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Raising the Bar


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.

  1. How visit notes were late as of eight this morning when you got to your desk?
  2. How many visits have been missed so far this week?
  3. Which of your nurses never turns in work late and how has he or she been recognized?
  4. 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.


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