Session Objectives. Healthcare Quality is A Team Goal 12/1/2014. Quality and Compliance: A Strategic Approach to Improve Outcomes

Transcription

1 Upper West Coast Regional Conference December 5, 2014 Quality and Compliance: A Strategic Approach to Improve Outcomes Lynda Hilliard, MBA, RN, CHC, CCEP Hilliard Compliance Consulting LLC Session Objectives 1. Describe key concepts of compliance effectiveness and quality of care 2. Understand the link between quality and compliance effectiveness 3. List at three strategies for leveraging quality and compliance to improve operational outcomes Healthcare Quality is A Team Goal 1

2 Definitions What is Quality? The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Institute of Medicine, TO ERR IS HUMAN: Building a Safer Health System (2000) What is Compliance? Laws Rules Regulations What is Compliance? Compliance is the act of conforming with stated requirements. Organizationally, it is achieved through: Management processes which identify the applicable requirements (defined by laws, regulations, contracts, strategies and policies), Assessment of the state of compliance risks and potential costs of non-compliance against the projected expenses to achieve compliance resulting in the prioritization, funding and initiation of corrective actions that are deemed necessary. 2

3 How Do We Define Compliance Effectiveness? Producing a decided, decisive, or desired effect... capable of producing a result. The extent to which the outcomes of an activity achieve its stated objectives. Outcomes the impact that compliance efforts have on an organization s level of compliance Intersection of Quality and Compliance Quality Management Professional Standards of Practice C O M P L I A N C E Audit and Monitoring Credentialing/Screening OIG Focus on Quality of Care Increasing Oversight Quality of Care CIAs Key Focus Area 28 Quality of Care CIAs (as of 1/4/2011) Additional Internal Requirements Quality of Care Review Program Board of Directors Dashboard - Communication Competency based training requirements 3

4 OIG Focus on Quality of Care Increasing Oversight The government and private payers are placing an increased emphasis on medical necessity and quality of care. The lines between coverage determinations and the government s expectation of clinical practice seem blurred. Current investigations appear to be focused on physicians medical judgment rather than the types of documentation and coding cases we have seen in the past. OIG Focus on Quality of Care Increasing Oversight Increasing trend to hold hospitals accountable for the physicians decisions within the four walls of the hospital. Due to the changing environment, it is becoming critical for compliance officers to work cooperatively with clinical and quality departments to evaluate the processes and limit exposure from not only an outcomes perspective but also a compliance perspective. Considerations Government reimbursement is moving towards a quality-based system. Non-compliance with core CoPs (quality of care), may not be reimbursed, or generates an external audit. Boards have a duty to recognize the emerging legal and compliance issues associated with quality of care initiatives and to direct executive leadership to address those issues. 4

5 Potential Gaps to Consider For traditional Medicare, there is no prior approval or authorization process. Non-emergent procedures are typically arranged between the scheduler at the physician s office and the hospital scheduling department. Records supporting medical necessity are not maintained at the facility. Potential Gaps to Consider Can present substantial headaches for the facility in the future due to accessibility and completeness of the records. May be little or no interaction between the patient and the hospital s clinical staff prior to the time of the procedure. Hospital assumes the physicians are doing the right thing and would never perform an unnecessary procedure. If a serious gap exists, work to get it filled Find a champion 5

6 Don t do other people s jobs Communicate and Collaborate Compliance is typically a staff function and independently monitors. Don t get involved in Turf Issues Collaborating for Success Systems Shared reports, trends and process improvement activities Committee membership Use Quality Tools To Improve Compliance Processes Process flow the procedural steps Use root cause analysis Delete unnecessary and expensive red tape in problem solving 6

7 Conclusions Quality of care is a primary compliance concern. The compliance officer must monitor, but cannot control the process. Reach out for help. Find a clinical champion. Use quality tools to improve compliance processes Questions Contact Information: Lynda Hilliard lyndahilliard@hotmail.com