MEDICAL CONNECTION
September
15 2012
Georgia Health Sciences Physicians and Clinical Staff
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S E P T E M B E R Pressures on Our System
Contact information:
New Faces of GHS a,b
Medical Connection is published monthly except for July and December for GHS physicians and clinical staff.
Q-HIP Scores
• Dr. William Kanto—Senior Vice President for
Evidence-Based Practices a,b,c The Power of Words a,b
Medical Affairs and Chief Medical Officer, Georgia Health Sciences Health System (kanto@georgiahealth.edu)
• Carole Poe—Medical Connection Liaison (cpoe@georgiahealth.edu)
• Publications Director—Christine Hurley
Deriso (cderiso@georgiahealth.edu)
• Editor/Designer—Patricia Johnson
(pjohnson1@georgiahealth.edu)
Hand-off Communications a,b,c
• Photographers—Patricia Johnson, Phil Jones,
GHSU Urology and Stock X-Chng
Links: www.georgiahealth.org
Pressures on Our System Dr. William Kanto Senior Vice President for Medical Affairs and Chief Medical Officer
More than 25 percent of our patients are on Medicare, which requires a particularly demanding process.
Patricia Johnson
I am going to try to explain a few issues
our health care system is facing in hopes of increasing your understanding of our frequent requests for assistance in so many different venues. But first, I want to thank you for your assistance in managing our admission and discharge process. We still have room for improvement and I hope you will continue your efforts, but thanks to you, we are doing better.
Your efforts—including increasing the volume of contemplated discharge orders and writing discharge orders as quickly as possible—have decreased the number of patients waiting for beds and improved the process overall. Many other issues are
on our plate, including one that recently came to light. As many of you know, we often have to obtain precertification from third-party payers before we can treat our patients, and the requirements are often very prescriptive.
The requirements can also affect the admission protocol—for instance, when patients require hospitalization for a procedure approved only on an outpatient basis. Medicare will not reimburse unless the type of admission meets certain requirements, even in cases of clerical errors. Recently, for
instance, a patient was hospitalized for a procedure requiring inpatient status. But an error on the admission form, and our inability to change the status due to queries that went unanswered, meant we were unable to collect on a $35,000-plus hospital bill.
It is vital to respond to queries from the UR department about your patients. UR reviews all Medicare patients to make sure we correctly identify their complexity and meet all requirements. Their queries may range from more specifically describing comorbidities and complications to requesting a change in admission status, as in the case above. Had that query been answered, we would have been reimbursed for our services—hence the importance of communication between UR and the patient’s resident/attending. We are working to improve our process for notifying the physicians, but need your help in making the process work. Answering
UR queries is also important
Pressures on Our System because of the staff’s expertise regarding the intricacies of coding. This expertise
D
enables troubleshooting in areas including documentation of the illness, diagnosis and complicating conditions. If done correctly, the HIMS coder will code the patient correctly based on the diagnosis and the complicating conditions and co-morbidities. Please encourage your team to respond as quickly as possible to these queries. If we all do this, everyone will benefit.
Reminder:
The flu vaccine is mandatory for all members of the medical staff. Vaccinations begin Oct. 17. All medical staff members must receive their vaccine by Dec. 1.
Exceptions:
1) previous adverse reaction to flu vaccine 2) egg allergy 3) religious objections
P o i n t s
Phil Jones
HIMS student, Hend Hilali learns coding at GHS.
t o
C o n s i d e r
1.
Physicians may be asked for further documentation so HIMS coders can appropriately classify patients.
2.
Only physicians—not UR personnel—can make entries in a medical record. The UR personnel may only request documentation; they cannot dictate what to say, per CMS guidelines.
3.
Correct coding increases the chance of higher reimbursement, particularly in the case of complications, which can affect hospital lengths of stays and our Risk Adjusted Mortality Rate.
New Faces of GHS Medical School: Sindh Medical College, Pakistan, 2005 Residency: University of Tennessee, 2011
Philip Catalano, M.D., Cardiothoracic Surgery
Medical School: Medical University of South Carolina, 1972 Internship: Ohio State University, 1973 Residency: Ohio State University, 1977 Fellowship: Ohio State University, 1979 – Thoracic Surgery
Gregory Cook, M.D., Obstetrics/Gynecology
Medical School: Medical College of Georgia, 1985 Residency: Medical College of Georgia, 1989
Dr. Cook is a community physician at Augusta GYN, PC.
Albert D. Copeland, Ph.D., M.D., Pediatric Hospitalist
Medical School: Medical College of Georgia, 1987 Graduate School: Medical College of Georgia, 1987 Internship: Medical College of Georgia, 1988 Residency: Louisiana State University, 1997 Dr. Copeland will be a Pediatric Hospitalist at Phoebe Putney Medical Center in Albany, Ga.
Cheryl Dickson, M.D., Pediatrics
Medical School: UMDNJ, 1980 Residency: UMDNJ, 1983 Fellowship: UMDNJ, 1984 -Adolescent Medicine
Dr. Dickson is Campus Associate Dean for Student & Multicultural Affairs UGA Health Sciences Campus in Athens, Ga.
Bruce Curtiss Gilbert, M.D., Diagnostic Radiology
Medical School: Mercer University, 2003 Residency: Brooke Army Medical Center, 2008
William Ry Patrick, M.D., Anesthesiology
Medical School: Medical College of Georgia, 2008 Residency: Georgia Health Sciences University, 2012
Dr. Patrick will begin a GHSU fellowship in pain management.
We l c o m e
Mahwish Ali, M.B.B.S., Internal Medicine
New Faces of GHS Urogynecology daVinci Robotics Medical School: University of Maryland, 2005 Residency: Pennsylvania Hospital, 2009 Fellowship: University of North Carolina, 2012 – Female Pelvic Medicine and Reconstructive Surgery
Peter Rosenquist, M.D., Psychiatry
Medical School: University of Nebraska, 1987 Residency: Chicago Medical School, 1991
Kalyan Tatineny, M.D., Pediatric Radiology
Medical School: University of Missouri – Kansas City, 2005 Internship: John Peter Smith Hospital, TX, 2007 Residency: St. Vincent’s Hospital, NY, 2010 Residency: SUNY-Stonybrook, 2011 Fellowship: CHMC Seattle, Wash.,2012 -Pediatric Radiology
Cristian Thomae, M.D., Obstetrics
Gynecology daVinci Robotics Medical School: Virginia Commonwealth University, 1983 Residency: Naval Medical Hospital, Va., 1988 Fellowship: UMDNJ, 1984 -Adolescent Medicine Dr. Thomae is a community physician at Augusta Obstetrics & Gynecology Specialists, LLC.
Paul Wallach, M.D., Internal Medicine
Medical School: University of South Florida, 1984 Internship: University of South Florida, 1985 Residency: University of South Florida, 1987 Dr. Wallach is Vice Dean of Academic Affairs at the GHSU Medical College of Georgia.
Cassandra White, M.D., General Surgery
Surgery Critical Care Medical School: University of Illinois, 2005 Internship: University of South Alabama, 2006 Residency: University of South Alabama, 2011 Fellowship: University of Pittsburgh -Surgery Critical Care, 2012
We l c o m e
Barbara Robinson, M.D., Gynecology
Q-HIP Scores Help Our Enterprise Flourish Linda F. Henderson, RHIA, CPHQ
Quality Management Director
Patricia Johnson
A hospital incentive program that assesses our patient safety measures, health outcome measures and member satisfaction measures attests to ongoing improvements. The Anthem
Blue Cross/Blue Shield Quality-In-Sights Hospital Incentive Program, or Q-HIP, rewards facilities with
processes in place ensuring that BlueCross/ BlueShield members receive optimal care. Q-HIP also rewards additional “bonus” measures. Some of the measures address the groundwork for quality care. Our program includes policies related to surgical safety (using a checklist similar to the World Health Organization’s) and perinatal care, among others, all of which demonstrate a platform for providing quality care in a safe manner. In addition to policies, we also report our quarterly results for the core measures. The specific measures that must be reported change annually, but to get credit, our organization must score 95-98 percent for the core measures. We
received 16 out of 25 points attributed to this segment through the third quarter in fiscal year 2012. Our increased focus on core measures is showing in our overall
scores each quarter. Improvements have been made, thanks to our medical staff and Clinical Service Chiefs. Our Hospital Consumer Assessment of Healthcare Providers and Systems Survey scores are pulled into the program at the end of the year, specifically how the patients rate their overall experience with our facility and their caregivers. For hospital-based providers, such as radiologists, emergency medicine physicians, pathologists and anesthesiologists, Q-HIP will pull their member satisfaction survey results for our facility into the tool. Managing
Q-HIP requires systemwide collaboration. Quality Management
communicates to the services what is needed each year and coordinates the posting of data each quarter. We will wrap up the 2011 Q-HIP year Oct. 31.
Remember: our Q-HIP performance reflects
the overall quality of care we provide to all patients, not just those with BlueCross/BlueShield insurance. Our ability to score “points” will improve our status among both patients and insurance providers.
Q-HIP
Our settlement with BCBS and our
financial benefit are tied to our performance and quality. We are pleased with this agreement. GHS physicans and staff are convinced the quality of care will be reflected in our Q-HIP score and result in enhancement of our payment. We are preparing to engage in similar discussions with other payers as look to the future payment for services.
Evidence-Based Practices Target Catheter-Associated Infections Rebecca Walker, BSEd, BSN, RN, CIC Director of Hospital Epidemiology care-associated infection, representing up to 80 percent of health care-acquired infections in hospitals. The goal, NPSG.07.06.01, states:
Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections (CAUTI). Hospitals must fully implement the goal by next January.
G U I D E L I N E S
Dr. Sisir Botta, GHSU Urology
Preventing catheter-associated urinary tract infections is the goal of a recently unveiled National Patient Safety Goal. The Joint Commission established National Patient Safety Goals in 2002 to enhance patient safety. The first group took effect in 2003, and others are developed or refined based on input from a Patient Safety Advisory Group composed of multidisciplinary professionals who address patient safety issues in a wide variety of health care settings. Based on feedback from practitioners, provider organizations, purchasers, consumer groups and other stakeholders, the commission determines the highest-priority patient safety issues and how best to address them. The commission also makes goals programspecific if they apply to a specific accreditation program.
The goal approved this year—preventing catheter-associated urinary tract infections for the hospital and critical access hospital accreditation programs—targets the most common health
Our Infections Committee has adopted guidelines published by the Centers for Disease Control and Prevention and the Society for Healthcare Epidemiology in America on this topic. The policy focuses on: � � � � � � �
Proper utilization Hand hygiene Aseptic insertion Proper securement Closed (sterile) drainage system Standard precautions for maintenance Adequate urinary flow
Proper utilization ensures that alternative methods to indwelling catheterization are used to manage urinary elimination whenever possible. Examples include bladder training, use of bladder scanners, intermittent catheterization and condom catheters in males. If an indwelling catheter is medically indicated (as documented by a physician), appropriate measures are taken to mitigate risks (i.e. hand hygiene, aseptic insertion, closed system, proper securement).
Evidence-Based Practices Target Catheter-Associated Infections Rebecca Walker, BSEd, BSN, RN, CIC Director of Hospital Epidemiology The most important component of proper utilization is the daily review of necessity.
Indwelling urinary catheters should be promptly removed when no longer needed. This priority should be a concerted effort between the medical and nursing staff. In addition to these guidelines, the Surgical Care Improvement Project mandates discontinuing indwelling catheters within 24 to 48 hours postoperatively unless continuation is appropriately indicated.
Patient Saftey Goal: Joint Commission
All of our inpatient settings monitor catheterassociated urinary tract infections. These events are reported to the CDC’s National Healthcare Safety Network. The infection rates associated with intensive care units are also now reported to Centers for Medicare and Medicaid Services, which uses these rates as part of the Inpatient Prospective Payment System for value-based purchasing. Our enterprise reported 11 cases last January through March, which equaled 11 observed when 11.706 was expected (a Standardized Infection Ratio of 0.940).
“The health of our patients and our bottom line demands our most vigilant efforts on this matter.”
Evidence-based practices preventing CAUTI: CDC CAUTI
JSTOR CAUTI
www.urologic.niddk.nih.gov
IT Services is working with Quality Management and Hospital Epidemiology to develop means
within the electronic health care record to remind the medical and nursing staff of the daily review of necessity. When indicated for continuance, the physician will be prompted to select the appropriate indication.
Evidence-Based Practices Target Catheter-Associated Infections Rebecca Walker, BSEd, BSN, RN, CIC Director of Hospital Epidemiology
The Centers for Disease Control and Prevention and Society for Healthcare Epidemiology
CATHETER USE:
10
Acute urinary retention or bladder outlet obstruction Accurate measurement of urinary output in critically ill patients Perioperative use in selected procedures Urological surgery or other surgery on contiguous structures of the genitourinary tract Anticipated prolonged duration of surgery (remove catheter in PACU) Anticipated receipt of large-volume infusions or diuretics during surgery Need for intraoperative monitoring of urinary output Assisted healing of perineal and sacral wounds in incontinent patients Prolonged immobilization for trauma or surgery Comfort care of the terminally ill patient if needed
The Power of Words Dr. Johnathan R. Gore Chief Hospitalist, Utilization Management Medical Director
Patricia Johnson
Do you think we take care of sick patients at
Georgia Health Sciences Medical Center? Obviously!
Prove it, you say?
Clinical Documentation Improvement does just that. It is what physicians document in patients’ initial H and P and daily record. How well we do it is neither simple nor easily appreciated. Sounds crazy, but it is true. As I noted in the August edition of Medical Connection, it is simply a matter of learning and being willing to play the game. The latest example discussed within Utilization Management involved a hematology/oncology patient admitted to Georgia Health Sciences Medical Center. This patient had a pancytopenia caused at least partly by chemotherapeutic agents. The patient’s record included the diagnosis, “CML with blast crisis,” with no mention of pancytopenia. The physician should have clinically documented “pancytopenia secondary to chemotherapeutic agent.”
The difference? Reimbursement of
$11,000, rather than almost $50,000.
This happens every day, costing us hundreds of thousands, if not millions, of dollars each year. Correct documentation isn’t a matter of working the system; it is a matter of fair and reasonable reimbursement.
“We do not believe there is anything inappropriate, unethical or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment that is supported by documentation in the medical record. We encourage hospitals to engage in complete and accurate coding.”—Federal Register, Vol. 72, No. 162, Wed.
Aug. 22, 2007, Rules and Regulations, pp. 47180– 47181. Please remember that coders can code only what is documented in the chart. They cannot “assume” or “use their judgment.” Clinical documentation specialists and coders must send queries to physicians to ask them to document more specifically so complicating conditions or major comorbid conditions can be documented and appropriately reimbursed. An
Power of Words Dr. Johnathan R. Gore Chief Hospitalist, Utilization Management Medical Director
131 Open wounds and lacerations, mild 198 Residual acute conditions: pain 112 Severe infective and parasitic diseases:meningitis 101 Common cold Stock X-Chng
electronic query system to ensure more uniform documentation will be unveiled soon. We will discuss documentation of different specialties and complications later. The details can be overwhelming, so we will take it slow. Please realize we are not trying to increase work but to better document the excellent patient care we provide.
Just imagine the differences required in documenting the kinds and severity of congestive heart failure or sepsis. Improved documentation will better position us to become the quaternary health care institution we aspire to be.
E X A M P L E S One or two words in a patient’s record can mean the difference between:
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GHSU’s Mortality Index, which determines our ranking among academic health care institutions regarding who is expected to die during hospitalization Tens of thousands of dollars in reimbursement based on a base DRG vs. a DRG with a complicating condition or major comorbid condition The quality of care we provide Other indices we are judged on compared to similar hospitals
Hand-Off Communications Enhance Patient Safety Teri Perry, MSN, RN Interim Chief Nurse, VP Adult Patient Care Services
Patricia Johnson
GHS hospital staff, Jessica Arnold, Patient Transport gives Katie Stevens, Registered Nurse patient arrival information.
Today’s health care delivery involves many interfaces and patient handoffs among multiple health care practitioners. A hospitalized patient may interact with health team members from many departments, with varying levels of educational and occupational training. Each one has an important role in patient care. Accurately communicating critical information is therefore vital to safe and effective clinical practice. Interdisciplinary collaboration is essential. If we do not collaborate, patients complain that they do not understand what is happening and are getting different stories from different specialists or teams.
the impact and importance of nonverbal communication between health team members as well as with the patient. The Joint Commission (2005) reminds us that even words with accurate content may be misinterpreted based on delivery style, including body language, tone of voice and eye contact. In today’s culture, critical information is often transmitted via email or text messages, which can lead to serious consequences if misinterpreted. Effective communication among all team members is vital in preventing errors.
The Joint Commission in 2005 mandated effective hand-off communication but allowed organizations to use or design a tool of their choice, as long as the tool reflects
the current status of the patient at hand-off regarding diagnosis, condition, care, treatment, medications, allergies and any recent or anticipated changes. We are challenged to make sure all levels of staff understand the information and follow the process. Regardless of where the hand-off takes place, a system must be in place to validate information. An individual must report the hand-off, and a receiver must accept it.
"One key requirement is for the two persons Patient safety is jeopardized when health to have opportunity to discuss/disagree on care professionals fail to relay critical the assessment and re-evaluate the patient information, misinterpret information and/or together." Patients who are unstable cannot be fail to assess the patient’s present status. Webster’s Dictionary defines communication as “the imparting of or interchange of thoughts, opinions or information by speech, writing or signs.” Health care workers must consider
transported only by a transporter. A professional must accompany them to their destination and must then stay with them. In our organization, health care professionals at all levels, from
Hand-Off Communications Enhance Patient Safety Teri Perry, MSN, RN Interim Chief Nurse, VP Adult Patient Care Services medical students to attending physicians, have accompanied unstable patients for diagnostic procedures to ensure patient safety. PAMPER is used during nursing shift changes, patient transport to ancillary testing areas, a physician’s transfer of complete responsibility of a patient, a physician transferring on-call responsibility and the hand-off by a nurse or physician from an emergency department to an inpatient unit, a different hospital, a nursing home or home health care.
The tool was created by a team of health team members, including physicians, nurses, respiratory therapists, transporters and ancillary team members. Face-to-face communication is preferred, but written communication is acceptable.
“We have begun to realize that the future of medicine and nursing are inextricably linked,” Dr. Darrell G. Kirch, President of the Association of American Medical Colleges and former MCG Dean, wrote recently. “Medicine and nursing share a unique relationship sharing educational and clinical facilities. Unfortunately, this relationship has not fostered collaboration.” Patient safety requires us to assess how we collaborate in caring for our patients. The use of a complete picture of patient status is essential to ensure excellent patient care and optimal effectiveness of all members of the health care team.
Our hand-off system is called PAMPER (see Corporate policy #14.125: Communication Handoff).
Phil Jones
Hand-Off Communications Enhance Patient Safety Teri Perry, MSN, RN Interim Chief Nurse, VP Adult Patient Care Services
P A M P E R
P A M P E R
atient information: diagnosis, demographics, DNR/AND status, social/Religious issues
llergies: medication, tape, latex, food
edications: either all medications or, depending on situation, last pain or blood pressure medication
recautions/Procedures: safety issues such as a fall, infection, risk for skin breakdown; type of surgery, NPO
quipment: ventilator, oxygen, pacemaker, line reconciliation
ecommendations/Response: From caregiver handing-off; question/answer time
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Georgia Health Sciences Physicians and Clinical Staff