10/2/2014 1 Mark It As Done: Closing the Loop on the Auditing Process Jenifer Carey, CPC-H, CPC-I Manager of Professional Education and Compliance Kim Schaefer-Garvey, MBA, CHRC Director of Compliance Key Objectives • Stop the boomerang effect…solutions for keeping the same professional audit findings from knocking at your door • Closing the loop– solutions for implementing corrective action plans • Successful strategies for fostering collaboration between compliance, physician leadership, and operations
Transcript
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Mark It As Done: Closing the Loop on the Auditing Process
Jenifer Carey, CPC-H, CPC-IManager of Professional Education and Compliance
Kim Schaefer-Garvey, MBA, CHRCDirector of Compliance
Key Objectives
• Stop the boomerang effect…solutions for keeping the same professional audit findings from knocking at your door
• Closing the loop– solutions for implementing corrective action plans
• Successful strategies for fostering collaboration between compliance, physician leadership, and operations
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Deciding What to Audit
• Working with a new EHR
• OIG Regulations
• Denials
• Previous concerns
• New initiatives
• New provider training
• High dollar services
What’s Been the Problem?
• We keep auditing
• We keep educating
• We think we have agreement with leadership on how
to fix it (“the plan”)
• So why do these problems keep resurfacing?
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• New Service
• New Provider
• New Charges
• New Practice
• New Service Line
• Transitioning a New Practice
Didn’t See That Coming…
• Going live on an EHR
• How did IT come up with that?
• Marked as reviewed
• Chief complaint/HPI
• Consults-The Three R’s
• Templates
• Shared visits
• Copy and paste
• Scribes
• Meaningful Use
• “Encounter” vs. “Progress Note”
• Dictation of all types
Guidelines Revisited…. Did someone change them without me knowing?
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• The Twinkie Wrapper Effect: Observation
• Fracture Care
• Infusions and Injections
• Documentation, documentation, documentation…
• Modifiers
• Regulations, Regulations, Regulations….
• ED service and procedures
• Patient/Family Conferences
• Teaching Guidelines
• Place of Service
• Level of Service
Groundhog Day!
Are Any of These Your Present “REALITY”-Can You Relate?
• Department didn’t exist/limited educational and auditing resources
• Nobody was minding the shop
• Myth– Operations knows how to implement change
• Provider/Leadership buy-in
• Provider/Operations stress related to patient volumes and revenue
• Everyone took every problem personally– the finger pointing game
• Provider/Operations fallback– Compliance is making me do this!
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So What’s Next?
• Create a credible and continuous auditing/implementation/monitoring process that would:– Engage all participants
– Build sound relationships
– Depersonalize
– Influence
– Create buy-in
– Done on a shoestring budget
– Create sustainability
Here’s the Solution in Six Easy Steps
Utilize tools from High Reliability, Influencer, and Leading Change to develop a credible and continuous auditing/implementation/monitoring process that fosters collaboration, communication and sustainable change.
1.Identify the topic/need
2.Get the right people around the table
3.Stick to the facts
4.Remove obstacles
5.Implement– create excitement
6.Monitor and feedback
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Step One: Identify the Topic/Need
• Gather any/all information to validate the topic/need
• Quantify the impact
• Draft an SBAR (High Reliability tool)– Situation – brief description of the situation
– Background – pertinent background-what got us to this point
– Assessment– summarize the facts-what do you think is really happening
– Recommendation– what are you asking for- what needs to happen next
Step Two: Getting the Right People Around the Table
• Determine your go–to group for buy-in (i.e., physician, operations, leadership)
• Ask your go–to group who they want involved
• Fill in the gaps:
– Influencers
– Process owners
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Step Three: Stick to the Facts
• Deliver the SBAR
• Elevator Speech – what are the key messages
• Keep it on the list – Running agenda with minutes
• Communicate, communicate, communicate
• KISS method
Step Four: Remove Obstacles
• Prepare for implementation
• Determine the desired outcome
• Audit performance if needed
• Determine elements that help or hinder the desired outcome
• Create a Force Field Analysis (taken from the Leading Change Toolkit)
• Perform pilot(s)
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Step Five: Implement-Create Excitement
• Develop/roll out education and handouts/scripting
• Develop a timeline for phase(s) of implementation
• Perform periodic check-ins with stakeholder group
• Round on new process(es) and gather real time feedback
• Determine what works and what doesn’t
• Fine tune process(es) as needed
• Finalize the SBAR to formally document the final process(es)
Step Six: Audit/Monitor and Feedback
• Determine the length of time after implementation to select an appropriate sample to audit.
• Recommended 30-90 days trial period
• Determine the scope of the audit and sample size
• Audit and analyze the results
• Share results with key stakeholders to determine if additional education/fixes are needed (update SBAR as needed)
• Once the final process has been approved, create an effective monitoring tool
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Dictation in the EHR – Sample SBAR• SITUATION: It has been identified through internal audits that there needs to be an internal control for monitoring when a provider
dictates a note rather than document the note in an EPIC template. If a provider dictates a note, they must leave the encounter open until the note is returned to their inbox and signed. The dictation, once signed, files back into the encounter and is the soledocumentation for the visit for that day. At that point the provider can close the note.
• BACKGROUND: Currently, only full dictation has been allowed. Partial dictation has been promised to the providers and could be available as early as April (actual date unknown). When partial dictation goes live, the risk for non- compliance will be huge.
• ASSESSMENT: Nuance has a report that shows every time a provider dictates, the time whether it is signed etc. The time that a provider dictates needs to be matched to the time that the provider closes and signs their note. The bill cannot be dropped until the documentation is complete and signed.
• RECOMMENDATION: Compliance is recommending a hard stop be created when dictation is used as opposed to the relying on the providers to remember not to close the note until the dictation was signed.
• Information presented on:
• In attendance:
• Next Steps:
• Who is responsible:
• Timeframe for completion:
• Who needs to receive the communication:
• Internal audit and monitoring plan:
– Indicate timeframe, frequency and scope
Dictation in the EHRWalking Through the Six Steps
• 1. Identify the topic/need
– Post Go-Live audit findings
– Drafted the SBAR
• 2. Getting the right people around the table
– Presented to the Specialty Group Leadership (physician and operations)
• 3. Stick to the facts
– Delivered the SBAR to the EHR Analyst leaders
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Dictation in the EHRWalking Through the Six Steps
• 4. Remove obstacles
– Validated and tested the desired process outcome
• 5. Implement and create excitement
– EHR analysts created and rolled out provider education
• 6. Audit/monitor and feedback
– Compliance audited the initial Go-Live. Monitoring occurs during periodic audits.
– SBAR was updated and the process is followed for all future department Go-Lives.
Acquisition of an Existing Practice – Remove Obstacles
Force Field AnalysisPreparing Providers for Transition
Helping Hindering Desired Outcome
Provider Education
Provider audits prior to transition
Lack of supporting
documentation and missing
charges
Increased supporting
documentation and compliance with billing practices
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Acquisition of an Existing PracticeWalking Through the Six Steps
• 1. Identify the topic/need
– Organizational notification of acquiring a large volume freestanding practice
– Drafted the SBAR
• 2. Getting the right people around the table
– Brainstormed to create a list of all stakeholders that were necessary. This included, but was not limited to: Legal, Compliance, Risk, EHR, Billing, Registration, Operations, and Physician Leadership
Acquisition of an Existing PracticeWalking Through the Six Steps
• 3. Stick to the facts
– Delivered the SBAR
– Running weekly agenda and minutes– kept it on the list
– Communicate, Communicate, Communicate
• 4. Remove obstacles
– Determine elements that help or hinder the desired outcome (Force Field Analysis)
– Pre-audit performed on all providers
– Validated and tested the desired process outcome
– Ongoing preparation for implementation
– SBAR was updated and the process is followed for all future department Go-Lives.
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Acquisition of an Existing PracticeWalking Through the Six Steps
• 5. Implement and create excitement
– Developed and rolled out provider education
– Developed timeline for phases(s) of implementation
– Performed weekly check-in meetings with the stakeholder group during the first month of Go-Live
– Round on new process(es) and gather real time feed back
– Fine tune process(es) as needed
– Finalize the SBAR
Acquisition of an Existing PracticeWalking Through the Six Steps
• 6. Audit/monitor and provide feedback
– Compliance audited 100% of all providers during the first two weeks of the initial Go-Live
– Share results with the key stakeholders to determine if additional education/fixes are needed
– SBAR was updated and the process is followed for all future department Go-Lives
– Ongoing monitoring plan was developed
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References
• High Reliability Training as taught by Healthcare Performance Improvement, LLC (HPI)
• Influencer – The Power to Change Anything by Patterson, Grenny, Maxfield, McMillan and Switzler
