Kusserow on Compliance: Debriefing complainants—24 question tips

It is very important to fully debrief any complainants and act in a very timely manner to avoid having them go elsewhere with their information—such as an attorney, government agency, media, etc. Any of these other channels could result in serious problems and possible liability. In many cases the information may come anonymously from the hotline, underscoring the importance that those answering the calls be trained on properly debriefing callers and be familiar with health care related issues.

Also, time is not a friend once information is received that may warrant immediate action. Complicating matters is that frequently a single complaint may include several different allegations, each of which needs to be addressed independently. In the debriefing process, once the story is told, specific clarifying questions need to be asked in guiding the person back through the information. This should be done by asking the standard WHO, WHAT, WHEN, WHERE, and WHY questions. These should be designed to expand on the factual details and to test and corroborate the information and be sure the chronologies of events are established.

It is important also to look for avenues and leads that will provide direction by which to either substantiate the allegations or dismiss them. Inasmuch as the allegations may relate to a specific event, something personal or organization wide, an ongoing process problem, etc. It is impossible to draft a set of question that would apply in every circumstance, however the following gives an idea about the types of questions that can be asked in a formal debriefing.

 

DEBRIEFING QUESTIONS

 

  1. What happened that led to the making of the complaint?
  2. Why are you coming forth with it now?
  3. What occurred, where, when, and how?
  4. Did the person who engaged in the conduct engage in similar conduct with anyone else?
  5. Has anyone else complained to you about similar conduct?
  6. When did it occur (date and time)?
  7. Where did it take place?
  8. How did you respond when it occurred?
  9. Who did you discuss it with and when? 
  10. What did you say? What did they say?
  11. How has this incident affected you?
  12. Has your job been affected in any way?
  13. Who else was present when the act occurred? 
  14. Where were they in relation to you? 
  15. Who else has any knowledge of the act? 
  16. Has anyone else discussed it with you? 
  17. If so, who and what did that person say? 
  18. Did anyone see you immediately after the act?
  19. Who else was involved, knows about, or witnessed it?
  20. Who else have you told (employees, supervisor, attorney, media,)?
  21. Why do you think it happened?
  22. What documentary evidence would help in the investigation?
  23. What do you believe should be done to resolve this matter?
  24. Has is happened before (an isolated event or part of a pattern)?

 

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on LinkedIn.

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Copyright © 2019 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: Medicare overpaying for graduate medical education (GME)

A study published in the Journal of the American Medical Association (JAMA) Internal Medicine raises questions about overpayments by Medicare for graduate medical education (GME) to train residents. By way of background, the Medicare Program makes payments to teaching hospitals for training physician residents. These payments are known as GME payments. Hospitals may also incur real and significant costs beyond training residents in the patient care setting. For those such costs, the Medicare Program makes direct GME (DGME) payments to hospitals for added direct costs incurred by teaching hospitals, such as stipends and/or fringe benefits paid to residents or to faculty who supervise the residents. The JAMA reported study suggests that if Medicare capped funds for GME at $150,000 per resident, it would free up over $1 billion a year and use the savings to address the shortage of doctors in certain specialties in underserved areas. The training of residents is funded by GME payments made to hospitals and health systems, largely through Medicare and Medicaid. Researchers examined cost reports to calculate GME payments to hospitals from 2000 to 2015 at among 1,624 teaching hospitals. The study found GME payment rates to hospitals in 2015 varied significantly, with 25 percent of hospitals receiving less than $105,761 while 25 percent received more than $182,233 per resident. Nearly half of teaching hospitals received more than the $150,000 per resident rate.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2019 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: Five major ambulatory risk areas

The Emergency Care Research Institute (ECRI) Institute analyzed 4,355 adverse events reported and found diagnostic testing errors pose the biggest risk to patients in ambulatory care settings with nearly half occurring in physician practices. Nearly half involved diagnostic testing errors with one fourth relating to medication safety and the remaining involving falls, security, and safety and privacy-related risks. The following risk areas were cited: 

Diagnostic testing errors. This is the leading cause of liability claims against primary care doctors and accounts for the highest proportion of payouts. Most of these errors involved laboratory tests. Other tests where problems occurred included imaging tests, pathology, and cardiology.

Medication safety events. Two-thirds of safety events were classified as wrong drug, wrong patient, or wrong time, the analysis found. Medication errors are a leading cause of malpractice claims in ambulatory care and can occur during any stage of the medication process. They are often the result of a series of failures within a system, the report said.

Falls. About half of the 800,000 hospitalizations from fall-related injuries occur in ambulatory settings in the exam room or waiting room.

HIPAA violations. Misunderstandings concerning HIPAA privacy and security rules prompted more than 350 HIPAA-related events to be reported to the ECRI Institute. The majority of these pertained to inadvertent disclosure of patients’ protected health information.

Security and safety incidents. Most such events involved verbal threats or disruptive behavior by patients or visitors.

Tips to Reduce Risks

 

  1. Provide decision support tools to assist in ordering the proper tests and monitoring processes for test tracking and follow-up.
  2. Standardized medication management procedures and create a policy directing how to report and manage safety events.
  3. Screen patients for fall risk at every visit, when a change in condition occurs and after a fall.
  4. Train staff on HIPAA Privacy/Security rules, particularly as they relate to disclosure of PHI.
  5. Train staff on what to do in the event of a violent incident and conduct monthly security and safety surveillance rounds.

 

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2019 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: New CMS proposed outpatient rules

The 2020 annual rule cycle has been active for CMS with several proposed rules in the outpatient prospective payment system (OPPS) area. Hospitals and health system executives should monitor these annual rules carefully for provisions that will affect their organizations’ operations. Among the significant regulatory rule proposals for hospital and health system executives are the following:

  1. Mandated disclosure of negotiated charges between health plans and hospitals for all items and services for about 300 “shoppable” services
  2. Proposed penalties which would be over $100,000 a year for noncompliant hospitals
  3. The addition of several ASC procedures
  4. The removal of total hip arthroplasty from the inpatient-only list for 2020, allowing the procedure to be performed on an outpatient basis
  5. Reduction of supervision level for hospital outpatient department from direct to general for hospital outpatient departments
  6. A requirement for prior authorization of certain outpatient department services.
  7. Continued payment reduction for 340B purchased drugs
  8. Increased per-day cost threshold for separate payment for certain outpatient drugs
  9. The establishment a prior authorization process for five categories of services that often may be cosmetic: blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, and vein ablation
  10. Various updates to Hospital Outpatient Quality Reporting Program requirements

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2019 Strategic Management Services, LLC. Published with permission.