Journey to Clinical Documentation Excellence at Centura Health

Shelley Clyne, MD, Enterprise Physician Advisor, Centura Health; Karen Simonenko, VP & GM, Clinical Quality and Revenue Integrity, Nuance; and Lisa Baris Schweppe, RHIT, CCS, CCDS, Director, Health Information Management, Nuance.

In 2018, Centura Health analyzed their Case Mix Index (CMI) data and found the clinical documentation process was among the functions most ripe for performance improvement.  The high-quality care that providers were delivering to patients wasn’t adequately captured in the documentation.  As part of an organizational initiative, Dr. Clyne combined her clinical skills with an understanding of the importance of Clinical Documentation Improvement to transform the program, educate providers, and re-invigorate the team.  Through this transformation, a focus on quality and analytics evolved, leading to improvements in Patient Safety Indicators (PSI) and quality ratings.  Dr. Clyne, Karen and Lisa share the journey, and the lessons learned along the way.