Five Quality and Compliance Tips

A major concentration within my firm, H2 Healthcare, is compliance work. My wife heads this section of the practice, and she is widely known as one of (if not THE) the foremost post-acute/senior living experts on clinical quality, compliance, and risk mitigation/risk management. Her book on reducing survey risk for SNFs is still available on Amazon: https://www.amazon.com/-/es/Diane-Hislop/dp/1556454988

What’s great about the book is that it is full of still relevant tools and processes to employ and reduce not just survey risk but also, litigation risk. Many of the tools are available on this site via various posts.

Most of my days involve working with and consulting with various partners. My wife is an obvious one, and another is our therapy partner group, Theracore Management Group (https://theracoremgmt.com) I helped start Theracore a number of years ago with two other partners (now owners) to provide unique therapy management services to post-acute providers and to assist with quality program development, clinical care delivery, etc. We also worked on numerous claims audits and education programs.

What I have learned from my work with my wife and the principals at Theracore, is that there are five backbone elements to an effective Quality and Compliance program for all post-acute providers. Embracing and working to incorporate these five programs into operations, not free-standing exercises, is critical to having an effective compliance program, an effective QAPI program, and efficient and effective operational performance (clinical outcomes, revenue integrity, etc.).

1. Audits – The key here is to use outside resources to regularly conduct claims and documentation audits. This function is a requirement (CMS) for a Compliance Program and a simply process to enhancing revenue integrity and reducing survey/certification risk, minimizing claims rejection, and enhancing revenue capture.  Providers cannot effectively, internally audit themselves.  Outside resources are the best resource and one that should, by doing the proper work, pay for their use.  Effective audits conduct the following reviews.
   • Match the assessment (MDS, OASIS, etc.) to the plan of care to the level/category billed.  This ensures proper coding and consistent billing.
   • Reviews the patient chart documentation of care provided to the assessment, plan of care, and level/services billed.  THIS IS THE BIGGEST CMS/RAC AUDIT RISK ORGANIZATIONS HAVE. CMS has outright said that documentation that doesn’t support the claim billed, and the level of care assessed is a significant issue.  An earlier post I wrote covers this topic and is available here: https://rhislop3.com/2023/06/01/snfs-get-ready-claims-audits-start-soon/
   • Review coding to OASIS, MDS for outliers – short stays, LUPA, etc.  I also like to look at risk areas when conducting these audits such as rehospitalizations, change of condition, emergency care transfers, etc.
2. Policy/Procedures – Providers are known to have big binders of policies and procedures that are never cracked and worse, unknown to staff in terms of content.  Health care fixates on policies and procedures, generating reams of paper compliance disconnected from reality, posing a HUGE survey and certification risk and fertile ground in a litigation situation.  Policies and procedures need to be routinely reviewed as part of the QAPI process and periodically, I recommend a review from an external expert.  Here’s why…
   • Often, many policies can be deleted, reducing risk.
   • Protocols are better suited than a policy.
   • Standards of practice can replace many policies as can algorithms, care pathways, etc.
   • Policies are too wordy and vague, causing staff to be uncertain or worse, oblivious to the policy.
   • Policies can be dated and inconsistent with current requirements or current standards. 
   • Procedures really need to be minimized and replace with or tied to, standards of practice.
3. Organizational Assessment – SNFs have this requirement and accredited HHAs and Hospices do too.  Basically, this process is simple though I have seen providers over-complicate it and turn it into a binder that no one looks at or understands.  The core is simple and can be really useful.
   • Given the normal daily, organizational resources (staff, management, equipment, facilities, etc.), what volume and acuity of patient can the organization safely care for.
   • What options/resources can become available to flex for higher volumes, higher acuity levels.
   • What are the organization’s care outcomes and compliance history and what QAPI projects are necessary to create improvements.
   • What is the normative payer mix/revenue model.  What is expense pro-forma tied to the revenue model.
4. Management Competency – The biggest risk most organizations have daily is management, line and executive.  The notion that management on most days is fully capable and competent is silly.  Turnover of staff is nearly 100% attributable to bad management, line and organizational.  Litigation is often a function of management not having resources, support, solid governance or core competency to operate within the constructs of daily life/the business that the provider is in.  Minimizing the risk posed by management capacity and competency requires an ongoing commitment organizationally, to management training and development. Conferences, by the way, are not the best source of this training.  Three important categories of development are required and ongoing.
   • Core business knowledge of the industry and operations that the provider works within.  Sadly, I have seen way too many times administrators to COOs, VPs, even CEOs (and most definitely, Boards) that lack core fundamental knowledge of the business they are in.  They don’t read, stay current, and know the basics of billings, revenue, program requirements, industry trends, challenges, etc. 
   • Basic HR, Finance, and operations knowledge such that the same matches their scope of responsibility.  Too many health care managers have never run a business, don’t have a business background, have no real tools for their work in terms of core competency found via business education, etc.  This is very true of technical leaders that climbed the ladder via clinical expertise.
   • CQI – planning development for sure, continued industry knowledge development, interpersonal and communication skills, expanding technical knowledge (going to lead an organization with a hospice, better learn hospice, etc.).
5. QAPI – Really good, really interwoven QAPI (quality assurance, performance improvement) programs can mitigate a bunch of risks and serve as a solid foundation for everything from revenue integrity, to policy and procedure development and reviews, to advancing best practices. to resolving patient complaints/concerns and poor outcomes to being survey/certification ready, daily.  QAPI at this level is not an exercise to be compliant, it is a culture that runs through the organization, all staff levels up to senior leadership and governance.  Into the way, way back machine, here’s a post on QAPI that provides the roadmap: https://rhislop3.com/2013/09/20/qapi-whats-it-all-about/    The presentations page on this site also includes a couple of QAPI presentations I did at various conferences.