I recently had some remodeling done in my home by a contractor. After discussing what I wanted done and presenting me with an estimate the contractor started measuring the space in the area to be remodeled. He used his tape measure and graph paper to accurately sketch the space in order to see what materials would be needed and how much. I would certainly judge him a poor craftsman if he did not take this all-important step. If he just showed up with a lumber, nails, and other materials without measuring first, I would think that he is wasting a lot of time and effort because he would probably have too much of some materials and not enough of others. Poor planning equals poor execution.
This same type of planning applies to making changes at your healthcare site. You need to assess the present state in order to make effective and efficient changes in the practice environment and processes. You need to go and see, go and measure.
Before examining with several examples how the assessment phase of implementing changes at a care site is carried out, let us examine why change is needed. The most essential reasons for change are to improve the care outcomes for patients, improve the care experience and to improve the income and financial health of the care site while reducing the costs for service, according the Institute for Healthcare Improvement. Other reasons include changes in regulations, such as the switch from ICD-9 coding to ICD-10; the change in payment models, such as the change from fee for service to payment based upon quality of outcomes; and the avoidance of risk, or improvement in risk management.
As a first example, let us examine the process of having a patient get lab work done, such as blood work for a physical, getting the results and reporting the results to the patient. This process is very important. Failure to report lab results with significant findings in a timely fashion to patients can result in poor health outcomes and can lead to higher risk for a practice, including a higher rate of lawsuits. The importance of this process is underscored in the article “Risky Business” in the September issue of Connexion magazine, published by the Medical Group Management Association (MGMA). According to the article, “Risk management is part of quality care.”
As part of a care site’s efforts to improve reporting of lab results an assessment of the present process and outcomes needs to be undertaken. A team that is working on this as a care improvement project will first want to assign a team member or members to find out how lab results are generally reported to patients. There may be more than one approach to this process at a site. Some physicians may have a nurse call the patient if the results are critical to the care of the patient. Some offices may mail the results to the patients. Some physicians may have the patients take the lab tests before an office visit and then discuss the results at the visit with the patient. I think that this last process is the best. As a part of recording the process used to report lab results those conducting the assessment should also find out what percentage of the results are actually communicated to the patient in a timely manner. A study done by the National Center for Biotechnology Information found that anywhere from 7% to 32% of results are not reported to patients at the sites studied in a 2011.
A second area for improvement that a practice management improvement team may want to address is the rate of claim denials at a site. Denial of reimbursement for claims can be very costly. Rebilling the claim is time intensive and requires much work. The team examining claim denials will first want to find out what are the most common reasons for claim denials at the site so that improvements can be made in billing and a higher percentage of claims are paid on the first submission. This is a part of problem solving called root cause analysis. According to a December 17, 2011 blog on the MGMA website, the common reasons for claim denial are registration errors, diagnosis not coded to the highest level of specificity and patient registration number is wrong or missing. The blog by Madeline Hyden reports that the best practices have a 4% claim denial on first submission. This can be used as a benchmark for your own practice.
A process change that is critical to the future financial health of a practice site is the implementation of ICD-10 coding. By October 1, 2014 care sites must begin using this diagnosis code or they will not be reimbursed for care given to patients. Transitioning to ICD-10 coding is complex and will take a great deal of time for most practices. In my opinion, care sites that have not already begun taking steps to implement ICD-10 may find the transition rushed and full of missteps. What are some of the first steps that need to be taken by a team overseeing the transition to ICD-10 coding? According to MGMA’s ICD-10 Implementation Toolkit, the team must find all of the places that ICD-9 is currently used: which software uses ICD-9 coding (practice management, EHR, coding software), who uses it (coders and clinicians as well as office staff) and which payers and vendors of the site are willing to effectively interact with the practice so as to insure a smooth transition. Once these assessments are addressed a smooth transition can be more effectively planned.
Assessment of the current state is extremely vital in making smooth and efficient changes in processes of care and management at a site. Understanding how a practice currently notifies patients of lab results, knowing the percentage of claims that are denied on first submission, and documenting the present scope of ICD-9 use at a site are all critical to implementing changes that improve care and the patient experience while increasing income. These illustrations can be applied to most other change management projects at care sites. Assessment is a key tool of change. After all, how can you reach your destination if you don’t know where you are now?
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