Mark It As Done: Closing the Loop on the Auditing Process

Mark It As Done: Closing the

Loop on the Auditing Process

Jenifer Carey, CPC-H, CPC-I

Manager of Professional Education and Compliance

Kim Schaefer-Garvey, MBA, CHRC

Director of Compliance

Key Objectives

• Stop the boomerang effect…solutions for keeping the

same professional audit findings from knocking at

your door

• Closing the loop– solutions for implementing

corrective action plans

• Successful strategies for fostering collaboration

between compliance, physician leadership, and

operations

Deciding What to Audit

• Working with a new EHR

• OIG Regulations

• Denials

• Previous concerns

• New initiatives

• New provider training

• High dollar services

What’s Been the Problem?

• We keep auditing

• We keep educating

• We think we have agreement with leadership on how

to fix it (“the plan”)

• So why do these problems keep resurfacing?

• New Service

• New Provider

• New Charges

• New Practice

• New Service Line

• Transitioning a

New Practice

Didn’t See That Coming…

• Going live on an EHR • How did IT come up with

that? • Marked as reviewed • Chief complaint/HPI • Consults-The Three R’s • Templates • Shared visits • Copy and paste • Scribes • Meaningful Use • “Encounter” vs. “Progress

Note” • Dictation of all types

Guidelines Revisited….

Did someone change them without me knowing?

• The Twinkie Wrapper Effect: Observation • Fracture Care • Infusions and Injections • Documentation, documentation, documentation… • Modifiers • Regulations, Regulations, Regulations…. • ED service and procedures • Patient/Family Conferences • Teaching Guidelines • Place of Service • Level of Service

Groundhog Day!

Are Any of These Your Present

“REALITY”-Can You Relate?

• Myth– Operations knows how to implement change • Provider/Leadership buy-in

• Provider/Operations stress related to patient volumes and revenue • Everyone took every problem personally– the finger pointing game • Provider/Operations fallback– Compliance is making me do this!

So What’s Next?

• Create a credible and continuous

auditing/implementation/monitoring process that

would:

– Engage all participants

– Build sound relationships

– Depersonalize

– Influence

– Create buy-in

– Done on a shoestring budget

– Create sustainability

Here’s the Solution in Six Easy Steps

Utilize tools from High Reliability, Influencer, and Leading

Change to develop a credible and continuous

auditing/implementation/monitoring process that fosters

collaboration, communication and sustainable change.

1.Identify the topic/need

2.Get the right people around the table

3.Stick to the facts

4.Remove obstacles

5.Implement– create excitement

6.Monitor and feedback

Step One: Identify the Topic/Need

• Gather any/all information to validate the topic/need

• Quantify the impact

• Draft an SBAR (High Reliability tool)

– Situation – brief description of the situation

– Background – pertinent background-what got us to this

point

– Assessment– summarize the facts-what do you think is

really happening

– Recommendation– what are you asking for- what needs to

happen next

Step Two: Getting the Right

People Around the Table

• Determine your go–to group for buy-in

(i.e., physician, operations, leadership)

• Ask your go–to group who they want involved

• Fill in the gaps:

– Influencers

– Process owners

Step Three: Stick to the Facts

• Deliver the SBAR

• Elevator Speech – what are the key messages

• Keep it on the list – Running agenda with minutes

• Communicate, communicate, communicate

• KISS method

Step Four: Remove Obstacles

• Prepare for implementation

• Determine the desired outcome

• Audit performance if needed

• Determine elements that help or hinder the desired

outcome

• Create a Force Field Analysis (taken from the

Leading Change Toolkit)

• Perform pilot(s)

Step Five:

Implement-Create Excitement

• Develop/roll out education and handouts/scripting

• Develop a timeline for phase(s) of implementation

• Perform periodic check-ins with stakeholder group

• Round on new process(es) and gather real time feedback

• Determine what works and what doesn’t

• Fine tune process(es) as needed

• Finalize the SBAR to formally document the final

process(es)

Step Six:

Audit/Monitor and Feedback

• Determine the length of time after implementation to select an

appropriate sample to audit.

• Recommended 30-90 days trial period

• Determine the scope of the audit and sample size

• Audit and analyze the results

• Share results with key stakeholders to determine if additional

education/fixes are needed (update SBAR as needed)

• Once the final process has been approved, create an effective

monitoring tool

Dictation in the EHR – Sample SBAR

dictates a note rather than document the note in an EPIC template. If a provider dictates a note, they must leave the encounter open until the note is returned to their inbox and signed. The dictation, once signed, files back into the encounter and is the sole documentation for the visit for that day. At that point the provider can close the note.

• BACKGROUND: Currently, only full dictation has been allowed. Partial dictation has been promised to the providers and could be

available as early as April (actual date unknown). When partial dictation goes live, the risk for non- compliance will be huge. • ASSESSMENT: Nuance has a report that shows every time a provider dictates, the time whether it is signed etc. The time that a

provider dictates needs to be matched to the time that the provider closes and signs their note. The bill cannot be dropped until the documentation is complete and signed.

• RECOMMENDATION: Compliance is recommending a hard stop be created when dictation is used as opposed to the relying on the

providers to remember not to close the note until the dictation was signed. • Information presented on:

• In attendance:

• Next Steps:

• Who is responsible:

• Timeframe for completion:

• Who needs to receive the communication:

• Internal audit and monitoring plan:

– Indicate timeframe, frequency and scope

Dictation in the EHR

Walking Through the Six Steps

• 1. Identify the topic/need

– Post Go-Live audit findings

– Drafted the SBAR

• 2. Getting the right people around the table

– Presented to the Specialty Group Leadership (physician and

operations)

• 3. Stick to the facts

Dictation in the EHR

Walking Through the Six Steps

• 4. Remove obstacles

– Validated and tested the desired process outcome

• 5. Implement and create excitement

– EHR analysts created and rolled out provider education

• 6. Audit/monitor and feedback

– Compliance audited the initial Go-Live. Monitoring occurs during periodic audits.

– SBAR was updated and the process is followed for all future department Go-Lives.

Acquisition of an Existing

Practice – Remove Obstacles

Force Field Analysis

Preparing Providers for Transition

Helping Hindering Desired  Outcome Provider  Education Provider  audits  prior to transition Lack of  supporting  documentation   and missing  charges Increased  supporting  documentation  and compliance  with  billing  practices

Acquisition of an Existing Practice

Walking Through the Six Steps

– Organizational notification of acquiring a large volume freestanding practice

– Drafted the SBAR

• 2. Getting the right people around the table

– Brainstormed to create a list of all stakeholders that were necessary. This included, but was not limited to: Legal, Compliance, Risk, EHR, Billing, Registration, Operations, and Physician Leadership

Acquisition of an Existing Practice

Walking Through the Six Steps

– Delivered the SBAR

– Running weekly agenda and minutes– kept it on the list – Communicate, Communicate, Communicate • 4. Remove obstacles

– Determine elements that help or hinder the desired outcome (Force Field Analysis)

– Pre-audit performed on all providers – Validated and tested the desired process outcome – Ongoing preparation for implementation

– SBAR was updated and the process is followed for all future department Go-Lives.

Acquisition of an Existing Practice

Walking Through the Six Steps

– Developed and rolled out provider education – Developed timeline for phases(s) of implementation

– Performed weekly check-in meetings with the stakeholder group during the first month of Go-Live

– Round on new process(es) and gather real time feed back – Fine tune process(es) as needed

– Finalize the SBAR

Acquisition of an Existing Practice

Walking Through the Six Steps

– Compliance audited 100% of all providers during the first two weeks of the initial Go-Live

– Share results with the key stakeholders to determine if additional education/fixes are needed

– SBAR was updated and the process is followed for all future department Go-Lives

References

• High Reliability Training as taught by Healthcare

Performance Improvement, LLC (HPI)

• Influencer – The Power to Change Anything by

Patterson, Grenny, Maxfield, McMillan and Switzler

• Leading Change by John P. Kotter

Questions?

• Jenifer Carey, CPC-H, CPC-I – [email protected] – 860-837-5556

• Kim Schaefer-Garvey, MBA, CHRC – [email protected] – 860-837-5551