Amphion Medical: Core Measure Compliance
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CMS Core Measures Compliance: Best Practices for Data Collection, Analysis and Reporting For many hospitals, the primary challenge with the core measure program is not achieving quality standards, but complying with the complex, time-consuming reporting process and staying current with constantly changing regulations.
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Amphion Medical: Core Measure Compliance
- 1. Core Measures CMS Core Measures Compliance: Best Practices for Data Collection, Analysis and Reporting Complex Compliance Avoiding the Fallout A Shortage of Talent Maintaining Compliance Seeking Outside Help Maximum Value 1 2 3 4 5 6 Welcome Complex Compliance Avoidingthe Fallout AShortage ofTalent Maintaining Compliance Seeking OutsideHelp Maximum Value123456
- 2. Welcome Complex Compliance Avoidingthe Fallout AShortage ofTalent Maintaining Compliance Seeking OutsideHelp Maximum Value123456 Welcome! The expectation for hospitals to achieve certain quality standards is not new. The formation of the National Quality Forum (NQF) in 1999 got the ball rolling with its focus on care outcomes. The Joint Commission took it a step further in 2001 with publication of the now-annual Top Performers on Key Quality Measures – and since 2002 has required accredited hospitals to report performance data. Since 2003, the Centers for Medicare and Medicaid Services (CMS) has linked Medicare reimbursement levels to quality measures performance. Leapfrog Group and Health Grades have also entered the fray.i However, it was implementation of the Value-based Purchasing Program, part of the Patient Protection and Affordable Care Act of 2010, that truly turned up the heat on hospitals in terms of demonstrating quality outcomes. For the first time, hospitals would receive bonuses—or be penalized—for their performance on an evolving set of CMS/Joint Commission core measures.ii For many hospitals, the primary challenge with the core measure program is not achieving quality standards, but complying with the complex, time-consuming reporting process and staying current with constantly changing regulations. i Scott, L. It’s all about the outcomes. HHN magazine. December 2010. http://www.hhnmag.com/hhnmag/jsp/articledisplay. jsp?dcrpath=HHNMAG/Article/data/12DEC2010/1210HHN_Coverstorydomain=HHNMAG. ii Rau J. How hospitals’quality bonuses and penalties were determined and how to use the data. Kaiser Health News. December 20, 2012. http://www.kaiserhealthnews.org/stories/2012/december/21/value-based-purchasing-methodology.aspx. 2
- 4. Welcome Complex Compliance Avoidingthe Fallout AShortage ofTalent Maintaining Compliance Seeking OutsideHelp Maximum Value123456 For better or worse, core measures are now the basis for reimbursement under Medicare’s pay-for-performance initiative. A growing number of payers also look at core measure performance during contract negotiations. As a result, hospitals need to develop a healthy respect for the financial impact of noncompliance. At minimum, financial penalties translate into a 1.25 percent reduction in reimbursements in fiscal year (FY) 2014, increasing annually by 0.25 percent until it caps out at 2 percent in FY 2017.iii Further, with CMS publishing core measures data on its public website, noncompliance could also affect a hospital’s reputation among its patient population. As the stakes get higher, so does the level of difficulty involved in maintaining compliant reporting processes. The number of required measures has continued to climb, increasing the level of difficulty involved with abstracting and validating the data. Exacerbating the challenge is a limited supply of internal resources and expertise that can be dedicated to reporting to ensure processes and data definitions are current and protocols are in place to guide appropriate documentation and abstraction. Balancing reporting requirements with the plethora of additional core duties for which quality departments are now responsible is a resource balancing act. It is rarely feasible to have abstractors dedicated exclusively—or even primarily—to reporting. As the number of metrics that must be reported under the Hospital Inpatient Quality Reporting (IQR) program increases with no corresponding change to submission deadlines, though, it has become nearly impossible for hospitals to stay on top of core measures reporting requirements without a dedicated team. Consider that the 2005 starter set for the IQR program included just 10 chart-abstracted measures. By 2010, the set had expanded to 44 different measures, including 26 chart-abstracted, 1 survey, 16 claims-based and 1 structural measure. In 2013, the total had increased to 57. By 2016, hospitals will be required to report on 60 different measures, including 42 chart-abstracted, 1 survey, 12 claims-based and 5 structural.iv The complexity of reporting is also escalating. Regulatory policies and recommendations from CMS and The Joint Commission tend to change from one reporting period to the next, while protocols and guidelines are revised and expanded annually. For example, when CMS revised the OP-19 Emergency Department (ED) Transition Record, it became too complex for many hospitals to manage. Compliant documentation required inclusion of all the following: » Major procedures and tests performed during the ED visit » Principal diagnosis at discharge or chief complaint » Patient instructions » The plan for follow-up care (or a statement that none was required), including designation of the primary physician, other healthcare professional or website to provide follow-up care » A list of new medications and changes to continued medications the patient should take post-discharge, with the quantity prescribed and/or dispensed (or intended duration) and instructions for each Hospitals had little time to create such a detailed and cumbersome document within their electronic medical record (EMR) systems. As a result, nearly all failed to comply. CMS eventually suspended the measure until further notice, but not until the damage was done for the majority of facilities.v iii Is your hospital ready for value-based purchasing? [fact sheet]. Health Services Advisory Group. 2013. http://www.hsag.com/App_Resources/Documents/VBP_factsheet_-FLCA_508.pdf. iv https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalRHQDAPU.html v CMS proposes hospital outpatient and ambulatory surgical centers policy and payment changes for 2014 [fact sheet]. Centers for Medicare Medicaid Services. July 8, 2013. http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-Sheets/2013-Fact-Sheets-Items/2013-07-08-3.html. 4
- 6. Welcome Complex Compliance Avoidingthe Fallout AShortage ofTalent Maintaining Compliance Seeking OutsideHelp Maximum Value123456 To avoid accumulating financial penalties and productivity-sapping backlogs, hospitals must not view core measures reporting as an occasional responsibility. Proper resources must be dedicated to keeping processes current against the rising tide of regulatory and guideline changes taking place throughout the year. These include regulatory policies and recommendations from CMS and The Joint Commission, which tend to change from one reporting period to the next, and protocols and guidelines that are revised and expanded annually. This shifting regulatory landscape can make it difficult to ensure reporting processes are consistently compliant without a resource dedicated to monitoring regulatory change and educating clinicians and staff on current and new core measures and proper abstraction. Consider the fallout if CMS makes just one change in its Surgical Care Improvement Project (SCIP) documentation requirements between quarterly reporting periods. If the change is missed, the documentation won’t be created and the hospital will fail on that measure—which can directly and negatively impact the bottom line. Dedicating resources and proper training is crucial to taming the chaos of a highly complex, time-consuming process that significantly impacts a hospital’s financial and competitive standing. This includes tasking one individual with continuously monitoring and communicating any changes to guidelines, metrics or requirements so they can immediately be integrated into the reporting process. Additionally, abstractors must be properly trained and credentialed to ensure they are capable of managing the overall process. For the validation piece alone, this entails maintaining skill levels sufficient to achieve accuracy levels of no less than 75 percent. 6
- 8. Welcome Complex Compliance Avoidingthe Fallout AShortage ofTalent Maintaining Compliance Seeking OutsideHelp Maximum Value123456 The complexity inherent in core measures reporting is not the only challenge hospitals are facing: The growing demand for qualified abstractors has created a growing shortage. As difficult as it is to recruit and retain abstractors with the skills and experience to meet performance standards, the potential price for failing to do so is too high to lower standards. Thus, careful evaluation is critical to ensuring the right people are in place to manage every stage of the process. Hospitals should seek out abstractors with health information management (HIM) credentials, such as Registered Health Information Technician (RHIT), Registered Healthcare Documentation Specialist (RHDS), Certified Healthcare Documentation Specialist (CHDS), Certified Medical Abstractor, Certified Coding Associate (CCA) and Certified Coding Specialist (CCS). Such credentials ensure individuals have the proper background in medical terminology and a comprehensive understanding of the patient medical record. Clinical credentials, such as Registered Nurse (RN) and Licensed Practical Nurse (LPN) are also important. They ensure individuals have a strong understanding of how the human body works and are prepared for the stronger base of clinical knowledge required for more advanced core measures and as codes transition from ICD-9 to ICD-10. Prospects should undergo proficiency testing to ensure skills are where they need to be. This should comprise both inpatient and outpatient questions from the current core measures set and its corresponding specifications manual. The best abstractors will pass with a score of at least 95 percent, which demonstrates a sufficient understanding of core measures and their impact on the hospital’s performance score. 8
- 10. Welcome Complex Compliance Avoidingthe Fallout AShortage ofTalent Maintaining Compliance Seeking OutsideHelp Maximum Value123456 In addition to ensuring the proper team is in place, hospitals should also evaluate the core measure reporting process itself to identify and eliminate any gaps, aberrant patterns or areas of weakness contributing to backlogs or missed deadlines. More importantly, evaluation will identify areas of weakness on the front end, such as with clinical documentation, which should be addressed through education or documentation improvement initiatives. The evaluation of the core measures reporting process should focus on three areas: deadline compliance, validation rates and regulatory comprehension. Missed deadlines can almost always be traced back to a lack of resources. Integrating reporting requirements with the additional core duties for which quality departments are now responsible is a delicate balance, particularly given the rapid rise in the number of IQR metrics. When abstractors must divide their time and attention between core measures reporting and their regular responsibilities, backlogs can quickly develop and deadlines are often missed. Once one deadline is missed, catching up is difficult without additional resources dedicated to the process. Overextended abstractors may also struggle to maintain appropriate validation scores, which should be in the 90-95 percent range. Consistently low scores may signal the need for additional training, creating yet another Catch-22. How do you set aside time for training to bring scores up when heavy workloads are contributing factors to the performance issue? Finding the answer to that question and addressing other issues uncovered by the analysis are important. They will streamline reporting, improve compliance and create a means by which documentation and processes can be enhanced and best practices put into place to drive improvements to publicly reported core measures. They will not only result in reporting that is compliant in terms of content and deadlines but also very likely help improve core measures performance, which will ultimately benefit the facility financially and boost its reputations for excellence among its patient population. 10
- 12. Welcome Complex Compliance Avoidingthe Fallout AShortage ofTalent Maintaining Compliance Seeking OutsideHelp Maximum Value123456 Because process weaknesses can often be traced back to insufficient resources, a growing number of hospitals are outsourcing their core measures abstracting to HIM vendors, thus freeing internal resources to focus on core responsibilities. However, to realize the full value of outsourcing core measures reporting, finding the right partner is imperative. As with any relationship, the success or failure of outsourcing core measure reporting rests on the quality of the partner selected. Look for a partner employing only credentialed abstractors with a minimum of 3–5 years of experience, all of whom should have passed a stringent proficiency test. The firm should be able to deliver an accuracy rate of no less than 95 percent. Finally, the firm should provide services designed to strengthen the hospital’s core measures performance, including weekly and quarterly education sessions, regular evaluations and recommendations for improvement. 12
- 14. Welcome Complex Compliance Avoidingthe Fallout AShortage ofTalent Maintaining Compliance Seeking OutsideHelp Maximum Value123456 Regardless of whether they are managed in-house or outsourced to a qualified vendor, reporting processes should be leveraged to drive improved core measures performance by identifying gaps and recommending process enhancements to close them. One example would be a hospital consistently failing the substance or tobacco use measure sets. An abstractor empowered to go beyond standard pass/fail core measure reporting could trace that failure to clinicians’neglecting to query patients about their smoking or alcohol use when completing admission documentation—a situation that can be fixed by simply adding the query to or highlighting the query in the admission order set. At a higher level, a report can be generated that highlights every outlier in order to identify the documentation issue causing the core measure failure. This report can then be used to identify trends that can be corrected with adjustments to order sets or documentation processes. It can even help identify individual clinicians who may require additional education. Improving core measure performance is a team effort. Providing those on the clinical frontlines with the information they need to improve documentation will ultimately drive quality outcomes. Doing so, however, requires strong, compliant and comprehensive reporting processes that reveal the cause of the core measure failures so they can be corrected and improved before they impact quality or the bottom line. 14