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By Andrew Awoniyi, ND, RN-BC
As we learned in the first semester of nursing school, if it was not documented it was not done. All reimbursements and future care goals are dependent upon accurate, thorough documentation, and essentially create an itemized receipt for a patient’s care journey.
Yet Charity Farnsworth found ineffective motivation for clinicians as the common barrier providers have in getting accurate documentation. Farnsworth, HealthCare ConsultLink senior vice president of consulting services, warned of the cyclical impact this will have on your bottom line. “If you have staff who are not engaged and they’re not making effort to document the way they need to, this will ultimately circle back to the agency being impacted negatively from a financial standpoint, which affects what they can then do for their staff and providers.”
With the deadline on the transition toward value-based care fast approaching, implementing and maintaining a Quality Assessment and Performance Improvement (QAPI) program should be a high priority for organizations to increase their chances for success in the new environment.
A QAPI Program is Tool for Success
This issue is bigger than just compliance and reimbursements and can often affect patient safety. “The first thing surveyors will be looking at is, ‘Have you kept your patient safe,’” says Arlene Maxim, a registered nurse and senior vice president of clinical services at Axxess, who also acts as an outside consultant for home healthcare agencies. She recounted instances where immediate jeopardy for patients put agencies out of business. These instances could have been avoided and provide lessons for other providers. Red flags, she added, are when an agency will “gloss over things” and not document the identified issue. Organizations must focus on identifying high-risk, high-volume or problem-prone areas that affect health outcomes and quality of care as they develop their QAPI program.
To motivate your employees to complete documentation that is accurate, timely and compliant, it is important to get employees invested in the delivery of high-quality care, understand the importance of QAPI and how they contribute to the organization and patient’s success. The role of documentation, identifying and sharing quality metric progress and rewarding achievement of goals are some ways to engage and motivate employees to be involved.
Agencies need to understand that they will not be penalized for finding a problem. They will be penalized for not fixing the problem.
Avoiding a deficiency like this starts with documenting the issue and what the organization is doing to fix it, which is essentially a QAPI program, a requirement under Medicare and something Maxim said agencies should improve for Home Health Value-Based Purchasing (HHVBP) success in 2023. “These QAPI goals are going to be the drivers for success as we go into January,” Maxim said.
Align Your Program for Success
Providers should be familiar with the triple aim, the focus of the Centers for Medicare and Medicaid Services (CMS): better care, smarter spending and healthier communities. Yet the up-and-coming quadruple aim, which has the added element of provider satisfaction, will help motivate your employees. Farnsworth cautioned, “If we only focus on the patients, we’re missing that key component. Clinicians who have a higher level of satisfaction in their roles are going to give better care and be more compliant with documentation to meet the expectations for value-based care.”
Where to Focus to Refine Your QAPI Program for Success
1. Your entire team, including the board of directors (BOD), should be involved.
The direction of an organization begins from the leadership team and the BODs who establish and drive the organization’s culture. Leaving out required components of a QAPI program when it comes to the board’s involvement is another frequent deficiency. “The board of directors oftentimes are people that come into the office a couple times and sign notes that say, ‘We had a board meeting’ and weren’t really involved. Now, QAPI actually has forced the board to take more of an interactive response with your agency,” said Maxim. It is important for the BOD to be familiar with the provider’s PI measures, metrics and trends and ask the important questions to improve the programs.
2. QAPI should be the culture of your organization.
A major error agencies make with their QAPI programs is just “checking off the boxes” to meet the basic requirements but go no further. That’s why Zaundra Ellis, director of hospice and palliative care solutions at Axxess, advised, “You should have systems in place where you measure progress – daily, weekly, monthly, quarterly and even annually. I think people really get tripped up with ‘How do I get all of this done,’ but when we take it apart and put it back together in smaller pieces, it makes it more manageable, and it also makes it more effective.”
3. More performance improvement measures (PIs) do not make your QAPI program more effective.
That leads to another common misconception: the more PIs, the better the QAPI program.
If you have trouble deciding which issue is most time-sensitive or critical, conduct a root cause analysis. “Most surveyors are only looking for two or three PIs in their programs,” said Maxim. “It’s better to have a few and do a really, really good job than to have a list of them.”
4. Individualize each patient’s plan of care – then follow it.
A common deficiency, a “low-hanging fruit,” can be found at the beginning of the care journey with patient goals derived from the referral and initial patient assessment findings. Documentation is as unique as each clinician, but ultimately the goal is: how do we tell the story? What is the intervention and what are the outcomes? “We’re past the days where you had two patients with the same primary diagnosis and their care plans were effectively the same as far as interventions,” said Farnsworth. The Medicare Conditions of Participation emphasizes the necessity of patient language, calling for clinicians to state things from both a clinical and patient perspective.
5. All paperwork should be accurate and accounted for.
“Basic paperwork – consents and other documents, are often taken for granted that they’re being done the way that they should.” Farnsworth noted that if the QAPI program is not structured to look for this, there will be gaps.
6. Create a Clinical Documentation Improvement (CDI) program.
Creating a CDI program will have a positive impact on more than one area of your business. This program is a formal process that lays out steps to take during documentation to measure and evaluate the quality care of your patients.
7. Focus on the Consumer Assessment of Healthcare Systems (CAHPS) questions.
Under VBP, 30% of the Total Performance Score (TPS) relies on patient experience of their care with organizations. Because of this, agencies should focus on CAHPS questions to ensure patients are receiving the best experience of care, something many agencies struggle with. This means training your staff to understand the importance of the survey, speak to patients using terminology presented in the CAHPS survey and delivering care in a way that drives improved patient outcomes.
A proven way to measure and track QAPI goals is through a HIPAA-compliant software. Agencies can put processes in place to ensure that plans of care are being documented and followed correctly, easing this heavy burden off your busy staff.
Interviews come from a recent healthcare industry event, led by healthcare technology leader Axxess and HealthCare ConsultLink.
Andrew Awoniyi is the director of patient engagement and clinical education for Axxess. In this role, Andrew is responsible for providing industry thought leadership and the strategic direction and delivery of Patient Engagement.