All facets of clinical practice, whether primary care provider, specialist, hospital, or post-acute, are facing the need to transform clinical processes sooner than later to avoid dings to Medicare Reimbursement.

The effectiveness of a clinical encounter is having a more significant impact on quality outcomes for the patient and reimbursement to the healthcare provider than ever before.

For example, with an acute care hospital discharge, key quality pieces should be in place such as making sure the discharge summary information gets to the primary care physician; the patient has a follow-up appointment prior to leaving the hospital; and the patient knows what to do if they have concerns, issues, or return of symptoms. If these steps are not in place, the likelihood increases of the patient getting sick and not knowing what to do or having an unnecessary emergency room visit and/or readmission.  Reimbursement is impacted to the hospital if the patient has a return ER visit or readmission.

Following are some practical suggestions for getting started on the road to transformation:

  • Establish clear vision and leadership
    • The “Change Vision” should be crafted with input from staff, written down, and communicated to all staff to elicit their support and understanding of the goals for the future. Staff need to understand the direction and what is needed to get there. Reimbursement is changing, and to remain viable we must transform current clinical processes.
    • For transformation to be successful, leaders of the organization must participate in and assist with driving the change. It is quite common for middle management such as practice managers or hospital unit directors to be put in the position to drive the change, with higher level leadership derailing initiatives by lack of participation in and support of the projects / initiatives needed.
  • Determine the processes that need changed and how that change will be measured
    • For example, reducing ER visits and hospital readmissions is a huge focus.
    • For your patient population, how would you address this focus?
      • Do patients need better instructions for when to call the office versus going to the ER? Do they know that you really want them to call and that you have 24/7 coverage? Do they know that their primary care physician and specialist will collaborate on their care? This is a change of mindset for patients and providers alike and will need creativity to re-educate and prepare for this focus.
      • Do patients need an outreach call from your office to check on them based on your concern for their level of risk? Do you have a risk stratification process in place? Do you have a “red light, yellow light, green light” or “1, 2, 3” risk level assigned to each patient? If a “red light” patient calls the office does your receptionist have a way to identify him or her as a high risk patient who should receive heightened attention?
      • Do your patients have a list of things to avoid? Do your patients know when to take or hold specific medications?
    • Obtain good baselines
      • In order to determine improvement, it is imperative to document good baselines for comparison later on. For example, if you’re going to put efforts in place to improve your diabetic patient A1c levels, in order to be able to measure improvement you need a baseline to measure against.
      • Break down the changes into measurable bites so that you can document whether your change was an improvement or not. In this example, determine how many diabetic patients are in your panel now. What is your first process improvement step? Perhaps it is calling all patients who haven’t been seen in a year and trying to get them scheduled for an appointment. Before putting that step in place, identify how many diabetic patients on your panel haven’t been seen in a year. That way, you can monitor that number on an ongoing basis for comparison so you know if your steps are being effective.
    • Assure all staff document correctly to capture the measure data
      • Study current methods of documentation within the practice; determine the best documentation processes for what you’re trying to achieve – who should document what, when and where. Then clearly communicate to all participating staff including quick reference guides with screen shots.
    • Monitor data collection and communicate results to all staff
      • Regular communication back to the staff regarding progress is important to reinforce use of the correct processes and documentation.

Once you have established clear leadership and vision for the project, determined what processes you’d like to change, obtained good baselines, assured that staff are documenting correctly, and are monitoring the data collection process you can move on to the fun part. Begin to muster the creative forces of your staff to actually improve patient care processes. Remember a key “Lean” principle is that the guy doing the work is the best one to know how to improve a process. Create opportunities for staff to brainstorm about how to do things better. Take suggestions seriously and initiate mini process improvement projects.

About Laura Buchanan MBA, BSN, RN

Ms. Buchanan is a Registered Nurse (RN) with 39 years of professional experience. She serves as a director with a focus on technology projects utilizing her clinical, management, business, and technical consulting experience. She has extensive experience with clinical transformation, workflow analysis, process design, vetting software options, data analysis, and implementing EHR systems.​

More Resources from Laura

We look forward to hearing what initiatives you’re working on and how we can help you accelerate success. Let’s talk.