The state Department of Health is investigating the death of another child at Seattle Children's hospital — a newborn who died two days before an 8-month-old girl died Sept. 19 of a medication overdose.
At a news briefing Thursday evening, Dr. David Fisher, Children's medical director, said the critically ill newborn was being transported from another hospital to Children's in Children's neonatal ambulance on Sept. 17.
When Fredonia (KS) Regional Hospital looked into updating its utilization review program, it focused on two key areas: involving the right people and being aware of its communication with the medical staff and its bylaws.
The goal of the program was to ensure that hospital resources were being allocated appropriately with the goals of maintaining quality patient care; achieving the best possible efficiency of hospital resources; promoting quality of care through the right level of analysis, review, and evaluation of clinical practices; and, of course, ensuring that the care being provided was medically necessary and appropriate.
"We had an existing utilization review policy, and it wasn't very effective," says Pam Harmon, RN, LNC, chief nursing officer at Fredonia. "We needed to be more diligent."
What they needed, she and her colleagues realized, was an active committee to help get the medical staff aligned with the most up-to-date utilization policy.
But first things first: involving the right people. As a starting point, Harmon reached out to the record review committee. The team also sought feedback from the organization's utilization review nurse.
Billers and coders were equally represented.
"I was previously unaware of the separateness of those two roles," says Harmon. "The billers, coders, business office, and medical records office all have specific jobs which, while we might think of them together, are completely separate in their minds. We needed to go beyond inviting just someone from the business office and medical records."
They also invited a social worker to the committee.
"She has so much to do with people being compliant in finding the right services," says Harmon.
The team was rounded out by the discharge planner. Additionally, Harmon suggests including the corporate compliance officer on the committee.
Once the right team was in place, the research began in earnest.
"We took a lot of information about what [various agencies] were looking at, things we needed to do for demonstrating medical necessity," says Harmon. She also searched online for sample policies from successful organizations to run side-by-side comparisons with her own organization's utilization policy.
"I set down what we were actually doing versus what we wanted to do," says Harmon.
The timing of this review was important as well—changes nationwide have put a focus on utilization in ways the healthcare community has not encountered before.
"Prior to healthcare reform, this was an area that at least half the country wasn't paying attention to—we weren't getting denials," says Harmon. "If anything had come back, hospitals could go back through the chart and fix it. This is no longer the case. We really need to get on top of this. We as an industry needed to fix it so we wouldn't get denials."
Also, with the concept of medical necessity looming on the horizon, hospitals need to be even more aware.
"When we get letters back, we try to make adjustments to make it fit. Hopefully we'll get less letters down the road, less denials," says Harmon.
Fredonia is a small hospital—a 25-bed critical access facility—but Harmon and her colleagues realized there must be one person charged with tracking utilization review full-time.
"You are going to lose a lot by not having someone focus on it every day," says Harmon. "This is a vitally important part of your hospital's operation plan."
Medical staff involvement
In order to implement this change in policy, Fredonia knew it would need medical staff buy-in. The hospital chose a representative of the medical staff to be a part of the development process and a standing member of the committee.
Harmon recruited one of the hospital's younger physicians to be on the committee. The thought was to find someone young enough to be open to new methods for discussing utilization review.
"This helped quite a bit," says Harmon.
The other benefit of involving the medical staff from the get-go: They would be able to hear about change from one of their own.
"It helps to hear it from their peers. Get someone young and ambitious who works well with other physicians," says Harmon. "They know that ultimately what we're teaching them here will reflect back on their clinics as well."
The next step was talking it over with the physicians.
"After developing the new policy, we took the whole plan back to the medical staff," says Harmon.
Any time large-scale change must run the gauntlet of the medical staff, hospitals know there will be a period of adjustment.
"They know they're going to have to change their outlook," says Harmon. "They are looking at us to give them the guidelines so they don't get in trouble with Medicare or Medicaid, all the powers that regulate if we get paid."
And, ultimately, all professionals want the best for their patients. In this case, patient care and financial requirements go hand in hand.
The new attitude Fredonia urged its medical staff to take? "Think in ink."
"We preach it all the time," says Harmon. "If you have a reason this person with normal blood values should be kept, write it down. We can't know a few years down the road what you were thinking when you made this call." Many times this will prevent a denial, she adds.
At first the physicians were resistant; some felt as though they were being told how to practice medicine. Now, however, they will call Harmon's office and run a process by her and her team. Physicians will explain what they're seeing and the process they want to follow, then ask for suggestions.
Following changes
Fredonia is part of the Great Plains Health Alliance, so it was constantly kept in the loop on utilization review updates from regulatory bodies. It also had access to resources to compare and contrast its existing policy with others.
"We pretty much knew what we had to do and how to get there," says Harmon.
The process of realigning the new policy took several months, however.
"The biggest thing is to stay on top of what [the field] is saying about [recovery audit contractors] and denials," says Harmon. "That changes what you're looking at and what you're thinking. All the time they're coming out with additional changes and updates."
Staying on top of CMS updates is the real key, though. "Get on their mailing list and be aware," she says. "It changes. What we put in our current policy is good, but things change."
Remember to look ahead. The sooner you trail behind the latest developments, the sooner your policy loses effectiveness. Don't be afraid to seek out seminars, online courses, or broadcast events to stay up to speed with the latest utilization review changes.
Little things can add up. For example, Fredonia found that notices providing opportunities to appeal denied claims were being included in remittance advices.
"They were making adjustments to our remittance advices, and at first we didn't catch it," says Harmon. "They weren't actually denying the whole account or stay, but they were looking at it and denying little things—if we charged for three IVs but only charted two [in error]. These weren't big-dollar issues, but when we went back through our remittance advices we found a number of them we weren't even aware of!"
It also helps to be in the loop with the right electronic resources. CMS and its various updates are a good starting point; the American Hospital Association also tracks changes and has mailing lists. Often, state and local organizations follow utilization changes and can be an ongoing resource for updates.
Finally, the right social networking tool can be a good way to reach out to fellow professionals for advice and to swap ideas.
In the end, the full backing of the board made development and implementation of Fredonia's policy a much more effective process. "We have an awesome board, and they listen to what we suggest. If we say it's important, they will back us up. We're fortunate," says Harmon. "Ultimately you could lose your Medicare certification if you don't do this right."
________________________________________________________________________ This article was adapted from one that originally appeared in the October 2010 issue of Briefings on The Joint Commission [http://www.hcmarketplace.com/prod-16/Briefings-on-The-Joint-Commission.html], an HCPro publication.
For more than 20 years, trial lawyer Rick Boothman defended doctors and hospitals in malpractice lawsuits. The job taught him plenty about the disconnect between the defensive behavior practiced by the medical establishment and the humane treatment patients want. So when the University of Michigan Health System needed a new in-house attorney in 2001, Boothman made an offer: hire me and revolutionize your approach. We’ll be up front with patients when medical errors happen, and we’ll pay quickly when a case warrants it, rather than dragging everybody into court. “It’s the decent thing to do,” says Boothman. A new study published in August found that since Michigan adopted Boothman’s program of disclosure and compensation, lawsuits have declined and legal-defense costs have dropped by 61 percent. There’s no proof that acknowledging mistakes led directly to savings, but it didn’t cause a malpractice frenzy either. “The sky doesn’t fall in when you are open and honest,” he says.
With fewer beds available due to budget cuts, the wing of the state hospital that houses mentally ill children and teenagers has suspended admissions for the second week in a row. The Anna Philbrook Unit stopped admitting children Thursday and was still at capacity late Friday afternoon. A week earlier, the unit had to suspend admissions for 48 hours.
That hasn't happened in "a very long time," said New Hampshire Hospital's acting CEO, Paula Mattis. But she said she expects the hospital will be forced to continue suspending admissions now that children and adolescents are being housed in the same wing.
Before this year, children age 14 and under who needed to be involuntarily admitted to the state hospital went to a separate building, the Anna Philbrook Center.
The economic recession, whether it is over or not, has pushed record numbers of Minnesotans into state-subsidized welfare and health insurance programs, according to figures published this week by the Department of Human Services.
The number of Minnesotans eligible for Medical Assistance, the state's version of Medicaid, climbed to 610,000 in an average month in fiscal 2010, compared with 557,000 on average in 2009. That is the largest one-year increase in at least the past decade and represents more than one in 10 Minnesotans.
Earlier this year, Sallie Latty, RN, BSN, MA, one of a pair of ANCC Magnet Recognition Program® (MRP) coordinators at St. Vincent Hospital Indianapolis, set out on a very specific research project. As part of crafting the organization's application documentation for MRP recognition, her focus turned to the Source of Evidence Transformational Leadership, Advocacy and Influence (SOE TL-4).
This requirement asks organizations to describe and demonstrate how the chief nursing officer is enabled to influence organization-wide changes. Latty devised an initial list of evidence and then reached out to her colleagues in the field for additional brainstorming ideas.
"When I started writing, I talked about our CNO and how she was able to influence the organization through her participation in the board of the directors," says Latty, who provided meeting minutes, discussed presentations the CNO gave, and highlighted her attendance.
She also focused on the CNO's job description.
"Even though we include the overall job description in our organization overview, we took this opportunity in the SOE to highlight specific competencies," says Latty.
There are some administrators who have a reporting relationship to the president of the organization but also have a dotted-line reporting relationship to the CNO.
"In the SOE, I talked specifically about the level of expertise required of a CNO in our organization," says Latty. She focused on competencies that affect the ability to influence, such as:
Coaching
Proficiency of teamwork
Decision-making ability
"I also focused on pieces of the organizational chart to give detail about her reporting relationships and factors that tie her in across the organization," says Latty.
Don't be afraid to ask for additional support from leadership, either.
"I also had our president write a letter summarizing his level of influence and how, in his absence, our CNO is the acting president," says Latty.
The biggest part of the document includes examples of the CNO's ability to influence the organization through her involvement with groups on multiple levels, key committees and councils where her voice would have an effect on the entire organization.
Key groups Latty discussed in the MRP document were:
Executive committees, such as the administrative council. All of the organization's executives at the highest level meet weekly, including the CNO.
Quality councils/committees, such as the quality committee of the board. This is a sub-council of the board of directors.
For each of these roles a roster is included, as well as minutes where appropriate, highlighting the CNO's expertise and identifying her contributions in blue ink.
"This could include any discussions she has led or where she has contributed her voice," says Latty.
Other key meetings detailed in the document include:
Quality and safety committee
Medical executive council
Departmental meetings
Business development
Patient safety committee
Risk and safety committee
Nursing peer review committees
Credentialing committee
The business development component is important because the organization is able to demonstrate the CNO's ownership over key projects and detail the progress of those projects.
"We also discuss how she's involved in our shared governance model," says Latty.
View from the field
Latty received a number of ideas from her colleagues in the field for inclusion in the report. The first, and most striking, was budget information.
"The whole focus we have here is to describe and demonstrate the ability of the CNO to influence organizationwide change—the budget can show she's put funding towards those changes," says Latty. "I hadn't thought of that!"
Others suggested information about board retreats. "We often do our strategic plan on these retreats," she says.
Still others suggested delving into further details about the CNO's role in quality improvement. Being a member of a committee is one thing, but is there anything beyond that to demonstrate the process behind her influence?
St. Vincent Hospital uses the Lean structure many hospitals are adopting, which its CNO is heavily involved in. Latty chose to include an explanation of how she influences this process and how Lean is used to influence the organization as a whole.
Challenges
There were some hiccups along the way in building the documentation needed to prove these facets of the CNO's role and influence.
"One thing I encountered was, when asking for meeting minutes for executive meetings, people don't want to let you take them," says Latty. "They're confidential documents. You have to be willing to have people tell you they can't send them to you."
Be prepared to go to the appropriate office, read through the document, and highlight the parts you need.
During this process, you may find that councils or committees don't update their charters or membership as often as they should.
"You don't want to include old information in your documentation," says Latty. "Motivate them to update their charter or membership list."
These smaller tasks can be very time-consuming, she notes. Anticipate spending more time than you would otherwise expect tracking down these items or requests.
Your CNO
Your greatest asset in creating this portion of your MRP document is your CNO.
"You need your CNO to be your advocate," says Latty. "They can be your intercessor in obtaining important documents or getting access to the right meeting minutes."
It is possible the CNO may not be comfortable standing in the spotlight—and this is a fear you need to help him or her get over.
"Once they see that what you're doing is to make them look as good as possible, they'll become your advocate," says Latty. "They're a great CNO and do all these wonderful things, and you want to capture that. Our own CNO, as we finish each SOE or component, thanks us for painting her in such a good light."
Because MRP designation is one of the organization's strategic initiatives, the board of directors has been behind the project from the start. The CNO takes on the role of keeping the board up to speed—which is key because, as Latty points out, it's important to have an open line of communication between you, the CNO, and the board through the whole process.
________________________________________________________________________ This article was adapted from one that originally appeared in the August 2010 issue of HCPro's Advisor to the ANCC Magnet Recognition Program®, an HCPro publication.