Volume 1

A Meeting of the Minds, or Who Is Responsible

Previous Chapter | Next Chapter: Clinical Documentation Quality Applies to All Settings

As with any strategic initiative, it is important to start at the top to show support for the direction the organization is taking. The leaders at the top in most healthcare organizations include the CEO, CFO and CMO. There may be others, but a common understanding of what is to be achieved and why, by this small group, along with excellent communication and support structures, will ensure success.

The team’s responsibility starts with communication about the vision, or the reason why the activity is being pursued. Every organization has its own model for implementing new functions that is driven by its culture and values. There are six basic activities that, if undertaken by the executive management team in your hospital, are likely to result in a more sustainable and successful clinical documentation program. These activities are described in detail in chapter 7.

Chapter 7 also describes the teaming process used in some healthcare organizations to achieve synchrony at the top level. The chapter also discusses some of the specific challenges with physicians who are employed versus those with admitting privileges only. Pulling all physicians into the fold requires some common elements and some designed specifically to meet the needs of the attending versus the employed physician.

Finally, special issues related to teaching hospitals and the participation of house staff is addressed. In particular, their relationships with attending physicians, clear communication of expectations, and consistent enforcement of the policy, as developed by the organization, are addressed.