the clinical documentation specialist who is often involved in all facets of a patient’s progress, from intake and admission right up through discharge.

    As the author points out, good healthcare is dependent on the right person performing the right role, which promotes excellent collaboration. And when people are allowed to function in their proper roles, job satisfaction increases, which in itself leads to better attitudes, which then leads to even deeper levels of collaboration and with it, the successful promotion of safe, quality care.

    Chapter 1 Introduction
    Chapter 2
    Building Trust and Communication
    Communication Styles
    Aggressiveness
    Passive-Aggressiveness
    Passiveness
    Assertiveness
    Aspects of Communication
    Communication and Trust
    Emotional Maturity
    Communication Assessment
    Code of Conduct
    Communication Template
    SBAR: Situation, Background, Assessment, and Recommendation
    Knowledge Differences
    Working Together
    Nursing Roles and Collaboration
    Other Opportunities to Collaborate
    Summary
    References
    Chapter 3 Impacts: Quality and Financial
    Length of Stay and Diagnosis-Related Groups
    DRG
    Hospital-Acquired Conditions
    Present on Admission
    Impacts of DRGs, POA, and HAC
    Post-acute Transfer Policy
    Outlier Payments
    Public Reporting
    Recovery Audit Contractors
    Considerations for Preparing for RAC
    Summary
    References
    Chapter 4 Clinical Documentation Specialist: Who Is Involved and What Is the Process?
    CDS Role
    CDS Process
    CDS Worksheet
    Unit-Based versus Physician-Based Model
    Chart Review
    Query Aspects
    Query Criteria
    Technology
    Systematic Review Method
    Physician Response Concerns
    The Working DRG Assignment and Impacts
    An Internal Audit
    Completing the Loop
    Data Collection and Considerations
    CDS Role Allocations and Job Description
    CDS Support
    Summary
    References
    Chapter 5 Clinical Documentation Specialist and Education
    CDS Training
    Clinical Knowledge and Experience
    Coding and DRG Terms
    The Query Process
    CDS Continued Education
    CDS and Nursing Education
    CDS and Physician Education
    Keeping Current and Understanding Change
    Applying Change
    Summary
    References
    Chapter 6 Collaboration with Hospital Case Management
    Case Management Legal and Quality Considerations
    Case Management and Ethical Aspects
    Importance of Clinical Knowledge and
    Case Management
    Terms for the Case Manager
    Case Management and the Admission Process
    Case Management and Physician Collaboration
    Case Management and Accurate Documentation
    The Discharge Plan
    Discharge Planning Checklist
    Multidisciplinary Team and Discharge Planning
    Readmissions
    Case Management and Post-discharge Follow-Up
    Case Management and Data Collection
    Summary
    References
    Chapter 7 Putting It All Together
    Scenario 1
    Scenario 2
    Scenario 3
    Scenario 4
    Summary
    References
    Chapter 8 Final Thoughts
    Index
    Author

    Biography

    MSN, RN, CMSRN, Clinical Documentation Management Specialist FHN Memorial Hospital

    With the rising importance of health care information, this book provides a broad but detailed overview of the role of the clinical documentation specialist (CDS). … The author, who has more than 20 years of nursing experience, portrays the role of nursing with accuracy and acumen. Her publication is unique, as evidenced by my literature search, which uncovered only two articles on the topic of the CDS. This book provides not only a comprehensive description of the CDS role, but also an excellent overview of the financial aspects of health care, especially coding and accurate diagnosis-related group (DRG) classification. … Overall, this book is an excellent resource for all clinicians who relate to the issues in health care that affect safe and quality patient care, the key word being collaboration.
    —Donna L. Baker, MS, APRN, ACNS-BC, CNOR, Medical Science Liaison Baxter Healthcare, in AORN Journal, Vol. 92, No. 6, December 2010

    Colleen Stukenberg writes from the perspective of one who has been there and done that. She is a skilled teacher who shares lessons she has learned in the trenches.
    —Beth Gale, RN, BSN

    Colleen has successfully navigated the clinical and front-end-revenue cycle job market over the last 20 years. Her acute care nursing, case management, and long-term care experience has built a well rounded and solid foundation for our Clinical Documentation program. Her vast knowledge and know-how has actualized one of the more successful documentation programs in the industry with the financial gains in a rural hospital rivaling major urban medical centers. Colleen is definitely an authority on Clinical Documentation programs and has much to share with her peers.
    —Tamar Gorenyuk, MBA, RHIA, Director, HIM & Resource Management, Freeport Health Network

    Colleen is a recognized expert in the field of Clinical Documentation Improvement (CDI). Anyone interested in implementing a successful Clinical Documentation Improvement Program should read this book before starting the process. Never before has this valuable information been presented in one, all-encompassing reference. The material covered in this book will help executives make informed choices about whether or not to hire a consulting firm and if so, which firm will best meet their needs. Colleen's perspective and experience implementing a CDI program provides the reader with time-tested tools of the trade and advice that will help guide new CDI Programs to excellence while avoiding the common challenges faced by faltering CDI Programs.
    — Lynne Spryszak, RN, CCDS, CPC-A, Manager, Precyse Solutions, LLC