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Rory Staunton was an active, athletic 12 year old who cut his arm diving for a basketball at his school’s gym. The next day, he arrived at a hospital emergency department (ED) in pain, feverish, and vomiting. ED doctors administered fluids, prescribed acetaminophen, and sent him home. Three nights later, Rory died in the ICU from sepsis.
Stories similar to Rory Staunton’s have become all too common. Sepsis affects 750,000 hospitalized patients in the United States every year, according to the Centers for Disease Control and Prevention. In addition, a survey of California hospitals by Kaiser Permanente found that sepsis was a factor in approximately 44-55 percent of hospital deaths between 2010 and 2012.
In addition to causing immense suffering, sepsis cost the U.S. healthcare system $20 billion in 2011, according to the Agency for Healthcare Research and Quality. Yet, many sepsis complications and deaths could be prevented with earlier and more coordinated attention (see the exhibit below).
Two health systems and a coalition of nine hospitals are among the progressive organizations improving sepsis outcomes and reducing related costs:
To fast-track their sepsis improvement efforts, these early adopters built on existing knowledge and best practices—disseminated by the Surviving Sepsis Campaign (SSC) and the Institute for Healthcare Improvement (IHI)—to standardize how sepsis is diagnosed and treated. The three programs averaged 50 percent reductions in mortality rates for sepsis patients in approximately six years.
The best practices encouraged by SSC and IHI focus on screening a broad set of patients for sepsis risk factors and symptoms, providing early resuscitation, and diagnosing patients as quickly as possible.
For example, Intermountain developed an early-detection screening protocol for sepsis, which is adapted from standard systemic inflammatory response syndrome (SIRS) criteria for body temperature, heart rate, respiratory rate, and white blood cell count:
This computerized protocol can be accessed and implemented by physicians and registered nurses.
North Shore-LIJ also uses early detection and diagnosis protocols in its 12 EDs. These processes include early administration of antibiotics and fluids when warranted and lactate tests that can detect sepsis. This proactive treatment has decreased ED door-to-doctor time for patients suspected to have sepsis. The system’s medical/surgical units have implemented similar processes.
The UCSF Collaborative’s screening and diagnosis process requires clinical staff to check vital signs and review a patient’s history of infection and consciousness level. In addition to receiving formal training on screening and diagnosis, the delivery care teams are given on-the-job assignments to solidify their ability to perform the processes. For example, participating hospitals developed specific nurse-driven protocols, which allow the treating nurse to order a lactic-acid test based on a positive sepsis screen or initiate other elements of the protocol.
“The thinking was that you have to use the knowledge in the real setting and understand what works and what doesn’t work to make strides,” says Julie Kliger, the UCSF Collaborative program director.
The 2012 SSC International Guidelines for Management of Severe Sepsis and Septic Shock recommend the use of evidence-based protocols and order sets to treat sepsis as quickly as possible. Such guidelines help clinicians choose appropriate antibiotics and other treatments and track each patient's progress against goals for systolic blood pressure, mean arterial pressure, central venous pressure, and venous oxygen saturation.
Intermountain critical care specialist Terry P. Clemmer, MD, worked with colleagues to adapt SSC recommendations into a evidence-based treatment bundle?—that works best in Intermountain’s care settings (see the exhibit below). “In our opinion, this local adaptation is a key to quality improvement success,” says Todd L. Allen, MD, an Intermountain emergency medicine specialist.
In addition to aligning the SSC guidelines with its internal processes, North Shore-LIJ put a major focus on detecting patients in earlier stages of the sepsis spectrum. “Our guidelines address how to better identify and aggressively treat potential cases of severe sepsis prior to definitive diagnosis,” says John D'Angelo, MD, executive director and senior vice president, North Shore-LIJ’s emergency medicine service line, emphasizing the word “potential.”
For example, North Shore-LIJ set a standard to administer antibiotics to patients with severe sepsis within 60 minutes?a more aggressive goal than the SSC guideline of 180 minutes.
Meanwhile the UCSF Collaborative has adopted practical strategies to expedite sepsis treatment, including paging a hospitalist when a patient screens positive for sepsis, stocking antibiotics on the floors, immediately transferring severe sepsis patients to the ICU, promptly arranging a critical care consult, and developing or expanding a rapid response team.
Creating structures, goals, and processes to spur quality improvement was an important aspect of all three programs.
For example, Intermountain created the Intensive Medicine Clinical Program to organize improvement efforts around clinical processes and support services rather than around traditional clinical departments, says Allen. This program created a nonhierarchical environment in which team members from the system’s 22 EDs, 15 intensive care units (ICUs), and other settings could promote cross-disciplinary learning about sepsis, says Allen. “We tried to find best practices and common ground rather than to seek out someone to blame,” he explains. “Everyone has different strengths and weaknesses. Everyone has something to learn and to teach,” he states. Working as a team, the sepsis program participants aligned goals, organized with proper resources and data streams, and were able to “dial in on performance improvement,” Allen said.
North Shore-LIJ created systemwide expectations and measures around sepsis. “We not only agreed on what the performance measures should be but on the specific definitions so everyone was on the same page, and there was comfort in the integrity of the data as we compared venues and locations,” says Martin E. Doerfler, MD, senior VP, clinical strategy and development, and associate chief medical officer.
Another important change has been the emphasis on “teamwork is paramount,” adds D'Angelo. “We are becoming self-aware, self-critical, and self-correcting as a clinical community regarding improvement,” he observes.
The UCSF Collaborative gathered decision makers from its participating hospitals at eight full-day training days over the course of 22 months. Early in this process, leaders determined the program’s four core strategies.
Hospital leaders also agreed to two project goals: a 15 percent reduction in the sepsis baseline mortality rate and 80 percent compliance with using the sepsis bundle, says Kliger.
USCF Collaborative achieved its goal in a little under three years: The sepsis mortality rate across the nine hospitals declined from 28 percent in June 2008 to 15 percent in April 2011. In July 2013, the rate stood at 14 percent. The program’s analysis indicated a 56 percent ROI.
North Shore-LIJ has achieved similar results, lowering its sepsis mortality rate to the current 15.1 percent from 31.5 percent in 2009.
Meanwhile, Intermountain has achieved single-digit mortality rates, which are among the best documented in a peer-review process, Allen says. By achieving about 80 percent compliance with the system’s treatment bundle, Intermountain decreased the mortality rate to about 9 percent in 2011, saving 362 lives against baseline during the four-year span. Believing that further improvement is possible, the Salt Lake City-based health system is now focused on improving its 80 percent compliance rate, says Allen.
Emblematic of many tragic stories, Rory Staunton’s death from sepsis spurred “Rory’s Regulations” in New York?the first state to require the use of sepsis best practices. Meanwhile, throughout the nation, increasing numbers of hospitals are undertaking sepsis-related quality improvement initiatives, using the experiences of Intermountain, North Shore-LIJ, and the UCSF Collaborative as guides.
These efforts bode well for patients who otherwise would not survive sepsis and for hospitals looking to reduce unnecessary costs.
Ray Valek is president of Valek & Company, Inc., LaGrange, Ill.
Interviewed for this article:Todd L. Allen, MD, is assistant quality officer and medical director of the Emergency Department Development Team, Intermountain Healthcare, Salt Lake City.
Julie Kliger is senior director, Alvarez and Marsal, and former program director, University of California, San Francisco, Integrative Nurse Leadership Program, San Francisco.
Martin E. Doerfler, MD, is senior VP, clinical strategy and development, and associate chief medical officer, North Shore-LIJ, Great Neck, N.Y.
John D'Angelo, MD, is executive director and senior VP, emergency medicine service line, North Shore-LIJ.
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A senior leader of VitalWare talks about the need to create a comprehensive pricing strategy for consumers and how to get started.
HealthTrust: Solving Workforce Management Challenges
Two of HealthTrust’s senior leaders talk about strategies for optimizing the hospital workforce to improve productivity and reduce waste.
Grant Thornton: Optimizing the Ambulatory Workforce
One of Grant Thornton’s senior healthcare consultants addresses the topic of workforce management and the importance of a data-driven approach.
Cedar: Reimagining the Patient Financial Experience
Cedar’s CEO and co-founder tackles the topic of patient payment and the importance of having an innovative patient financial management system.
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Patient financial engagement is more challenging than ever – and more critical. With patient responsibility as a percentage of revenue on the rise, providers have seen their billing-related costs and accounts receivable levels increase. If increasing collection yield and reducing costs are a priority for your organization, the metrics outlined in this presentation will provide the framework you need to understand what’s working and what’s not, in order to guide your overall patient financial engagement initiatives and optimize results.
10 Ways to Reduce Patient Statement Volume (and Reduce Costs)
No two patients are the same. Each has a very personal healthcare experience, and each has distinct financial needs and preferences that have an impact on how, when and if they chose to pay their healthcare bill. It’s no longer effective to apply static billing techniques to solve the complex challenge of collecting balances from patients. The need to tailor financial conversations and payment options to individual needs and preferences is critical. This presentation provides 10 recommendations that will not only help you improve payment performance through a more tailored approach, but take control of rising collection costs.
Reduce Patient Balances Sent to Collection Agencies: Approaching New Problems with New Approaches
This white paper, written by Apex Vice President of Solutions and Services, Carrie Romandine, discusses the importance of patient segmentation and messaging specifically related to the patient revenue cycle. Applying strategic messaging that is tailored to each patient type will not only better educate consumers on payment options specific to their billing needs, but it will maximize the amount collected before sending to collections. Further, targeted messaging should be applied across all points of patient interaction (i.e. point of service, customer service, patient statements) and analyzed regularly for maximized results.
The Future of Online Patient Billing Portals
This white paper, written by Apex President Patrick Maurer, discusses methods to increase patient adoption of online payments. Providers are now seeking ways to incrementally collect more payments due from patients as well as speeding up the rate of collections. This white paper shows why patient-centric approaches to online payment portals are important complements to traditional provider-centric approaches.
Payment Portals Can Improve Self-Pay Collections and Support Meaningful Use
Increased electronic engagement between healthcare providers and patients provides significant opportunities for improving revenue cycle metrics and encouraging patients to access EHRs. This article, written by Apex Founder and CEO Brian Kueppers, explores a number of strategies to create synergy between patient billing, online payment portals and electronic health record (EHR) software to realize a high ROI in speed to payment, patient satisfaction and portal adoption for meaningful use.
Large Health System Drives 10% UP (Patient Payments) and 10% DOWN (Billing-related Costs)
Faced with a rising tide of bad debt, a large Southeastern healthcare system was seeing a sharp decline in net patient revenues. The need to improve collections was dire. By integrating critical tools and processes, the health system was able to increase online payments and improve its financial position. Taking a holistic approach increased overall collection yield by 10% while costs came down because the number of statements sent to patients fell by 10%, which equated to a $1.3M annualized improvement in patient cash over a six-month period. This case study explains how.
ICD-10: Managing Performance
With the ICD10 deadline quickly approaching and daily responsibilities not slowing down, final preparations for October 1 require strategic prioritization and laser focus.
Clarity Drives Collections
Read how Gwinnett Medical Center provides clear connections to financial information, offers multiple payment options for patients, and gives onsite staff the ability to collect payments at multiple points throughout the care process.
Orlando Health Gains Insight into Denials, Reduces A/R Days with RelayAnalytics Acuity
Read how Orlando Health was able to perform deeper dives into claims data to help the health system see claim rejections more quickly–even on the front end–and reduce A/R days.
Revenue Cycle Payment Clarity
To maintain fiscal fitness and boost patient satisfaction and loyalty, healthcare providers need visibility into when and how much they will be paid–by whom–and the ability to better navigate obstacles to payment. They need payment clarity. This whitepaper illuminates this concept that is winning fans at forward-thinking hospitals.
Streamlining the Patient Billing Process
Financial services staff are always looking for ways to improve the verification, billing and collections processes, and Munson Healthcare is no different. Read about how they streamlined the billing process to produce cleaner bills on the front end and helped financial services staff collect more than $1 million in additional upfront annual revenue in one year.
Wallace Thomson Hospital Automates to Maximize Limited Resources
Effective revenue cycle management can be a challenge for any hospital, but for smaller providers it is even tougher. Read how Wallace Thomson identified unreimbursed procedures, streamlined claims management, and improved its ability to determine charity eligibility.
7 Steps for Building and Funding Sustainability Projects
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Key Capital Considerations for Mergers and Acquisitions
Health care is a dynamic mergers and acquisitions market with numerous hospitals and health systems contemplating or pursuing formal arrangements with other entities. These relationships often pose a strategic benefit, such as enhancing competencies across the continuum, facilitating economies of scale, or giving the participants a competitive advantage in a crowded market. Underpinning any profitable acquisition is a robust capital planning strategy that ensures an organization reserves sufficient funds and efficiently onboards partners that advance the enterprise mission and values.
Key Capital Considerations for Mergers and Acquisitions
The success of healthcare mergers, acquisitions, and other affiliations is predicated in part on available capital, and the need for and sources of funding are considerations present throughout the partnering process, from choosing a partner to evaluating an arrangement’s capital needs to selecting an integration model to finding the right money source to finance the deal. This whitepaper offers several strategies that health system leaders have used to assess and manage capital needs for their growing networks.
Trend Watch: Providers adapt as value-based care moves from hype to reality
Announcements from several commercial payers and the Centers for Medicare and Medicaid Services (CMS) early in 2015 around increased efforts to form value-based contracts with providers seemed to point to an impending rise in risk-based contracting. Rather than wait for disruption from the outside in, health care providers are now making inroads on collaborating with payers on various risk-based contracting models to increase the value of health care from within.
Yuma Regional Medical Center case study
Yuma Regional Medical Center (YRMC) is a not-for-profit hospital serving a population of roughly 200,000 in Yuma and the surrounding communities.
Before becoming a ZirMed client, Yuma was attempting to manually monitor hundreds of thousands of charges which led to significant charge capture leakage. Learn how Yuma & ZirMed worked together to address underlying collections issues at the front end, thus increasing Yuma’s overall bottom line.
Reforming with a New 50-Bed Acute Care Facility
Kindred Hospital Rehabilitation Services works with partners to audit the market and the facility’s role in that market to identify opportunities for improvement. This approach leads to successes; Kindred’s clinical rehab and management expertise complements our partners’ strengths. Every facility and challenge is unique, and requires a full objective analysis.
5-Minute Briefing on Revenue Integrity Through HIM WhitePaper Hospitals FS
As the critical link between patient care and reimbursement, health information enables more complete and accurate revenue capture. This 5-Minute White Paper Briefing shares how to achieve cost-effective revenue integrity by your optimizing HIM systems.
5-Minute Briefing on Accelerating Cash Flow Through HIM WhitePaper Hospitals FS
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5-Minute Briefing on Reducing the Cost of RCM WhitePaper Hospitals FS
Qualified coders are getting harder to come by, and even the most seasoned professional can struggle with the complexity of ICD-10. This 5-Minute White Paper Briefing explains how partnerships can help improve coding and other key RCM operations potentially at a cost savings.
Providers Focus Too Much On Revenue Cycle Management
The point of managing your revenue cycle isn’t just to improve revenue and cash flow. It’s to do those things effectively by consistently following best practices— while spending as little time, money, and energy on them as possible.
Lucille Packard Children’s Hospital Stanford Case Study
How Lucile Packard Children’s Hospital Stanford increased payments received within 45 days by 20% and reduced paper submission claims by 70% by using ZirMed solutions.
Using Predictive Modeling To Detect Meaningful Correlations Across Claims Denials Data
The reasons claims are denied are so varied that managing denials can feel like chasing a thousand different tails. This situation is not surprising given that a hypothetical denial rate of just 5 percent translates to tens of thousands of denied claims per year for large hospitals—where real‐world denial rates often range from 12 to 22 percent. Read about how predictive modeling can detect meaningful correlations across claims denials data.
ZOLL and Emergency Mobile Health Care Case Study
Emergency Mobile Health Care (EMHC) was founded to be and remains an exclusively locally owned and operated emergency medical service organization; today EMHC serves a population of more than a million people in and around Memphis, answering 75,000 calls each year.
Maximizing Medicare Reimbursements White Paper
Since the Physician Quality Reporting Initiative (PQRI) introduction, CMS has paid more than $100 million in bonus payments to participants. However, these bonuses ended in 2015; providers who successfully meet the reporting requirements in 2016 will avoid the 2% negative payment adjustment in 2018, so now is the time to act! Included in this whitepaper are implications of increasing patient responsibility, collections best practices, and collections and internal control solutions.
Denials Deconstructed: Getting Your Claims Paid
Getting paid what your physician deserves—that’s the goal of every biller. Yet even for the best billers, achieving that success can be elusive when denials stand in the way of success, presenting challenges at every turn. Denials aren’t going away, but you can learn techniques to manage and even prevent them.Join practice management expert Elizabeth W. Woodcock, MBA, FACMPE, CPC, to: Discover methods to translate denial data into business intelligence to improve your bottom line, determine staff productivity benchmarks for billers, and recognize common mistakes in denial management.
Automation and Operational Improvement Drive Sustainable Results
Physician practices must improve organizational efficiency to compete in this era of reduced reimbursement and escalating administrative costs.
Revenue Cycle Management Resolves Migration Implementation Issues
Many healthcare organizations are pursuing next-generation health information systems solutions. Learn more about Navigant's work with University of Michigan Health System.
Partnering For Success – Provider Achieves Strength in Stability
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Building a Clinically-Integrated Network
As value-based payment models evolve, providers are challenged to maintain superior clinical outcomes while controlling costs.
Winning in the Post-Acute Marketplace
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Building A Common Vision with Employed Physicians
HSG helped the physicians and executives of St. Claire Regional in Morehead, Kentucky, define their shared vision for how the group would evolve over the next decade. As well as, develop the strategic and operational priorities which refocused and accelerated the group’s evolution.
Practice Performance Improvement
The client was a nine-hospital health system with 14 clinics serving communities in a multi-state market with very limited access to care, poor economic conditions, high unemployment, and a heavy Medicare/Medicaid/uninsured payer mix. In most of these communities, the system was the sole source of care.
Though the clinics were of substantial size (they employed 98 physicians) and comprised of multiple specialists, the physicians functioned as individuals and the practices lacked any real group culture.
Clinical Integration Without Spending a Fortune
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Contrary to popular belief, we have clients who have generated substantial shared savings and a significant ROI over time, without massive investments. Yes, some financial capital is required for resources the CIN providers can’t bring to the table themselves. But the size of that investment can be miniscule relative to the value it produces: improved outcomes and documentation for payers.
Adding Value to Physician Compensation
Today’s concerns about physician compensation are the result of the changing healthcare environment. The transition to value is slow, but finally becoming a reality. Proactive hospitals want to ensure that provider incentives are properly aligned with ever-increasing value-based demands.
This report focuses on the three big questions HSG receives about adding value to physician compensation; Why are organizations redesigning their provider compensation plans? What elements and parameters must be part of successful compensation plans? How are organizations implementing compensation changes?
Effective Revenue Cycle Management in Your Network
Revenue Cycle Management has become an even more complex issue with declining reimbursements, implementation of Electronic Health Records, evolving local carrier determinations (LCD), and payer credentialing [The emphasis on healthcare fraud, abuse and compliance has increased the importance of accuracy of data reporting and claims filing).
The efficiency of a medical practice’s billing operations has critical impact on the financial performance. In many cases, patient billings are the primary revenue source that pays staff salaries, provider compensation and overhead operating cost. Inefficiencies or inaccurate billing will contribute to operating losses.
Succeeding in Value-Based Care
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One common misconception is that the CIN can’t do anything significant until it has obtained the FTC’s “clinically integrated” stamp of approval. While the network must satisfy the FTC’s definition of clinical integration before single signature contracting for FFS rates and contracts can legally start, hospitals and providers can enjoy three key benefits during the development process.
Therapy: Benefits at All Levels of Care
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Does Your Budgeting Process Lack Accountability?
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Cost Accounting: the Key to Cost Management and Profitability
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