Prince William Health System and Inova Health System tightened their visitation policies to better protect patients, guests, and staff members from the H1N1 virus, officials from the Virginia-based organizations said. Both hospital companies are not allowing guests younger than 18 to visit. In addition, guests older than 18 who are demonstrating flulike symptoms will not be allowed into the Inova patient care units and are "urged" not to visit Prince William Health System.
Disruptive employees aren't commonplace in most healthcare settings. But they aren't so rare that you shouldn't have a plan in place for how to deal with them. Unfortunately, that's a message a lot of medical groups and hospitals aren't getting.
"Many practices do not have formal employee personnel policy and procedure manuals," says John McDaniel of New Orleans-based consultancy Peak Performance Physicians, LLC.
"Even if they have some simple policies and procedures, they usually only relate to things like sick time, vacations, and holidays," McDaniel says. "In a large percentage of cases, they do not spell out a disciplinary process or how an employee grievance process should be conducted. That is what usually gets them in trouble."
Mary J. Witt, vice president of The Camden Group, a consulting firm in El Segundo, CA, says it's more effective to deal with disruptive behavior proactively—before it starts—but that's difficult if your organization doesn't have a code of conduct in place.
"One of the biggest problems I find when I go into practices is there are not measurable performance standards established for the various functions in the practice," Witt says. "Then it becomes difficult to hold staff or physicians accountable because you haven't clearly defined your expectations for good behavior and good performance."
Once you've established a code of conduct, and employees understand your expectations, "it is easier to come back and have discussions with the employee about what is not working," Witt says. "You've set the stage for what the expectations are. You've helped them clearly understand by your definition and performance standards what is expected, so it becomes easier to have that conversation."
Three types of disruptive behavior
Peak Performance Physicians breaks down disruptive behavior into three categories:
Group 1 is the garden-variety rudeness or yelling at physicians, patients, or fellow staff; a breach of confidentiality; or a failure to follow dress codes, which can usually be resolved with a quick corrective chat identifying the problem, a reminder of practice policies, and documentation that the event occurred.
Group 2 disruptive behavior would include ongoing problems that have been previously identified and addressed, but not rectified, along with issues like failing to complete assigned tasks.
Group 3 behaviors are usually severe, and could warrant immediate termination for offenses, such as embezzling or other theft of medications or equipment, or flagrant and consistent abuse or sexual harassment.
Except in the most extreme instances that warrant immediate termination, your physician practice should follow the same guidelines for every situation that requires an intervention, McDaniel says.
"The first step would be a verbal and or written reprimand. Even if it is verbal, notes need to be taken, it needs to be in writing, and both parties should sign it," McDaniel says. "If there is not improvement, the second step would be a probationary period—one more chance—in writing and dated. The third step is termination. It's a formal documented process."
When it comes to addressing disruptive behavior, Witt has three rules: "Document, document, document."
"That means that you have documented all along that you have spoken with the employee, you've told them what the problem was, and you've given them the opportunity to correct it. You have to make sure the documentation is there."
The signed documentation doesn't have to mean that the employee agrees with the corrective action, only that that he or she has been notified about it.
Witt also recommends having employees sign job description and code of conduct forms. "That way, I know they've gotten it and it is their responsibility to read it and understand it," she says.
Address disruptive behavior immediately. "You don't want to ignore those issues and then suddenly take them up six months after they happen," Witt says. "If a problem occurs, you want to immediately address that with the employee. Set for them what the expected behavior is so they clearly understand what is expected of them."
Don't be judgmental. Using precise, measurable standards will take a lot of the emotion out of an employee corrective action because you're being objective and factual, Witt says. She also recommends steering clear of emotionally laden words when confronting a disruptive employee.
"I hear people say they want to tell their employee they have a bad attitude. Well, that doesn't tell the employee anything and that begins to get to an emotional level and can make employees defensive," Witt says. "Instead, you need to think about how that bad attitude translates into behavior. It might mean that if I have a bad attitude, I'm not smiling and greeting patients warmly when they walk through the door, or I'm snarling at coworkers. Focus on the behaviors."
Hear the employee's version of events. Although it's important to document everything in case you find yourself defending a wrongful discharge law suit, McDaniel says it's also important not to run a kangaroo court in your practice. Be fair.
"Employees should be given an opportunity for due process," he says. "Give them the opportunity to be heard. If there is a third person who can corroborate the employee's side, that person should be interviewed."
Witt says you should determine whether the disruptive behavior is an employee's reaction to adverse working conditions that inhibit job performance. "Are there issues in the practice that make it difficult for the employee to be successful? If that is the case, you need to fix those issues before you can hold the employee accountable," she says.
For example, if you expect your employees to efficiently greet and register patients while simultaneously answering 20 phone calls, it's going to be difficult for them to do a good job. "You have to ensure that your processes don't create barriers to good employee performance as well," Witt says.
You also can't assume that your employees have the knowledge or the skill sets needed for the tasks to which they are assigned. "If I am expecting them to work on the computer, and they don't know the particular software program, it's unreasonable for me to expect them to perform well," Witt says.
HHS posted instructions this week for submitting a privacy or security breach of protected health information (PHI) to the secretary of HHS.
The instructions come a little more than a month after HHS released final guidance on breach notification and the acceptable conditions for covered entities and business associates to encrypt and destroy patient records in order to prevent breaches of PHI.
The breach notification regulations took effect September 23, but covered entities and business associates (BAs) need not worry about HHS enforcement until February 22, 2010.
Surely, the form released this week is one your organization wants to avoid. However, it's a good time to look at its requirements. Covered entities and their BAs should be well under way constructing a breach notification process, and it's good to know what HHS wants in this form.
If a breach affects 500 or more individuals, a covered entity must provide the secretary with notice without "unreasonable delay" and in no case later than 60 days from the breach discovery. The notice must be submitted electronically by using this link with completed information.
The same form will be used for breaches of fewer than 500. However, covered entities must provide notice to the secretary on those breaches only annually. (All notifications of these breaches occurring in a calendar year must be submitted within 60 days of the end of the calendar year in which the breaches occurred).
HHS' form includes the following sections:
Section 1 - Covered Entity. Includes basics like name, address, type of covered entity.
Section 2 –Business Associate. Same as Section 1, but if the breach happened at a BA's facility.
Section 3 –Breach. This includes:
Date of breach
Date of discovery
Number of individuals affected
Type of breach (theft, loss, improper disposal)
Location of breach information
Type of PHI involved
Description of breach
Safeguards in place prior to breach
Section 4 – Notice of Breach and Actions Taken. This includes actions your organization took in response to the breach (security/privacy safeguards, mitigation, sanctions, policies, and procedures).
Section 5 – Attestation. This is verification the information your organization submitted is true and a reminder: "OCR may be required to release information provided in your breach notification."
Frank Ruelas, director of compliance and risk management at Maryvale Hospital and principal, HIPAA Boot Camp, in Casa Grande, AZ, says he got an error message when testing the form.
"I am hoping that whoever is managing the form considers installing some icons where people can click to get ‘help' on the form to avoid getting into a submit-error message-resubmit loop like the one I fell into without any specific directions or guidance on how to fix the error on the form," he says.
HHS' breach notification provisions include:
Notice to patients of breaches "without reasonable delay" within 60 days
Notice to covered entities by BAs when BAs discover a breach
Notice to "prominent media outlets" on breaches of more than 500 individuals
Notice to "next of kin" on breaches of patients who are deceased
Notice to the Secretary of HHS of breaches of 500 or more without reasonable delay
Annual notice to the Secretary of HHS of breaches of less than 500 of "unsecured PHI" that pose a significant financial risk or other harm to the individual, such as reputation
This article provides consumers with "little-known ways" to protect themselves when they go to the hospital. The author talks about hospital mistakes and ratings, for example, but the value in this piece is insight into what patients might be asking your front-line staff when they are scheduled to visit your hospital for surgery or other reasons.
They're still not the majority in terms of hospital leadership, but maybe it's time to pay a little more attention to women and healthcare, at least as far as the strategic direction your hospital or health system should be taking. I just got my hands on HCUP Facts and Figures: Statistics on Hospital-Based Care in the United States, 2007, from the Agency for Healthcare Research and Quality. I know it's a mouthful, but you should get your hands on it too.
Even though its most recent information is from 2007, it's a treasure trove of data that might help your strategic planning for years to come. The part of the extensive report that stands out most to me is Section 2, which probes deeply into inpatient hospital stays by diagnosis. We all know that women are big decision-makers in healthcare. Men often let their health and the health of their families take a back seat to other concerns. Not women. But you knew that already.
However, what you might not know is that women, particularly young women, could be the key to your success or failure as CEO in the coming years.
Here's why:
Conditions related to pregnancy and childbirth were the reason for more than one out of every five female hospitalizations in 2007.
When combined with stays for newborn infants, these hospitalizations accounted for one-quarter of all stays.
As I mentioned, those are only two statistics in a report that bursts with them, but they stood out to me in because if you're pouring money into your orthopedic or heart program and paying little attention to women's health, you might be playing your cards at the wrong table, so to speak.
Taking time to study this report can help you distinguish between the hype and the reality of where you should be investing your critical and limited capital budget. For instance, we keep hearing how the uninsured are putting extreme pressure on the healthcare system. There's a lot of truth to that hype, but according to this report, the uninsured accounted for about 6% of all hospital stays in 2007—about the same as in 1997.
At least to the extent that the uninsured affect your hospital's prospects as a going concern, those numbers don't create panic in the hearts of many of the CEOs I know. Still, the share of discharges billed to private insurance fell from 39% to 35% between 1997 and 2007, reflecting the decline in the population with private insurance coverage. So I'm not minimizing the struggles you're facing in getting paid, just that facts and statistics have a funny way of helping you discover the truth behind the hype—and helping you make strategic decisions based on reality and not noise level.
And the truth is this:
Maternal discharges increased to 5 million in 2007, a 16% increase since 1997.
Infant hospitalizations increased to 4.7 million in 2007, a 21% increase since 1997
So what does that tell you about where you should be investing your capital dollars? I thought so. And you can take that straight to the board.
Note: You can sign up to receive HealthLeaders Media Corner Office, a free weekly e-newsletter that reports on key management trends and strategies that affect healthcare CEOs and senior leaders.
RACs have begun auditing at this point, and providers in some states may have received their first denial letters this week. But many providers seem to still be waiting, holding their breath, and worrying whether the mail carrier might deliver their first RAC demand letter(s) that day.
However tempting it may be to simply wait, providers can still use this time effectively while they wait. Consider the following tips from several RAC experts:
Verify your contact information with your RAC. Yes, you may have submit your contact information to your RAC months ago, but use this time to verify your RAC has the information and it is correct, says Yvonne Focke, RN, BSN, MBA, director of revenue cycle and integrated care services at St. Elizabeth Healthcare in Kentucky. Focke submitted her preferred contact information for all RAC correspondence months ago, but recently discovered her RAC didn't have the information. Checking to make sure the RAC has your information is especially important if you are part of a large health system. And try to get written or e-mail confirmation from your RAC verifying it has the correct information on file for your organization, says Focke.
Test your processes and those of your vendors. Send yourself a test RAC letter to see where it ends up and when, says William L. Malm, ND, RN, healthcare consultant for Craneware. You will see where a real RAC letter might get hung up and you'll be able to adjust accordingly before the real thing arrives. Malm calls this the “Zero dollar test”— it costs nothing but a $.44 stamp, and can teach you so much about your work flow. RACs are testing themselves right now, and providers should be doing the same, he says.
Form good habits. Take this opportunity to form habits now that will help you later, says Tanja Twist, MBA/HCM, director of patient financial services at Methodist Hospital of Southern California. For instance, it may sound simple, but providers should be checking their RAC's Web site regularly, watching for any updates/changes. Providers should get into the habit of doing this now before the auditing begins so it will become part of their regular routine.
Share what you know. RACs have posted approved issues for most states at this point. So do something with that knowledge, says Nancy Beckley, MS, MBA, CHC, of the Bloomingdale Consulting Group, Inc. Educate staff members who may work in high-risk areas subject to automated review in your state (e.g., speech or physical therapy, OB-GYN, etc.). Go over the necessary pathway from service delivery to data entry, from edit tables to bill drop, etc. This will help pinpoint potential problems from both clinicians and finance in those areas RACs have identified as targets.
Prevent high-dollar medical necessity denials while there's still time. To prevent high-dollar admission necessity denials, take a close look at current processes for evaluating and supporting accurate level of care determinations (e.g., inpatient, outpatient, outpatient with observation services), says Deborah K. Hale, CCS, president and CEO of Administrative Consultant Service, LLC. To accurately respond to improper level of care determinations prior to patient discharge, a hospital's utilization review (UR) committee responsibilities should be compared with the Medicare's Conditions of Participation for the UR Committee (CoP 482.30) and make any necessary corrections, she says.
Review Medicare Transmittal 107, 1760 (effective July 1) and 1803 (effective October 1) to ensure you are evaluating medical necessity and issuing condition code 44 in a manner consistent with the Medicare Benefit Policy Manual, Chapter 1. In particular, note Transmittal 1803, which clarifies the need for the involvement of two physicians—the first being the physician who makes the medical necessity determination and who may not be the treating physician, and the second being the attending physician, says Joe Zebrowitz, MD, executive vice president for Executive Health Resources.
A decline in patient volume plus increasing bad debt related to patients' financial challenges were cited by the Medical Group Management Association (MGMA) as possible reasons for its members' drop in revenues in 2008 for the first time in several years. Many of these medical practices responded by cutting overhead costs—but not enough to accommodate reduced revenues, MGMA reported.
Multispecialty group practices saw a 1.9% decrease in total medical revenue in 2008, according to the MGMA's "Cost Survey: 2009 Reports Based on 2008 Data." MGMA obtained data on both multispecialty groups and single specialty practices, but used multispecialty data as a proxy for overall trends.
The report noted that declining revenues on average may be linked to a decline in patient volume—indicated by a 9.9% drop in the number of procedures and an 11.3% drop in the number of patients from 2006 to 2008. Also, bad debt in multispecialty group practices from fee for service charges rose 13% during that time, which suggests that patients could have had greater difficulties paying their medical bills.
In 2008, multispecialty practices reduced their overhead expenses 1.4% by usually cutting support staff costs by 1.5%—the first decline in several years. Overall, support staff costs made up 32% of medical practice expenses. The report noted, though, that while medical groups reduced support staff costs, their total employee count remained steady—suggesting that employees may have gone without raises or bonuses, or may have had pay cuts.
For specialty practices, OB/GYN and gastroenterology practices showed decreases in total medical revenue after operating costs. However, cardiology, family practice, anesthesiology, pediatrics, orthopedic surgery, and urology groups reported increases.
The data demonstrated that "the trickle down effect that a tough economy can have on a collection of businesses that are already stressed by crushing administrative burdens," said William Jessee, MD, MGMA's president and CEO. "Even in a good economy, many of our member practices have trouble staying financially solvent, so now it's more important than ever that practices look for ways to operate as efficiently and effectively as possible."
The Department of Health and Human Services OIG released its 2010 OIG Work Plan, giving healthcare compliance professionals an idea of what types of audits and reviews to expect in the coming fiscal year.
The annual Work Plan describes the various projects that different departments of the OIG plan to do, as well as projects that are in process. These departments include the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and Office of Counsel to the Inspector General.
In the 2010 Work Plan, the OIG grouped ongoing and planned reviews into two major parts:
CMS – Reviews related to Medicare, Medicaid, information systems controls, the Childrens Health Insurance Program, and related investigation and legal counsel to OIG.
Public Health and Human Services Programs and Department-wide Issues – Reviews related to agencies such as the Centers for Disease Control and Prevention, the Food and Drug Administration, the National Institutes of Health, the Administration on Aging, and the Administration for Children and Families. This part also describes department-wide issues, such as financial accounting and information systems management.
The Work Plan also includes reviews related to the American Recovery and Reinvestment Act of 2009, described in Appendix A of the document.
Stay tuned for further coverage and analysis from our compliance experts of the 2010 OIG Work Plan.
In a marathon session, the Senate Finance Committee wrapped up its seventh and final day of hearings on its $900 billion healthcare reform bill after 2 a.m. Friday.
The bill, which could be voted on by the full committee as early as next Tuesday following a scoring analysis from the Congressional Budget Office (CBO), has for the past two weeks elicited sharp debate over what ultimately was included in the bill (for instance, value-based physician payment formula, individual mandates) and what was not (a public option).
Numerous amendments were withdrawn Thursday because they lacked the requisite scoring—or cost estimates—from CBO. However, the process gave several senators an opportunity to let Committee Chairman Max Baucus (D-MT) know what they thought was missing from the bill.
Sen. Jay Rockefeller (D-WV), whose public option amendment was voted down by the panel on Tuesday, revisited one issue that he touched on that day: Incorporating a medical loss ratio of 85% on all healthcare insurers. This means that insurers would be responsible for making sure that at least 85% of their dollars went to paying for healthcare—and not profits, overhead, or marketing, he said.
"It's time we demand something from insurers in exchange" for the $465 billion in subsidies that insurers would be getting over the next 10 years under the proposed reform plan, Rockefeller said. He noted that much of the medical loss ratio data is not available to consumers in many states. Sen. Charles Grassley (R-IA), though, questioned if such a provision would be micromanaging insurers.
Rockefeller withdrew the amendment from consideration, but he said he may reintroduce it when reform legislation moves to the Senate floor for debate.
Also during the day, challenges arose over how some of the bill's provisions could impact the middle class. In particular, GOP panel members said the bill went against what President Obama had said about not increasing taxes on that middle class group.
"I think the American people will be surprised to learn that the only way to enact healthcare reform is through a tax burden," said Sen. Jim Bunning (R-KY). Most of the Republican proposals to exempt middle class taxpayers from fees and taxes in the Senate bill were defeated on 12 to 11 votes.
However, one amendment proposed by Sen. Olympia Snowe (R-ME) and Sen. Charles Schumer (D-NY) passed 22-1. The amendment called for lowering penalties that families could face from failing to obtain health insurance under the insurance mandate: the maximum penalty would be reduced from a high of $1,900 annually to $200 in 2014 and rise to $800 in 2017.
An amendment proposed by Sen. Maria Cantwell (D-WA) that would give states the ability to negotiate with health insurers to provide coverage at a lower cost was approved 12-11. "What's unique about it is . . . that it's a public plan but negotiated by the private sector in ensuring that there is a choice for individuals who want to receive this public benefit option," she said.
Under the original provision in the Chairman’s mark, individuals with income between 133% and 200% of the poverty level (about $44,000 a year) would have been eligible for tax subsidies to help them purchase individual insurance coverage. With Cantwell’s proposal, the revenues to the states could be redirected voluntarily where they could negotiate and cover this group more cost-effectively, she said.
This model is based on Washington State’s 20-year-old Basic Health Plan. Cantwell said this model could provide coverage to up to 75% of the state’s uninsured population.
Following the full Finance Committee vote next week on the bill, it will be combined, through negotiations, with the Senate Health, Education, Labor and Pensions (HELP) Committee healthcare reform bill. If negotiations proceed as expected, Senate floor debate could begin by mid-October.
The Senate Finance Committee, the fifth and final congressional panel to contribute to the healthcare reform legislation, rejected the final amendment of a session at 2:08 a.m. Oct. 2 to complete the measure that is expected to form the backbone of health reform legislation. Finance Committee Chairman Max Baucus (D-MT) delayed a vote until next week, though he said he has enough support to pass the package out of committee. The bill, which Senate Majority Leader Harry M. Reid (D-NV) will merge with a Senate health committee measure, appears to meet the reform criteria Obama laid out last month in an address to Congress, reports the Washington Post.
