Cat Ears
January 19, 2010
Did you know that cats have 32 muscles in each ear? Surely you will agree with me that this information is fascinating. But as interesting as that tidbit of information is, can you really say that it is useful outside of a small circle of academics?
That’s the way a lot of the information we collect in home health is – useless out of context. We obsess about visits per episode. We want to know what our competitors are doing or what the national average is. We want to know what other people are doing with case mix weights. All of this information is useless unless it is viewed in context.
Take visits per episode, for example. I have clients that admit a lot of post op ortho patients. And I have other clients who have very few therapy patients. I have yet another client who sees a lot of psychiatric patients. To use a standard number of visits per episode for the purposes of comparison is absurd. This is not to say that you don’t need to know how many visits per episode you are providing but this information must be reviewed with your payment and cost information.
Another area we obsess about is productivity. How many visits per day are nurses doing? In other words, are my nurses more or less productive than yours and how can I get them to do more visits? Like visits per episode, there are so many unique variables inside individual agencies that it is ridiculous to take a single number for comparison without putting it into the context of the agency. How are the nurses paid? Are they salary, per hour or per visit? How many miles are logged in each week for the nurses? Is most of the driving done on an interstate or on back roads and in some cases cold, icy mountain roads?
Costs per visit can be calculated so many ways that unless you have a heart to heart with your accountant, you may never know what your true cost per visit is. Furthermore, is it appropriate to use your actual Medicare cost per visit when considering outliers or fee for service private pay home health? A good Medicare accountant is one who can not only help you make these decisions but who can explain in plain English what your numbers mean so that you can make information driven decisions.
I love numbers. But numbers are like power tools. As useful as they are, they can be equally as dangerous in the wrong hands.
But if you’re just in the mood for something interesting, try this. The word, ‘almost’ is the longest word in the English language in which all the letters are in alphabetical order.
If you have any questions about what your numbers mean or if you know any other completely useless but interesting facts, please post below or email them to us.
How to Minimize Income
January 18, 2010
I have never been inside an agency that has too much cash on hand but if you happen to be one who would like to earn a little less money, I can help. Follow the steps outlined below to minimize your income and prevent the problem of not knowing what to do with all your extra money.
- Do not invest in ICD-9 or OASIS training for your staff. They can read the internet just like everyone else.
- Make sure that every patient in your agency is scheduled to be seen by a nurse once a week for nine weeks. It doesn’t matter how many or how few visits are needed to provide good care. What’s important is that it is easy to follow a 1w9 pattern.
- Do not waste your time putting in processes to manage therapy. You only stand to make money if therapy is tightly managed and missed visits are made up as quickly as possible.
- Make frequent use of the hospital. Not only will you lose money by providing extra care to patients discharged from the hospital but your patients might just be safer there if you are planning on implementing any of these measures.
- Do not provide any management training for your nurses. Simply expect that because they are ideal clinicians that they will know how to manage a business and staff.
- Finally, hire your staff indiscriminately. Anyone with an R and an N behind their name can do OASIS. If you are bound and determined to keep extra cash to a minimum, treat the nurses as though they are disposable and easily replaceable. Certainly that is the case if you are not looking for loyal, qualified employees.
Anyone who tries any of these strategies, please post a comment so we can evaluate their effectiveness.
A Simpler Approach to Quality Assurance
January 14, 2010
Too many times when I speak about quality assurance, nurses can’t help but roll their eyes and sigh. To many nurses, the complicated procedures and less than timely findings of quality assurance activities are practically irrelevant to their patient care. When QA activities are relevant, they are often presented in a format that is not understood easily by clinicians who do not live in the world of Quality Assurance. And to be honest, I am not impressed with the typical quality assurance program in most agencies.
To be sure, we are great at finding deficiencies in our clinical records. We collect data for days. If every home health agency in the country pooled their data collection we could fill the National Library of Congress if the data were stored on flash drives. But usually what we do about the data falls into one of two categories. Daily we give the nurses ‘correction’ slips or some similar document so they can ‘fix’ the chart in question or we report aggregate findings at a quarterly meeting along with a complicated diagram and p values and n values and tell everyone we expect improvement by the next quarterly meeting. The meeting attendees who manage to maintain consciousness throughout the entire meeting have no idea how to go about adjusting the variables that factor into the equation without a statistics class.
It can and should be easier. Here is how QA works on Planet Julianne.
- Do a few clinical record reviews. Write down your findings.
- Discuss your findings with agency leadership and the staff and determine which three trends are affecting your care. There may 20 pertinent findings. But you are not that good. Focus on the big three. Otherwise you will be busy for the rest of your career without ever accomplishing true change.
- Bring the field staff into the QA meeting.
- Pay very close attention to this step. ASK THE FIELD STAFF HOW THE QA TEAM CAN HELP THEM IMPROVE PERFORMANCE
- This next step is even more important. LISTEN TO YOUR NURSES.
- Design a simple plan. Simple as in, Problem, Plan of Action, Follow up. Leave fishbone diagrams and flow sheets to the artistically inclined. They have never hurt a QA process but other than looking good on survey, they don’t necessarily help.
- Monitor progress – in the simplest manner possible. QA is not about data collection although you certainly can’t have QA without valid data. But if your focus is missed visits, look for missed visits. If you found no problems with timeliness of MD signatures, wait until the next quarter to look at them again. Focus, focus, focus.
- Review findings with DON monthly.
- At the quarter report on improvement.
- This is another very important step. In fact, pay close attention because this is likely the most important step. IF THERE IS NO IMPROVEMENT, REALIZE THAT YOUR PLAN FAILED. YOUR NURSES DID NOT FAIL. YOU DID NOT FAIL. THE PLAN FAILED. Once you start blaming people you will lose focus and never achieve another positive result in your QA activities for the rest of your life.
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Be willing to go back to the drawing board and try again. Being willing and able to recognize a failed plan is a huge success for anyone involved in QA activities.
Consultants like me like to go to an agency and tell everyone what worked in other agencies. Big deal. What works for your company is dependent on your staff, their talents, your problems, etc. Just as we design care plans to meet the individual needs of the patient, we should design QA activities to meet the unique needs of agencies.
So that’s my take on QA. Keep it simple. Make it work for your agency. Transform your QA staff from ‘chart police’ nobody likes into resources for the rest of the nurses. Have some fun with it.
I guarantee you success.
Case Conferencing
January 12, 2010
When it comes to good patient care there is no substitute for case conferencing. In my years of experience, I have seen agencies who chose not to conduct a structured case conference, agencies who held a meeting where patients were discussed just long enough to meet minimum standards and I have seen agencies that make the absolute most out of a weekly or bi-monthly case conference. Guess which agencies do better overall?
With OASIS-C now a reality, there are even more reasons to conduct a thorough case conference that includes process measures. In doing so, discharge reviews will be much easier to perform.
These are some of the processes I’ve seen at various agencies over the years that make case conferencing more effective. Pick and choose those ones that you like and send us any other ideas we might not have heard.
- Prepare a list of patients up for recert in advance so that charts can be reviewed by the RN who will do the recertification visit.
- Invite all disciplines involved in care. I have seen some agencies where aides are not included. This is a critical mistake.
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Ensure that all the questions you want answered in case conference are addressed. You may want to make a short form or post the questions in the agency. That way the nurse who is reviewing the clinical record prior to case conference is aware of the information that she will be asked. Consider the following questions:
- Has the patient seen the doctor this episode and if so, why?
- Was any lab drawn? What are the abnormal results?
- Were there any medication changes?
- Was the patient taught on all medications?
- Did the patient go to the hospital at all? Why?
- Does the patient have heart failure? If so, what are the weight ranges?
- Does the patient have diabetes? What are the blood sugar ranges?
- Did any falls, injuries or other adverse events occur during the episode?
- Did the patient have a wound? Describe at beginning and end of episode. State wound care and any changes that occurred in the last episode.
- How was the patient’s pain managed? Were any interventions implemented with or without success?
- If a staff member is not able to attend, try to include them on the telephone.
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Get signatures of all attendees.
Or you could just pull the staff in from the field, feed them donuts and do the bare minimum to demonstrate compliance to the care coordination condition of participation. Either way, it costs whenever you bring field staff in for mandatory meetings. Why not get the most for your dollar?
Field Report
January 10, 2010
For those of you who missed me last week, I was out of town at a client’s office that was undergoing a recertification survey. In the grand scheme of things, the survey was terrific with no real issues until the last day of survey. At that point, true to form, an issue with wound care was discovered.
This wasn’t an accidental discovery. The surveyors came armed with knowledge that my client’s OBQM reports were slightly higher than average in wound deterioration and falls. No issues were identified regarding falls but wound care was an issue.
In this case, the wound care was done correctly. There was a confusing frequency issue when wound care orders changed but the frequency did not. I doubt that would have ranked even a mention in survey. But the way this survey was conducted was much more in depth than previous surveys. The entire chart was reviewed to determine what my client could have done differently. And it is worth sharing with you because it happens all the time.
The patient was scheduled to go to the hospital for major surgery. Upon checking into the hospital, the surgery was cancelled and the patient was sent home on Lovenox. Neither the patient nor the physician thought to call the home health care agency. The agency did try to call the hospital but the hospital said that no patient had been admitted by that name. So the agency waited assuming the patient was in another hospital. Several days later the agency somehow re-established contact with the patient and began treating the patient.
The question that the surveyors had was valid. Why didn’t my client know that the patient was out of the hospital? It is true that nobody called the agency. And maybe you could argue that my client fulfilled their responsibilities by calling the hospital. But the question the surveyors had was simply, ‘Could the agency have done more?’ And the answer is ridiculously simple. Yes.
And in the future they will. But take note. This survey didn’t nitpick over confusion in frequencies. They didn’t cite the agency for not following wound care orders to the T. Throughout the survey questions were asked about other patients and the answers were sometimes lacking. But these were not issues that were trends or led to an adverse outcome. What the surveyors took issue with was the fact that patient who received care suffered an adverse event that might could have been avoided. And that’s what counts.
I would have preferred a flawless survey but this survey was honest and the changes that my client will make in order to correct the conditional level deficiency will go a long way to preventing hospitalizations in the future. And if that’s the direction surveys will be taking, it is fine with me.
Meanwhile, the agency did very well other than the confusion regarding this patient. Heed the warning. Every agency has one train wrecked chart. It is no longer a strategy to hope that it won’t be discovered by random chart selection. These surveyors knew where to look before they hit the door.
And congrats to my client who had an overall very good survey.
