Conferences help CMs, MDs agree on avoidable days
Meetings were learning experience for both groups
When an analysis of case management showed that physician advisors and clinical case managers often disagreed about attributing avoidable days to physicians, Judy Milne, RN, MSN, CPHQ, decided to turn the discrepancies into a learning experience for the entire team.
At Sarasota (FL) Memorial Hospital, where Milne is director of integrated case management and quality improvement, avoidable days must be attributed to either the system or to physicians.
Physician avoidable days mean the physician isn’t taking the necessary steps to progress the patient’s care and recovery or has failed to write a discharge order.
System delays include occasions when the patient or family hasn’t made a final decision about a post-acute facility, when there is no vacant bed at the receiving facility, or when there are other factors that do not relate specifically to the physician’s plan of care.
A physician advisor has to concur with the clinical case manager’s assessment before the avoidable day can be attributed to a physician. The hospital has two physician advisors who work part time with the case managers. One is a surgeon; the other is the medical director, who reviews the nonsurgical cases.
When Milne began tracking avoidable days by physician, the agreement rate between the clinical case manager and the physician advisors was only 50%.
"As we evolved the role of our physician advisor, we reached a point where the clinical case managers were frustrated, because at least half the time, the physician advisors would reject attributing the avoidable day to the attending physician. The case managers felt like the physician advisors were not reviewing the cases based on criteria but were using their gut reaction," she says.
Milne’s team started digging to find out why there was such a discrepancy between what the clinical case managers believed and what the physician advisors decided.
"We wanted to find the reason for the lack of agreement and work to enhance the capability for both parties. Sometimes it was because the physician advisor wasn’t as educated about continued-stay criteria as the case managers, sometimes it was a question of the physician’s judgment, and sometimes it was due to relationships of the physician advisor with the physician being reviewed," she says.
The team started daily avoidable-day rounds, a meeting in which both physician advisors met with all the case managers. Previously, the physician advisors would meet individually on the unit with the case managers who were reporting avoidable days.
"We used these meetings as a substantial learning opportunity for both the clinical case managers and the physician advisors. The team conferences got all the issues out into the open, and each member of the team learned from it," she says.
When the rounds started, the team set a goal of 60% agreement.
"The avoidable day meetings were an amazing success. We soon had an agreement rate that was in the 90th percentile and above. That’s when we stopped monitoring it so intensely," Milne says.
During the meetings, each case manager would present a potential avoidable day, and the entire team would discuss it and reach a conclusion about whether it was an avoidable day and whether it should be attributed to a physician or the system.
Often there were a number of factors that affected the discrepancy between the case manager’s evaluation and the physician advisor’s decision.
For instance, even though some cases didn’t appear to meet criteria by the book, the patient was still at risk, and an additional day in the hospital was appropriate, Milne says.
"Everybody learned the kind of clinical judgment a physician would have about a particular case. Now if a case manager encounters a similar situation, they wouldn’t even consider making it an avoidable day," she says.
The clinical case managers took the opportunity to educate the physician advisors about Medicare guidelines and other criteria.
"The learning was a two-way street. It helped the physicians understand and interpret criteria and helped the case managers learn that some cases were not necessarily an avoidable day but were cases when care wasn’t being provided at the right level," she says.
Now the avoidable day review certification is handled through the hospital’s case management software.
When case managers find potential avoidable days attributable to a physician, they refer the cases for review, using the case management software. When the physician advisors go through the cases on the computer, they review each case and, based on the review, may talk to the attending physician. The involved physician is notified via an auto-fax to his or her office with basic case information.
The physician advisor enters his or her conclusions into the software, where the case manager can access them and document the final outcome in the system.
The case managers and physicians still call each other if there are questions.
The physician advisors conduct a monthly retrospective audit on the percent of cases identified as avoidable days. The number of avoidable days is down to 11.5%, a dramatic drop from the 1997 rate of 45%, when the hospital started its case management initiatives. The case management team has a target of capturing at least 50% of the avoidable days.
"When we look at avoidable days, we can identify them by category and determine if there is an area of opportunity from an operational standpoint or look at diagnoses that seem to be problematic or physicians that have more avoidable days than their peers," Milne says.
The hospital sends reports to each physician who had more than six physician-related avoidable days in a quarter, giving specific information on the days, including a comparison to the hospitalwide physician avoidable day rate.
When an analysis of case management showed that physician advisors and clinical case managers often disagreed about attributing avoidable days to physicians, Judy Milne, RN, MSN, CPHQ, decided to turn the discrepancies into a learning experience for the entire team.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content. TESTING
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