As of September 18, all four RACs were conducting automated audits, according to an October 6 American Hospital Association (AHA) RAC program update. But only 16 of the 23 audits underway were on hospital outpatient claims, according to the AHA. (The others were therefore on physician and durable medical equipment claims.)
The AHA also updated providers on the arrival of additional types of RAC audits (e.g., DRG validation and medical necessity). RACs have already requested the ability to audit for more than 100 different issues, according to the AHA. Some of these include code and DRG validation reviews, which CMS has not yet approved, choosing instead to begin solely with automated audits involving no need for medical record review.
And while DRG and coding reviews could begin as soon as November, the AHA says CMS may delay the onset of medical necessity reviews so it can first establish a process that would give providers the ability to re-bill all eligible outpatient claims. CMS previously announced medical necessity reviews would begin in January 2010.
The AHA update also addressed the problems with the current remittance advice process. According to the update:
"CMS is aware of several problems with the current process that prevent claim-level reconciliation by hospitals… Instead of claims-level detail, the remittance advice combines information on all recoupments occurring on a particular day into a single batched amount. The lack of claim-level data on the remittance advice at the point of recoupment prevents hospitals from reconciling anticipated recoupments with actual recoupments."
CMS plans to implement a solution next summer, the details being announced via a future CMS transmittal and MedLearn Matters article, according to the AHA.
CMS will also be changing its medical record request limit policies, according to the update. CMS will base the new request limits on tax ID numbers as opposed to national provider identifiers (NPI), eliminating confusion for providers with multiple NPIs.
Finally, the program update notes that RACs will make an effort to use both Interqual and Milliman screening criteria when auditing. The RACs would aim to use the same criteria originally used by the MAC or FI that processed the initial claim.
Staff development specialists are well aware that the way new employees are oriented to an organization has a significant effect on their job satisfaction and, ultimately, on retention. It is essential that we take this belief and translate it into evidence-based practice. One very innovative educator did just that when she revised her nursing orientation program to help increase nursing retention rates in her organization.
Sylvia E. Prickitt-White, RN, BSN, MEd, is the nursing education/wound care clinical coordinator at the Heart of Lancaster Regional Medical Center, a 140-bed hospital in Lititz, PA. As the educator in the hospital, Prickitt-White found that orientation was taking more and more of her time. The demand for orientation was linked to the need to hire and orient new nurses on a very frequent basis. In 2005, she began to notice what she calls a "drastic turnover" of both new and experienced nurses.
"They would stay for about three to six months and then resign," says Prickitt-White. "Our retention rate of newly-hired nurses was about 25% to 30%."
At that time, general orientation took one week and unit-based orientation lasted for three months. She wanted to know why nurses were leaving so began contacting nurses who had left the organization. She says new nurses reported feeling "removed and disjointed once they left the safety of new employee orientation" and also reported a lack of connection after orientation was completed.
New orientation initiatives
As part of her efforts to find a solution to the problem, Prickitt-White conducted an extensive literature review on the topic of retention and orientation. According to the literature, nurse retention is boosted by some type of formal program that extends beyond orientation, such as a residency or mentoring program, that allow for regular contact with designated peers throughout the first year of employment.
Armed with evidence from her literature review, she approached administration and received permission to implement a new program. She designed an extended orientation program that lasts throughout the first year of a nurse's employment. She says the purpose is to "bring new employees together to give them information they may have heard during orientation, but may not have absorbed due to the extensive amount of information thrust upon new employees."
This program also gives them a chance to reconnect with each other and share comments, concerns, and triumphs. The year-long program is called Connections and consists of four components: Connecting the dots, focusing the picture, keeping the focus, and completing the puzzle.
Connecting the dots
"Connecting the dots" is a half-day program designed to help "pull the pieces together," says Prickitt-White. Held one month after the initial general orientation of a group of nurses, it brings the group back together.
The half-day program gives nurses a forum to reconnect with their group and allows them to ask questions and express concerns—both to each other and to Prickitt-White—in a supportive, non-threatening environment. It also fosters cohesiveness and a support network.
In addition to taking part in open discussions, the group has a chance to meet with people important to their practice, but who were not part of their general orientation due to time constraints, such as the diabetic educator. The chief nursing officer (CNO) also attends, giving the nurses an opportunity to discuss issues with her as well.
Focusing the picture
The next part of the program, "focusing the picture," is held three to four months after the group's hire date. The hospital may have more than one orientation group depending on how many orientations have been held during this time period. "Focusing" is held between the first and second shift and the second and third shift and is a two-hour program. Nurses are financially compensated if attending the class on off-duty hours, and, thus far, attendance has been good.
"Focusing" concentrates on hospital processes that may not have been addressed or were only briefly addressed in previous classes. Some topics include rapid response teams, hand-off communication, and a discussion of how they are doing with the documentation system and bar code medication administration. Depending on the response, Prickitt-White might offer some remediation work with nurses regarding medication administration and documentation.
And of course, a key part is the ongoing emphasis on communication and support.
Keeping the focus
"Keeping the focus" is split into two sessions, one at six months after hire and one at the nine month mark. Classes are offered to accommodate the needs of nurses who work various shifts. The content is flexible so that additional topics and issues can be addressed as needed. Topics addressed may include updates on National Patient Safety Goals, annual competencies, risk management, Medicare reimbursement, or Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey results. Prickitt-White notes that discussing HCAHPS results, which reflect patients' experiences of their hospitalization, helps to focus nurses on thinking about customer service as well as clinical interventions.
The program also makes sure to allot time for open-ended discussion.
Completing the puzzle
The final component of the program, "completing the puzzle," is a class held about one year after hire. The session is scheduled for a time when most of the group is scheduled to work and is presented as a breakfast or lunch buffet.
The group members themselves guide this open-ended discussion, which serves to bring closure to the first year of employment. They also evaluate the orientation program to provide feedback on their experiences.
Results
Prickitt-White is "thrilled" with the link between her new program and retention rates.
"The retention rate one year after program implementation jumped to 65%," she says. "Today, three years later, retention has reached 80%."
Although many factors influence retention, it is clear that there is an association between the new program and improved retention. Other program strengths include enhanced communication, increased feelings of support among and for orientees, and more time for orientees to become assimilated into the organization. Challenges include the ongoing need to work with new administrators and managers to maintain buy in for the new program, scheduling nurses to attend the third and fourth program sessions (by this point they are carrying full patient loads and need to be covered on their units), and finding ways to effectively utilize orientation feedback.
Editor's note: Prickitt-White presented her findings at the Pennsylvania Workforce Investment Board conference in March 2009. She is currently working on developing a manuscript for publication to share her success with other staff development specialists. Prickitt-White's innovation has not only helped her organization and its newly-hired nurses, but has added to the evidence-based body of staff development knowledge as well.This article was adapted from one that originally appeared in the October 2009 issue ofThe Staff Educator, an HCPro publication.
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Editor's note: UPDATED -- 3:30 p.m. Friday, October, 16: A judge today halted enforcement of a New York State directive requiring that all healthcare workers be vaccinated for the seasonal flu and swine flu. Justice McNamara scheduled a hearing on the case for Oct. 30.
As the campaign to inoculate America against the H1N1 virus started to ramp up last week, so did the controversy. Reports of hospitals and health systems mandating all employees receive H1N1 vaccines brought cries of civil rights infringements. In particular, the decision by the New York state Department of Health requiring all hospital, home health, and hospice workers receive the vaccination by November 30 caused widespread protests from nurses in the state. The New York state Nurses Association has been deluged with calls and emails, and a protest rally in Albany attracted several hundred people.
With the H1N1 virus spreading across the country, the uproar leaves many nursing leaders scratching their heads. Considering the safety of our patients, why won't nurses just get the shot?
Myths and misperceptions
The reasons fall into two categories, which broadly intersect: a simple dislike of being forced to do something, and legitimate concerns about the new vaccine's safety and efficacy.
The nurses protesting in Albany cited the infringement of their civil rights, but concerns about safety were behind much of their fervor.
These issues contain some genuine concerns, along with a good chunk of misinformation. I was thinking about this as I sat with a group of moms in my neighborhood on Saturday. As the kids ran around playing, talk inevitably turned to H1N1.
"There's no way I'm going to get it or get my kids vaccinated," announced one mom. She "enlightened" the rest of the group the vaccine is made with things the FDA hasn't approved for use in vaccines and it was likely to cause Guillain-Barré Syndrome. And just like that, we were all a little bit more concerned based on what turns out to be bad information.
Many of the misperceptions and fears prevalent in the community at large are equally common among healthcare providers. There are also misconceptions surrounding concerns that the vaccine is new, and long-term efficacy has not been demonstrated. I talked with a nurse the other day who said it wasn't that she didn't want to have the vaccine at all. She just wanted to wait until it had been out for a few months and she saw what happened.
Focus on education
Faced with the lack of knowledge about the vaccine and the many sources of hysteria or gossip, it is critical that healthcare organizations focus on staff education to ensure employees understand the facts about H1N1 and the vaccine.
Any imformation distributed to staff should include information from the CDC that the vaccine is not untested. It was created the same way as the seasonal flu vaccine that is routinely given to hundreds of millions of people, and rapid clinical trials showed the same lack of serious side effects in H1N1 vaccine as with the regular flu shot.
The concern about Guillain-Barré Syndrome dates back to the 1976 strain of swine flu (which many of your employees may vividly remember), when a vaccine was associated with some instances of the syndrome. But since that date, no flu vaccine has been clearly linked to Guillain-Barré Syndrome, and certainly not H1N1.
Eileen Dohmann, MBA, RN, NEA-BC, vice president of nursing at Mary Washington Hospital in Fredericksburg, VA, says her organization's focus on education has resulted in increased seasonal flu vaccination rates, and they plan to follow the same tactic for H1N1.
Staff who reject a seasonal flu vaccination fill out a form explaining why, allowing the hospital to analyze the reasons and provide additional education on common concerns.
When the H1N1 vaccine becomes available in their region, Dohmann says they will offer it to staff based on priority. Nurses in the ED and labor and delivery, for example, will receive highest priority.
"We are not making it mandatory," says Dohmann. "The issue is allowing people to protect their right to choose whether they want to take it or not. We will be strongly encouraging them to do so. I see our role as the employer is to make sure they're as educated as we can get them to be, that we give them the information so they can make an educated decision."
Some organizations are restricting caregivers who have not received the vaccine from direct patient contact. Other organizations have considered issues such as whether pregnant nurses should not care for H1N1 infected patients.
Dohmann says her organization has chosen not to go down that path. "We're supposed to be practicing universal precautions on every patient anyway. Are we suddenly going to say now for flu we're going to treat it differently?"
Dohmann remembers when universal precautions were first identified. "Patients can always have something that you don't want to catch. And so the best way for you to protect yourself and other patients is to follow universal precautions. And so that's where we spend much more time and effort."
Dohmann advises that hospitals should focus on hand washing and increase reminders for clinicians to coach each other and monitor one another's compliance.
Nursing leaders can provide employees with education about H1N1 and the vaccine in many different ways, such as articles and quick tips in newsletters, on the Internet, and on social media sites such as Twitter and Facebook.
Dohmann notes that the gradual delivery of the vaccines may even prove to be a good thing. As the first round of people are vaccinated, those who were initially concerned will see few side effects and generally good results—and hopefully be the first standing in line for the next batch of supplies.
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The telemedicine device and services market will reach $3.6 billion in annual revenue within the next five years, according to a new report from research firm Pike & Fischer. The report, titled "Telemedicine and the Economic Stimulus: Broadband Opportunities in a Swelling Market," attributed the growth in the telemedicine market to advances in wireless broadband networks, smart phones and data compression technologies; the federal stimulus package; and the need to curb rising healthcare costs.
The U.S. Army Telemedicine and Advanced Technology Research Center has awarded a $730,000 grant to the data integration group LiveData to develop standards for clinical information integration. LiveData will use the funds to develop an integrated clinical environment through its MD-ICEMAN project. The project is a collaborative effort of the Center for Integration of Medicine and Innovative Technology, LiveData, and Massachusetts General Hospital.
The Certification Commission for Health Information Technology announced that vendors and developers can start applying for its new "modular" certification programs that focus on meeting meaningful use requirements in the health IT stimulus law. With this approach, vendors can apply for certification for electronic health record system modules, such as e-prescribing or electronic patient registries.
A couple of weeks ago, North Shore-LIJ Health System announced it is investing $400 million in electronic health records to connect providers in its community. As part of the initiative, the 14-hospital system is offering to subsidize up to 85% of the software and operating costs of EHRs for some 7,000 affiliated physicians in New York City and Long Island.
John Bosco, North Shore-LIJ's chief information officer, says the EHR is an essential tool to improve quality and safety for patients and eventually reduce costs. "The EHR will enable the management of entire episodes of care across practitioners and environments, so as we get into payment reform that we all expect to come down the pike, such as bundled payments, we will have the tools in place to coordinate care across the different care environments and be able to adhere to the new billing regulations," he says.
So what do physicians think of the program? The community physicians are excited about this, says Simon E. Prince, MD, a Manhasset, NY-based nephrologist, who is also the president of the medical staff at North Shore University Hospital. "We can get a state-of-the-art EMR at a rock bottom price and qualify for stimulus money," he says.
But that excitement is not without some controversy. North Shore-LIJ is offering physicians two options.
The connected model is a 50% subsidy for all of the costs associated with buying, operating, and using an EHR from Allscripts—as permitted by law—for five years. Under this model, the physician agrees to allow the exchange of clinical data between care environments, says Bosco. "When a patient comes to the ED unexpectedly, the physician would be able to pull some amount of information from the physician's office EHR," he explains. "Or if the patient is discharged from the hospital, we can push a discharge report or summary to the physician's EHR system."
The integrated model is an 85% subsidy that includes all of the above, plus physicians would agree to follow clinical practice parameters that are built into the Allscripts system and are based on recognized standards from the National Quality Forum and other nationally recognized standards of care for certain disease states. In addition, physicians would report their performance data back to North Shore-LIJ on a monthly basis, so that the health system can aggregate that data to determine the impact the program is having on the community. "To follow those guidelines and report that data back to us we'll give them a bigger incentive," says Bosco.
And it is the reporting of that performance data that is causing the most consternation among physicians. Doctors are concerned about who will have access to that data, what type of data will North Shore-LIJ be looking at and why, explains Prince. "From a dollars and cents standpoint, it seems as though the hospital is negotiating in the best interest of the physicians and it looks to be a pretty clear win-win," Prince says, adding that there is still a healthy degree of skepticism among some physicians about the program.
Bosco says that the goals of the program are first and foremost to measure and manage quality, reduce unnecessary testing and delays when a patient comes into the ED, or help improve the transition of care. "That is what will really impact quality and cost overall," he says.
North Shore-LIJ is planning some town hall events to address physicians' concerns about the program, Prince says. The program will launch in November with 15 to 20 physician practices that have agreed to be early adopters. Then around April 2010, the health system will begin full deployment. Physicians have until the end of 2011 to sign up for the subsidies, says Bosco.
"The risk-benefit ratio is in favor of grabbing the opportunity and enjoying the subsidy," says Prince, who plans to take advantage of the full 85% subsidy. Besides, it is only a matter of time until that data is out there anyway, he says.
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Frank Douglas, MD, president and CEO of the Austen BioInnovation Institute in Akron, Ohio and Matthew Becker, MD, associate professor of polymer science at the University of Akron, discuss the business implications of biomaterials and the focus areas of the Austen BioInnovation Institute, which is a collaboration of five medical and educational institutions—Akron Children's Hospital, Akron General Health System, Northeastern Ohio Universities Colleges of Medicine and Pharmacy, Summa Health System, and The University of Akron. [Sponsored by Emdeon]
The Senate Finance Committee will meet today to vote on its 10-year $829 billion reform package—with a wall of controversy facing it. After working with the committee for months on reform provisions, America's Health Insurance Plans (AHIP) appeared to have reversed course Monday by criticizing the emerging plan in a report that said the legislation could ratchet up the cost of coverage.
A report, prepared by PricewaterhouseCoopers, said that the Senate legislation on average would cause the cost of private health insurance coverage to increase by 26% between 2009 and 2013 under the current system and 79% between 2009 and 2019 if the several provisions on insurance market reforms and taxes on health plans are implemented.
The report immediately received harsh criticism on Capitol Hill and the White House. A Finance Committee spokesman called it "a company hatchet job, plain and simple."
At the White House, criticism was leveled at AHIP for trying to "confuse" the issue. In its blog—entitled "Reality Check: AHIP's 'Study' Hard to Take Seriously," the White House disputed AHIP's finding and stated point by point how the Finance panel's legislation would instead lower costs.
There is a much better chance of dying in a one star rated hospital compared to a five star rated hospital, according to the 12th annual HealthGrades study on Hospital Quality in America released Tuesday.
"Year over year, we've continued to see that not only are our five-star star hospitals better, but they have improved at a much faster rate," said Kristin Reed, one of the study's co-authors from HealthGrades of Golden, CO.
The company annually examined nearly 40 million Medicare hospitalization records—observing patient outcomes among 5,000 of the nation's non-federal hospitals. It reviewed 28 different procedures and treatments for this study—looking at complications and mortality. These findings are available for public review.
According to the current annual study, patients at highly rated hospitals had a 52% lower chance of dying compared with the U.S. hospital average, a "quality chasm" that has continued during the past decade even as mortality rates overall have declined.
Among the other study findings:
Risk adjusted mortality at the nation’s hospitals improved, on average, 10.99% from 2006 through 2008.
If all hospitals performed at the level of a five star rated hospital across the 17 procedures and diagnoses studied, 224,537 Medicare lives may have been saved from 2006 through 2008.
Roughly 57% (127,488) of the potentially preventable deaths were associated with four diagnoses: sepsis (44,622); pneumonia (29,251); heart failure (26,374); and respiratory failure (27,241).
Over the last three years of studies, Ohio and Florida consistently have had the greatest percentage of hospitals in the top 15% for risk adjusted mortality.
As for complications for all procedures studied, patients faced a 80% lower chance of experiencing one or more in hospital complications in a five star rated hospital compared to a one star rated hospital. In addition, there was a 61.22% lower chance of experiencing one or more in hospital complications in a five star rated hospital when compared to the nationwide average.
The report also noted this year that Joint Commission stroke certified hospitals were almost twice as likely to attain five star status in stroke (30% of certified hospitals were five star versus about 16% of non certified) while fewer of the stroke certified hospitals fell into the one star category (12% versus 20%).
Overall, Joint Commission stroke certified hospitals had an 8% lower risk adjusted mortality rate compared to hospitals that were not stroke certified.
