As we look forward to the holidays and the New Year, it is impossible not to wonder what exciting opportunities 2014 will bring.   It’s no secret that healthcare providers and vendors are being challenged like never before to develop products and implement  programs that ensure compliance amidst an ever-changing landscape of initiatives that not only impact a facility’s reputation, but its bottom line as well.

Although most organizations tackle them separately, the direct correlation between the quality of patient care and an organization’s fiscal performance cannot be underestimated or over-analyzed.  New policies, such as ICD-10, readmissions regulations, the Two-Midnight Rule, value-based purchasing, and RAC audits are changing the way organizations need to approach quality measure reporting.  To remain competitive, solvent, and a “provider of choice,” it is essential to develop both clinical and financial metrics, as well as detailed and meaningful data analytics that transparently describe performance.  Once obtained, these analytics can be used to drive critical performance improvement activities.

Traditionally, we see patterns of process ownership: health information management (HIM) “owns” ICD-10 initiatives, quality teams “own” all things related to core measures, compliance teams “own” RAC audits, and so on.  I challenge this structure.  Leadership, clinical teams, and committee members often duplicate efforts, and while each stakeholder may have an eye on a specific piece of the puzzle, having so many disparate parts compromises the integrity of the whole.  I propose a high level leadership team who can manage the entire process and secure appropriate buy-in and membership.

To use a non-healthcare example, consider the success of the “School House Rock!” hit “I’m Just a Bill,” that explains the process of how a bill becomes a law.  This legislative process, successful quality measure reporting relies on a well-orchestrated series of handoffs.  Uncoordinated efforts often produce unwieldy amounts of data that makes analysis nearly impossible.  As the data stewards for the organization, HIM professionals play a pivotal role, streamlining the collection, dissemination, and analysis of key quality metrics, which improves quality and accurate reimbursement.

For example, if a required clinical intervention, such as the timely administration of an antibiotic prior to surgery, isn’t documented, it can’t be coded.  If this action isn’t coded, it can’t be billed, and therefore can’t be used to satisfy the Surgical Care Improvement Project (SCIP) compliance measure.  Furthermore, if, unfortunately, the patient has an untoward outcome, Risk Management cannot defend that quality care was indeed delivered.

While that may seem an extreme example, it is one that likely occurs every day in at least one facility across the country.  Successful organizations, those that have shifted the traditional paradigms to an HIM-lead process, are reaping the benefits of coordinated efforts.  There are several strategies that can be used to drive successful quality measure programs, including:

  • Creating enterprise-wide teams to ensure the entire process leads to the accurate capture of information: This includes anyone who is involved with or has a stake in the clinical documentation processes and outcomes (physicians, coders, abstraction staff, billing staff, EHR implementation staff, billers, and vendors).
  • Maximizing data collection: Carefully collecting select data points, slicing and analyzing the information to track many different metrics helps centralize and streamline the process, improving the data’s integrity and maximizing program resources.
  • Employing concurrent abstraction, clinical documentation improvement and coding activities: This allows clinicians to manage care while the patient is still in the bed, which ensures delivery of the safest and most appropriate care, in combination with the correct documentation that supports the care rationale and reimbursement.
  • Performing proactive performance analysis: Being aware of and taking proactive measure to correct deficiencies, address problem areas or patterns within the organization helps with the delivery of high quality care.  Additionally, this helps to prepare organization for the public reporting of data, as well for reimbursement changes (e.g. observation status vs. 2 midnight rule).
  • Timely processing of data: Because quality measures and reimbursement are claims-based, the more frequently the data is processed and transmitted to the vendor, the more closely organizations can monitor the results.  This enables them to identify downward trends and take action through intervention procedures, nearly in real-time.
  • Including tomorrow’s requirements on today’s dashboards: Planning for the future is key, so forecast what additional information might be useful for your organization to track.  You can always adjust as new data is needed.

To hear more about the strategies organizations across the country are using to overcome regulatory challenges, and to learn how your organization can develop and implement a successful plan, attend the Health Care Compliance Association (HCCA) webinar, “The Relationship between Quality Measures on the Bottom Line and RAC Susceptibility,” on Friday, December 6 at 1:00 p.m. ET or stop by Nuance’s booth (#Hi-805) at the Institute for Healthcare Improvement’s (IHI) Annual National Forum on Quality Improvement in Health Care to learn more.




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Cathy Gorman-Klug

About Cathy Gorman-Klug

Cathy has over 30 years of experience in healthcare. She has extensive experience in project design, implementation, and management. In her current role as Product Manager, she is responsible for product strategy and product marketing for Nuance’s quality products. Previously, as a Corporate Director of Privacy and Data Security, she was responsible for compliance with requirements imposed by HIPAA, and other regulatory and accreditation standards for an integrated health system with over 7,000 employees. She holds a Master’s of Science in Nursing Administration from Seton Hall University.