The carrot and the stick: How to make sure your documentation's correct
The carrot and the stick: How to make sure your documentation's correct
Supervisors must become compliance officers for their departments
Compliance. It's the latest buzzword in health care, having already spawned a whole new generation of consultants, legal specialists, and "compliance officers" charged with policing your hospital from the inside. But among all the talk of multimillion-dollar settlements, anti-kickback statutes, Stark laws, and other legal mumbo jumbo, the point that often gets lost is what any of this has to do with you.
The fact is, experts say, compliance issues affect every department of every hospital in the country, and no one's immune - least of all case managers with discharge planning responsibilities. In fact, in its model compliance "guidance" for hospitals, released in February, the Office of the Inspector General (the enforcement arm of the federal Department of Health and Human Services) singled out discharge planning as a "risk area." (See related story on federal regulations, p. 171.)
Case managers are on the front lines of the compliance wars, right along with the billing department and medical staff. How you do your job can have a direct impact on your hospital's accreditation, Medicare participation, and legal standing.
In one recent example, a hospital in Florida found itself in hot water when discharge planners there transferred a patient to a nursing home without properly filling out the necessary paperwork. A simple omission - failing to note on a form that the patient had a history of psychiatric problems - ultimately caused the hospital to lose its Medicare provider status.
Because no one documented the patient's mental problems on the state-required form, "they couldn't then go back and say, 'We didn't know the guy had a psych history,'" says Sharon Baschon, RN, utilization resource management consultant with the Baschon Group in Durham, NC. "They may or may not have known, but there was no documentation to protect them."
After the incident occurred, the hospital brought Baschon in to help develop a solution to its documentation woes. The solution, she discovered, wasn't just a matter of developing a new transfer form or educating case management staff on how to fill out forms properly and having supervisors double-check accuracy before error-filled forms went out the door.
"Part of the action plan [we developed] was that every single transfer form that went out of the hospital would be checked by a supervisor," she says. "I was there a week and a half, and I can't tell you how many came back incorrect. It felt like we were banging our heads against the wall."
Part of the problem with poor documentation, she says, is that case managers sometimes assume discharge planning duties without much training in their new responsibilities. "They often end up taking over a discharge and may not be as up on all the rules and regs as they should be. For the case manager coming into it, there are a lot of opportunities to overlook the requirements if they haven't been adequately educated."
But just as important as proper training is effective supervision, Baschon adds. "We really don't do a good job of holding people's feet to the fire and making them accountable," she says. "If I tell you, 'Your job is to fill this form out correctly,' then my job as boss is to check charts on a periodic basis so there aren't any surprises."
Indeed, Baschon claims that supervisors often spend too much time "making everything positive. We assume everybody will do the right thing if we just tell them about it. But what do you do when people don't do the right thing? That's why we have compliance officers now - because nobody's been held accountable."
Experts say that when it comes to case management, it's really up to supervisors themselves to become department-level compliance officers. "I've seen a lot of situations where you have an outside attorney like me coming in, or the hospital hires a new compliance officer who doesn't have any experience with case management," says Vicki Myckowiak, JD, an attorney with Steinberg, O'Connor, & Burns in Detroit, specializing in health care compliance issues. "The next thing you know, they're telling case managers they have to do something that makes absolutely no sense for them. So to the extent that case managers can take a more proactive role, I think that would be a great thing for them to do."
In fact, case managers are a natural choice when it comes to compliance, considering that an effective compliance program isn't all that different from an effective quality improvement process, Myckowiak says. "For example, if you're looking at billing compliance, you find out what the billing standards are, then you take a look at what you have by auditing it and seeing if you comply. If you find that you don't comply, then you take some corrective action to bring things into compliance. Afterward, you set up a monitoring system to make sure you remain in compliance. That's all a compliance program really is; it's just applied to different sorts of areas than traditional QI [quality improvement]."
The best way to keep your department compliant is to make sure your documentation is complete and accurate, says F. Lisa Murtha, JD, senior manager and director of the control and compliance program at Deloitte & Touche LLP in Philadelphia. "What it all comes down to," Murtha says, "is that you're only as compliant as your documentation proves you to be. I can't tell you how many hospitals I've been to over the past year that have terrific internal policies and procedures. But the problem is that they're not documented anywhere."
When things aren't documented, staff must rely on word of mouth to get the message. The problem with word of mouth, as any gossip knows, is that stories tend to change when they're retold. "It's like that game, 'whisper down the lane,'" she says. "Often, by the time the information gets in the hands of the person who really needs it, it's been contorted in so many different ways that it doesn't really resemble the truth anymore."
When it comes to discharge planning, appropriate documentation is especially important at several key points, Murtha adds. For example, make sure your paperwork clearly reflects the physician's recommendation for discharge and the recommended time frame. Also, make sure that the appropriate people physically sign off on the patient's medical record and discharge notes. It's also important to document that staff have talked with patients and their family members about what's going to happen to them after discharge and why. Pay special attention to documenting that you gave patients a choice of which home health agency, nursing home, or skilled nursing facility they want to be discharged to, Murtha stresses.
When it comes to patient choice, some hospitals offer patients a prepared list of local providers. The list has a carbon behind it and a place for patients to sign that they've reviewed and understood their options. "If you're sitting down with the patient and family anyway, it's a step that takes all of two seconds, and it's just so worth it," she says.
Whatever system of documentation you implement, however, make sure someone is accountable for checking that it's correct. "I guarantee you that when there's a bad outcome [after discharge], you can go back and find that the form will be filled out incorrectly," Baschon says.
For more information, contact:
Sharon Baschon, RN, utilization resource management consultant, The Baschon Group, 1821 Hillandale Road, Suite 1-B-107, Durham, NC 27705. Telephone: (919) 383-1108.
F. Lisa Murtha, JD, senior manager and director, control and compliance practice, Deloitte & Touche LLP, 1700 Market St., Philadelphia, PA 19103-3984. Telephone: (215) 977-7535.
Vicki Myckowiak, JD, law firm of Steinberg, O'Connor, & Burns, 1724 Ford Building, Detroit, MI 48226-3901. Telephone: (313) 963-1002.
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