If staff members in your facility think their concerns are not being heard or taken seriously by senior leadership, it might be time to implement patient safety rounds or expand your existing program. Not only can patient safety rounds find trouble spots that leaders may not have known existed, they also may improve the culture among staff members.
"The intent of the Patient Safety WalkRounds™ is to bring senior leadership out to the front line to talk about what concerns the frontline staff about taking care of their patients safely," says Erin Graydon-Baker, MS, RRT, director of patient safety at Brigham and Women's Hospital in Boston. "If the program contains vigilance around feedback, I think it improves culture."
BWH has been using the IHI's Patient Safety WalkRounds model since 2001. Allan Frankel, MD, then-director of patient safety for Partners Healthcare and affiliate of the IHI, thought BWH would be a great place to test the WalkRounds, and the hospital has had success with them ever since, says Graydon-Baker.
Frankel and some of his colleagues recently published a study in Health Services Research that showed implementing WalkRounds helped increase perceptions of patient safety with frontline caregivers. The study, partially funded by the AHRQ, followed 21 care areas at seven hospitals that had implemented WalkRounds for 18 months.
Prior to the study, one-third of care areas had patient safety climate scores below 60%; after the study, only 7% were below this number. Additionally, researchers saw significant improvement in how often staff members' discuss patient safety issues and report concerns.
How BWH's WalkRounds work
BWH requires that one member of senior leadership take part in the WalkRounds. This member can be any of the following:
Chief medical officer
President or CEO
Chief nursing officer
Chief operating officer
BWH feels so strongly about having a member of this senior leadership team in attendance that if, for some reason, the leader scheduled to take part in the WalkRounds cannot attend, Graydon-Baker reschedules the safety round.
Additionally, the vice presidents of each area are invited. The chief information officer often attends because BWH is a technology-driven hospital, Graydon-Baker says. Other staff members who usually attend include a pharmacist, the medication safety officer, a physician leader, and the nurse manager of the area in which the patient safety rounds are taking place.
Each week, a senior leader will visit one area of the hospital. An area could be a patient care floor, a service department, or an outpatient clinic.
The weekly WalkRounds take 45–50 minutes to complete, says Graydon-Baker. Because the hospital is so big, it takes about 18 months to do rounds throughout the entire facility.
Most importantly, in attendance are the staff members from the area of the hospital in which the patient safety rounds are taking place. Graydon-Baker begins informally by describing the purpose of the rounds and introducing everyone in attendance to staff members.
Additionally, because BWH has been doing the rounds since 2001, she recaps the issues brought up the previous time that area had its patient safety round and whether those issues were addressed. Providing this feedback shows staff members that their concerns are being taken seriously.
She then starts off the questioning and lets the senior executives take over.
"There's always going to be that little bit of reluctance initially, but once [staff members] get talking, it doesn't matter, and the playing field is leveled. They're very forthcoming about their issues," says Graydon-Baker.
Questions senior leaders might ask include:
How will the next patient be harmed in your area?
How does the environment fail you?
What happened the last time a patient was hurt as a result of how we delivered care?
What keeps you up at night?
Keys to successful patient safety rounds
There are three main requirements for ensuring that your patient safety rounds will be a success:
The full participation of senior leadership is a must. Unless senior leaders are engaged and believe that hosting the WalkRounds is essential to patient safety, staff members will not be convinced that leadership really cares.
A robust database or infrastructure is necessary for compiling and analyzing the data that come out of the WalkRounds.
A mechanism for follow-up with the staff members involved with the WalkRounds is necessary.
Graydon-Baker says about one month after the WalkRounds take place, she sends out questionnaires to those staff members who were included to gauge whether they thought the leaders were listening to their concerns.
"There are questions like, ‘Do you think we take you seriously?' and ‘Have you seen improvements?' on the survey," says Graydon-Baker. "But that's solely dependent on the feedback you give them—even if it's negative feedback, even if it's, 'I can't do this right now; we heard you, and we're going to track this.'"
Mergers and acquisitions are on the increase, and they bring with them a host of compensation-related issues. Knowing what they are and dealing with them early in the process can go a long way in cementing the new relationship.
Terrigal Burn, MD, board chair at the Palo Alto (CA) Foundation Medical Group (PAFMG), is working through many of those merger-related challenges now. PAFMG is a multispecialty group practice affiliated with Sutter Health. It was established January 1, 2008, through the merger of Camino Medical Group, Palo Alto Medical Clinic, and Santa Cruz Medical Clinic. Today, PAFMG operates as a single entity with more than 850 physicians serving more than 600,000 patients.
The process started in 2006, with regular meetings among the leadership of each practice. Among the questions discussed were:
What was the business case for a merger?
Would anything short of full integration achieve the goals desired for the merger?
What would this new group look like?
The merger itself was just the beginning of a process that continues today. Integrating the compensation plans is "still very much a work in progress," Burn says. But that was to be expected. "We anticipated that this would be a multiyear process," he says.
Burn notes that although the merger was a marriage of three similar groups, reconciling even slight differences required effort. What seemed like minor differences at the outset were "not so small when facing difficult decisions," he says—especially decisions related to compensation.
And that's why it's critical to address the philosophical principles before a merger. The details will prove challenging enough, but trying to tackle fundamental philosophical differences could be insurmountable.
Establish the fundamentals
Assess each entity's principles and philosophies. For example, one group may have a "split revenues equally" mind-set, whereas the other may take an "eat what you kill" approach, says Steven A. Nahm, vice president of The Camden Group in El Segundo, CA. Basic philosophical differences can undermine a merger.
Fortunately, each of the three groups constituting PAFMG had a similar perspective, says Burn. Each group provided compensation in a similar fashion, based on production and measured by wRVUs.
One of the fundamental issues the leadership had to address early on was whether the merged group would embrace the philosophy of equal work for equal pay. "We decided it was a principle we believed in for the solidarity and unity of the group," Burn says.
But the philosophy had to be more than theoretical; it had to be practical. Before agreeing to this concept, the leaders looked at the regions in which the groups were based. Since there was little disparity in housing costs and regional compensation rates, they decided they could move forward with equal work for equal pay.
"But we also wanted to do this embracing the concept of 'do no harm,' " Burn adds. Modeling the benefits of integration, including more programs of excellence and more superspecialization, the leadership anticipated that the flow of revenue would allow for both.
As a result, those physicians being paid less at the time of the merger have seen their compensation rise more quickly.
This article was adapted from one that originally appeared in the June 2009 issue of Physician Compensation and Recruitment, a HealthLeaders Media publication.
It's here. After months of speculation and roundtables and public pledges, the first healthcare reform bill emerged this week from the Senate Health, Education, Labor and Pensions Commission, chaired by Senator Ted Kennedy. It certainly won't be the only bill, but it marks the beginning of what should be an interesting, and probably volatile, few months for the healthcare industry.
But for all of the answers in the 615-page draft of the "Affordable Health Choices Act," many questions remain, particularly for physicians. And the picture becomes less clear when other sources of healthcare reform legislation are considered.
It looks like all Americans will be required to have insurance and there will be greater oversight of the insurance industry, as well as more emphasis on primary care and prevention. But here's what we still don't know:
1. What will replace the Sustainable Growth Rate formula? Kennedy's legislation doesn't even mention the sustainable growth rate, but a memo released by the House Committees on Ways and Means, Energy and Commerce, and Education and Labor calls for replacing the "currently flawed" SGR formula that determines physician pay rates. Replace it with what, it doesn't say. That answer should come later in the process, but I have a feeling that will be one of the most difficult issues to resolve.
2. Will a public plan make it through? The Affordable Health Choices Act calls for new "insurance exchanges" to facilitate universal coverage, in part to avoid the controversy surrounding public plans. Republicans oppose a government-backed insurance plan, and perhaps more importantly, some conservative Democrats want it only as a last resort.
What about doctors? Conventional wisdom (and political pundits) says that physicians are opposed to another government payer, but I think opinions are fairly evenly-divided. Perhaps one of the biggest surprises in our HealthLeaders Media Industry Survey this year was that so many physicians supported some sort of universal coverage, in many cases even single-payer. The AMA has come out against a plan, in part because it could drive out private insurers.
3. Will primary care benefit at the expense of specialists? This is a question I've been exploring for months, and the early legislation doesn't clear up much. As expected, there is more money for training and rewarding primary care in Kennedy's bill. Normally, that would require specialists to take a hit, but we're obviously playing by new rules now. If the SGR formula goes out the window, then anything is possible.
4. What will happen to MedPAC? There is talk of making the Medicare Payment Advisory Commission part of the executive branch and giving it power to enact changes. This could be good or bad. If MedPAC had power in the past, Congress couldn't have blocked the physician reimbursement decreases that the committee recommends on an annual basis. On the other hand, it would have had the authority to tweak the payment system annually instead of waiting until sweeping changes were necessary to prevent a crisis.
There are, of course, many more issues that will be fiercely debated over the summer. This is just the beginning. President Obama wants to sign the final legislation by October, so we have nearly four months of wrangling and politicking before we find out any real answers to the big questions of the day.
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In this op-ed piece published in the New York Times, Peter Bach, MD, discusses a potential payment solution for Medicare. He proposes a "reverse Dutch auction" where Medicare would set a target number of physicians for an oversupplied region and then offer to sign up specialists at a certain payment rate.
In the United States, there are rural electric co-ops, milk co-ops, child care co-ops, and food co-ops. So why not healthcare co-ops?
The idea of member-run healthcare insurance cooperatives was proposed this week by Senate Budget Committee Chairman Kent Conrad (D-ND) as an alternate approach to proposed public health insurance options in healthcare reform legislation pending on Capitol Hill—and it has been garnering its share of attention.
The reason primarily is because it is not a government-run program—a major sticking point for many Senate Republicans and some Democrats about public insurance plans. And, the idea may not be as far-fetched as some may think.
In discussing his idea, Conrad points out that the Group Health Cooperative, based in Seattle, is a consumer governed, nonprofit healthcare system; the cooperative has operated for more than 60 years and serves more than half a millon residents in Washington State and Idaho.
As proposed, a health cooperative is owned and operated for the benefit of its members—individuals and businesses with fewer than 10 employees. Senate Finance Chairman Max Baucus (D MT) on Wednesday requested that Conrad work with Sen. Charles Schumer (D NY), an author of a healthcare reform bill himself, to iron out details.
According to Baucus, who is preparing to mark-up a healthcare reform bill next week, Conrad's proposal remains "an option." Baucus' Republican counterpart on the committee, Sen. Charles Grassley (R-Iowa), said it could have potential.
But other ideas still abound on the committee regarding a public insurance plan. On Wednesday, Sen. John Rockefeller IV (D-WV), chairman of the Senate Finance Subcommittee on Health Care, introduced a new measure that would establish and offer a public plan option within a national health insurance exchange.
Under Rockefeller's proposal, a new Office of Health Plan Management within the Department of Health and Human Services would operate the plan. The president would appoint an administrator of the plan, which would be financially sustaining—subject to an annual third-party audit.
Funds to operate the plan would come from premiums from individuals enrolled in the plan and from contributions of employers not providing health insurance benefits. To help consumers make informed choices, the national office would be required to "promote consistent standards" for information about the plan and "to promote transparency in coverage" to consumers and healthcare providers.
In a statement accompanying the introduction of his legislation, Rockefeller emphasized that "a public plan is the only real solution" to addressing current challenges under the healthcare system.
Increasingly in demand, gastroenterology, orthopedic, and dermatology specialists can resolve bottlenecks in their appointment calendars and increase revenue dramatically by using more physician assistants and nurse practitioners to help treat patients, according to a new California Healthcare Foundation study.
However, not all states' scope of practice laws may be sufficiently broad to allow the practice. Also, more postgraduate training programs are needed for PAs and NPs to gain proficiency so they don't have to be trained on the job.
The authors wrote that practitioners who use PAs and NPs reported that outcomes were almost always positive and the time they saved allowed physicians to spend more time with more complex patients.
The California Healthcare Foundation study evaluated six practices across the country that now use PAs and NPs to bridge the gap in providing care to their patients. The study, "Physician Assistants and Nurse Practitioners in Specialty Care: Six Practices Make It Work," was conducted by researchers at the Center for Health Professions at the University of California, San Francisco.
The authors, Catherine Dower and Sharon Christian, interviewed gastroenterologists, dermatologists, and orthopedic specialists who use nurse practitioners and physicians assistants in both hospital and clinic settings in Federal Way, WA; High Point, NC; Salem, OR; Fontana, CA; Gainesville, FL; and Springfield, MO.
The report concluded "these models generally improved access, reduced wait times and proved financially sustainable."
Although third-party payers have varying reimbursement schedules for services provided by NPs and PAs, "when these clinicians independently provide services to patients, Medicare typically reimburses at 85% of the physician reimbursement rates," the researchers wrote.
Outpatient services are billed under Medicare's "incident to" physician care provisions, which pay at 100% of the physician's reimbursement rate as long as the following conditions are met:
The specialist physician is physically on-site at the time the NP or PA provides the care.
The specialist physician personally treats and diagnoses patients on their first visit, although the NP or PA provides subsequent care.
The specialist physician treats and diagnoses patients with new conditions, though NPs and PAs may provide subsequent care.
The specialist physician remains involved in the patient's care.
Financially, using NPs and PAs brings a good return, the authors wrote. Although rates paid by Medi-Cal, California's Medicaid program, are extremely low, it reimburses PAs and NPs at 100% of the amount payable to a physician for the same service, the study said.
"Practices that participated in the study reported being in good financial positions in large part because of their integration of PAs and NPs," the authors wrote. "Many offices arranged their practice models to comply with Medicare policy allowing them to bill NP and PA services at 100% of the physician rate. Even if they billed some services at 85%, the increased patient volume and the lower salaries of NPs and PAs contributed to solid financing."
One drawback the authors mentioned is that initially, some physicians were unaware of what services NPs and PAs were able to provide. Some "stressed that some physicians were very concerned about the competence of PAs and NPs," and worried that physicians just starting their practices might be uncomfortable incorporating such caregivers "before the practice is financially well established."
However, "A number of medical specialty practices across the U.S. rely in part on NPs and PAs to provide clinical care, including (these) high-demand specialties," the authors concluded. "These practices have successfully improved access to care for patient populations that have been experiencing significant wait times to see specialists."
While none of the newest Recovery Audit Contractor FAQs released by CMS—it published 15 in the last week—are particularly surprising, they are perhaps a sign that CMS is continuing to make every effort to share RAC information providers need to know through as many channels as possible.
It may be sharing the same information during RAC outreach sessions or during Open Door Forum calls, but now the information is also readily available to those who wish to learn about RACs in a Q&A format.
The new or updated questions include the following:
What is the reimbursement procedure and rate for photocopy charges associated with records for RAC audits?
How will the RACs determine which claims to review?
Whose claims will be reviewed under the RAC program?
Under what circumstances can a RAC, make a finding that an overpayment or underpayment exists without requesting medical records?
Under what circumstances will a RAC request medical records in order to determine if an overpayment exists.
How long does a provider have to submit medical records when requested by a RAC?
Do RACs look for underpayments? What happens if they find an underpaid claim?
How are the RACs paid for finding underpayments?
If a provider repays or Medicare recoups an alleged overpayment identified by the RAC and the provider later wins an appeal, will CMS reimburse the provider with interest?
Will the RAC review evaluation and management services on outpatient hospital claims?
Will the RACs replace all current review entities?
Will the timing for appeals by the Medicare contractors be the same for the RACs?
How are the RACs paid for finding and recovering overpayments?
Will the RAC appeal process mirror the regular Medicare appeal process?
How will the RACs choose the healthcare entity that is to be reviewed for over- or underpayments? Will it be a random process?
If you have a RAC question for CMS you have yet to have resolved, perhaps now is a good time to send in your question—CMS may just be in the mood to answer 15 more questions this week.
The American Medical Association is letting Congress know that it will oppose creation of a government-sponsored insurance plan, which President Obama and many other Democrats see as an essential element of legislation to remake the healthcare system. The opposition, which comes as Obama prepares to address the powerful doctors' group on in Chicago, could be a major hurdle for advocates of a public insurance plan.
Green Bay, WI, is one of the highest-value health communities in the nation, a city that by numerous measures has managed to control medical spending while steadily improving health outcomes. In his drive to rein in healthcare costs, President Obama is increasingly focused on wasteful medical care that does not extend life and may actually be harmful. A town-hall-style meeting, his first as president to promote health reform, is intended to spotlight one city's strategy for squeezing out waste without hurting quality.
Over vehement objections of major Florida businesses, some health insurers, and consumer groups, Gov. Charlie Crist signed into law a bill that will require insurers to send payments of claims directly to out-of-network doctors, if the patient allows. The provision has sparked a maelstrom of debate over the issue of out-of-network doctors charging whatever they want, rather than accepting negotiated discounts for in-network doctors. Insurance Consumer Advocate Sean Shaw urged the governor to veto the legislation because the bill was "a backward step from attempts to corral the spiraling cost of healthcare and put more consumers at grave financial risk."
