Physicians don't always realize the correlation between their clinical documentation and the level of credit they get for providing quality patient care.
[Editor’s Note: the following blog was written by Jennifer Woodworth]
No one chooses to work in the healthcare industry because it’s easy. We do it because we want to help others. The mounting frustrations doctors face as the result of an increasingly burdensome healthcare system are not only understandable, they are justifiable. These men and women did not go to medical school to sit through hours of meetings about code sets. Their primary responsibility is to treat patients. And for those of us who work with them, it is our role to be the trusted partner of our doctors and clinical care teams — to ensure they share the right information where and when it’s needed. I’ve spent close to a decade working with physicians on clinical documentation to make sure it reflects their intent and they get credit for the level of care they are providing.
Over the years, the doctors have taught me some valuable lessons. When it comes to implementing a successful clinical documentation improvement (CDI) program, start with these three fundamentals:
Skip the catering: meet your doctors where they are
Everyone is busy, especially doctors, and initially, we tried to engage with them by holding early morning meetings where we provided breakfast and information about our CDI program. We quickly discovered that we were left with not much more than a tray of cold eggs and pancakes. So we made adjustments and began meeting doctors where they were — in their departments, on grand rounds and within the agenda of a medical staff meeting. This significantly improved physician engagement and helped us better collaborate on capturing the patient’s care in a way that was accurate and complete not just to other doctors. CDI programs are not one-size-fits all, and keeping this in mind as you reach out to your physician teams is very important.
Become a translator for health IT language
Because specialty groups each have their own medical vocabularies, different registries and workflows, they will also face unique challenges and concerns. Swedish Health Services is a multi-hospital health system that includes a heart and neural hospital. When we implemented our CDI program, we realized that we needed to tailor our approach by physician specialty — what was an important quality driver in one clinical area is not necessarily the same in another. Swedish is a “5-star institution,” and we need to uphold that reputation. So, in order to do this, we first had to figure out what each specialty group’s quality scoring was based upon, and then sit down and work with our physicians to show them the impact their documentation was actually having on their scores.
Seeing clinical data is believing
Doctors have analytical minds, after all, that’s how they decide how and when to modify treatment plans — by looking at results and analyzing the data. This holds true for clinical documentation, too. They don’t always realize that how they document is just as important as how they are providing care; in fact, it’s the proof they are doing the right thing for patients. When we reviewed our clinical data, we found that our ICU patients were typically on ventilators longer than the average, which was negatively impacting our quality scores. Sitting down with our ICU physician team, we conducted a retrospective review and discovered that the majority of these patients had pre-existing respiratory conditions that necessitated an extended time on a mechanical ventilator. It wasn’t that they weren’t receiving good treatment, it was, in fact, our doctors doing the right thing for these patients — keeping them on the ventilator longer because they needed it — that was negatively skewing our numbers. It was a simple error of omission: our doctors didn’t realize that by not fully documenting their patients’ pre-existing conditions in the clinical record, they were hurting their reputation as great doctors, and ours as an excellent hospital.
While not always easy, changing a culture to support a value-based care model makes sense: hospitals and healthcare organizations get paid, or not, based on how they care for their patients. Our physicians trust us to help them accurately represent the good care they are providing, and, in turn, we use CDI data to identify areas where together we can optimize quality to do what’s best for the patient.
The accurate clinical data that results from an effective CDI program not only helps our doctors earn credit for the good work they do, but also improves patient care and reimbursement for our organization. Accurate clinical data also enables us to get a clear picture of who our patient population is so we can adequately prepare for their future health needs. And, at the end of the day, that is what healthcare and the continuum of care is all about.
Jennifer Woodworth is the Director, Clinical Documentation Integrity Program (CDIP) at Swedish Health Services in Seattle, Washington. This blog originally appeared on Nuance Communications’ blog, What’s Next.
[Editor’s Note: the following blog was written by Paul Vosters, Discovery Health Partners president and COO]
Organizational and technology structures can keep health plans from recognizing, understanding and resolving their payment integrity challenges. However, another factor may be at the root cause of some of those challenges: eligibility.
Eligibility issues impact a multitude of payment integrity areas including Coordination of Benefits and Medicare Secondary Payer validation and, to a lesser extent, Workers’ Compensation, Other-Party Liability and Subrogation. In fact, our research indicates that approximately 30% of payment integrity costs are driven by eligibility errors. In addition to the financial cost of payment integrity errors, eligibility issues can also have a direct effect on member satisfaction. Claims that are declined due to inaccurate or out-of-date eligibility data can lead to member abrasion and lost market share as well.
At their core, these issues all stem from the fact that health plans lack a single, definitive resource for making eligibility status determinations prior to paying a claim. This creates tremendous downstream issues as health plans make business decisions and pay claims based on flawed data.
The complex structure of health plans means that member eligibility is updated at multiple points in the claims payment process and is managed by multiple departments across the organization. As a result, it’s often inconsistent, outdated or inaccurate, and leads to improper claims payments. Until plans are able to establish a single source of the truth for eligibility, these inaccuracies can cost plans millions of dollars. Let’s examine a few of these challenges more closely:
Multiple data sources
The sheer number of data sources feeding the master eligibility file has a significant impact on accuracy. Information comes from the members, providers, CMS, data-match vendors and other data sources. These feeds are all subject to their own timelines, standards and information challenges. In addition, these external feeds to eligibility status have a high rate of change, creating a complex hierarchy of overlapping status updates. Plans are challenged to manage these work processes and make a clear determination of primacy and eligibility that can support all of the transactions that rely on this data.
The eligibility challenge isn’t just technical, it is also frequently organizational. Eligibility is commonly managed by line of business, meaning that status updates made by one group are not necessarily shared across the organization. For example, changes in a member’s eligibility status might not be effectively communicated between the commercial and government lines of business as the member moves from commercial to Medicare Advantage coverage. With no clear owner of the member eligibility status, managing the data across departments adds an additional level of complexity.
In addition to being spread out across different departments, responsibility for managing eligibility status is shared by several administrative systems. Plans often make the mistake of addressing eligibility in a single point solution, rather than taking an enterprise view of member eligibility management. Claims and enrollment systems often fail to address eligibility on a consistent transactional basis, and frequently capture crucial updates in notes or text format. Eligibility data is rarely shared between systems, and because there is no single data master, the priority of status changes is unclear.
Looking to the future…
Health plans have the opportunity to dramatically improve their payment integrity performance and member retention by managing member eligibility as a business asset. The ideal solution will provide a complete and integrated picture of eligibility status across membership types and lines of business, while providing validated data for downstream applications. Doing so will require a shift in culture, as well as new technologies. Nonetheless, there are strategies that let you achieve progress in a staged progression, which we will explore in future posts. Managing eligibility data as a strategic asset is worth the effort, as it will result in millions of dollars in recoveries and cost avoidance.
[Editor’s Note: The following blog was written by Dr. Anthony Oliva]
Being able to "speak doctor" ensures that physicians are accurately capturing the level they provide to patients, and enables healthcare organizations to correctly identify their patient populations and predict their future healthcare needs.
I’ve worked as a CMO at hospital systems for much of my career, and one thing that I’ve learned is the importance of knowing how to speak doctor. This means listening for clues one physician shares with another about a patient that are critical to their immediate assessment and delivery of patient care. Physicians can communicate a lot of information very quickly, in very few words, and because other clinicians are trained to understand and to act quickly, the system worked… most of the time. Until recently. Now short written notes or verbal handoffs are a thing of the past and what is being conveyed about patients’ conditions may not be clear or may be buried in charts with note bloat, which is a real problem for money, patients, and predicting risks. Here are the three big problems you need to fix to get ready for population health:
Problem #1: Say what you mean
The way doctors speak is different than the coding language needed for billing and hospital payments. The impact is real, unrealized revenue for a hospital or health system when care is provided, but not documented by a physician in the EMR. The last place I worked realized $9 million of traditional revenue by fixing physician documentation up front, and Swedish Medical Center secured more than $18 million in appropriate reimbursement. Better translation of what doctors say up front through a Clinical Documentation Improvement (CDI) program brings predictable financial improvements.
Problem #2: It’s in the patient story details
When a doctor’s clinical documentation leaves clues everywhere in the chart pointing to a risky condition, but sparse clinical documentation leaves out specific details, good care may not look like it. That carries big risks for physicians and healthcare organizations that need to look good on scorecards and quality outcomes. When clinical speak indicates a potential condition, complication or cause for treatment, but it isn’t translated into co-morbidities or diagnosis codes in a record, a patient receiving healthcare may look much healthier than he or she really is. I can’t tell you how many times I’ve seen a chart when a patient spent three days in the ICU being treated for sepsis, which is a very serious and expensive situation, but the chart classified the patient through codes as having something close to a bladder infection because the diagnosis was not properly identified. In today’s competitive healthcare environment, a doctor cannot afford to look bad to payers or patients.
Problem #3: Know your patient population
Your crystal ball better predict the future correctly. When it comes to population health and accountable care, the rules are changing. If your charts don’t accurately reflect how sick your patients are or the conditions you treat in your community, there will be no path to population health management because you won’t really know your populations.
Healthcare is changing and everyone is assuming more risk ‒ physicians, provider organizations and even patients ‒ and in order to stack your team with the right types of providers, who are resourced to deliver the right services that your patients want and need, you have to know what those needs are and what they will be in the future. Accurate clinical documentation that starts with physicians today is a prerequisite for predictive modeling. No one wants to prepare for one patient population and then look back later wondering why mortality is so high or the level of care and resource drain is so much greater than anticipated. That is a problem we are solving for today.
And it starts with physicians. Hearing and understanding them, and then helping them translate what they do into the appropriate documentation is key. What a physician sees when he looks at a chart may seem completely obvious, but we live in a world where unless the words are documented in that chart, the care being provided won’t count. It’s time to retrain doctors to explain what they do in a language everyone will better understand, and reap the clinical and financial benefits. We can do this with the basic building block of a clinically-focused CDI program to help with the translation.
Dr. Anthony Oliva, DO, MMM, FACPE, is the National Medical Director at Nuance Communications. This blog first appeared on What’s Next.
There is a culture of certainty in healthcare that is driving unnecessary testing and increasing costs. But some organizations are using the latest technology innovations in radiology to help improve patient care and protect their bottom line.
[Editor’s Note: the following blog was written by Karen Holzberger]
A few years ago, there was a witty car commercial advertising an alert feature that took the guesswork out of filling your tires by gently beeping to signal the appropriate pressure had been reached. It featured a series of vignettes where the car horn would beep, cautioning the owner to reconsider just as he was about to overdo something (for instance, betting all of his money on one roll of the dice). The concept of getting a reminder at the point of a decision is a compelling one, particularly if it can save you time or aggravation and guide you to do the right thing. In healthcare, any technology that can provide that level of support will have a profound impact on patient care.
Albeit humorous, that car commercial wasn’t far off the mark with healthcare challenges. Unnecessary medical imaging exposes patients to additional radiation doses and results in approximately $12 billion wasted each year, but it has also had another unintended downstream effect. It has fueled a culture of medical certainty, where tests are ordered in hopes of shedding light on some of the grey areas of diagnostic imaging, including incidental findings. The reality is that incidental findings are almost always a given, but not always a problem. So how do you know what to test further and what to monitor? And while one radiologist may choose the former option with a patient who has an incidental node finding, another might decide to go with the latter option, so who is right?
Beep! It’s important
This is a jarring situation when so starkly presented, which is why the American College of Radiology (ACR) has released clinical guidelines on incidental findings. By offering clinical decision support on findings covering eleven organs, the ACR is helping radiologists protect their patients through established best practices for diagnostic testing.
While this is a great step forward for the industry, some hospitals are taking it one step further. Massachusetts General Hospital (MGH) is using its radiology reporting platform to provide real-time quality guidance at the point-of-care to drive better patient care. Now, when a radiologist is reading a report and notes an incidental finding, the system will automatically ping her with evidence-based recommendations for that finding. For instance, if the node is a certain size, it should be tested further. These clinical guidance best practices are updated constantly, which means that radiologists have access to the most up-to-date information when treating their patients and can make the most informed decisions based on industry best practices.
Patients deserve and need to have the best and most thorough care; however, this shouldn’t put them at risk for unneeded radiation exposure. It is neither safe, nor financially sustainable. Health IT innovations like these – that can ping clinicians in real-time with the latest in quality guidance – will be the tipping point in the shift to value-based care. They will forever change the standard of patient care and the landscape of the healthcare industry, and that is exactly what we need.
Karen Holzberger is the Vice President and General Manager
for Diagnostics at Nuance Communications. This blog originally appeared on What’s Next.
[Editor's Note: the following blog was written by Brian Garavaglia]
As we become more technologically advanced, we have come to increasingly enjoy many of the immediate pleasures of using such things as smart phones, emails, webinars, and teleconferences just to name a few to communicate with others with a level of immediacy that has never before been witnessed. Yet, has it really enhanced our communication? Many have come to think so. However, given the high level of technology and the great availability of communication technology that avails itself to so many individuals, one has to wonder why so many communication problems continue to happen.
Healthcare facilities, including hospitals and nursing care centers, have frequently been plagued with communication issues. Many of the problems often lead to serious errors in treatment. As we have come to be more involved in constant communication with others, using our cell phones, our emails, and our Twitter accounts, we have also become more involved in using poor syntactical methods for conveying information. I am amazed at the poor structure that I often receive in these various modes of communication. I often witness broken sentences that are disconnected and fragmented, often without any proper syntactical structure. This often leads one to infer what is being conveyed through these pieces of disjointed communication. As should be quite evident, when individuals start to infer about the meaning of ambiguous and muddy communication, incorrect assumptions can be made, which can often lead to critical errors, and in the case of healthcare issues, errors that can have fatal consequences.
Unfortunately, we have continued to experience severe issues in communication within healthcare. Part of it is due to the culture of healthcare. We have often become quite accustom to using brief, arcane symbols for larger meanings. For years the use of these forms of medical communication, such as b.i.d for two times daily, or NPO for nothing by mouth have come to be standard ways of communication. Yet, they have been far from unambiguous and have frequently led to errors due to a less than clear form of communication. Now, we have come to use cell phones and emails that we feel can be used with total disregard for any proper grammatical standard. Interaction among physicians, nurses and other medical practitioners using these forms of communication have often led to a form of brevity in which subjects and objects are deleted from the sentence structure, fragments now become substitutes for sentences, as well as creating forms of communications that often fail to make sense because of the brief, unstructured, and agrammatical forms of communication we have come to take as standard forms for communication through these modalities. Many of these forms of communication become a scattering of neologisms, which if they were to happen within a normal form of verbal communication, would frequently be manifestations of schizophrenia. Yet, we have come to tolerate this type of poor grammar, syntax, and hence poor communication techniques, especially for important levels of communication in our healthcare environments.
What is becoming apparent is that as we come to rely more on higher levels of technology to communicate, we continue to face further degradation of our communication ability. We previously relied considerably on interpersonal, written, and vocal levels of communication. However, with modern technology we have continued to use mediums such as email, Twitters and text messaging that has further made use of cryptic methods of communication, symbols and emoticons as well as used partial phraseology instead of sentences with proper and clear syntax. This type of ambiguous communication that has become so readily accepted and used creates the potential for disastrous implications in healthcare. In an area, such as nursing care facilities, in which you often need to communicate with greater precision for the health and welfare of the residents that you serve, having to be a cryptologist to decode the poor communication that has become all too common through our texting and emails is creating situations that is rife for continued uncertainty among the communicants.
I continue to be amazed at how intelligent individuals have come 1) to rely on heightened forms of communications that they 2) use so poorly. I must make it clear that it is not technology that has led to the poor communication that has come to exist in many areas of our society, including healthcare. In fact, one would think that with the ubiquitous modes of high levels of technology that we can now use, it would make communication much clearer. Technology has the potential to make us communicate with greater precision. However, we have come to take technological innovations for granted because they are so readily available to us. We have come to use these forms of modern technology in a sloppy manner, which has obfuscated our ability to communicate with a level of clarity.
Furthermore, our continuously increasing levels of reliance on these technological modalities for communication have further led to a degradation of our interpersonal ability to communicate with each other in a situational context. Think about the problems that this portends, especially in healthcare. This is an organizational climate that depends on interpersonal interaction. Our healthcare environment has already become quite alienating with the higher levels of technology that often distance the patient from the caregiver. Now, with individuals walking around healthcare facilities, with cell phones and other forms of computerized devices that they cryptically use to communicate with and that we have become so reliant on, we often have lost many of the very important skills that make care so ‘human,’ our ability to communicate in a clear and precise manner.
Mistakes in healthcare are not new. Furthermore, communication problems have frequently been endemic in healthcare, and in particular, as it applies to this article, long-term care. Mistakes found within long-term care are frequently the result of poor communication and with the use of our more advanced communication technology, coupled with acceptance, if not an outright toleration for, using vague, ambiguous and often highly cryptic phraseology, the likelihood for further issues related to the technology and associated ways of communication that we have come to employ with this form of technology foreshadows continued problems in the years ahead.
It must be remembered that again this is not an indictment against technology. As stated if used appropriately it can have the potential for enhancing our communication as well as the provision of care to those in long-term care environments. However, we must be aware that using technology to communicate in the manner that we are currently using it only alienates the caregiver from the person that is receiving care. Furthermore, and even more important, unless we correct the way we communicate, using more appropriate syntax and communicating our thoughts in a clear and concise manner, we will create a toxic environment, filled with ambiguity and the need to infer meaning that will only have a deleterious impact on those that we care for in our long-term care facilities.
[Editor’s Note: the following blog was written by A J
Johnson, general manager of analytics solutions, TriZetto
In today’s healthcare environment, it is challenging for
providers to succeed financially. Operational costs for providers continue to
rise while reimbursement rates decline. And, it’s harder to get paid as more
employers shift medical costs over to employees. In fact, more than half
(55%) of patient payment responsibility after insurance ends up as bad debt.1
To help offset these financial challenges, you need to get
paid correctly from payers. A big part of that is identifying, appealing and
tracking claims that were denied incorrectly. However, provider offices are
already so busy, and arguing with payers about claims denials is probably one
of the last things you want to add to your “to do” list.
When appealing all of your claims denials seems out of reach,
focus on harvesting your “lowest hanging fruit” to see a better return on your
time investment. Here are two ways to identify which denials will yield the
highest return when appealed.
1. Focus on denials with the
highest probability of getting paid. These are denials that you can most easily
address, such as denials where information was missing from a field or where
coding or data was incorrect due to human error. You can quickly fix this
information and resubmit the claim for reimbursement.
2. Other denials may be out of
your control, such as denials due to a service that was never documented or
benefit eligibility issues. You won’t be able to convince the payer to pay for
undocumented services or change their fee schedule contract, so these denials
are not worth your time to appeal. However, to help stop this type of denial
from occurring in the future, you should go back and review your eligibility
verification process to ensure it is working correctly.
Of all the efforts you put toward ensuring your organization
is financially successful, managing denials may be the most critical step
– especially when you consider that providers transmit millions of claims every
day and even the best-performing medical practices experience a denial rate of
5%.2 In addition, the transition to ICD-10 is expected to
compound this problem with denial rates projected to rise anywhere from 100 -
The potential revenue loss from claim denials isn’t easy to
see when it’s hidden. But, letting denials pile up can hurt your bottom line,
and leaves behind revenue that is ripe for the picking. Focusing on
“low-hanging fruit” denials will help you receive the best return on your staff
For information on other types denials that represent the
“lowest hanging fruit,” read this free e-book: Denials Management Best Practices: Identifying the Lowest
1“Overhauling the U.S. Health Care Payment
System,” by McKinsey & Co., June 2007; “Cultivating the Self-Pay
Discipline,” The Advisory Board Company, Financial Leadership Council, 2007.
2Medical Group Management Association,
Performance and Practices of Successful Medical Groups, 2013.
3Workgroup for Electronic Data Interchange,
“ICD-10 Critical Metrics.” October 2012.
[Editor’s Note: the following blog post was
written by Greg Girard, director of product, HealthCare with Calgary Scientific]
At Nebraska Medicine, technology innovations bring with them
opportunities to enhance patient care. The ability to integrate patient images
with synchronized and simultaneous audio and video has Nebraska Medicine’s
telehealth coordinator Kyle Hall looking at new ways to implement telehealth
and mobile devices, such as iPads and Google Glass, at clinics and hospitals.
and Medical Imaging
conferencing to imaging has been really difficult,” explains Hall. “Now with
ResolutionMD’s support for audio visual data, we have a one stop shop that
allows us to access patient images from multiple modalities while viewing audio
In hospital and clinic settings, telehealth sessions are
frequently conducted with the use of telehealth carts which integrated wireless
Internet access, video monitors, cameras and CPUs on a mobile cart that can be
wheeled between patient rooms or from bed to bed in an ER. While patient images
from specific PACS or image modalities have been integrated with telehealth
video conferencing systems that run on these telehealth carts, Hall is
experimenting with adding enterprise-wide image access to the carts by using
ResolutionMD for both viewing images and displaying real-time audio visual
feeds. With this combination of health IT, no matter what the source of a
patient image is, the telehealth cart will display it during a video
“Now with grand rounds and patient care conferences,
specialists can be part of the process without being there in person,” says
Hall. “Multiple video connections that include the patient and provider and the
specialists can be running while they all view the same image.”
The combination of ResolutionMD with
telehealth carts is not only efficient, it’s also cost effective.
“We anticipate that we can significantly reduce the amount
spent on audio visual equipment,” he explains. “With an Internet connection,
the cart can go anywhere and offer an all-inclusive solution”
Most exciting, the video feed to the telehealth cart can be
coming from any source including Google Glass. In a teletrauma situation, for
example, the provider can be the source of the patient feed while patient
images are displayed on the monitor. Using Google Glass, the provider can move
around while providing the real-time patient conferencing feed instead of
relying on the telehealth cart’s fixed camera.
“With this set up, the telehealth cart becomes the center
point of communication, displaying patient images coming in from a PACS, the
connection with a remotely located specialist and the provider’s view of the
patient through the Google Glass,” says Hall.
While challenges remain in implementing this combination of
technologies, using such a system for local connections between providers on a
hospital campus is not far off. Keeping the communications local, or within a
hospital campus network, eliminates security issues as well as transmission
issues that come with using the cloud for Google Glass feeds.
“Localization takes the jitter out of wearable
telepresence,” explains Hall. “It also improves speed, lowers costs on the
network side and makes the security team happy.”
With new rules that allow the use of telehealth by
Accountable Care Organizations and the increased emphasis on coordinated
IT departments are turning to telehealth as an efficient way to connect
providers that work at the same hospital or within the same integrated health
system. In the near future, Nebraska Medicine’s providers may be using
Google Glasses to facilitate these connections.
[Editor’s Note: the following blog post was written by Steve Whitehurst, CEO of Health Fidelity]
As we continue our transition from a fee-for-service world to a new set of programs promoting value-based care, it is apparent that data is going to be a key factor in separating the successful programs from the failures. Value-based care takes into account patient outcomes over a period of time and aims to deliver these outcomes at a reasonable cost to both the individual and to the overall system. The delivery side of value-based care typically relies on evidence-based medicine and best practices in providing care.
A number of value-based care models and related programs are being tested through various public and private initiatives. Among them are:
1. Medicare Shared Savings Program - also known as Medicare Accountable Care Organizations (Medicare ACO)
2. Physician incentive programs such as Physician Quality Reporting System
3. Medicare value-based purchasing
4. Bundled Payments for Care Improvement (BPCI) for episodes of care
5. Capitated payment programs that quantify long-term risk such as Medicare Advantage
6. Value-based payment modifier
A common theme among these is the necessity of data to evaluate success or failure of the programs. Since many (if not all) of these programs are in the experimentation stage, a deep understanding of data can transform the way populations are evaluated and cared for. Additionally, data can change the payment equation by accurately predicting the cost of care for patients by understanding risk factors and health trends.
Big data in healthcare refers to the identification, capture and rationalization of data from traditional and non-traditional data sources. Traditional data sources include clinical, financial and operational data. Clinical data is typically obtained from electronic health records, which are now pervasive in the country as a result of the Meaningful Use program. Financial data is obtained from claims, revenue cycles and other billing systems. Lastly, operational data is obtained from supply chain management, resource management and purchasing systems. Non-traditional data sources include patient-reported data via tools such as personal health records and patient forums/affinity groups, data collected through devices that ranges from monitoring vital signs to measuring blood glucose and other important indicators as well as public health data sources such as infectious disease registries, immunization registries etc. Last but not the least are health and wellness trends that add to available data.
As is apparent, this is a treasure-trove of data and, if used correctly, it can further the goals of value-based care. For example, using available demographic data, clinical data, risk factors and long-term prognosis can be determined, and thus the suitability for membership in an ACO from a population of eligible patients. Similarly, risk due to chronic conditions can be correctly identified, analyzed and managed for better long-term clinical and financial outcomes in certain Medicare programs. Quality measures that impact incentive programs for physicians can be more accurately measured by having access to a variety of data sources.
To summarize, data is already helping make value-based care more successful. We are still in the nascent stages of being able to collect, analyze and use all available data sources. In fact, it is not immediately clear how the non-traditional data sources will impact care delivery and cost reduction; however, the trend is unmistakable that having access to large volumes and a wide variety of data will allow us to ask questions that influence the way care is delivered, outcomes are improved and cost is reduced.
[Editor's note: This blog is posted on behalf of Paul Spiegelman, chief culture officer, Stericycle, Inc., award-winning speaker and best-selling author of "Patients Come Second."]
Gallup, a global research and consulting firm, annually conducts a survey called "The State of the American Workplace." This year the results should alarm American business leaders, particularly our healthcare colleagues.
Of the approximately 100 million people in America who hold full-time jobs, 50% of American workers are not engaged. Another 20% of those surveyed - 20 million people - are actively disengaged from work. Chances are these employees - statistically 70% of our workforce-will not improve our patient experience or fulfill our institutions' mission unless the culture changes.
Their discontent affects your bottom line, too. Disengaged workers cost the U.S. between $450 billion to $550 billion each year in lost productivity. They can also cause increased physical injury. Gallup compared the top 25% of engaged teams with the bottom 25% and found that the poorly managed teams experienced 50% more accidents than their counterparts. Employee injuries mean risk-particularly related to costs, compliance and reputation. With millions of dollars now at risk based on patient satisfaction and the increase in pay for performance initiatives, how do we prioritize our efforts for the best return on investment?
The answer is we need to start inside. We need to show our commitment to our own employees first, because engaged employees will provide better patient care, which in turn will drive patient loyalty, and positively impact the bottom line. We need to focus on our core purpose as healthcare organizations to heal and promote health. And we need to rally around initiatives that make our employees feel good about the impact they are making. One such initiative that touches all of these issues, makes the world a better place, and impacts the bottom line is sustainability. Greening operations is an opportune platform to align employees to your institution's values, provide them with more training for a safer work environment and bolster pride in their employer-all of which results in better engagement.
Define and Align Your Values
The healthcare landscape is in a state of constant change: 90% of newly hired physicians are employed by brick and mortar hospitals and our networks are getting more spread out with multiple sites with the growing development IDNs and ACOs. This is why we need to align our teams with a common strategy and purpose.
The first steps in making sustainability an element of your cultural framework is to make sure that it is stated as part of your organizational vision . For example:
- Define sustainability as a core value
- Quantify what it means to have a sustainable "impact" for your organization - measure and monitor over time
- Recruit executive buy-in; the message has to be delivered repeatedly and consistently from the top
Help the Initiative Trickle Down
Establishing "green teams" empowers employees to help manage sustainability initiatives with pride.
- Find internal champions and develop an oversight committee
- Recruit department representatives to be the conduit to their teams. Engage in friendly competitions and publish results and best practices
- Become a thought leader in your own community by publicizing your impact on patient safety and the environment via your organization's public channels and trade media
Learn From Others
When it comes to building great cultures around sustainability, there are some influential examples in our industry. Consider the following:
- John Hopkins Hospital found employee education a critical component to green operations. Through recycling, its overall trash production decreased by 17 percent.
Beaumont Hospital, Royal Oak, a 1,070-bed hospital in metro Detroit, has 500 "green officers" - employees who are ambassadors of green practices to their departments.
Measure the Initiative: Going Green, Seeing Green
Can greening operations also drive financial results? With a culture of properly engaged employees, of course it can! Arkansas Children's Hospital saw a significant cost savings with a "Know Where to Throw" campaign that educated employees about red-bag disposal, resulting in a 32% waste reduction and a six-figure savings.
By making purposeful culture changes, supported by consistent and ongoing training and communication, your management team leverages the power of engaged employees. As this base grows, your patients, community and environment can feel the power of a well-managed and motivated staff. And if we have a motivated staff, we'll see better patient care, better safety scores and better financial results.
Editor's note: the following blog post was written by Tom Hills, executive vice president of sales, PerfectServe
I regularly cross paths with hospital executives looking to integrate the latest and greatest health IT tool or processes. By far their primary challenge in adopting new technology is dealing with resistance to change. Last month, I attended a bi-annual Health Management Academy meeting that addressed this common obstacle. The forum - which brought together CEOs, CMOs, COOs and CFOs from the largest health systems in the US - sparked me to think about a few things causing this barrier to adoption, and how we can overcome them:
The value of time - In healthcare, time is money. But when the next big thing is at our fingertips, how do we capture the attention of administrative leaders when there are so many initiatives competing for their time? I think the solution lies in physician leadership. I can attest to the fact that hospitals and health systems with early adopter physician visionaries are more successful in rallying their organization to consider innovative, easy-to-use technologies that support more efficient and higher quality care. It's important to involve these doctors in the decision-making process from the get-go, as this often spurs adoption of the technology once it's been implemented.
- Real-time revenue vs. long-term investment - Current change in health care is requiring CFOs to attack every budget line item. Thus, providers are wary of implementing something new and innovative if it can't demonstrate clear and immediate ROI. But oftentimes, the real value of a solution comes from using it over a long period of time. Key to the successful implementation of technology is considering the long-term value - in helping to drive more efficient communication processes, a more mobile clinical workforce, faster time-to-treatment, etc. - versus focusing only on the short-term return on the investment.
- The "risk" of implementation - Health systems all across the country are consolidating resources through M&A, reorganization and downsizing, often causing leaders to be more averse to taking risk. New technology isn't often apt to make it into the mix, as it adds another unknown variable that clinicians need to get used to. But it can be a valuable tool in standardizing care across multiple facilities and departments. Provider leadership must show a commitment to innovation by devoting time and budget to it, perhaps by even creating a separate "innovation fund" to fuel these critical projects.
What's clear to me is that while the industry as a whole recognizes that innovation is critical to improving care delivery, it can be challenging during tough times to inspire the adoption of new technologies across provider organizations. Providers need to be sure to continue to commit to funding innovation despite uncertain return. Fostering collaboration between physicians and executives to choose the best new technologies can help ensure the innovations that do make the cut are ones with the highest odds of success.
Editor's note: this is the final installment of the 3-part series on ‘Integrating Labor Across ACOs.' It was written by Chris Fox, CEO of Avantas
In the first two posts of this three-part blog post series, I outlined the current state of ACOs, the need to focus on labor across the organization, including medical groups, and offered a few key labor management strategies to take advantage of the opportunities of belonging to an ACO (and not let the potential inefficiencies of a larger organization take hold).
In this final post I'll discuss technology, specifically what you should look for in labor management software to effectively manage your workforce at the enterprise level - the key to capturing economies of scale in an ACO. Before I get into that however, I want to stress the importance of what we see as one of the most integral, but too often neglected steps in a technology implementation: policy and process alignment.
Labor management is complex. You can't just plug in a solution and expect all the pain points to disappear. It takes some due diligence to make sure the foundation is set; then comes technology. Part of that due diligence is policy and process alignment. Every organization has specific business rules it operates under. These rules can be things like last float/last cancel policies and protocols for how staff sign up for open shifts. Within the outpatient/clinic world, this can include things like consistent shift start times, the ability to share like skills across locations, and standardized labor targets within like cost centers. It is crucial that any policies your organization is utilizing are standardized across the enterprise and that they are carried out in practice, every time.
The alignment between policies and practices is crucial because your workforce management software should serve to automate them. By embedding your rules into your labor management tool you all but ensure consistency - and consistency leads to predictable and sustainable results. Within an ACO, as multiple hospitals and clinics may be involved, standardization can yield substantial savings and process improvements. This brings us to the list of what to look for in labor management software:
- Customizable. As I just mentioned, your software should have your business rules embedded. Ideally, the vendor you partner with for your software solution will have expertise in best practice labor management strategies. If they do, they will understand how crucial this step of the process is. If your solution is going to help you achieve your specific business goals and work within your unique culture, it must be tailored to help you do just that.
- Accurate Forecasting. This is virtually becoming a standard feature in labor management software. Many vendors tout the accuracy of their predictions, but the key question to ask here is how far out are the predictions accurate. Many are claiming a high degree of accuracy, but it's only a day or two before the shift. This does little to help an organization build better initial schedules. Once schedules are built around an accurate prediction, that forecast must be continually refined in the weeks leading up to the shift, with anticipated holes in the schedule being automatically posted as open shifts for qualified staff to pick up. This increased accuracy of initial schedules along with a continually refined prediction of needs will help your organization be proactive in its approach to delivering patient care.
- Analytics Powered. Famed management consultant Peter Drucker said "What gets measured gets managed." This has never been more true, but one of the problems today is that there is so much to measure. A health system can generate hundreds of metrics. The key is deciphering what metrics are the most meaningful - which ones, if tracked and improved on, will help the organization realize the greatest benefits. For analytics to be powerful they must be transparent. Meaning, everyone who should have access does have access. Next, the data must be easy to understand and prescriptive, so those who view it know what to do to improve. Finally, it must be timely. If it is not timely it is not actionable. Lessons can be learned from older data, but true power comes from the ability to leverage data to make course corrections so targets are hit now, not the following pay period or next quarter.
- Cloud-based. With virtually all organizations we partner with, we are replacing a competitor's software. Typically, the tools we replace are not cloud-based. This usually means we are supplanting a software that is several versions outdated. This happens for several reasons, one of which is "version fatigue." It often seems like no sooner has a tool been installed, the vendor is back pushing the organization to purchase an upgrade. This can be an especially hard sell if the software does not have widespread user adoption and is, consequently, not producing the results the vendor promised. With a web-based tool there is no versioning. You always have the latest enhancements and functionality. And most vendors provide, or should provide, these updates at no additional cost. Within an ACO, web-based software solutions, where applicable, can provide substantial cost savings and provide greater flexibility to staff, who can access the tool any time anywhere.
It's important to mention here that cultural change must be a key component of any new technology implementation. Technology serves to automate best practices. It will not fix anything unless the people using it are focused on doing so. An organization's leaders and employees must be committed to learning what they must do to reach their objectives and then make the necessary changes to actually do it. Within an ACO, whose members may be dozens of hospitals and/or clinics, the need to address cultural change elements is absolutely crucial.
Editor's note: this blog post was written by Leigh Ann Myers, vice president and Chief Clinical Officer at PerfectServe
I spend a lot of time discussing the need to fix broken clinical communication processes in hospitals. That's partially because I've experienced these issues personally, but also because I've spent much of my career trying to address them. The clinical communications problem that challenges the industry now extends beyond the four walls of the hospital, and this has serious implications when it comes to reducing readmissions to avoid costly CMS penalties.
Today, when patients leave the hospital, their care is transitioned to a range of different folks - from care coordinators to home heath managers to primary care physicians to nursing homes. Each of those entities likely prefers to be contacted in a range of different ways, at different times and with different types of information. If that system or process is flawed or cumbersome, the result is that the necessary information doesn't reach the right outpatient coordinator - whoever it is - and the patient is at risk of missing follow-ups, skipping a medication or experiencing delays in the care they're provided.
For example, say an outpatient care coordinator is following a chronically ill patient.
Step 1: The patient arrives in the ED and is admitted to the hospital. Is that outpatient care coordinator notified? Is the PCP? And how? Is there a way to confirm that message was received? Is there a way to escalate the communication should either of these folks be out of the office or unavailable?
Step 2: The patient is admitted to the hospital. Is the outpatient care coordinator notified at this point? The PCP? How do they know or find out what happened to their patient while they were in the hospital? For that matter, how much information is communicated from the care coordinator or PCP to hospital staff about that patient's history of chronic illness and current treatment regimen?
Step 3: The patient is discharged, and told to follow-up with primary care within 48 hours. Does the care coordinator or PCP know this? If the patient forgets to schedule an appointment, who is responsible for follow-up with them? If they do schedule an appointment, does the PCP or care coordinator know what medication they were sent home on, or what the results of lab work done in the hospital were? Is it easy for them to obtain this information, or will it cause a delay in patient care?
These questions get to the root of the problem - it isn't about technology, it is about process. Effective communication processes are complex to determine and implement, but they are key to balancing the readmissions equation. I know I want my family members' care team (inpatient and outpatient) talking to each other, helping them remain healthy and out of the hospital.
Editor's note: this blog post was writen by Chris Fox, CEO, Avantas
In the first post in this three-part series focusing on the potential of enterprise workforce management strategies and technology in ACOs, I outlined the current state of ACOs, the year-one results of the Pioneer group, and the need to focus on labor, especially within medical groups – the growing driver of care in this model. In this post I’ll dive into key strategies to include upfront in your labor optimization plan and highlight how they set the framework for predictable and sustainable positive clinical, operational, and financial results.
The rise of ACOs alongside the increase in healthcare consolidation has created a lot of opportunities for providers to grow their patient base and expand services, develop more reliable referral systems and better coordinate care, as well as decrease expenses by creating efficiencies. It’s this last element that can be the trickiest from the perspective of labor management. When organizations consolidate or partner they can sometimes open a Pandora’s Box of issues including:
- Staff size and layering that does not reflect patient demand
- The amalgamation of policies and practices that can be inefficient and disparate
One of the main reasons this can happen is that “staffing and scheduling” is typically considered a tactical process rather than a strategic opportunity. Labor optimization is not about the activities that occur within the few hours leading up to a shift, but rather the planning done over months and weeks to ensure a repeatable structure of efficiency.
Following are two of the main elements that must be part of that planning.
Right Sizing and Layering Staffing
An enormous amount of savings can be realized by answering two seemingly simple questions:
- What number of core staff do you need on each unit/medical group practice site to meet workload benchmarks and patient demand while limiting overtime, cancelation, and floating?
- How many and what types of staff do you need to fill in when core staff can’t take a patient, such as increases in census?
Simple questions maybe, but the answers to each require some digging, analysis, and best practice application. By looking at key optimization statistics (e.g., workload, “FTE leakage,” incidental worked time, etc.), core staff behaviors and trends, historical census levels and predicted future census, staffing levels, payroll data, and various HR information an organization can determine the number of core staff it needs on a unit-to-unit level. This is a number that will need evaluation every six months to a year to account for changes in volume due to increased competition, new physician hiring, etc., but that initial baseline is imperative.
Determining and then hiring the right number of core staff is the first priority. Next, organizations must have the right number and layering of internal contingency – PRN / per diem and float resources – to provide a flexible supply of resources that can cover off on PTO, leave, education / meeting time, and sudden spikes in volumes/census across the organization.
Policy Standardization and Practice Alignment
An organization’s staffing polices, and how they are applied, can vary greatly across the entities forming an ACO. For some context on this, we have seen stand alone, 200-bed facilities as well as specialty practices with policy and practice variances unit to unit, shift to shift, and minute to minute depending on the individuals involved. These variances can include things like not following an approved cancelation order to using unapproved agency personnel. At larger, more complex organizations these issues are often compounded to the extent that standardization (and faithful application) can amount to millions of dollars in savings opportunities, not to mention improvements to morale that come with employees knowing that the rules are applied fairly and consistently.
The heavy lifting comes with the cultural issues inherent with any change in process. Effective change management and communication protocols must be employed and followed if any change will be successful. This can be especially complicated when it comes to ACOs and system consolidations when you are dealing with different organizational cultures. That said, clear, consistent communication that explains to individuals across the enterprise the reasons why a change is being implemented along with the “what’s in it for them” goes a long way to helping create buy-in.
The final post in this series will focus on strategies to leverage technology, and more importantly, meaningful data to automate the gains of establishing the right size and layering of resources and standardizing and enforcing policies and processes.
This blog was written by Anthony Cirillo, FACHE, a healthcare consultant and aging expert who helps CEOs connect the dots that start healthcare movements. Contact him at firstname.lastname@example.org and learn more at www.4wardfast.com.
Half of new nurses are verbally abused in their first three months of work
Empathy and moral reasoning erode during the third year of medical school
One in five nurses report being depressed
And on it goes. In August, the RN Work Project
reported that half of 1,300 nurses surveyed reported “moderate” verbal abuse from doctors and other nurses, defined as up to five incidences in the last three months.
Of course these findings have consequences. According to Pearson and Porath, in the book, “The Cost of Bad Behavior: How Incivility Is Damaging Your Business and What to Do About It’, work place incivility has these consequences:
Loss of work time worrying about the incident and future interactions with the offender
A weakened sense of commitment to the organization
Weakened effort on the job
Decrease in the amount of time spent at work
Spend time thinking about another job
Actually change jobs
And they pin a cost to this. To be exact, a 10,000 employee organization where half the workforce has one incident of incivility annually costs the organization $71,000,000. Yes that is six zeroes.
In a March Harvard Business Review blog, How Happy Is Your Organization?, the author poses some pertinent questions that might help gauge the happiness of your organization such as:
Shawn Achor of Good Think, Inc. and the most noted expert on happiness says that “Happy brains improve business, education and health outcomes.” I am working with colleagues to bring Happiness work into healthcare. You see we used to think that if we were healthy we would be happy. It turns out it is just the opposite. In order to be healthy, holistically, you need to be happy.
The good news is that happiness can be taught and practiced. In a recent Hospital Impact blog, I shared the first principle we teach organizations - Be Conscious. I call it being in the moment. Here is an excerpt from that blog.
“Life is more joyous when lived consciously. This lack of awareness causes some to live in a "walking sleep" in which actions are done but feelings are absent. You may call it going through the motions. When you live consciously you are aware of your feelings as you experience life.”
There are exercises that go along with this and the other four principles. These principles are:
Honor Your Feelings – locate the deeper nature of how you feel, communicate those feelings constructively and use them to guide conscious decision
Co-Create What Works – in other words give up the notion that you are right and the other person is wrong. We are here to work together
Release Your Desire to Control Others – you can’t do it anyway so why get all frustrated
Learn Your Life Lessons – realize discomfort is a part of life and that it serves you only if you pay attention to it and honor what it is trying to teach you
This last one resonates with me particularly. Entering this year, I was coming off the breakup of what it hindsight was a terrible business relationship. It caused me to pause and re-evaluate how I do business. There were hard lessons. But I followed the last principle, got uncomfortable, and then changed things.
In a Health Leaders survey, 22 percent of leaders reported that lack of cultural fit and employee buy-in was their biggest obstacle to their patient experience initiatives. No wonder. Can’t have “fit” if employees are not happy.
Some may roll their eyes at the warm and fuzzy of this happiness stuff. Before you do, take the Happiness Survey and see how you rate. It just might be that we have to get back to whistling while we work.
This blog is posted on behalf of Abraham Gutman, CEO of AG Mednet. We welcome comments.
About a month ago a friend sent me a link to an article entitled "Building a Better Clinical Trial System." After reading it, I had to make sure it actually appeared on The Daily Beast, and it was not from a satirical magazine like Mad or The Onion.
The article argues that governments, not companies, should be in charge of drug discovery and testing. The author bases her argument on two points. First, that pharmaceutical companies choose to withhold comparative results obtained when testing their drug against that of industry competitors. Second, that the elimination of disease is "a true public good."
Of the thousands of arguments I have against this idea, I'm unsure of which I should present in this short post. I would encourage the author to take a look at the drug development activities of the old Soviet Union, as well as present day North Korea, and analyze the real life success of her vision. It is a well-known fact that government controlled bureaucracies have hardly ever produced innovation, unless one considers the self-preservation of the bureaucracy to be an achievement.
The article tries to imply, sub rosa, that companies by their very nature, do not work for the common good, perhaps because of their need to earn a profit from their work. That of course is precisely why companies can work for the greater good. The biggest motivator for innovation is profitability, and we know that even if you work for a charity, you are the beneficiary of someone else's ability to help your organization. This help is only available if they have a surplus of capital, small as it may be, which is ultimately: profit. Implying that competing for and profiting from finding cures for disease is evil, ignores the lessons of history.
Marxism is dead for good reason. Pharmaceutical companies risk billions of dollars of their shareholders' capital searching for elusive cures, just as agricultural and manufacturing companies do in their fields. Would the author say that John Deere's research in combines does not promote the greater good? As such, should the government be in charge of building tractors?
What if a computer chip manufacturer, trying a new technology finds that it's less compelling than that of their competitor, and chooses not to publish their results? Aren't computers part of the greater good too? After all, they can be found in pacemakers, MRI scanners and other life saving devices.
Perhaps we should just nationalize Pfizer, Monsanto, and Intel. We know how well that strategy has worked for the Venezuelan people and their oil industry. There is a place for government in drug research, and it's not to compete, but rather to regulate. These regulations promote safety, and they have been found to be valuable. Not perfect, but effective. They can certainly be refined, so long as they don't remove competition.
Without competition it's only a matter of time before we begin having to import all our food from ... wait, nobody else in the world has the needed production scale of the US, which is fueled by ... markets and competition.