Between the Accreditation Council for Graduate Medical Education's (ACGME) call for more stringent supervision standards and charges of improper amounts of resident supervision, Texas's Parkland Hospital's—resident supervision is a hot button issue for hospitals.
Supervision is a fundamental principle of medical education, but it hasn't been a focus of accreditation, educational, professional, or governmental organizations' standards until recently. The lack of attention means that residents may not be receiving appropriate supervision during training.
“Supervision really requires attending physicians to be proactive in providing supervision, and residents understanding and appreciating that role and seeking supervision,” Jeanne M. Farnan, MD, MHPE, assistant professor of medicine at the University of Chicago explains.
Faculty usually are not trained on how to provide proper supervision, making it even more important to encourage residents to actively seek help when they need it, says Vineet M. Arora, MD, MA, assistant professor of medicine, internal medicine associate program director, and assistant dean for curricular innovation at the Pritzker School of Medicine and the University of Chicago.
The following are reasons why residents feel uncomfortable contacting their attending physicians:
Concern over revealing a knowledge gap. Residents fail to call because they're afraid the attending physician will think that they're not as smart as their peers, and they are hesitant to admit that they do not know something. Both attending physicians and residents must view uncertainty as an impetus for the resident to reach out to the supervisor, Farnan says.
A desire to make decisions on their own. “Often, calling an attending and asking a question will interfere with the resident's own decision-making style and their own processing of the case,” Farnan explains. Residents want to talk to the attending physician about the case without having their clinical decision-making influenced by the attending physician.
Perception that the attending physician does not want to be called. Attending physicians often communicate a call-me-but-don't-call-me message to residents, which prevents residents from reaching out. “An attending will say, 'Here's my pager and my cell phone. Call me anytime, but I'm going to be at a dinner,' ” Farnan says. “Clearly that sends a message of 'Don't call me.'" Not answering calls or pages or chastising residents for calling also lessens the likelihood residents will reach out when they need help.
Attending physicians must take steps to facilitate supervision, but they need training and support from program leadership.
“People assume that you graduate from residency and you know how to be a good supervisor. Sometimes that's the case, and sometimes it's not,” Arora says.
The following tips will help faculty members become better at providing supervision and also eliminate many of the barriers residents face when asking for help:
Set clear expectations up front. Specifically outline in what circumstances you want the resident to notify you about a patient's condition. For example, Farnan tells residents that she wants them to call her anytime an end-of-life decision arises, or when a patient suffers an adverse event, dies, or goes to the ICU. Residents write these instructions on the sign-out sheets, and Farnan receives calls from the cross-cover residents caring for her patients, too.
Also, establish a time every night at which the resident will call you, such as 10 p.m. Recognize that residents get busy and may forget to call. If that is the case, attending physicians should take responsibility and page the residents, Arora says.
Be available. Attending physicians should answer all calls while on service. Some attending physicians may think that not responding or not providing residents guidance when asked promotes trainees' autonomy, but that's not the case. Instead, absentee attendings often cause residents to feel abandoned, Arora says.
Address uncertainty. Faculty members should assure residents, especially junior trainees, that uncertainty is part of education and they should not feel bad about asking for help.
Faculty members should also be aware of when residents feel the most uncertain, such as during rapidly escalating situations when many decisions must be made in a compressed time frame, and let residents know that it's okay to call during those high-stress encounters, says Farnan.
Tailor supervision. A one-size-fits-all approach does not apply to supervision, Arora says. Faculty members need to do some reconnaissance work up front and tailor their approach in order to provide appropriate supervision. Attending physicians should consider the learner's background and determine what his or her needs are.
Make discussions worthwhile. Conversations should be a back-and-forth dialogue between the resident and attending physician. Because few attending physicians have formal training in being a supervisor, they may tend to overmanage and not cultivate the resident's clinical decision-making skills.
Focus on patient safety. Because residents can sometimes resent supervision, program leaders and attending physicians should focus on patient safety when supervising trainees. “We tell residents that part of learning about patient safety is working on a team, and part of working on a team is communicating with your attending and others on team,” Arora says.
Julie McCoy is associate editor for the residency market. For more residency-related news, click here.
Facing declining patient volumes and tough economic times, hospitals have sought to minimize costs by reducing staff. Layoffs have been abundant as hospitals have attempted to get by with a leaner staff. However, prudent leadership teams should be mindful that any uptake in patient volume—driven, for example, by a bad flu season—can leave a hospital stranded and scrambling to increase staff. Also, consider the influx of the newly insured entering the healthcare system. The work demand of care providers such as internists, hospitalists, nurses, and personal care assistants will undoubtedly increase exponentially. It is important for health leaders to look forward and be prepared for a potential increase in demand, using all available tools, including one of the most valuable tools: a well-defined incentive program.
Incentives can be a powerful tool to increase workforce capacity when patient volume or intensity increases. A sound and effective incentive program must be time limited, proactively initiated only when very specific predetermined conditions and criteria are present, and provide the type of incentive that motivates the target population. All three of these characteristics must be present; otherwise, an incentive program quickly becomes a very expensive exercise in staffing frustration—one that is difficult to reverse.
Having an incentive program that is time limited prevents it from becoming embedded within the compensation structure or seen as a “given” by the employees. Also, by limiting an incentive to a short period of time, management can evaluate its cost versus its efficacy. For example, limit an incentive to only winter months when workload is expected to exceed the workforce’s capacity. Or, host a popular national event and offer an incentive to staff to commit to be available to work extra shifts during that specific week if needed. By using an incentive in a time limited manner, employees may be more motivated to commit to work while the incentive is available.
Incentives also need to be based on specific criteria and set to motion in a proactive manner. A common mistake seen in some organizations is to put in place a “crisis incentive bonus” intended to be used for a severe shortage of staff, but is unfortunately constructed in a way that incents the staff to drive the system into crisis in order to collect the incentive pay. A preferred operational solution is to offer additional incentives to staff who commit to be available to work before a crisis occurs, especially during high-risk periods. Other organizations have experienced success in offering staff a bonus to sign up to be available for work before the schedule is posted. By using pre-determined quantitative-based criteria, such as staffing deficit by department or nursing intensity measures, an incentive bonus can be enacted if needed. The result is adequate staffing, and the system never reaches the crisis point. The criteria-based proactive approach can save countless hours of work typically spent in trying to find adequate resources.
By definition, an incentive should motivate the workforce to fulfill the needs of the system. Most incentive systems are based on financial rewards; however, an increasing number of studies indicate that time away from the workplace is highly valued by nurses and other healthcare workers and should be considered in an incentive program. Another alternative is to use the annual or biannual employee surveys to understand the workforce specific motivators to build into an incentive program.
However, a cost-effective incentive program should always be preceded by a sound staffing and scheduling system. As powerful and useful as a good incentive system can be, it cannot replace a scheduling system constructed to align with the projected workload and administered so that work assignments are as equitable as possible.
Benchmarking current resource utilization against similar healthcare organizations and departments can serve as good, reliable check of efficiency. Continual scheduling inequities that are perceived to drive an unreasonable or unpredictable workload are a strong motivator for employees to leave an organization. An effective scheduling system is the most efficient and cost-effective manner to save operational dollars and retain staff. However, healthcare workload volumes do tend to fluctuate with seasonal pathogens, physician practice patterns, and other unpredictable patterns, necessitating additional workforce resources.
As healthcare reform comes into focus and changes the manner in which care will be accessed and provided, new techniques will be needed to retain the current workforce and attract new entrants. Using tools such as a sound incentive program will continue to be a powerful tool for health leaders to meet future challenges.
Bonnie L. Barndt-Maglio, PhD, RN, is a vice president at the Camden Group, where she specializes in incentive management and other ways organizations can substantially improve current operations while successfully navigating likely healthcare reform initiatives.
They call Missouri the “Show Me State,” but perhaps that name is better suited for Florida. Amendment 7—otherwise known as the Patient Right to Know about Adverse Medical Incidents Act—makes what would normally be considered protected peer review information discoverable to the public.
Many states have taken strides to protect peer review documentation from discoverability in an effort to promote thorough and candid peer review and encourage physicians to report near misses. Thus, if Dr. Smith makes a mistake that results in a near miss and subsequently works with the medical staff’s peer review committee to improve his performance, he doesn’t have to worry about a lawyer digging up and using the documentation of those efforts against him in the future.
However, Florida voters passed Amendment 7 in 2004 under the belief that they have the right to know if a physician is or has been involved in any type of adverse medical event. In the Sunshine State, a patient or plaintiff’s lawyer can subpoena peer review documentation regarding any physician for any reason—no holds barred.
In theory, it makes sense for patients to have the right to know if their physician has been involved in an adverse event, but Amendment 7 has caused physicians and medical staffs in hospitals to stifle peer review—the primary function of the medical staff.
As case law continues to build, it is becoming clear just how broad this amendment is. In 2008, the Florida Supreme Court ruled in Notami Hospital of Florida, Inc. v. Bowen and Florida Hospital Waterman, Inc. v. Buster that Amendment 7 trumps all other Florida laws that protect peer review privilege. In July 2010, The District Court of Appeal of Florida ruled that the defendant hospital must produce a risk management incident report, a peer review form, and other peer review documents to the plaintiff in Baldwin v. Shands. This most recent decision emphasizes just how much information patients—and their lawyers—have at their fingertips.
“There has been a move to reduce or eliminate documentation on medical review activities. A lot of peer review committees now do not take minutes of their meetings, and if they do, they are sanitized. The minutes are broad, and no patients or physicians are identified,” says George Indest, Esq., an attorney with The Health Law Firm in Altamonte Springs, FL.
However, choosing to keep only sketchy documentation of peer review activities can have a negative effect on peer review as a whole. According to Indest, inadequate documentation can result the medical staff’s inability to obtain meaningful feedback from the healthcare providers involved in specific incidents when they are unable to identify the specific incident or patient about whom feedback is sought.
They may also be unable to comply with certifying or accrediting organizations’ guidelines and requirements or unable to demonstrate compliance with state requirements for peer review activities.
Jonathan H. Burroughs, MD, MBA, FACPE, FACEP, CMSL, senior consultant with The Greeley Company, suggests that medical staffs in Florida should hire an independent attorney to act as a member of the medical staff peer review committee and keep minutes. The minutes should be sparing. “Don’t write down who said what about whom. Only document that you’ve reviewed the case and what the findings and improvement process are. In other words, you should just document the outcomes, not the discussion.”
The minutes then live with the attorney’s office, rather than with the medical staff, and are therefore protected under attorney/client privilege. It is important that the attorney who is on the peer review committee is not the attorney who regularly represents the medical staff or the attorney who regularly represents the hospital to avoid conflicts of interest.
“Be sure that attorney work product information and documentation is prepared only by your attorneys and the paralegals working directly for them and do not use routine attorney work product documents and information in your peer review activities. Otherwise they may be discoverable,” adds Indest.
Burroughs also suggests that hospitals join or create a patient safety organization under the Patient Safety and Quality Improvement Act (PSQIA). Under this act, peer review documentation that is reported to a patient safety organization is considered patient safety work product and is not discoverable or permissible at a fair hearing or in a court of law.
Although this is a reasonable strategy for protecting peer review documents, Burroughs warns that if the hospital thinks that it may take action against a physician, it can’t use patient safety work product that has already been reported to a patient safety organization against the physician during the fair hearing. “I always tell clients that they have to consider whether they are going to take professional review action at some point. If they do, they should keep the body of evidence.”
Indest adds that taking advantage of the provisions under PSQIA is a smart idea. “A federal privilege will, in most cases, take precedence over any conflicting state law—including this one.”
Payors are struggling to manage contracts that vary from facility to facility, from procedure to procedure, with significant deviation within each contract. The situation is likely to become exacerbated by bundled payments, escalating regulation, and evolving reforms.
Taking contracts and associated claims from negotiation to adjudication has never been more complex.
Payors struggle to manage contracts that vary from facility to facility, from procedure to procedure, with significant deviation within each contract. These highly complex agreements are usually negotiated by hospital administrators and lawyers, and are frequently expressed in phrases that must then be interpreted by the operations staff and put into precise terms that can be executed by claims systems or processed manually by claims staff.
This is a daunting task as these terms are typically highly nuanced. For example, a policy may state: “If an ER visit turns into an inpatient stay, the health plan will be billed only for the inpatient stay.” The burden then falls upon the operations staff to determine if this applies to an inpatient stay that follows an ER visit within 24 hours. What about 36 hours? What if the stay becomes an observation visit? Who decides?
Payment Systems Pushed to the Breaking Point
Today’s contracting processes and claims systems are being pushed beyond their stated purpose and designs. Many health plans use legacy systems that were implemented during simpler eras, when payors dealt with one claim at a time. Even some updated systems lack the flexibility to handle changes to standard plan policies, enforce new complex policies, and make appropriate connections between separate claims that should be grouped.
For example, a plan may have a policy stating: “When a member has a test, such as a preadmission lab test, followed by an elective admission, both the test and admission will be treated as a single episode.” But in the negotiation process, the payment policy may be disregarded in order to get a concession in another area or win in a particular facility. Today’s payment systems lack the capabilities to adjudicate these types of variances to standard policies.
Policy enforcement can be another hurdle, especially when it comes to grouping separate claims—which may also stymie the payment system. A contract that was negotiated on a DRG basis may state that a re-admission within 30 days will be considered part of that DRG. In this scenario, a plan could have a member who had a knee surgery and then was re-admitted for an infection due to that surgery, but if the contract did not specify that such an infection would be considered part of the DRG then the plan would pay additionally for the infection admission.
A very sophisticated system is needed to tie those two separate claims together and determine that they should be treated as part of the original admission and DRG. This is beyond the scope of the vast majority of today’s systems.
Simply put, current payment systems were not designed to accommodate the ever-increasing complexities that are an outgrowth of the current negotiation process. The result is a payment environment that does not meet the needs of payors or providers. And this situation is likely to become exacerbated as we move towards a future of bundled payments, escalating regulation and ever-evolving reforms.
A New Class of Systems to Meet Complex Needs
Addressing payors’ existing and future contracting and claims challenges requires a new breed of payment system. As a starting point, plans need to view contracting as an extension of payment, not just as a negotiation or workflow vehicle. They also need to consider medical policies, payment policies, contract terms, and waste and abuse prevention as part of the payment continuum versus separate pieces.
Claims can’t be paid in a vacuum. The audit department is a great place to see if claims performance is really being managed as a continuum. If adjustments are continually being made within the audit department, it is probably because there are inconsistencies along the way.
In addition, plans must look for systems with the capabilities to look across claims and providers. Systems that cannot accommodate complicated policies must give way so that payors can facilitate appropriate master payment for contracts as they exist today and how they will be in the future.
Payors will have an opportunity to view payment performance more holistically as they start looking at payment policies and contracts for ICD-10 conversions. This can also become an important step towards developing the capability to execute bundled payments and episodes of care with contract terms and payment policy rules that look across facilities and providers.
The good news is that next-generation payment management systems are available. They can address the payment performance continuum and work alongside the existing claim processing system to automate clinical payment policy, business rules and contract terms, delivering the critical intelligence that is needed for virtually every payment decision. Payors that implement these new, end-to-end payment management solutions will be able to realize significant savings today through increased efficiencies and reduced penalties and rework. Most importantly, they will be positioned strategically to address the intricacies of emerging bundled payment and episode of care initiatives.
Jim Evans is Vice President of McKesson Health Solutions.
Until 2007, nurses at Riley Hospital for Children in Indianapolis relied on traditional shift change reporting methods to communicate patient care information from caregiver to caregiver. But when challenged by Riley’s leadership team to find ways to improve hospital documentation, the Clinical Practice Council began looking at a standardized approach to hospitalwide shift change reporting.
After a six-month pilot program, an educational video and PowerPoint® presentation, and another six-month training process, Riley implemented its hospitalwide nurse-to-nurse shift change report at the bedside with families.
Not only did leadership, the nursing staff, and physicians accept the process, but patients and families also became more involved and felt safer as a result.
Riley was recently recognized for its efforts by the National Patient Safety Foundation with the 2010 Socius Award, which symbolizes the relationship between healthcare providers and the patients and families they serve.
Developing a hospitalwide process
Melanie Cline, RN, MSN, clinical director at Riley, teamed up with a 30-person group of staff nurses, educators, the clinical nurse specialist, clinical managers, and the family-centered care coordinator to review current literature and best practices for shift report processes.
“Our highest priority was to include parents in the process as their involvement and input is critical to achieving the best outcomes for each child,” says Cline.
The old process consisted of the charge nurse gathering information from the nurses going off shift about 30 minutes before the change of shift. Another 30 minutes would pass while the charge nurse documented the information.
In addition to making sure the parents were included in the shift report, Cline also had to keep the staff’s best interests in mind. Nurses commonly complained that the handoff information they received could be 60?90 minutes old with the previous process. The staff nurses coming on shift would often find that their patient’s condition had changed by the time they got to the patient.
“When dealing with pediatrics, a child’s condition can change within a matter of minutes,” says Cline. “Getting to the patient sooner is better so potentially avoidable problems are picked up right away.”
Another factor that was vital to determining the components of the shift report was making sure the nurse going off shift and the nurse coming on shift could visualize the patient together, says Cline. This helped develop an understanding of how the patient was assessed on the previous shift.
Finally, Cline and her team developed five standards that are always included in the shift change report:
Head-to-toe assessment
Nurse-to-nurse involvement in viewing
Medication check
Orders verification
Care plan
The five standards of a shift report
The head-to-toe assessment, the first of the five standards, involves the nurses coming on and off shift as well as the patient’s parents. This assessment enhances patient safety—in fact, it has helped identify a few near misses.
“In one case, nurses were discussing pain in a 3-year-old’s left knee, and the mother spoke up and corrected their information, saying it was actually the right knee that was bothering the patient,” says Cline.
The second shift report standard ensures that nurses examine their patient together and discuss how each patient was assessed and monitored. Cline offers the example of a patient’s breathing: Nurses can establish how the patient is breathing and how each patient’s “normal” breathing looks.
The third standard, medication check, is a safety measure that also saves time. During the old process, nurses coming on shift would often have to call the previous nurse at home to double-check medication information.
“By conducting the medication check in real time, it helps save time and eliminates oversights or omissions on the chart,” says Cline.
The orders verification, the fourth standard, involves reviewing all current physician orders and communicating the implementation status of all new orders.
Finally, nurses discuss the care plan with the patient and the family at the patient’s bedside. This is where the next 12 hours of care are planned.
Cline says the entire process takes 30 minutes to complete, and even though the new process takes the same amount of time as the old one, in the grand scheme of things, it saves the staff time.
For instance, nurses no longer need to call nurses off shift to clarify a medication question because the two nurses review this information together during the shift report. Also, with parents now involved in the process, nurses can get questions answered up front as opposed to trying to find the parents later on during the shift.
Education and training
Before these standards and the bedside shift report could be implemented hospitalwide, Cline and her team developed a PowerPoint presentation and video to help educate staff members on the new process. The video reviewed the process step by step—using staff nurses as actors—and reminded staff of the importance of consistency.
Patients and their families also were involved in making the video. At the end of the video, parents described in their own words how the old process was sometimes scary but the new one helped them feel safer.
“It was very powerful for the staff to hear a parent’s testimony about how the old shift report left them out of the process, which can be frightening,” says Cline.
After viewing the video and PowerPoint presentation, those team members responsible for developing the new process coached and observed nursing staff on three occasions prior to rolling out the new bedside shift reporting.
“The 30 staff members who were part of the developmental process came in days, nights, and weekends to coach and mentor their colleagues,” says Cline.
The process took another six months for all units at Riley to successfully implement, making the total time for implementation one year, Cline says.
Finally, in January 2008, all nurses at Riley were involved in the nurse-to-nurse shift change bedside reporting involving parents.
Buy-in from all levels
Some nurses were skeptical of the new process, thinking it would take more time than before because the addition of family involvement would slow them down, says Cline.
As time passed, however, the skeptics began to appreciate the new bedside reporting for the communication it improves and the questions it eliminates—both of which save time in the end.
“The process kind of sold itself to a lot of the staff because of the situations they avoided, like the near misses,” says Cline. The new process ensures that nurses coming on shift visualize patients before the nurse going off shift leaves the unit.
Words of advice
As family-centered care is the focus at Riley, Cline suggests getting the parents or family members involved early on and keeping them engaged throughout the process.
“Having the patient and their family involved is critical,” says Cline. “It helps with any clarification or mix-up in communication that might occur during handoffs and offers comfort to the patient and family during this critical time.” This article was adapted from one that originally appeared in the August 2010 issue of Patient Safety Monitor (Briefings on Patient Safety), an HCPro publication.
Listen to Brian Ahier, health IT expert at Mid-Columbia Medical Center, discusses the implications of stimulus funds, the HITECH Act, and meaningful use on community and rural hospitals.
On July 30, CMS issued the inpatient prospective payment system (IPPS) final rule to update policies and rates for fiscal year (FY) 2011, which maintains long-standing CMS policy and implements some provisions of the Patient Protection and Affordable Care Act (PPACA).
CMS updated acute care hospital rates by 2.35%. This update reflects a market basket increase of 2.6% for inflation, which is a slight increase over the FY 2010 inflation rate. The final rule reduces the 2.6% inflation update by 0.25%, as required by PPACA.
CMS finalizes 2.9% DCA to offset overpayments
Despite strong opposition from the hospital community, CMS also finalized its proposed documentation and coding adjustment (DCA) of -2.9% to offset overpayments that resulted from documentation and coding practices under the new Medicare severity DRG (MS-DRG) system that in their opinion, did not reflect actual increases in patient severity. CMS states in the final rule:
Under legislation passed in 2007, CMS is required to recoup the entire amount of FY 2008 and 2009 excess spending due to changes in hospital coding practices no later than FY 2012. CMS has determined that a -5.8% adjustment is necessary to recoup these overpayments. The -2.9% adjustment for FY 2011 is one-half of this amount.
But many in the provider community argued that the increased payments were actually a product of faulty calculations by CMS and, indeed, the severity of illness of the patients did increase.
“The truth is that the overpayment of hospitals is really related to inappropriate definitions of codes and inappropriate advice on how to use and sequence ICD-9 codes for DRG assignments. This has led to a massive maximization of DRGs with MCCs [major complications and comorbidities] at the expense of the DRGs that really reflected what was wrong with the patient,” says Robert S. Gold, MD, CEO of DCBA Inc., in Atlanta.
As recently as last week, in a letter to CMS, the American Hospital Association (AHA), the Federation of American Hospitals, and the Association of American Medical Colleges cited two independent studies that underscore their concerns about CMS’ methodology for determining the effect changes in documentation and coding have had on the Medicare patient case mix index.
“Obviously, I am saddened by the enormity of the documentation and coding adjustment, however CMS has been forthright with their promise to implement this, even though I do not agree with their methodology,” says James S. Kennedy, MD, CCS, managing director at FTI Healthcare in Atlanta.
The American Hospital Association expressed its disappointment with the finalized DCA in Friday’s AHA News Now daily report.
"America’s hospitals strongly disagree with the Centers for Medicare & Medicaid Services' final inpatient rule," said AHA President and CEO Rich Umbdenstock. "In issuing its final rule, CMS failed to listen to concerns from members of Congress . . . CMS also failed to acknowledge independent studies that show CMS' methodology does not take into account what we all know: hospital patients are increasingly sicker.”
This DCA creates a challenge for hospitals, which will need to focus additional efforts on documentation and coding specificity, says Gloryanne Bryant, RHIA, CCS, CCDS, regional managing director of HIM for NCAL revenue cycle at Kaiser Foundation Health Plan Inc. & Hospitals in Oakland, CA.
“I was disappointed to see not only that [CMS] continues to use [DCA methodology] but that the DCA was as much as it was,” Bryant says. “I think this will present struggles and challenges to hospitals, including documentation and coding improvement that is valid and accurate.”
Provider community reacts to downgrade of acute renal failure
CMS also finalized a provision to downgrade acute kidney failure or injury (ICD-9-CM code 584.9) from an MCC to a complication and comorbidity (CC), a troubling move to many in the provider community. The downgrade comes as a result of over-reporting of ICD-9-CM code 584.9 in cases where patients do not meet the criteria.
“Renal failure is the only acute organ failure that is not an MCC,” says Gold. “It’s this over-reporting that has diluted the risk factors for patients who really do have significant renal damage by adding patients who don’t.”
Many providers have advocated for a revision of ICD-9-CM code category 584 to better reflect the stages of acute kidney injury.
“I’m very disappointed in CMS’ discussion and approach to the acute kidney injury issue, especially their lack of taking responsibility as a member of the ICD-9 Cooperating Parties for the inadequacies of the ICD-9 code set referable to this issue,” Kennedy says.
“Those hospitals that have CDI [clinical documentation improvement] programs and don’t have over-reporting are getting hit with the DCA penalty just as much as the hospitals who caused it, and that’s not fair,” Gold adds. "This is not saying that all CDI programs are falsely reporting AKI at all. But some are.
Inadequate code definitions and sequencing guidelines have led to some hospitals resequencing codes for a higher-paying DRG when it probably was inappropriate to do so, says Gold. He adds that it’s imperative that CMS consult interested parties (e.g., AHA, American Health Information Management Association, National Center for Health Statistics, and Association for Clinical Documentation Improvement Specialists) along with physician specialty leadership who can provide the needed clinical insights to come to a consensus on appropriate definitions.
“[All of these groups] need to come to a reconciliation of what the true definitions of these conditions are that deserve these codes and how they should be sequenced properly so people cannot possibly miscode for dollars,” Gold says.
Kennedy urges the hospital community to take note that CMS plans to target encephalopathy next year. “It’s very important that the coded data set actually reflects severity of illness if hospitals or providers are to prevail in their discussions with CMS,” he says.
CMS clarifies three-day rule
CMS used the final rule to clarify its three-day payment window, or three-day rule, and implement new legislative provisions under the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010. Under the three-day rule, a hospital must include on the claim for a Medicare beneficiary’s inpatient stay the charges for all outpatient diagnostic services and admission-related nondiagnostic services provided during the payment window. Many in the provider community felt that clarification of the three-day rule was long overdue.
There had been some confusion and there were possibly a couple of loopholes in the three-day rule, so this clarification tightens up the rule,” Bryant says. “It’s not a 72-hour rule, for one thing. The rule is specific to three calendar days.”
The IPPS final rule fact sheet states:
The Medicare law requires hospitals to include diagnostic services and most admission-related non-diagnostic services provided in the hospital outpatient department on the day of admission or 3 calendar days prior to admission (one day for hospital not paid under the IPPS) as part of the inpatient stay. The policy protects Medicare and the beneficiary from paying separately under Medicare Part B for services that should be included in the Part A payment for the inpatient stay.
This will require that hospitals devote some additional attention in the compliance arena for the three-day rule, particularly for bill processing and claims submission, Bryant says.
CMS addressed the question of whether a nondiagnostic service was related or unrelated to the reason for the inpatient admission. Legislative changes prompted CMS to revisit the previous relationship, defined by an exact diagnosis code match. CMS will implement a new process, using a new condition code, modifier, or some other identifier, for hospitals to mark nondiagnostic services that are clinically unrelated to the inpatient admission, and therefore eligible for payment under the OPPS.
“It’s very important for hospital management and specific departments to read the final rule carefully so that implementation can be achieved successfully,” Bryant says.
CMS makes MS-DRG changes
There are several noteworthy MS-DRG changes in the final rule. For example, CMS split MS-DRG 9 (Bone marrow transplant) into two new MS-DRGs, given the wide variation in costs:
MS-DRG 14 (Allogenic bone marrow transplant), with a relative weight of 11.5947
MS-DRG 15 (Autologous bone marrow transplant), with a relative weight of 5.9504
CMS also allowed the inclusion of ICD-9-CM code 251.3 (postsurgical hypoinsulinemia) as an acceptable principal diagnosis for MS-DRG 8 (Simultaneous kidney/pancreas transplant) and MS-DRG 10 (Pancreas transplant). Note the following five MS-DRGs with relative weight reductions:
622 (Skin grafts and wound debridement for endocrine, nutritional and metabolic disorders with MCC), -19.2%
855 (Infectious and parasitic diseases with operative room procedure without CC/MCC), -19.0%
10 (Pancreas transplant), -11.5%
420 (Hepatobiliary diagnostic procedures with MCC), -11.5%
624 (Skin grafts and wound debridement for endocrine, nutritional and metabolic disorders without CC/MCC), -10.5%
In addition, consider the following five MS-DRGs with relative weight increases:
770 (Abortion with dilation and curettage, aspiration curettage, or hysterotomy), 30.8%
585 (Breast biopsy, local excision and other breast procedures without CC/MCC), 21.2%
779 (Abortion without dilation and curettage), 21.1%
725 (Benign prostatic hypertrophy with MCC), 19.3%
686 (Kidney and urinary tract neoplasms with MCC), 18.7%
CMS adds 12 new quality indicators
CMS added 12 items to the measures set for the reporting hospital quality data for annual payment update (RHQDAPU) program, and retired one current measure, mortality for selected surgical procedures (composite).
However, CMS will consider only 10 of the new measures, including rates of occurrence for eight of 10 categories of conditions that are subject to the hospital-acquired conditions (HAC) policy, in determining a hospital’s FY 2012 update. Specifically, CMS is adding the following eight categories of conditions included on the HAC list:
Foreign object retained after surgery
Air embolism
Blood incompatibility
Pressure ulcer stages III and IV
Falls and trauma (including fracture, dislocation, intracranial injury, crushing injury, burn, and electric shock)
Vascular catheter-associated infection
Catheter-associated urinary tract infection
Manifestations of poor glycemic control
The other two measures are two additional patient safety Indicators, postoperative respiratory failure and postoperative pulmonary embolism or deep vein thrombosis.
“If you look at the list of those indicators, good documentation will be needed to support and validate them,” Bryant says.
The Detroit Medical Center and its network of eight hospitals have served as a safety net for thousands of poor patients throughout southeastern Michigan. So when its pending sale to a for-profit hospital system was announced in March, there were mixed reactions about the impact on the safety net. Cash-poor non-profit hospitals, unable to borrow money for needed improvements in facilities and equipment, are eagerly seeking for-profit suitors. And for-profit hospital companies and investment firms — eyeing the improving economy and the expected influx of millions more insured Americans as a result of the new federal health overhaul law — see opportunity in the non-profit sector. But the transactions are also reigniting a long-running debate: Are the deals good for patients, or do they result in an overemphasis on profits that poses a threat to the quality of care?
Leaders of California's nurses union said that their members will respect a judge's order that bars them from striking at University of California hospitals. At the same time, the union plans to rally at the hospitals and student health centers, as well as two private facilities in the Los Angeles area. The nurses' plan to strike came months after contract negotiations broke down last year over their demand that hospital officials increase staffing at the five hospitals and four student centers.
Los Angeles County health officials cited numerous inaccuracies in a complaint filed with regulators that alleged emergency room patients at County-USC Medical Center faced excessive waits, among other issues. At the same time, officials acknowledged that hospital staff failed to protect patient privacy. The in-depth response came as state regulators paid a surprise visit to the county-run hospital to investigate the complaint.