Tired of tardy charts? Be nice, but have teeth
Try fiscal remedies before suspensions
When Rose Dunn surveyed her colleagues in the HIM field, she wasn’t surprised that 42% reported their hospitals do not consistently enforce penalties against physicians who are late completing their charts.
The reality of modern health care is that hospitals need revenue badly, and doctors bring in patients who produce that revenue. Taking harsh measures against physicians especially high admitters can cut off a source of revenue.
Dunn, RRA, CPA, FACHE, vice president of First Class Solutions, a St. Louis health care consulting company, says information managers must do a delicate balancing act when they set policies for chart completion.
"Hospitals aren’t occupied at 100% capacity as they were in the past, so it has to be a softer, nicer approach," she says. "However, it has to have some teeth or the physicians, like everyone else, will take advantage of the system and paperwork will the last thing that will be accomplished."
Here are her suggestions for taming this tiger:
• Get the backing you need.
Your specific approach may depend on the severity of the problem, but here are two steps Dunn says are critical:
1. Get the medical staff leadership to sign off on your policy.
2. Follow the policy regardless of the admitting volume of any individual physician.
"If either of those are not in place, failure will definitely occur," says Dunn.
• Try fiscal penalties first.
If you have the medical staff support and enforce the policy consistently, you still may have doctors who are late and who will place their medical staff positions in jeopardy. Start with a fiscal approach by setting fines, not suspension.
"The rationale for the fine rather than admitting privilege suspension is that when there is an admitting privilege or operating room or consulting privilege suspended, the person who gets penalized is the patient," says Dunn. "When a physician is suspended, he or she has to either move the patient to another hospital, which they typically do, or they’ll have another physician from the practice do the operation or consultation." That means the physician’s group still gets the revenue, but the patient has to go through the hassle of being moved. A fine specifically penalizes the person who caused the problem, not the patient, she says.
The fines need not be steep, she says, suggesting that $100 would be sufficient when a chart misses the completion deadline.
• Acceptable allowances.
While there should be no exceptions for physicians just because of their revenue-producing power, you should make exceptions for special circumstances, such as vacations and deaths in the family.
But make these exceptions specific, she says. For instance, a vacation exception might require that the physician not be seeing patients at the office. "Otherwise you’ll have physicians on vacation,’ but who are seeing a full schedule of patients at their office," Dunn says.
• The last resort suspensions.
If a physician is habitually late, a suspension of privileges may be unavoidable, Dunn says. "I don’t typically support suspensions, but I do when you have a really serious backlog problem and have had inconsistent enforcement in the past." Suspensions also can serve as a notice to all physicians that the hospital considers documentation to be a critical matter that will not be overlooked, she says. Once that message goes through, your hospital can return to a "softer, sweeter policy of the fines," she adds.
• Don’t dirty your own hands.
Any suspension should be handled by the hospital’s executive committee or its medical records committee, because it is a medical staff monitoring function, she says. The medical records department merely passes the information along, Dunn says. Remember that the policy should be a rule of the medical staff, not the HIM department.
While there must be no exceptions for high admitters, Dunn notes that frequently such physicians have adjunct people who could be allowed to help with the record handling. For instance, physician assistants, office nurses, or health information managers who work for doctors could prepare the files for a physician to review and sign.
Rewards also can be useful if certain problems are overcome. Some notable success is being reported in that area by David Chin, director of medical information for East Orange (NJ) Memorial Hospital, where prizes have help cut the number of delinquent charts dramatically and expedited hospital reimbursement. (For details, see story, p. 28.)
The faster pace of reimbursement comes with a small price tag, Chin says. "Even though we give away these prizes, the amount of money we spend is only a minimal amount compared to the millions we’re getting [in faster reimbursement]."
One reward-based alternative is a reverse fine, Dunn suggests. For instance, a physician who completes 98% of his or her charts within seven days of discharge could be given the same amount as he or she would be fined for not completing the charts. You might even want to consider using the fines paid by delinquent doctors to fund the reverse fine pool, she adds.
Dunn says she has seen fine pools that work well. "As soon as money is taken out of their billfold they become more attentive to the job of completing their records."
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