VC Notes Archive
Office of the Vice Chancellor
Friday, October 4, 2019
Patient Care - Beyond the Basics
Good morning!
Today I’m going to focus on our clinical mission, and particularly on a number of measures we are taking to improve performance.
When I think about patient care I first think about the care we provide to patients to manage their illnesses or conditions: the diagnostic assessments, the medicines, the procedures, the surgeries, the recovery care – all with compassion and thoughtfulness. To use the time-worn football analogy, this is the “blocking and tackling” of patient care. If we don’t get this right, we lose the game.
But there is so much more. There are, for example, what I will call the “hotel” aspects of patient care. The food we serve. The facilities we offer – how nice they are and how clean and well-maintained they are kept. And the inspired customer service patients receive from the moment they schedule an appointment to the time they leave our care. These are not life-and-death issues, but they matter greatly to patients and their families.
And then there are what might be described as the business aspects of patient care. And as you might expect of business activities, they directly involve money.
The first focus is on what we call revenue cycle activities. These are all the administrative and clinical processes “that contribute to the capture, management and collection of patient service revenue,” according to one definition. And that’s no small matter. Of our $1.5 billion annual budget, nearly $1.2 billion is fueled by patient care revenue.
With all that in mind, we are taking a number of steps to improve our revenue cycle processes. These range from fine-tuning to a more substantial overhaul.
In the latter category is clinical documentation. Documentation begins in the clinical setting, with the compilation by physicians and other clinical team members of the patient’s medical record. The record must be thorough, complete and in compliance with hospital and medical staff policies. A team of coders then reviews the record, in concert with the clinical staff, and assigns charges where applicable based on a set of diagnosis codes.
Coding is complicated work and requires highly specialized training. There are currently 72,000 diagnosis codes! And coding can only be as good as the documentation on which it is based. From a coding and reimbursement perspective, if it’s not documented, it didn’t happen. But this is not only a financial issue; accurate and complete documentation is a clinical quality issue as well.
For all of these reasons, we are kicking off a multidisciplinary task force to develop and implement a data-driven program to address documentation deficiencies, improve efficiency and accuracy, and engage the workforce in improving and standardizing documentation and coding. I am serving as the executive sponsor of this effort, while Dr. Michael Henderson, chief medical officer, and Gail Scarboro-Hritz, interim chief revenue cycle officer, are serving as program leads.
Other revenue cycle improvement efforts currently underway include:
• Introducing a patient financing program to better serve our patients who pay out of pocket and to help us operate more efficiently in our business office
• Formalizing a Revenue Cycle Training and Development Program to serve as the foundation for our culture of accountability
• Implementing a pre-service financial clearance process for outpatient services to more efficiently determine eligibility and benefits, obtain prior authorizations when required, provide financial counseling and increase point-of-service collections
• Implementing a process to identify and manage charity care more efficiently to accurately recognize applicable cases and decrease bad debt
• Assessing the accuracy of payments from insurance companies to identify underpayments and pursue full expected reimbursement
• Focusing on an exemplary patient experience in all facets of revenue cycle operations
The other major business focus in front of us is capacity management and patient “throughput” – in other words, enhancing our ability to care for patients in an efficient manner so they don’t experience needless delays in discharge that hinder the admission of new patients.
During the last few years, we have seen an increased demand for our patient care services as well as an increase in the acuity level – or the complexity – of our patients. It is great news that more and more patients are choosing UMMC for their care. We are growing our capacity to care for these patients, but at times the demand has increased faster than we can expand – creating some real growing pains.
A challenge we have been facing day in and day out is the need for additional capacity in all of our patient care areas – the inpatient, ambulatory, operating room and intensive care settings. University Hospital has been at or above capacity more than 87 percent of the calendar year to date. On average, the hospital is above capacity 25 days per month. Through Mississippi MED-COM, we typically accept about 1,250 patient transfers each month but have to “redirect” approximately 130-150 transfers due to capacity constraints.
We have taken a number of steps to respond to this increased demand, going back several years. These include:
• Reallocating 4Wiser as a 30-bed medical-surgical unit in 2014
• Opening 10 beds in the Cardiovascular ICU in 2015
• Reallocating 15 beds on 5Wiser for medical-surgical patients in 2018
• Using 10 beds in the Short Stay Procedure Area for patients awaiting a room
• Adding a five-bed observation unit and enhancing a number of patient flow processes in the Adult Emergency Department
• Reconverting 2West from offices back to a 13-bed patient unit in 2019
We’ve also improved processes to expedite patient movement or monitor bottlenecks. For example, we beefed up our case management and utilization review efforts. We established a group to monitor the length of patient stays and evaluate options for cases that fall outside normal ranges. And to avoid the buildup of discharges that occur on Mondays when admissions also begin peaking, we increased weekend coverage of a number of services, such as physical and occupational therapy, pharmacy, dialysis, durable medical equipment and discharge planning.
We’ve also looked beyond our Jackson campus to deal with our capacity issues:
• We’re working on agreements with nursing homes, long-term care facilities, home care companies and hospices to streamline our ability to release discharged patients to those locations.
• We’ve established a joint venture with Merit Health Madison to perform surgical procedures at its hospital, leaving our ORs available for more complex cases.
• We’ve transferred several patients who don’t need to be in a tertiary care hospital to UMMC Grenada.
• We’ve established a team to carefully look at the placement of some of our very difficult-to-place patients. Since June 1, those enhanced efforts have resulted in the discharge of 41 patients representing 6,372 patient days.
• To better inform our efforts, we are reviewing data regarding observed-to-expected length of stay and discharge patterns throughout the week.
I’ve covered a lot of ground today. But I hope you can see that there is a lot going on to improve our work related to the business of patient care. And there are a lot of people working extra hard to make it happen. We will always put the care first in our patient care, but these other activities that directly impact the bottom line can’t be overlooked. Because without money, we can’t do all the good things we do for those we serve, and that help us all reach A Healthier Mississippi.
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@LAWoodwardMD
