Connection in Revenue Cycle Improvement
by Jim Zelem, Process Improvement Mentor
Published on Apr 26, 2021
Phoenix Medical Management was able to participate with a small group of experts to discuss how to evaluate and improve the CDI world. Jim shares his white-paper on how an outsiders prospective for process improvement can be applied to clinical documentation integrity.
The mission of any hospital is patient care. However, there is another component of the hospital; the business aspect. To ensure the integrity of care and appropriate reimbursement, documentation is crucial. The patient story, initial diagnosis, tests being ordered, medication given, test results, revised diagnosis, physical therapy, diets, patient progress or lack thereof, etc. needs to be properly documented. All this information resides in an Electronic Medical Record (EMR). Everyone that has anything to do with a person’s care has to properly document anything to do with their care.
That EMR is also used on the business aspect of the hospital as it was originally designed to be a billing tool. Since it contains everything there is to know about a person’s stay, it serves as the basis for proper coding for billing purposes. Only accurate coding will translate into getting paid for the services rendered.
Hospitals and health facilities are constantly dealing with payment issues for a multitude of reasons. Insurance companies are constantly denying payments and based on their contracts and standards, they have that right.
As a process engineer, problems have always intrigued me. Why is this challenge happening? Why can’t it be rectified or even prevented? And again, there are a multitude of reasons. As I have been told so many times, it’s complicated with a lot of moving parts. Every situation is unique. The list goes on.
To get a better understanding of the situation, I wanted to have a small team of people living with the problems and brainstorm a solution. I’ve learned that people living with the problem are extremely creative. They will always find a way to fix the problem. Their knowledge of the process is priceless.
However, as much as they can help, unknowingly they can also impede improvement. They are so involved on the tasks and functions that they might not have the ability to see the overall picture. As a process improvement specialist, I see the entire picture from a 10,000-foot view and, from the old expression, I can see the forest through the trees from that view. The staff doing the work are so entrenched in the trees that they do not have the ability to see the entire forest and can’t simplify the situation. And on the other hand, I see the forest but too far away to see all the trees, which is the actual details. It is that challenge of the different views that sheds the light for improvement. The team learns to take a step back to provide a better clarification.
I would like to compare my participation as a coach on a football team. As you know, the players
play the game and as a coach, I don’t. However, I have the ability to sit in the press box and get an overall view of the entire field. I can see things happening that they can’t. Working together, we can make the right changes to win the game.
With the help of a few people, a team was created. Here are those members:
• Tiffany Ferguson, LMSW, ACM
Chief Executive Officer at Phoenix Medical Management, Inc
• Jennifer Foskett MBA, RHIA, CPC
Healthcare revenue integrity analyst, healthcare business intelligence analyst
• Sonal Patel, CPMA, CPC, CMC, ICD-10-CM
Healthcare Coder and Compliance Consultant at Nexsen Pruet, LLC ? Podcast Creator and Host for the Paint The Medical Picture Podcast series
• Dr. John Zelem
Physician Owner at Streamline Solutions Consulting, Inc
As with any process, regardless of the industry, I have found that a successful process must have the following criteria, which I call MPDT.
M - Mission
P – Prevention
D - Dashboard
T – Teamwork
In our initial meeting, each person was asked to provide their view of the problem, which was:
• Trying to quantify problems, where they occur and to get people to recognize them.
• Utilize standardization, and accountability and silos
• Identify silos as they exist
• There are very convoluted systems and too many people
• No accountability, no control, lack of communications and coordination
The team agreed to the following mission statement: “Fostering documentation integrity in pursuit of capturing the patients’ clinical story”.
The following is a list of players in the process and their role:
Utilization Specialists – work to review the medical necessity in the documentation and recommend level of care for patient in the hospital
CDI – (Quality Assurance) assures that the quality of the documentation provided supports the codes that are used for billing
Case Managers – responsible for the navigation and coordination of the progression and transition of patient care
Physician Advisor – provides expertise to all of the mandatory components as a clinical resource bridging the gap between clinical and non-clinical aspects and aids in the recommendation for level of care beyond commercial criteria
Coding – converts documentation to supportable codes
Physicians – provides, directs, and evaluates the medical care of the customer and documents and communicates this appropriately in the medical record
Nursing – performs and helps to carry out the patient care, insuring that physician orders are carried out, helping the patient and family navigate throughout the hospital encounter and document appropriately – can include Wound Care initial and follow-up care including documentation
Central Business Office (CBO) – review claims and insure that they are accurate at the time of billing at the back end and paid appropriately in compliance with the UB-04, they are the clearing house for denials of payments
Quality – assures that everything occurs at the highest standard of evidentiary practices (excluding medical records)
Compliance - obeying regulations, standards, orders, rules, or requests and the state of being willing to do the right thing, having integrity and assuring accountability to meet those standards of the medical record (auditing)
IT/Informatics/Analytics – managing the EMR and the security such as HIPAA regulations
HIM/Medical Records – repository of the medical record, overseer of policies regarding the EMR
Advanced Practice Providers (APP) – physician extenders providing a lot of the care and documentation
Dietary – assess and manage malnutrition and other disease states and documents accordingly
PT/OT - assess and manage and documents accordingly, contingent on patient’s clinical condition
Speech - assess and manage and documents accordingly, contingent on patient’s clinical condition
Everyone tries to do their job to the best of their ability, which includes all the necessary investigation and rework to ensure quality patient care and accurate documentation that coded properly for billing purposes.
The number of queries can range from typically 20-40 per day.
CDI reports tends to monitor tasks rather than the impact of their work.
• Complicated and not standardized
• Good coders know they need to do their due diligence when assigning codes
• Tends to be reactive and not proactive
The problems typically start with the onset of documentation. It became abundantly clear that doctors typically do not document well in a hospital setting. There are many possible reasons for this in deficiency, such as:
• It is not taught in medical school
• Doctors are more concerned on care and less on documentation
To further complicate the issue of documentation with doctors, many times the executives of a hospital are not willing to address the issue. Simply talking about a problem isn’t addressing the issue. To address an issue, there has to be follow-up and consequences. Simply put, if there isn’t a consequence for speeding, why would people stop speeding?
However, this is a double-edged sword for hospitals. I’m sure they want to hold doctors more accountable but if they become too strict, the doctor just might take his/her services to another hospital. This will have a significant bearing on hospitals regarding both financial and reputation. It would take a concerted effort by many hospital communities to rectify that situation. Another possible solution is either medical school or government mandate, which will not happen anytime soon.
Unfortunately, the major emphasis seems to be correcting the problem and very little effort on prevention.
To alleviate the problems, we need to focus on Prevention, a Dashboard and Teamwork. People tend to concentrate on issues that are both Important and Urgent. Things that are a crisis, pressing problems, and deadline driven issues. Actually, people that continually work out of this quadrant are considered to be urgent dependent.
For a proactive approach, you need to prioritize your efforts on important issues that are non-urgent as outlined in quadrant II above. Topics that fit that criteria are preparation, prevention, planning, true re-creation and empowerment.
Everything listed in that quadrant are very important but as you can see, none of them are urgent. Nothing listed in that quadrant are deadline driven, a pressing problem or a crisis. However, concentrating on the topics listed in quadrant II will make your organization that much better and in time will actually reduce the items that are presently urgent.
It takes both determination and a concentrated effort to shift both your focus and others to these topics. Plus, all the pressing problems and deadline driven items will eventually consume your attention once again. However, I highly recommend that you schedule an hour a day to these topics. As time permits, try to increase your time.
Concentrating on prevention is the first step. Problems are constantly popping up, especially when 20-40 plus queries occur daily depending on the size of your facility. We know these problems are being fixed but unfortunately, the next step, being prevention doesn’t occur. In essence, the urgency has been satisfied because the problem has been fixed. So, off to the next problem.
For continuous improvement, it is important to take the next step when the problem has been resolved. Simply ask, what can be done to prevent future occurrences of that problem. And one of the canned answers is that it does not happen that often. Well, that can’t be the answer for 40+ queries.
It is important to log the problem, corrective, and the prevention action. It will come into play in the future. People will remember problems when they re-occur, and it will be a great reference to see what corrective and preventative action was done in the past. In fact, knowing previous preventative action that didn’t resolve the actually problem, will be instrumental to hone in on the root cause of the problem.
Correcting a problem is just that. Doing what is necessary to correct what is wrong. For example, coding doesn’t know what the correct code is to ensure payment. The appropriate people get together and correct the record so it can be coded properly.
However, what was the root cause of the problem? What caused the problem in the first place? That’s what preventative action does. It forces us to find the root cause of the problem and implement action to fix it. Only then, will future occurrences be stopped.
A simple dashboard tracking a couple phases of queries should be created. It needs to track the quality of the system and is the pulse of the situation. Based on the information extracted from the brainstorming session, the initial tracking item should be queries and it should consist of the following:
• Queries issued per day
• Queries resulting in a correction per day
• Queries where prevention was investigated, and action taken
The quantity of suggested items can vary from day to day. Therefore, I would also track the total quantity on a weekly basis and create a line graph. This will allow for trend analysis. Are things getting better, worse or staying the same.
The dashboard is a work-in-process and might require changes once data is being captured.
Teamwork is crucial to the success of continuous improvement. Coaching is also important but again, it is the team that wins the game.
The team I am proposing is not a department team. I am referring to cross departmental teams. The team should comprise of the people that can actually work the goal. Each department has their responsibility to insure everything comes together as a whole.
The personality composition of these teams is very important. You need a mixture of all four types.
D – Dominance
Decisive, organized, optimistic, and strong willed. Very task orientated
I – Influencing
Easygoing, witty, optimistic, and outgoing. Highly relationship oriented
S – Steadiness
Pessimistic, soft-spoken, and artistic. Good at analyzing and goal oriented
C – Cautious
Pessimistic, strong-willed, and soft spoken. Good analyzers
The inspirational person is needed to celebrate the victories. The cautious and steady person is needed to ensure the quality. They are good at analyzing the data. The driven person is needed to ensure the process runs properly and meets the daily requirements. The important thing to remember is that each personality sees the task at hand differently. Working together, they will accomplish a great deal.
The brainstorming team created two teams; consensus and escalation. The consensus team will have weekly meetings and consist of the following areas:
• Denial team
Note: the members of the team will be the people actually doing the work and working managers
The consensus team will request ad hoc members as needed, which are:
• Clinical staff – nursing, physicians, physician advisors
• Revenue Integrity
Purpose of the team and meeting:
• Review the amount of queries
• Review the amount of repetitive queries
• Review the method or resolution in correcting the problem
• Most importantly, review preventative action and its effectiveness
• Ensure preventative action has been implemented
For those issues that could not be resolved by the consensus team, they will be sent to the escalation team. The sole purpose of this team is to resolve the issues that the consensus team could not.
This team will meet as needed and will consist of the following:
• Working managers from the consensus team and the directors of those areas
Both the working managers and directors will request ad hoc members to the meeting as required. The ad hoc members will consist of the same areas as listed for the consensus team.
As with anything, there are always drawbacks with the two biggest being “change is hard to implement” and “avoiding conflict”. And both are viable concerns. Change is hard to implement. Everyone has a comfort zone and implementing change takes you out of your comfort. Secondly, when change is being implemented, conflicts can arise.
Many people do not like challenges, and I get it. But don’t allow challenges to start the “blame” game. Placing blame doesn’t fix anything. Others are conflict averse and don’t confront the problem or people, so nothing changes. Stick to the facts of the situation. Only when you exhaust all other possibilities is it time to look at the operator.
It all starts with keeping your eye on the mission, which is the integrity of patient care and appropriate reimbursement. And it all starts and end with documentation. Accurate documentation is the vehicle for success.
Refocusing efforts is key to making this happen. Change the focus from fixing the problem to preventing it. Over time, the problems will be eliminated. Step back and schedule time each day for prevention. Besides fixing the problem, take it another step further and determine how to prevent future occurrences of the same problem.
Refocus data collection to support the mission. Task oriented data only monitors quantity, which doesn’t support the mission. Instead, collect data that monitors the quality of your process and documentation. Monitor preventative action. How many problems have been prevented from happening again? How many problems re-occurred even after the preventative action was implemented? Monitor the success of the mission.
And most importantly, build cross functional teams. Trust and empower the team to do the right thing. Coach them. Remove the barriers that hinder them. The people that do the work is the key. They know the problems. Help them refocus on prevention.
If possible, have someone oversee things from a distance. Like a drone, they see more. Questions need to be asked. Challenging others can be uncomfortable but done correctly, it inspires creativity.
So, if you are unhappy with what you got, then change. And if that change didn’t work, then change again.