Catherine Gormam-Klug, RN/MSN

Cathy, has over thirty years’ experience in healthcare. In addition to a varied clinical background, she has extensive experience in project design, implementation and management. As Director of the Quality Service Line for Nuance’s Quality Management Suite, she is responsible for product strategy for the Clintegrity 360 | Quality Measures, Performance Analytics and Narrative Search solutions This includes monitoring the regulatory horizon to ensure that current and future Clintegrity 360 | Quality solutions are compliant with new and revised regulations; including but not limited to TJC; CMS; HIPAA, value-based purchasing, the American Recovery and Reinvestment Act.

A frequent speaker, author and blogger on Quality and Compliance activities, Cathy truly understands the challenges industry stakeholders face, and uses her experience to help them meet the ever increasing and changing regulatory and accreditation requirements. Prior to her role with Nuance, Cathy served as a Corporate Director of Regulatory Requirements, Privacy and Data Security for an integrated health system.

Most years, the nearing of the end of summer and the beginning of fall conjure up thoughts of back-to-school activities, all things pumpkin and apple, crisp air, and hayrides! For most in healthcare, however, especially those who work within health information management, quality, and revenue cycle roles, many of these thoughts haven’t even begun to surface. Nor is it likely that the normal fall activities will be embraced as heartily as in years past. Why? The change of seasons and all that it brings is just another reminder of one of the biggest changes that healthcare has seen in years: the advent of ICD-10 and all that it brings.

While arguably, there are individuals who remain under the assumption that ICD-10 is “just” a coding and health information concern, those in the aforementioned areas (and in many other realms in healthcare) know that this is simply not the case. This change brings no more of a “one-department” change than Y2K was an IT responsibility, or the HIPAA rules were and are a compliance responsibility. 

Yes, coding is in the eye of the storm, and as with any storm, the effects can be far-reaching. Attention now must be focused on those areas surrounding the eye of the storm.

As we all are aware, all hospitals that receive Medicare funding, which generally accounts for close to 60 percent of a hospital’s reimbursement, must submit certain proscribed core measures to the Centers for Medicare & Medicaid Services (CMS) to receive the Medicare annual payment update. The Joint Commission also requires the submission of core measures for accreditation and certain certifications (stroke, heart failure, etc.). One of the domains in value-based purchasing (VBP) is the submission of core measures. Keep in mind how patients are selected for inclusion or exclusion from core measures: through administrative data, commonly known as the uniform bill. Coding is in the eye of the storm, but core measures are in the eyewall! 

Taking this a step further, let’s look at the impact of ICD-10 on VBP beyond core measures. Value-based purchasing also includes the Hospital Readmission Reduction Program (HRRP) and the hospital-acquired conditions (HACs) domains. Both of these are “penalty only” and represent the potential for significant loss of revenue. Although there have been some impressive downward trends in both of these domains over the last two years, the need to proactively monitor and improve continues. 

Documentation integrity no doubt will play an even greater role during the ICD-10 transition. With the number of available code sets growing exponentially, accurate and timely documentation is of the essence in order to ensure the delivery of safe and cost-effective patient care. Documentation integrity and improvement interventions need to begin at the beginning: at the time of admission. Organizations still struggle with accurate documentation and thus coding of present-on-admission (POA) conditions. Failure to precisely document comorbid conditions can result in patient safety concerns as well as falsely increase the hospital’s HACs rate. In the presence of certain comorbid conditions, what would normally be classified as a HAC are excluded from the calculation, just as certain patients are excluded from core measure requirements. The importance and impact of a detailed review and documentation of comorbid conditions cannot be overemphasized! It is widely recognized that patients with comorbid conditions are at a greater risk for hospital-acquired conditions. During a performance improvement project at a multi-hospital system in the Mid-Atlantic, it was discovered that poor documentation and coding inaccuracies were greatly skewing the numbers of HACs. Through a cross-functional approach, however, the system successfully improved both patient care and the bottom line.

Accuracy of the date of admission carries a frequently overlooked potential for generating inaccurate reporting on readmission rates. Be certain that dates and times are accurate and consistent throughout the medical record. A discrepancy of just a few minutes or hours can trigger readmission penalties.

Just as with any other healthcare initiative, preparing and planning for ICD-10 requires a cross-functional approach and effort. Reimbursement from commercial payors is not the only revenue at risk. VBP, the Delivery System Reform Incentive Program, and state-based initiatives, all of which provide financial incentives and penalties, also represent revenue at risk. 

It is not too late to finalize (or build) your preparedness kit! Here are some essentials you will need:

  • Know your current and historical performance data:
    • Hospital-acquired conditions
    • Present-on-admission conditions
    • Readmission data
    • Core measure performance
    • Value-based purchasing performance
  • Know your patients:
    • Rate of comorbid conditions
    • Most frequent pairings of comorbid conditions
    • Most frequent types of HACs
    • Conditions with the highest readmission rates
    • Discharge disposition of those with high readmission rates
  • Know your physicians:
    • Readmission performance
    • Rate of complications
    • Rate of HACs
    • Discharge practices
  • Tighten up:
    • Denial appeals process
    • Use of inter-rater reliability for core measure consistency
    • Coding quality control practices
    • Data steward practices and control

As the date for the great transition draws nearer, focus on the horizon and look at the big picture. Whether you are in the eye of the storm or anywhere near it, with careful and strategic planning, you will weather the storm.

About the Author

Catherine Gorman-Klug has over 30 years of experience in healthcare. In addition to a varied clinical background, she has extensive experience in project design, implementation, and management. As director of the Quality Service Line for Nuance’s Quality Management Suite, she is responsible for product strategy for the Clintegrity 360|Quality Measures, Performance Analytics, and Narrative Search Solutions. This includes monitoring the regulatory horizon to ensure that current and future Clintegrity 360|Quality solutions are compliant with new and revised regulations, including but not limited to TJC, CMS, HIPAA, value-based purchasing, and the American Recovery and Reinvestment Act.

A frequent speaker, author, and blogger on quality and compliance activities, Cathy truly understands the challenges industry stakeholders face, and she uses her experience to help them meet the ever-increasing and changing regulatory and accreditation requirements. Prior to her role with Nuance, Cathy served as a corporate director of regulatory requirements, privacy, and data security for an integrated health system.

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c gormanIt is interesting to consider that the value-based purchasing domain, whose scoring is based on criteria tied to the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), relies on what in any other circumstance would be considered skewed or flawed data. Unlike any other domain within the program, the scoring cannot be tied directly to fact- and evidence-based documentation.

CMS.gov provides the following definition: “The HCAHPS survey is the first national, standardized, publicly reported survey of patients’ perspectives of hospital care. HCAHPS (pronounced "H-caps"), also known as the CAHPS Hospital Survey, is a survey instrument and data collection methodology for measuring patients' perceptions of their hospital experience. While many hospitals have collected information on patient satisfaction for their own internal use, until HCAHPS there was no national standard for collecting and publicly reporting information about patient experience of care that allowed valid comparisons to be made across hospitals locally, regionally, and nationally.”

The Beryl Institute (www.theberylinstitute.org), whose overarching goal is improving the practices that define the patient experience through collaboration, offers a very clear and encompassing definition of the patient experience. They define it as “the sum of all interactions, shaped by an organization’s culture, that influence patient perceptions across the continuum of care.” The Merriam-Webster dictionary defines perception as “the way you think about or understand someone or something.”

Long before the advent of value-based purchasing, patient satisfaction has been on the radar of healthcare organizations nationwide. In the mid- to late 1990s a myriad of programs were introduced and enjoyed wide success and implementation. The Disney Leadership Institute for Healthcare and the Studer Group were on the tip of hospital administrators’ tongues nationwide. Who among us has not read, or at least heard of “If Disney Ran Your Hospital?”

Many have scoffed at these programs and dismissed them as hype. The feeling was that if patients need to come to the hospital, they will. But is that really fair and accurate? The findings say no. Patient satisfaction, which has evolved into the patient experience, is well worth the investment of time, money, and resources. No longer is a dissatisfied patient solely a risk to a hospital’s reputation. The stakes are much greater.

Disengaged or dissatisfied patients are more likely to experience:

  •       A medical error
  •       Hospital-acquired conditions
  •       Greater numbers of readmissions

Consider for a moment the Beryl philosophy, which includes the entire continuum of care. For many patients that continuum and their associated experiences begin prior to even arriving at the hospital. Their first touch point may be the scheduling of routine diagnostics, outpatient procedures, or pre-admission tests. Many organizations have created centralized call centers and portals to increase efficiency and availability of scheduling options. While this may appeal to millennials and some baby boomers, they do not represent the majority of the patient population. Roughly 60 percent of all hospital payments are derived from Medicare. Yes, there are many tech-savvy seniors, but think of your own frustration with IVR systems: How many times do you have to hit “0” for a “live person?” Is the implementation of technology-based solutions really the best approach to enhancing the patient experience? Or would the availability of a Navigator program be a better fit in some situations and with some populations? Are the technology-based solutions truly designed for the populations you serve? For example, in how many different languages is your patient portal written?

Let’s now consider another location on the journey through the continuum: discharge. While some may argue that discharge is a time of joy for patients, others would argue that it is a time of stress. Concerns about new diagnoses, new medications, dietary restrictions, and possibly, new daily practices (blood pressure monitoring, for example) are likely weighing heavily on many patients’ minds. Have they been sufficiently prepared for discharge? Or will things come as somewhat of a surprise? (“Mr. Jones, I have great news for you! Your doctor decided you can go home tonight instead of tomorrow morning!”) 

As with many aspects of healthcare, discharge planning and preparation is both an art and a science. Done well it results in great success; done quickly or carelessly it can result in medication complications, anxiety, readmissions, and a poor patient experience. A piece of the discharge process that cannot be overlooked or underestimated is the time it actually takes for the patient to be transported from the facility. Hospitals’ internal transportation delays and lack of available staff plague many facilities, and these factors often are cited as patient dis-satisfiers, not only during the discharge process but during the admission process and the stay itself.

Creating positive patient experiences is clearly worth the effort. Remember, with HCHAPS it is an all-or-nothing score. The new Hospital Five-Star rating system cannot be underestimated either. What if something can be done to help control the often “uncontrollable?”

Here are a few suggestions for empowering all team members along the entire continuum of care to control the patient experience:

  • Every team member must understand, remain focused on, and continually evaluate on the patient experience
  • Every team member must be educated and engaged in:
    • Recognizing a dissatisfied patient or family member
    • Expressing empathy for the dissatisfaction, whatever the cause
    • Scripts for responding to concerns
    • Processes for handling and addressing concerns:
    • During “normal” business hours
    • On off-shifts
    • On weekends and holidays
  • Team members should be kept in the loop on the concerns they have when escalated; they are the front lines and patients and families will ask them
  • Patient experience teams must be cross-functional
  • Positive outcomes and resolutions should be celebrated

Given the research supporting that disengaged or dissatisfied patients are more likely to experience a medical error, hospital-acquired conditions, and a greater number of readmissions – plus the simple reality that hospitals can be penalized on multiple areas within these domains related to just one patient and his or her experience – what will you do to “control the uncontrollable?”

About the Author

Catherine Gorman-Klug has over 30 years of experience in healthcare. In addition to a varied clinical background, she has extensive experience in project design, implementation, and management. As director of the Quality Service Line for Nuance’s Quality Management Suite, she is responsible for product strategy for the Clintegrity 360|Quality Measures, Performance Analytics, and Narrative Search Solutions. This includes monitoring the regulatory horizon to ensure that current and future Clintegrity 360|Quality solutions are compliant with new and revised regulations, including but not limited to TJC; CMS; HIPAA; value-based purchasing; and the American Recovery and Reinvestment Act.

A frequent speaker, author, and blogger on quality and compliance activities, Cathy truly understands the challenges industry stakeholders face, and she uses her experience to help them meet the ever-increasing and changing regulatory and accreditation requirements. Prior to her role with Nuance, Cathy served as a corporate director of regulatory requirements, privacy, and data security for an integrated health system.

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c gormanThese seemingly innocuous questions cited in the headline seem to be being asked in hospitals everywhere these days. But in this ever-changing environment of healthcare reform and pay-for-performance the answer is rarely if ever simple! No corner of the building, no meeting or causal lunch in the hospital cafeteria is immune to being morphed into an impromptu educational session. Once reserved for the harried weeks leading up to accreditation surveys scheduled months in advance and with the dates widely known, this fervor to understand the rules of the game and what the score is has become a way of life. What is causing the stir? Value-based purchasing (VBP), of course!

While certainly not a new phenomenon to those in the worlds of quality, clinical documentation improvement (CDI), and health information management (HIM), interest is at a crescendo among stakeholders who in the past would have happily remained on the sidelines, allowing the "accreditation team" work its magic in coordinating successful surveys. Accreditation is one thing, but the bottom line is quite another story. And in addition, performance is publicly available!

As penalties continue to increase and pose a very real threat to hospitals' overall financial solvency and reputation, the expanded healthcare team wants and needs to understand the components of the initiatives – and most of all, how they, as an organization, are doing. An often unstated but frequently anticipated question is "how much better are we performing than 'them?'" Further complicating the equation is the ever-changing and evolving requirements and associated percentages. Truthfully, sometimes it feels like one must be a trigonometry professor to get it all straight!

We all know it is an issue, but shy of locking yourself in your office and never eating, what are the best answers to these questions?

Patients: First and foremost, pay-for-performance and its associated components are about the core of healthcare: the patients! Delivering safe, effective, cost-effective care for the best outcomes is a basic and grounding concept. Keep this uppermost in your mind and messaging, and the rest comes easy.

In a perfect world, the above would be enough to ebb the flow of questions. But since we know that isn't the case, here are some are some tips for success.

Patience: It is no secret that many of your current "students" are new to the intricacies, pitfalls, and pain of the "off-stage" regulatory process – but most are familiar with the "on-stage" performance when regulators are on site. Embracing each query as a teachable moment will make it easier for you to educate the team.

Preparation: You know the questions are going to come, so be prepared! Knowing that most adult learners don't retain all they are told, keep hallway conversations light and on point. Have a basic script that answers the basic questions for these chance encounters. But prepare documents, FAQs, and dashboards that can be emailed or presented at meetings.

Prudence: Be judicious in mailing out dashboards, benchmarking data, and distributing other documents that are dynamic and easily can be misunderstood and misconstrued. Keep in mind how easy it is to hit "forward" and redistribute these documents to others. No one wants to be in the middle of a virtual game of telephone, especially when the data is old. Better to send easily consumed documents and an offer to provide live education.

Practice: Practice your response for these unscheduled meetings. Keep it simple and consistent. Do not assume that the game of virtual telephone will not carry over to conversations. Practice until it is a well-known script. Provide the scripting to others on your team so the message is consistent.

Performance Analysis: Data speaks, and we all know and practice that already. But in this arena you need to think outside the box. Think of all the questions you have been asked and also of those you anticipate. Prepare metrics to address them, even if it is to demonstrate the non-applicability of the data.

Proactive Monitoring: Know what you will be measured upon tomorrow and monitor for this today. Monitor and report so there will be no surprises.

Plan: Plan remediation for tomorrow today! Include the performance improvement plans in all that you report. But remember, report and explain. Just hitting "send" is not the right option.

Public Relations: Don't be shy about including them in your education and scripting. These folks are word-smithing pros! They will make sure your message is clear, crisp, and very unlikely to be misconstrued.

Presentations: Once you have gotten your dashboards, FAQs, and scripting down pat, schedule live presentations. Go to as many meetings as you can, and do a road show. The more stakeholders who hear the message and planning firsthand, the less likely there will be for misunderstanding.

Parameters: As with any other initiative that can have serious public implications, work with leadership and public relations to establish what can and will be shared publicly before a situation arises. Hospital performance and all the components of VBP are prime fodder for media coverage. They will be armed with the publicly viable data, so you need to be armed with the facts and a well-prepared spokesperson.

Perseverance: Value-based purchasing and its associated components is a journey, not a destination. Performance is dynamic and not static. Just like most things in healthcare, there will be victories and there will be performance slippage. This is just a different initiative, not a new concept.

Patients: Coming full circle, remember, this is where the focus belongs. The patient is at the center of the healthcare universe. They expect and deserve the best care that can be offered. But are their expectations and perceptions always correct, or even fair?

Healthcare is dynamic, and this is a concept we all know well. Some things are out of our hands and cannot be controlled; they are the proverbial unknown variables. Is the patient's interpretation of their experiences the latest unknown variable?

Contact the Author

Cathy has over 30 years of experience in healthcare. In addition to a varied clinical background, she has extensive experience in project design, implementation, and management. As director of the Quality Service Line for Nuance's Quality Management Suite, she is responsible for product strategy for the Clintegrity 360|Quality Measures, Performance Analytics, and Narrative Search Solutions. This includes monitoring the regulatory horizon to ensure that current and future Clintegrity 360|Quality solutions are compliant with new and revised regulations, including but not limited to TJC; CMS; HIPAA; value-based purchasing; and the American Recovery and Reinvestment Act.

A frequent speaker, author, and blogger on quality and compliance activities, Cathy truly understands the challenges industry stakeholders face, and she uses her experience to help them meet the ever-increasing and changing regulatory and accreditation requirements. Prior to her role with Nuance, Cathy served as a corporate director of regulatory requirements, privacy, and data security for an integrated health system.

Contact the Author

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