Progress Notes Extra September 2010 Cosigning Verbal Orders One of the elements of performance identified by The Joint Commission (TJC) is that Verbal Orders are to be authenticated within 48 hours. Hospitals are being surveyed on this element, and we must ensure our performance meets their expectations. While the Medical Staff is encouraged to place orders through Epic; there are situations and circumstances where verbal orders are the only alternative for continued care of a patient. If verbal orders are placed; they must be authenticated within 48 hours as identified by TJC. There are many ways to navigate Epic screens in order to cosign verbal orders; what works best for you will depend on your workflow. The most three most common ways to access orders needing cosign are from: Patient List report IP Orders to Cosign Navigators from within the Patient s Chart In Basket Here is an example of signing verbal orders as you review the patient chart 1. From the Patient List or from ANY navigator within the patient s chart, select Cosign IP Orders from the navigator s Table of Contents 2. The IP Orders to Cosign activity opens with options to sign individual orders, sign a whole section of orders, sign ALL of your orders, or to defer incorrectly assigned orders: 1
If you have any questions about Epic, contact the Customer Support Desk at (937) 208-6000 and ask for the medical staff trainer. Corporate Compliance Tip Sheet (Medicare-Medicaid focused) Excluded Provider Status All providers Office of Inspector General (OIG) maintains list of companies & individuals who cannot be reimbursed from federal funds. Placement on this list is a result of a healthcare felony conviction, loss of license, or nonpayment of healthcare education loans. Medicare providers cannot employ, do business with, or accept orders from an excluded provider. Reinstatement is not automatic. Ohio Medicaid maintains a similar list. Check list for current employees and providers. Check prospective employees before hire. Educate providers & staff to notify office management if exclusion should occur. OIG - http://exclusions.oig.hhs.gov/ Ohio Medicaid-http://jfs.ohio.gov/ohp/providers/TerminatedProviders.stm Government Auditors All providers CMS has hired multiple contractors to audit for payment errors. These include, but are not limited to, Recovery Audit Contractors (RAC) and Medicaid Integrity Contractors (MIC). Ohio s MIC has not yet been announced. Respond to all contacts from contractors Ohio s RAC - http://racb.cgi.com/ Inpatient Only Procedures 2
Surgeon offices Medicare maintains list of surgical procedures that will be reimbursed ONLY when procedure is performed on an inpatient. No hospital reimbursement is received when the procedure is performed on an outpatient, including Observation patients. Review the list for procedures performed by your physician(s). When scheduling one of the procedures on this list, indicate that the patient must be an inpatient (not PPR, SDA, OBS, etc) CMS-1414-FC, addendum E or http://www.cms.gov/hospitaloutpatientpps/hord/itemdetail.asp?filtert ype=none&filterbydid=0&sortbydid=3&sortorder=descending&itemi D=CMS1230047&intNumPerPage=10 Medical necessity for outpatient tests/procedures All ordering providers Documents are provided at the local (LCD) or national (NCD) levels that spell out the diagnoses, signs, &/or symptoms that meet Medicare s definition of medical necessity for reimbursement. If medical necessity is not met by the diagnosis, sign, or symptom on the order, the patient may be billed for the test/procedure. Medical necessity rules may be different when the test/procedure is done in the hospital versus a physician office. Respond to hospital registration staff if contacted about an order. Assist your providers to understand the regulations. LCD s (hospitals)- http://www.ngsmedicare.com/medicalpolicycenter.aspx?catid=1 LCD s (physician offices) - http://www.cms.gov/mcd/results_index.asp?from2=results_index.asp&con tractor=17&from='lmrpstate'&retired=&name=palmetto%20gba%20(00 883,%20Carrier)&letter_range=4& NCD s for all - http://www.cms.gov/mcd/index_list.asp?list_type=ncd OIG Annual Work Plan All providers OIG publishes annual Work Plan (usually in October) to outline their audit focus for the upcoming year. There is a section specific to physician practices. Review for applicability to your practice. Use this to develop audit plan. http://oig.hhs.gov/publications/workplan.asp Ordering provider enrolled in Medicare All ordering providers Effective Jan 3, 2011, Part B services will be reimbursed only when the ordering provider is enrolled in Medicare. Confirm that all ordering providers are enrolled in Medicare. http://www.cms.gov/mlnmattersarticles/downloads/se1011.pdf 3
Signature Requirements All providers Medicare requires that all medical record entries, including outpatient orders, are authenticated by the author. Signature stamps are not permitted. Medicare will deny payment if stamp is noted during an audit. Handwritten or electronic signatures are permissible. Eliminate use of signature stamps on office records and outpatient orders. http://www.cms.gov/transmittals/downloads/r327pi.pdf *To access a web address identified above, copy and paste the address into your Internet web browser address line and click Go HELPFUL TIPS TO IMPROVE PATIENT SATISFACTION COMMUNICATION WITH DOCTORS Physicians are becoming more aware of the Communication with Physicians domain of the HCAPHS patient perception survey. Many of our physicians have asked how they can improve their scores. The following is a breakdown of each physician directed question about communication, and a discussion of the pain question, which is heavily physician driven. (HCAHPS is Hospital Consumer Assessment of Health Providers and Systems) During this hospital stay, how often did doctors treat you with courtesy and respect? Question Definition This item asks patients to assess the frequency with which he or she perceived the physician as courteous and respectful. Respect and courtesy are similar constructs, both tied to explicit behaviors. The degree to which a physician s interaction with a patient is courteous indicates respect toward the patient. Friendliness is judged according to the physician s verbal and nonverbal behavior. Patients tend to respond negatively to physicians who do not make eye contact, who do not respect their privacy, or who use a familiar name without permission. 4
Improvement Solutions Behaviors to reinforce include o Using patient and family members desired name and title (Mrs., Ms., Mr.) o Saying please when making requests and responding with thank you o Knocking before entering a room o Introducing yourself to the patient and family members o Explaining what you will do and why before doing it o Apologizing and saying excuse me if interrupting a conversation or activity o Using prominent ID badges with large type that include name and title o Getting down on the patient s level by sitting on a stool or chair o Making eye contact Numerous studies have identified specific behaviors that, when employed, consistently improve patient s satisfaction with the physicians and the overall health care experience. These behaviors include patient-centered communication (e.g., expressing interest in the patient as a person, allowing the patient time to tell his or her story, and information-giving tailored to the patient); thorough explanations; interpersonal skills; questioning psychosocial issues; emotional/empathic communication skills training; employing a warm, friendly and reassuring manner; talking about the patient s specific therapeutic interventions; reflective pausing; and active listening behaviors. Allow patients to express their concerns fully without interruption. Physician-patient communication research has found that physicians allow patients to speak for only 17-23 seconds on average before being interrupted. Maintain eye contact. Few gestures carry more weight than looking someone straight in the eye. Among other meanings, eye contact displays your willingness to listen and your acknowledgement of the other person s worth. Patients with poorer health status tend to rate the courtesy and respect of doctors lower than average. This may be because many physicians have difficulty communicating bad news or connecting with patients who have poor prognoses. Most physicians strive to be good communicators. With practice, physicians can become expert empathic communicators, especially in difficult situations. Geisinger Health System achieved tremendous success by sending sixteen physicians to the Bayer Institute for Health Care Communication to be trained to teach communication workshops. These physicians then went back to their facility to teach monthly workshops to their fellow physicians. 5
COMMUNICATION WITH DOCTORS During this hospital stay, how often did doctors listen carefully to you? Question Definition This question asks patients to estimate how frequently they felt physicians effectively listened. Listening carefully is evidenced through physicians behaviors: body language, expressions of concern, empathic communication, and other visible demonstrations of understanding. Patients respond positively to physicians who encourage the disclosure of feelings, elicit and respect concerns, and acknowledge patients fears. Patients respond negatively to physicians who ignore them or seem uncomfortable with patient s emotional expressions. Improvement Solutions Ask for patient s perspective on the illness, such as what they think caused the condition, its impact on their daily activities, what they struggle with, and what they are worried about. Patients perceive that physicians are paying attention and listening when they are at eye level. Sit down next to patients. Two minutes sitting at the bedside is perceived to be better than ten minutes standing in the doorway. Explicitly ask if there is anything else the patient wishes to discuss during your visit. Respond empathically to patients expressions of emotion. Physicians who are not recent graduates may pursue continuing medical education at the many medical schools that offer courses on communication, patient education, listening skills, empathy and emotional care. 6
COMMUNICATION WITH DOCTORS During this hospital stay, how often did doctors explain things in a way you could understand? Question Definition This question asks patients to recollect the frequency with which physicians provided understandable explanations. The patient will try to look back at each specific encounter with the physician and recall whether or not the physician effectively communicated the situation and resolved the patient s questions, reservations and uncertainties. The physician is usually the one who communicates the most emotionally significant and technically complex information to patients. In these encounters, different people have different informational needs and expectations. To some extent, these needs vary with age, socioeconomic status, and cultural background. Improvement Solutions In general, patients possess several specific expectations for information communicated by their physician. For example, high patient satisfaction is more likely when surgery patients receive the following: (1) patient-centered and patient-specific instruction before surgery and then before discharge, particularly with regard to the nature of timing of symptoms relief; (2) realistic appraisals of the potential impact of the operation on the individual s functioning and sense of well being; (3) a visit by the surgeon before and after the operation; and (4) appropriate professional contact, support, and follow-up after discharge (Jones, Burney & Christy, 2000). End patient encounters with Do you have any questions? Is there anything else I can do for you right now? Baptist Health Medical Center (North Little Rock, Arkansas) and other Press Ganey clients have substantially improved patient s perceptions of physicians using a variety of best practices, including the following: a. Physician Rounds: Coordination ensures that physicians round at the same time. This is facilitated by nursing units organized by patient category. Keeping all of the patients with similar illnesses in the same area reduces the amount of time physicians have to spend rounding and enhances ongoing relationships between unit staff and physicians. 7
b. Nurse Rounds with Physicians: Have nurses round with physicians this is an opportunity to build a positive relationship with the medical staff. Ensure that nursing unit managers are on the floor and visible when the physicians are rounding. At the end of every round, have the nurses ask physicians What did we do right today? and Where are opportunities for improvement? PAIN CONTROL During this hospital stay, how often was your pain well controlled? Question Definition This item asks the patient to recall the frequency with which their pain was reduced to tolerable levels. If patients recall one or two particularly stressful incidents of excruciating pain, they may not respond with always to this HCAHPS question. The issue of pain control is a complex one; each person experiences pain in his or her own unique way (e.g., different thresholds for what is manageable, different ways of handling pain). Expectations play a role as well. Patients or parents who expect little or no pain may be alarmed by the constant presence of muscle soreness or aches. Improvement Solutions Identify appropriate pain management as a patient right Educate patients on how to communicate pain and what to expect Include pain management follow-p on the patient s discharge instructions Tell patients that you are committed to doing everything in your power to alleviate their pain. Ask if there are any specific pain control strategies that they find helpful Provide comprehensive information on the various pharmacologic and nonpharmacologic pain control options available to patients. Introduce this information to patients and families as far upstream as possible. Consider introducing this information at preadmission or mailing to the home of elective surgery patients If you cannot accommodate requests for a specific pain control technique, explain why (e.g., safe dosing, timing guidelines) and offer viable alternatives Don t limit your service quality improvement vision to patients in their rooms. Patients can experience pain anywhere, at any time, including before elective surgeries, in pre-op, during tests and therapies, and on the way home. Fully evaluate the potential opportunities for creating pain free patient experiences at every point throughout the care continuum. Involve the Pain Service for patients whose pain is difficult to manage. The Pain Service can be reached via hospital pager at 334-3546 8
Brattleboro Memorial Hospital (Brattleboro, Vermont), a national leader in pain management services, achieved extraordinary results by instituting dozens of interventions over the past few years, including the following: o Pain Control Preferences: For elective surgery, patients are asked in preadmission for their pain management preferences and/or if they would like to be sent information in pain management. Preferences also are elicited after the procedure as they may change through the experience of hospitalization, surgery, and/or pain. Patient s preferences and beliefs are respected and met to the best of the hospital s ability. This includes providing the opportunity to numerous alternative/complementary therapies. o Preoperative Assessment: Elective surgery patients come in for a preoperative assessment appointment in their physician s office that includes a pain assessment. The patient is also given contact information for the anesthesiologist in case they have any questions or wishes to discuss anesthesia options before surgery. o Hospital-wide Pain Management/Assessment Training: Everyone in the hospital is capable of assessing patient s pain, soliciting a pain rating from patients, and providing either pain relief or a swift referral. (Adapted from Press Ganey Solutions Starters) NEW PAT HOURS New hours for PAT 8:30am to 6pm Monday through Thursday. Out patient lab new hours are 8:30am to 5pm Monday through Friday UPDATING H&Ps A H&P done before date of admission requires an update. Best Practice recommends updating the H&P electronically. This can be done by using the H&P Bridge Note in Epic. This makes it available to everyone immediately. GSH Oncology Staff and Physicians tops in clinical trials. Medical Oncologists Dr. Shamim Jilani, Dr. James Sabiers and Dr. Howard Gross were among the top physicians placing the most patients on oncology clinical trials through the Dayton Clinical Oncology Program. DCOP has fifteen hospital members throughout the region. GSH oncologists work closely with Katherine Peyton, RN, OCN and Eileen Flynn RN, BSN, OCN who were the number one nurse team in placing the most oncology patients on clinical trials. 9
HIT Team 19 Enhancements: HIT Team 19 reports two recent enhancements to the surgery scheduling process, including preparation of the patient for total joint procedures. First, an additional Total Joint Class has been added to reduce conflicts for patients and enhance surgical scheduling flexibility. An additional class has been added on Thursdays, resulting in classes now being offered on Tuesday, Wednesday, and Thursday. Classes are held at Good Samaritan Hospital as part of the P.A.T. process. Secondly, P.A.T. hours have been modified to ensure we are accommodating the needs of the patients. New hours are 8:30am until 6:00pm, Monday through Thursday. Friday hours remain 8:00am until 4:30pm. Patients have verbalized the later hours are preferred due to a variety of reasons, but often to perform P.A.T. testing after their work hours. Both of these changes have already been implemented with favorable comments from the patients. CODING CLARIFICATION When a coder needs additional documentation in order to accurately code an account, (s)he will send an In Basket message to the physician. A chart deficiency will also be created based upon the message. To access the message from In Basket: 1. Click on the Coding Clarification Request folder and then on the message. 2. The message will display in the pane at the bottom of your screen. Review the message. 10
3. Provide documentation in an addendum to a note or an addendum to a dictated report. Do not answer the message through In Basket, since this is not part of the legal record. 4. Click on Enc on the toolbar to open the chart to the appropriate visit. Click on the Notes tab to add a new note or to add an addendum to an existing note. 5. After you have provided the appropriate documentation, close chart. This will return you to the In Basket folder. Highlight the message in your Coding Clarification Request folder and click on Reply. A screen will appear addressing your response to the coder. Type a message, such as Done or Dictated, and click on Accept to send your response to the coder. The message will clear from the Coding Clarification folder and the deficiency will complete. 11