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Understanding Organizational Building Blocks · Building Blocks of all Organizational Systems Structure Committee Structure as “Information Highway” Board Hospital Medical Staff

Mar 17, 2020

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Page 1: Understanding Organizational Building Blocks · Building Blocks of all Organizational Systems Structure Committee Structure as “Information Highway” Board Hospital Medical Staff

Understanding Organizational Building Blocks

1© PACE Healthcare Consulting, LLC - 2015

Page 2: Understanding Organizational Building Blocks · Building Blocks of all Organizational Systems Structure Committee Structure as “Information Highway” Board Hospital Medical Staff

2

Building Blocks of all Organizational SystemsS

tru

ctu

re

Committee Structure as

“Information Highway”

Board

Hospital

Medical Staff

Organizational Structure

(Organization Charts)

Hospital

Medical Staff

Information Technology

Infrastructure & EMR

(WHAT)

Pro

cess

Board & Hospital Plans

(Compliance, Quality, UM)

Committee Minutes

IT Use & Access to Data

Policies and Procedures

Chart Review and Reporting

Education and Training

Rounding for Results

Human Resources &

Evaluations

Peer Review

(WHEN, WHERE, WHY)

Peo

ple

Staffing Levels

Staff Knowledge

Staff Training

Accountability

Culture

(WHO)

Continual Measurement and Accountability

© PACE Healthcare Consulting, LLC - 2015

Page 3: Understanding Organizational Building Blocks · Building Blocks of all Organizational Systems Structure Committee Structure as “Information Highway” Board Hospital Medical Staff

Traditional Organization ChartGoverning Board

Chief of Staff CEO

Business Development

Officer

Physician Relations

CNO

Clinical Departments

COO

Ancillary Departments

Quality Officer

Clinical Quality

Patient Safety/Risk

Infection ControlMedical Staff

Support

Care Management

CFO

Patient Financial Services and Registration

Controller

Accounting

Health Information

Mgmt Systems

Physician Advisor

Human Resources

Compliance Officer

3© PACE Healthcare Consulting, LLC - 2015

Page 4: Understanding Organizational Building Blocks · Building Blocks of all Organizational Systems Structure Committee Structure as “Information Highway” Board Hospital Medical Staff

Governing Board

Medical Executive

Committee

CEOCompliance

Officer

Performance

Improvement

Committee

Utilization

Review

Committee

(KPIs)

Chart Audit

Committee

Hospital

Departments

(KPIs)

Executive Team

Finance

Compliance

Committee

Revenue Cycle

Team

RAC/Billing

Compliance

Committee

Formal reporting structure

Lines of team collaboration, e.g. information sharing, cross-functional teams, etc.

Peer Review

Committee

(KPIs)

Qu

ali

ty D

ep

art

me

nt

an

d R

ep

ort

ing

Su

pp

ort

Str

uct

ure

, P

roce

ss,

an

d P

eo

ple

Performance

Improvement

Teams

Continuous

Survey

Readiness

Team

Developed by Elizabeth Lamkin, PACE

Committee Structure

4

© PACE Healthcare Consulting, LLC - 2015

Page 5: Understanding Organizational Building Blocks · Building Blocks of all Organizational Systems Structure Committee Structure as “Information Highway” Board Hospital Medical Staff

The Power of the Committee

Pearson's Law: "That which is measured improves. That which is measured and reported improves

exponentially." - Karl Pearson

5© PACE Healthcare Consulting, LLC - 2015

Page 6: Understanding Organizational Building Blocks · Building Blocks of all Organizational Systems Structure Committee Structure as “Information Highway” Board Hospital Medical Staff

Utilization Management Committee

© PACE Healthcare Consulting, LLC - 20156

Utilization Management Committee

Case Management Department KPIs

Physician Advisor KPIs

Physician Scorecard Reporting

RAC/Billing Compliance Committee

HIMMS Department

Departments

Committees

� Standard Chart Reviews� Peer Chart

Reviews

� Inter-disciplinary Chart Reviews

• Open • Closed• Special Studies

Quality Department

Information Flow

� Scorecards� Analytics

Business Intelligence & IT

Hospital KPIs / Scorecards

� KPIs� Performance

Improvement Projects

Other Hospital Departments /

Committees

Page 7: Understanding Organizational Building Blocks · Building Blocks of all Organizational Systems Structure Committee Structure as “Information Highway” Board Hospital Medical Staff

Your Team for Revenue Cycle Integrity

BusinessOfficeCare Management

NursingAncillariesHIMSFinance (Correct

Charge Master)

Care Management Physician Advisor Nursing

Medical StaffClinical StaffClinical DocumentationImprovement (CDI)HIMSIT

Finance FinanceCare Management

Finance

FinanceCare ManagementPhysician AdvisorComplianceFinance

ContractingCare Management

7

Physician LeaderHospital Leader

© PACE Healthcare Consulting, LLC - 2015

Page 8: Understanding Organizational Building Blocks · Building Blocks of all Organizational Systems Structure Committee Structure as “Information Highway” Board Hospital Medical Staff

For Herding Groups

8© PACE Healthcare Consulting, LLC - 2015

Page 9: Understanding Organizational Building Blocks · Building Blocks of all Organizational Systems Structure Committee Structure as “Information Highway” Board Hospital Medical Staff

Use Agendas to Provide Structure and a System of

Accountability for Outcomes

RAC Committee Meeting Agenda

Date: Time/Location:

Facilitator: Care Management Director Record Keeper: Administrative Assistant

Majority of Work is Completed Outside of Committee / Purpose: Committee has Oversight and Accountability of Structure, Process and People Related to RAC and Billing Compliance

9

# Topic/Action ItemsTime Limit (minutes)

Tab Responsible

1 Call to Order 1 Chair

2 Approve Minutes (distributed via email prior to meeting) 5 A All

3 Standing Reports

1) Update on RAC/OIG websites/Issues

2) Results of Risk Assessment

3) Actual Recoupment for Quarter

4) Other External Billing Audits in Process

5) Education: a) Staff b) Physicians

6) Chart Review (Variances/Trends)

7) Revenue Cycle (Denials/Bill Holds) Trends

10 B As assigned

4 Care Management/Physician Advisor Report (Variances)

1) Concurrent Chart Review Findings

a) Medical Necessity

b) Continued Stay

c) Other

2) Physician Issues (Trending Report/No Names)

3) Discharge Appropriateness

4) Code 44 Usage

5) Other issues

10 C Chair and PA

© PACE Healthcare Consulting, LLC - 2015

Page 10: Understanding Organizational Building Blocks · Building Blocks of all Organizational Systems Structure Committee Structure as “Information Highway” Board Hospital Medical Staff

Use Agendas (cont.)

10

# Topic/Action ItemsTime Limit (minutes)

Tab Responsible

6 RAC Correspondence

1) Pre-payment Audits

2) Post Payment Review Results Letters

a) Automated Reviews

b) Complex Reviews

c) Extrapolation

3) Demand Letters

4) Overpayment Amount

5) Reserve Set Up

6) Notification to Compliance/C-Suite

10 E Revenue Cycle

RAC

Coordinator

7 Appeals

1) Number of Claims that Meet Criteria for Appeal

2) Number of Actual Appeals

3) Percent Logged into Internal Appeal Tracking Database

4) Report on Active Appeals

5) Report on Appeal Status in Regional RAC Tracking

6) Appeals Requiring CEO Approval for Continuance (Cost/Benefit

Analysis)

5 F Care

Management

RAC

Coordinator

8 New or Old Business 5 All

9 Set time for next meeting 5 Chair

10 Adjourn 1 Chair

© PACE Healthcare Consulting, LLC - 2015

Page 11: Understanding Organizational Building Blocks · Building Blocks of all Organizational Systems Structure Committee Structure as “Information Highway” Board Hospital Medical Staff

Utilization Management Committee (UMC)

Example Utilization Management Committee Meeting Agenda

Date: Time/Location:

Chair: Physician

Facilitator: Care Management Director Record Keeper: Administrative Assistant

Majority of Work is Completed Outside of Committee / Purpose: Committee has Oversight and Accountability of Structure, Process and People Related to RAC and Billing Compliance

11

# TopicTime Limit (minutes)

Tab Responsible

1 Call to Order 1 Chair2 Approve Minutes (distributed via email prior to meeting) 5 A All3 Standard Reports/Scorecard:

Admissions/Length of Stay/CMITop Ten DRG’sFocus DRG’sReadmissionsAvoidable DaysDenialsOne Day StaysCompliance with Two-Midnight RuleObservation Bed Status and Hours Transfer Data for inpatient patient and ED Operative and Invasive Procedure ReviewPEPPER Report Summary

20 B All as assigned

© PACE Healthcare Consulting, LLC - 2015

Page 12: Understanding Organizational Building Blocks · Building Blocks of all Organizational Systems Structure Committee Structure as “Information Highway” Board Hospital Medical Staff

UM Agenda (cont.)

12

# TopicTime Limit (minutes)

Tab Responsible

4 Clinical Protocols Policy Reviews UR PI initiatives RAC Activity and UpdatesTracking and Trending of Physician UM Performance issuesReferrals to Peer Review

10 E All

5 Customize to Facility Needs 5 F All

6 New or Old Business 5 All7 Set time for next meeting 1 Chair8 Adjourn 1 Chair

© PACE Healthcare Consulting, LLC - 2015

Page 13: Understanding Organizational Building Blocks · Building Blocks of all Organizational Systems Structure Committee Structure as “Information Highway” Board Hospital Medical Staff

Section of UM Scorecard

© PACE Healthcare Consulting, LLC - 2015

Page 14: Understanding Organizational Building Blocks · Building Blocks of all Organizational Systems Structure Committee Structure as “Information Highway” Board Hospital Medical Staff

14

Physician Scorecard Reporting

Make sure you include additional indicators for 2 Midnight Rule and Observation Patients

© PACE Healthcare Consulting, LLC - 2015

Page 15: Understanding Organizational Building Blocks · Building Blocks of all Organizational Systems Structure Committee Structure as “Information Highway” Board Hospital Medical Staff

Administrative “Charting” Minutes

15© PACE Healthcare Consulting, LLC - 2015

Page 16: Understanding Organizational Building Blocks · Building Blocks of all Organizational Systems Structure Committee Structure as “Information Highway” Board Hospital Medical Staff

Elizabeth Lamkin

[email protected]

16© PACE Healthcare Consulting, LLC - 2015