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Six Sigma project improves documentation of patient status
Initiative includes standardized admission process, better communication
A Six Sigma project to improve documentation of patient status has resulted in increased satisfaction, increased productivity, and decreased denials for Medicare reimbursement for Virtua Health, a four-hospital health system in southern New Jersey.
"We needed to avoid being denied for services and to meet Centers for Medicare & Medicaid Services [CMS] compliance requirements. At the same time, we wanted to improve our ability to notify the patient of his or her admission status at the time of service," says Adrienne Elberfeld, Six Sigma Black Belt and Six Sigma champion-operations improvement.
The initiative has resulted in a dramatic decrease in the number of cases for which the hospital couldn't bill because the patients didn't meet medical necessity criteria, adds Rita S. Veterano, RN, BS, MSHA, assistant vice president, corporate case management.
"Patients are admitted through the emergency department and are assessed by the emergency department physician who initiates the process about what level of service is required — whether the patient is treated and discharged, admitted as an inpatient, or admitted to observation. One of our main concerns when we started this project was that many times, the patient status wasn't reflected in the medical record," she says.
The hospital system's Six Sigma team included representatives from nursing, case management, finance, compliance, information technology, patient access, and physicians.
At the beginning of the project, the team examined how the information was shared once the emergency department physician or admitting physician made the decision on patient status.
At that time, physicians wrote an order that was transferred to the emergency department unit secretary, who called the bed flow coordinator, who contacted the unit to alert the staff that a patient was being admitted. Many times, the bed flow coordinator didn't tell the nurse on the floor the correct patient status and many times, nobody wrote the status down, Veterano says.
"With the manual system, it was a labor- intensive process. We were counting on people instead of entering the information in the electronic medical record," Elberfeld says.
At three of four Virtua campuses, the patients were being held in the emergency department for as long as six hours after their admissions status had been determined and a bed had been assigned.
"The patient was registered in an inpatient bed but didn't leave the emergency department. Paperwork said they were on the unit, but physically, they were still in the emergency department. This caused problems on many levels. For instance, there could be a change of status while the patient was in the emergency department and this might not be communicated to the unit," Veterano says.
The team created standardized processes at all four hospitals, including standardized physician order paperwork and computerized physician order entry that has the patient status line highlighted in the emergency department physician order entry.
The team educated the medical staff on inpatient vs. observation criteria and the new standardized practices and presents monthly education through the medical management committee. A presentation on observation status is included in the new physician orientation program.
At Virtua, case managers review 100% of patients using InterQual criteria, even the short-stay patients who have been discharged from the hospital.
If a patient doesn't meet criteria for medical necessity, the case managers discuss the case with the attending physician as well as the medical director dedicated to the case management department.
"If the medical director doesn't agree with the clinical decision, he reaches out to the attending physician as well as the emergency department physician who initiated the patient status," says Veterano.
The case management department creates reports on observation action and its financial impact on a weekly basis for the health system's senior leadership group.
The department tracks admission status trends and uses the information to target trends, which physicians may need additional education on from the medical director for case management.
For instance, if data show that a particular physician tends to place patients in observation status when they should be admitted as inpatients, the medical director for case management educates the physician, Veterano says.
"At Virtua, the patient is our primary focus. When we began our initiative to ensure that patients were in the correct status, we also worked on improving our communications to make the patient aware of their admission status and what it means," Veterano says.
For instance, observation is considered to be an outpatient service, and there may be a Medicare copay associated with the stay, she notes.
"Patients sometimes didn't understand that even though they stayed overnight in a hospital bed, they still were considered an outpatient and had a Medicare copay. We needed to provide education to patients and family members in order to meet that challenge," Veterano adds.
In additional to helping patients understand their admission status while they are in the hospital, the case management department takes a proactive approach to the problem and educates seniors in community settings.
"We educate them while they are here, but we decided to go into the community and speak to community groups to educate our seniors about what observation status means before they go to the hospital," Veterano says.