The California Chapter of the RBMA convened Friday on the Queen Mary in Long Beach, California, with an agenda that addressed a quartet of the most compelling issues in radiology today: quality, the transition to ICD-10, and state and federal legislative and regulatory news.
The meeting got underway with a presentation from Lisa Mead, RN, MS, on “Quality as a Business Strategy: Designing a Program from Start to Finish.” Mead, a quality and leadership development consultant and former practice administrator of Scottsdale Medical Imaging, Ltd, provided a three-hour master class on the fundamental techniques and tools of quality improvement.
Noting that many practices approach quality as boxes to check off on government compliance programs, Mead says that a well-crafted program that seeks to limit unnecessary variation, utilizes dashboards, and establishes and measures benchmarks, will go further than meeting regulatory requirements.
“It will help drive your business,” she emphasizes. “You can use hope as a strategy, but it usually doesn’t motivate the masses to join your mission.”
Don’t be discouraged by the lack of benchmarks in radiology, which Mead acknowledges are underdeveloped. Winners in this game engage by identifying key business factors based on what is important to the organization and its value; examining how those tasks are performed and if they are repeatable; looking at how they are measured; and asking how they can be improved.
Benchmarks are best developed internally. “’Best is contextual,” she notes. “Best practices in one organization could be mediocre for another. You are trying to improve you.”
A Quality Culture
Before getting started, leadership must be engaged and committed to building a culture to support quality improvement. Move from who did it, to what happened, Mead says. A fair and just culture, she says, recognizes the difference between human error, risky behavior, and reckless behavior. “If we can hold people accountable for good behavior, we can really launch the program,” she says.
Whether you use the Baldrige framework (which is free and offers copious resources), the Boeing Process Management Model, Lean, or Six Sigma, all reviewed by Mead, quality improvement is less a destination than it is process management, based on a series of steps that repeat in a loop until the practice gets to a desired goal: plan, do, study, act, as identified in the Boeing model, then repeat.
“Devise and implement a plan for improvement and then start again,” Mead says. “You are always on a loop until you get the results you want."
Examples of processes to look at include quality plan development, peer review, scheduling, overtime reduction, and cycle time for PET, CT, and MRI. Mead reports that she resorted to the latter many times as a practice administrator to find the $6 million to $9 million she sought on an annual basis in response to reimbursement cuts.
Don’t be discouraged by the nagging question, why hasn’t this generated more improvement in our practice? “Excellence is a journey,” she reminds. “We are understanding what the whole business is about.”
ICD-10: Dreaded—and Ignored
“I want you to take all of the tools she just gave you and figure out how to use them for ICD-10, because it truly is a process of continuous quality improvement,” Karna W. Morrow, CPC, RCC, consultant for Atlanta-based Coding Strategies and an AHIMA-approved ICD-10 trainer, advises.
While reminding administrators that October 1, 2014, is an implementation deadline, not an enforcement deadline, Morrow bemoans the prevailing belief among radiology practices that ICD-10 compliance is a billing or coding responsibility.
“ICD-10 is not about your vendor,” she says. “I don’t care who they are or how many bells and whistles they have: At the end of the day, do they dictate the medical record?”
While the radiologist dictates the report, the entire practice must share responsibility for gathering the four pieces of information that ICD-10 requires of any bill: the location, the severity, the context, and the story/details.
“We have a lot of opportunities to impact the process before we even get to our radiologists,” Morrow says. “Figure out who owns the details and train accordingly.
The first line of defense is the scheduling office. “They need to proof the order and make sure that the four key components are there,” she says.
The second line of defense is registration, another opportunity to review the requisition and solicit additional detail from the patient.
The third line of defense is technologist. “You need to train them too,” Morrow says.
The fourth line is the radiologist. They need to know what has to be in the report, and dictation aids can be created to assist them. They can’t be expected, however, to include the necessary information unless it has already been gathered by someone with direct patient contact.
“It’s a shared responsibility,” Morrow emphasizes. “A lot of cancers, for instance, are going to require radiologists to code the use of alcohol and tobacco. You can’t expect radiologists to know that.”
The fifth line of defense is the referring physician, and Morrow reports that some proactive practices are doing lunch-and-learns with referring physicians to train them on how to fill out requisition forms, which must be revised to solicit the specificity ICD-10 demands.
Implementing ICD-10 is a massive undertaking, with productivity implications for everything from how much time it takes the radiologist to dictate the additional details required to the extra time it takes radiology billing personnel to type in an alpha-numeric code (as opposed to the current 10-key process).
Morrow recommends getting everyone on board now: “You are not going to do this along. We are expecting a denial rate to increase by 100% to 200%. You need to figure out how to minimize the impact to your practice.”
Two primary causes of denial within the scope of the practice are expected to be incomplete physician documentation (47%) and coding staff mistakes (12%). Morrow suggests double-coding 10% of “at-risk” studies, “and have the machine tell you which ones were a mistake.”
“You have to get this on the calendar now,” she says. “You can’t double-code until you’ve trained physicians in documentation.”
Start planning for every contingency today, Morrow advises. For instance, have a very specific conversation with your billing company if they are using natural language processing to find out where the engine is reading: the entire report or just the impression?
Manage the humanness of the conversion as well, Morrow advises. “Think about how to manage the stress in your office,” she says. Don’t wait until September to tell your coders that they can’t take a vacation in the final quarter of the year—especially if vacation time doesn’t rollover.
In the event that a dramatic decrease in cash flow ensures, make sure that sufficient dollars are in reserve to cover bills (and year-end bonuses) or secure a line of credit.
Morrow has already scheduled October and November appointments with her major payors.
“We are going to have to approach this in a lot of different ways to accomplish everything that needs to get done,” Morrow notes. “This is a huge project, and the biggest mistake we are going to make is assuming people know what they need to know.”