Wincing as I sit down to blog today on quality improvement and the patient experience, my left knee compels me to share its humble story: the cautionary tale about a systemic problem that if left untreated could have staggering consequences for you and me.
On Memorial Day, I injured my knee and was treated at an urgent care clinic within my insurance network. I left on crutches, wearing a knee brace; and carrying a prescription for pain medication and an order to see an orthopedic surgeon -- all provided to me by the the clinic. Several weeks later, I received my insurance company's Explanation of Benefits telling me that the clinic's invoice was paid. Now, let's fast forward to September, when an unexplained bill for $500 from a company I never heard of arrived in my mailbox. My insurer explained that the bill was for “medical equipment” -- the crutches and knee brace -- provided to me because the urgent care clinic's medical equipment supplier is not in my insurance network.
How is the consumer able to make an informed decision under circumstances like these?
With all the talk about waste in medicine, all the hoopla about reform, all the uncertainty and staggering costs, how can the consumer ever make informed decisions under circumstances like these? Here I am in pain, doing my best to make sure my visit is covered, following my insurance company’s rules, and still I end up paying $500 for crutches and a brace that I could have purchased from a network vendor for a fraction of that had anyone bothered to inform me that the equipment would be billed separately and that the clinic’s vendor was not in my insurance network. As a consumer, could I possibly have known this information?
It’s a buyer-beware health care environment, but every effort is made to make costs, insurance payments, and all other financial aspects of receiving health care services as confusing and obscure as possible for patients.
It's not just that I’m out of pocket $500 in addition to my $1,000/month health insurance premium. It's about wasted dollars due to lack of transparency.
It's the fact that an injured patient in pain was charged $500 because she was not informed that the medical equipment was not covered by her insurance. It's the fact that she could have been given a choice to purchase it for $500 at the clinic, or for $100 at a local drugstore. The system provided no transparency or choice to the patient, who then had no choice except to pay $400 for the system's lack of transparency.
Multiply this type of experience by each of us several times a year, plus all the other ways this same scenario plays out, and it's easy to see billions of wasted dollars paid to health care providers who take no responsibility for providing information that helps consumers make informed choices.
I think it's highway robbery, no different from Medicare fraud or any other rip-off of a government program, except that it is happening to individual consumers like you and me. If I can be given an estimate of costs by other professionals, why can’t medical providers do the same? That way, we could all participate in helping to control and bring down the costs of health care.
Monday, September 27, 2010
Tuesday, September 14, 2010
Multi-million Dollar Jury Damage Awards…. It’s a New Day for LTC
Last week Skilled Healthcare Group, Inc., one of the nation’s largest providers of skilled nursing, rehabilitation, and hospice services, settled an understaffing lawsuit for $50 million in its skilled nursing facilities, avoiding a $677 million jury award. On news of the settlement, the Company’s stock value rose as much as 31%. The class-action lawsuit resulted in a jury award of $677 million in damages for allegations that the company understaffed 22 of its California facilities, which is thought to be the largest award in the US this year.
Skilled Care seems to have a strong compliance program and presence. It has a code of ethics and business conduct. The Company seems ahead of many in the compliance arena. So, what went wrong?
This story is a harbinger of more compliance risk to come.
Compliance can no longer address mere minimums to reduce risk; it cannot be driven entirely in response to regulators. Compliance has to grow out of an ethical culture that rewards honest reporting and other processes such as audits and independent investigations that are reported at high levels. These practices cause important findings to be triaged and addressed with the sense of urgency they require. If problems were identified with the staffing data being kept by Skilled Healthcare, compliance systems were needed to escalate those problems quickly to high levels where they could be analyzed fully and corrected company-wide. If facilities were not following the Company’s policy in regard to staffing, compliance needed to be there with the capability of raising the issue in whatever way was required to get it resolved.
It’s a new day where compliance is concerned. One thing we know for sure is that the regulators, advocacy groups, lawyers and juries will be happy to “catch” us and create the pain that often precipitates change. We need to do this for ourselves so that we are not continually dragged around by outside forces, paying handsomely and living under threat of being bankrupted by forces we cannot control. Doing this will require new thinking, new actions, new commitments from long-term care. It will require significant change.
Ethical culture is deeper than mere compliance--it is everyone in the organization “doing the right thing” simply because it is the right thing to do, not because they fear negative consequences. In an ethical culture, all staff, visibly led by executive staff, are completely invested in doing well by doing good, even when it isn’t easy. This produces a much more positive, life-affirming environment in which to live and work because it is driven by doing good rather than by fear. Doing good breeds doing good and fear breeds fear.
Long-term care has done so much unrecognized good—we need to build on that with our compliance programs and practices. Many organizations are doing this successfully. I'd be interested to have you share your thoughts about how your company is doing this.
Skilled Care seems to have a strong compliance program and presence. It has a code of ethics and business conduct. The Company seems ahead of many in the compliance arena. So, what went wrong?
This story is a harbinger of more compliance risk to come.
Compliance can no longer address mere minimums to reduce risk; it cannot be driven entirely in response to regulators. Compliance has to grow out of an ethical culture that rewards honest reporting and other processes such as audits and independent investigations that are reported at high levels. These practices cause important findings to be triaged and addressed with the sense of urgency they require. If problems were identified with the staffing data being kept by Skilled Healthcare, compliance systems were needed to escalate those problems quickly to high levels where they could be analyzed fully and corrected company-wide. If facilities were not following the Company’s policy in regard to staffing, compliance needed to be there with the capability of raising the issue in whatever way was required to get it resolved.
It’s a new day where compliance is concerned. One thing we know for sure is that the regulators, advocacy groups, lawyers and juries will be happy to “catch” us and create the pain that often precipitates change. We need to do this for ourselves so that we are not continually dragged around by outside forces, paying handsomely and living under threat of being bankrupted by forces we cannot control. Doing this will require new thinking, new actions, new commitments from long-term care. It will require significant change.
Ethical culture is deeper than mere compliance--it is everyone in the organization “doing the right thing” simply because it is the right thing to do, not because they fear negative consequences. In an ethical culture, all staff, visibly led by executive staff, are completely invested in doing well by doing good, even when it isn’t easy. This produces a much more positive, life-affirming environment in which to live and work because it is driven by doing good rather than by fear. Doing good breeds doing good and fear breeds fear.
Long-term care has done so much unrecognized good—we need to build on that with our compliance programs and practices. Many organizations are doing this successfully. I'd be interested to have you share your thoughts about how your company is doing this.
Friday, September 3, 2010
On Leading the Charge for Charge Nurses
This morning, I was glad to read that the American Society of Consultant Pharmacists has come out strongly in favor of nurses being able to “act on behalf of physicians in prescribing pain medications.” I agree with their position, and blogged on this topic when the DEA first decided to start a drug war in the hallways of our facilities.
While long-term care calls its nurses “charge nurses,” historically we have not really known how to put them in charge.
We'll put a charge nurse in the station to deal with physicians, residents, families, visitors, regulators, vendors, lost and found, emergent and urgent issues such as abuse allegations, falls, changes of condition and risk-related events, wheel chairs, CNAs, activities, tray accuracy, and of course med passes and charting. Yet, our charge nurses are offered little in the way of supervisory development so they can have the skills needed to be successful in managing these complex stakeholders and all their competing and varied interests.
Truth be told, we in long-term care work around our charge nurses quite a bit.
When the director of nursing or director of staff development is on duty, she or he often problem solves directly with CNAs, RNAs, families and visitors, leaving the charge nurse out of the communications loop. Then on weekends while visiting our residents, families often address their questions, issues and concerns to the one person who tends not to be included in problem solving: the charge nurse. So why are we surprised to learn that "I don't know" is the most common response families and visitors hear from the charge nurse? Clearly this response offers no comfort or sense of confidence to the family or visitor, and colors their perceptions about our facilities.
As an expert in organizational change, I have worked with companies to build supervisory strength in their charge nurse core. Improving charge skills and also ensuring that they can really use their new skills in the work place are both essential components of developing supervisory strength. Generally the role of RN supervisors and the DNS and DSD also come into play and need to be sorted out to ensure that the charge nurses are well positioned to use their supervisory skills. Companies that have been successful with this endeavor have seen improved customer satisfaction, reduced charge nurse and CNA turnover, a downward trend in work-related injuries while providing care, and in some cases even improved quality indicators (i.e., favorable trends in weight loss, falls, and participation in activities, among others).
All of this leads me to believe that empowering charge nurses to be in charge is an idea whose time has come.
By giving charge nurses not only supervisory skills development training but also including them in communications about problem issues and problem solving.
The charge nurse is the hub of the wheel of change.
With all the demands facing long-term care today and the incredible pace of sweeping change coming with health care reform, QIS surveys, MDS 3.0, RUGS IV, among others, we are in a place of not knowing and not being able to predict how the environment will change and how we will have to adapt in the coming years. What we do know is that those who can shift fast enough with confidence and strength will come out ahead. At the facility level, the charge nurse is the hub of the wheel of change—and the key to rapid and effective adaptation in times like these.
What are your thoughts about strengthening the role of the long-term care facility charge nurse?
While long-term care calls its nurses “charge nurses,” historically we have not really known how to put them in charge.
We'll put a charge nurse in the station to deal with physicians, residents, families, visitors, regulators, vendors, lost and found, emergent and urgent issues such as abuse allegations, falls, changes of condition and risk-related events, wheel chairs, CNAs, activities, tray accuracy, and of course med passes and charting. Yet, our charge nurses are offered little in the way of supervisory development so they can have the skills needed to be successful in managing these complex stakeholders and all their competing and varied interests.
Truth be told, we in long-term care work around our charge nurses quite a bit.
When the director of nursing or director of staff development is on duty, she or he often problem solves directly with CNAs, RNAs, families and visitors, leaving the charge nurse out of the communications loop. Then on weekends while visiting our residents, families often address their questions, issues and concerns to the one person who tends not to be included in problem solving: the charge nurse. So why are we surprised to learn that "I don't know" is the most common response families and visitors hear from the charge nurse? Clearly this response offers no comfort or sense of confidence to the family or visitor, and colors their perceptions about our facilities.
As an expert in organizational change, I have worked with companies to build supervisory strength in their charge nurse core. Improving charge skills and also ensuring that they can really use their new skills in the work place are both essential components of developing supervisory strength. Generally the role of RN supervisors and the DNS and DSD also come into play and need to be sorted out to ensure that the charge nurses are well positioned to use their supervisory skills. Companies that have been successful with this endeavor have seen improved customer satisfaction, reduced charge nurse and CNA turnover, a downward trend in work-related injuries while providing care, and in some cases even improved quality indicators (i.e., favorable trends in weight loss, falls, and participation in activities, among others).
All of this leads me to believe that empowering charge nurses to be in charge is an idea whose time has come.
By giving charge nurses not only supervisory skills development training but also including them in communications about problem issues and problem solving.
The charge nurse is the hub of the wheel of change.
With all the demands facing long-term care today and the incredible pace of sweeping change coming with health care reform, QIS surveys, MDS 3.0, RUGS IV, among others, we are in a place of not knowing and not being able to predict how the environment will change and how we will have to adapt in the coming years. What we do know is that those who can shift fast enough with confidence and strength will come out ahead. At the facility level, the charge nurse is the hub of the wheel of change—and the key to rapid and effective adaptation in times like these.
What are your thoughts about strengthening the role of the long-term care facility charge nurse?
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