Farewell, Mr. Lewis
June 11, 2010
I have had the pleasure of knowing Jeff Lewis since our college days. This is what I remember about him from college. I had an Ovation guitar and Jeff had an Oscilloscope. Why? Who knows? It wasn’t for any job related purpose nor did he have any classes that required students to own an oscilloscope. I think he just wanted one. For those of you who are somewhat normal, an oscilloscope is a device for converting sounds into a graphic depiction of their waves. Like a lie detector for music.
And since my guitar had an unusual shape, he wanted to see if the sound waves produced from the guitar varied from other sound waves from other guitars. Yes, he did. The very idea of having a new way to use his oscilloscope excited him the way free beer excited the rest of us. We were in college after all.
He was still in college when the first version of Lewis Prompt was developed because an agency casually mentioned there wasn’t a lot of software for home health. So, he produced a ‘little program’ and that was his first client. I am not sure what he charged but the project was completed more out of a curiosity to see if he could do it rather than financial motivations. He was, after all, an engineering student.
Twenty five years later, you will still find Jeff trying to do things just to see what happens. A year or so ago, I shared with him that nurses in this football town complained that it was impossible to get a physician’s attention during an LSU football game. Ever curious, Jeff took OASIS data from all his Louisiana clients and found it to be true. We have much lower hospitalization rates when games are played away rather than in town. I wonder if CMS ever studied the effects of sporting events on hospitalization rates.
I’ve had the opportunity of working with him on other projects as well. He took his NAHC speeches very seriously often developing new data from his vast databases to present his ideas. In the world of internet and power point, it is getting increasingly rare to find someone who offers new insight into common everyday problems. Many times, I have used information he has farmed from his vast database to shape my practice.
So last week, Jeff did something extreme even by his standards. He sold Lewis Computer Services. I had the chance to talk to some of his staff about unrelated matters right after the sale was announced and they are pretty excited. They will miss Jeff but like me, I can’t quite believe he has a made a final exit.
Or has he? One thing I know about Jeff is that he follows his heart regardless of where the rest of the herd is going. But I suspect there will be Jeff sightings in the future. I am just not sure where they will be.
Please join me in thanking Mr. Lewis for all of his original contributions to our industry and wish him happy trails in the future. And for all you Lewis computer users out there, keep me up to speed on the new company! I hear they have a lot to offer. I’m just not sure what as yet.
Raising the Bar
June 9, 2010
Albert Einstein defined insanity as doing the same thing and expecting different results. I think he was talking about us.
If I were to ask all the Directors of Nursing at all of my clients what their five biggest clinical concerns were, I would be told the following:
- Timeliness of work
- ICD-9 Coding
- OASIS Coding
- Missed Visits
- Incomplete documentation
What it all comes to is that nurses in the field are not placing the quality and timeliness of their paperwork at the top of their priority list. And what do we do when paperwork of poor quality is submitted late to the office? We educate. We counsel. We discipline. We pull our hair out.
Has it worked?
I didn’t think so.
So, I challenge all the administrators, QA nurses and Directors of Nursing out there to answer me a few questions.
- How visit notes were late as of eight this morning when you got to your desk?
- How many visits have been missed so far this week?
- Which of your nurses never turns in work late and how has he or she been recognized?
- Are all of your referrals being admitted on time?
Most people can answer most of these questions with a fair amount of certainty. That isn’t good enough.
You will not raise the bar of clinical performance in the field if the corporate management culture does not change the focus of the agency. In order to ensure that processes to ensure timely submission of paperwork are in place, management needs daily, timely and relevant information.
Consider the following two scenarios. In the first, a QA nurse does a quarterly review and notes that only 92 percent of care plans are signed timely. Upon further review, the QA team tracks the late orders to 485′s that are not sent to physicians timely because of late paperwork from field staff. The DON ‘educates’ the nurses and writes a stern memo. 3 months later, quarterly review of clinical records reveals no significant improvement.
In the second scenario, the DON is apprised weekly of late paperwork. Nurses who are habitually late with a significant portion of their paperwork are identified. A staff member is assigned to call them daily for paperwork. In addition, nurses who are seldom late are identified. The DON reduces the number of visits for the nurse who cannot seem to keep up with paperwork and gives the nurse who is always timely some sort of recognition. No DON should be without ‘Thank You’ cards in their desk and an occasional gift card can be really motivating as well.
Eventually, tough decisions may have to be made. But, it is easier to identify which decision needs to be made when you have an abundance of timely information.
My friend Jeanine says that people do what you inspect – not what you expect. She may be on to something. In any event, when senior management, billing offices, team leaders, etc. put timeliness of visit notes at the top of their priority list, field staff will invariably follow suit.
Your thoughts and comments are always welcome below.
Patient Protection and Affordable Care Act
June 8, 2010
What does the Patient Protection and Affordable Care Act mean to us? There is much left to be determined but so far, the health care lawyers in the South Louisana together with accounts have come up with some of the basics. Emily Grey Black of Breazeale, Sachse & Wilson, LLP has generously offered to share the handouts from last week’s conference on Health Care Reform with my readers. Since I am wholly unable to answer questions, you may direct questions to Emily or leave a comment below.
Having attended the conference, I was a little surprised at how much the physician changes may very well affect ancillary operations such as home health and hospice so be sure to pay attention to the physician disclosure requirements and changes and refinements to Stark and Anti Kickback laws.
Click here to read the handouts.
Checklist Manifesto for Nurses
June 4, 2010
Checklist Manifesto
I took the time out to read the highly rated book, Checklist Manifesto by Atul Gawande. No murder, no mystery, just the chronicle of how a pre-surgical checklist was developed and the research that went into it. And yet, I loved it.
Now, nurses are the kings and queens of checklists. Everything we do, practically, can be described as a checklist. Visit notes with prompts for complete head to toe assessments, OASIS assessments, and transfer/discharge documents are all checklists for the most part. We have no shortage of checklists. And it takes a lot for me to suggest one more piece of paper for nurses to include in their daily lives. But that is exactly what I am suggesting.
The Checklist Manifesto explores how a pre-surgical checklist was developed and implemented in multiple countries across the globe. The results were universal. Surgical outcomes improved. Much attention is given to pre-flight checklists for pilots with the result of decreasing plane crashes. Gawande’s supposition is that the more complex our daily tasks become, the harder it is for us to remember all the steps necessary.
The difference as I see it between pre-flight checklists and pre-surgical checklists is that surgeons and pilots pause before cutting or flying and ensure that the necessary steps have been taken to improve the chances of a good outcome. Additionally, because the checklist usually includes multiple parties working together, coordination of efforts is greatly enhanced.
As nurses, we pull out our checklists once we arrive at a patient’s home for a visit. It is when we are isolated without peers that we realize we forgot a teaching guide. Or we have driven 20 miles in bad weather only to find out that the patient was at the MD office. Where is our Pre-Visit checklist?
I have to wonder if a short checklist for home health and hospice nurses might actually improve our outcomes and reduce our utilization. In the coming years, health care reform is going to demand that we use our time with the patient as efficiently as possible.
Of course, each nurse and each agency has its variables. I don’t know if it would be possible to develop a universal checklist for all hospice and home health nurses. But, within your agency, I bet it is worth a try to come up with a short pre-visit checklist. A good start might be:
-
Patient called prior to visit to confirm.
- New drugs in home?
- Any concerns that need to be addressed before visit?
- If not able to confirm, why?
- If another nurse made the visit prior to this visit, has report been given?
- Has the current 485 and all orders been reviewed prior to visit?
- Are all teaching materials printed and available for patient?
- Is there any lab or supervisory visits due?
None of the above items are missed with great frequency by most nurses. However, when reviewing clinical records, it is precisely one of these missed steps that can cause errors, duplicate teaching, missed supervisory visits, etc. In fact, it is precisely BECAUSE these errors are infrequent on an individual basis that they occur.
Nine times out of ten when I discover a trend in clinical records, education is suggested as the remedy. Like surgical teams that do not need to be taught to verify patient identity, some nursing mistakes are not the result of lack of education. Rather the complexity of our tasks is daunting and occasional oversights result in lost revenue, poor care coordination and diminished outcomes.
If you have a quiet weekend ahead of you, please read the Checklist Manifesto by Atul Gawande and let me know what you think. Or if you have already read it, please share your thoughts below in the comments section or email me.
The Psychology of Health Care Spending
June 2, 2010
I had the privilege of listening to the best and brightest Lawyers and other healthcare experts in Louisiana talk today about Healthcare Reform and what it might mean to our industry. Alas, there are still many unknowns. While the law specifically requires certain things of providers, it offers very little guidance on how to meet those requirements. It will be a long wait, I suspect, until further guidance is available.
One of the guest speakers was Congressman Bill Cassidy from Louisiana. He spoke of the ‘psychology of health care spending’. As I understood him, he supposes that when patients are made aware of how their healthcare dollars are being spent and are encouraged to participate in their care, we will see greater efficiency in the delivery of healthcare. Of course, as a politician, he was much more skilled in delivering his message than I am at delivering it for him.
But it made me think. First of all, in home health, do you really think that if patients were aware that an average home health aide visit to assist with a bath was costing about $60.00, would patients really ‘need’ them? Are patients aware that the average cost of a skilled nursing visit is just over $100.00 and therapy visits are closer to $150.00? In hospice, payment is made for every day that a patient is on service regardless of whether or not any services are rendered on that day. Do patients know that we are being paid even on days when we aren’t scheduled to visit?
Heaven forbid we should burden a patient with financial information when we don’t even burden ourselves with it half the time.
Do we, as nurses, ever think about what our services are costing our payor sources? Frankly, I think we are worth every penny – most of the time. What about those visits we do when we just casually stop by and teach on the first medicine we see? When we spend ten minutes in a patient’s home to give an insulin injection for a BID patient, are we really providing a service worth $100.00?
One way to calculate our worth is to determine how many hospitalizations we have prevented. And yet, even today, I run across nurses who do not know what their agency hospitalization rate is. When I show them their hospitalization rate, they explain that their patients are old and have chronic diseases and are largely illiterate and poor. Hellooo? Who doesn’t have a patient mix that looks like that? None of my clients.
For now, though, as we wait for the inevitable changes to come, we should be focusing on providing value to our payor sources. That means giving our patients care that results in better outcomes and taking the time required to prepare for visits, follow an organized plan of care and keeping our patient at home. That is what home health and hospice nurses do. We care for sick people in their homes.
