Study points out key barriers to compliance with CMS

Experts insist challenges can be overcome

An "Issue Brief" from Mathematica Policy Research Inc., published in March 2006, sheds some new light on the challenges that hospitals face in meeting compliance measures from the Centers for Medicare & Medicaid Services (CMS). The brief shares the results of its assessment of CMS's Hospital Quality Initiative, including a national telephone survey of hospital quality improvement directors, chief executive officers, and chief medical officers, on internal impacts of Hospital Compare. More than a quarter of the hospitals that showed a significant decline in a measure said the decline was due to documentation problems or bad outlier cases. For hospitals showing substantial room for improvement on one or more measures, survey responses revealed three main barriers to improving their scores:

  • Inaccurate documentation: Cited as a barrier by 90% of responses from both quality improvement directors and senior executives.
  • Failure to involve physicians: Reported by 76% of senior executives and 83% of quality improvement directors.
  • Insufficient resources: Between 70% and 76% of survey respondents cited a general lack of financial resources.

(The entire Issue Brief is available at the following web site:

Despite the large numbers of respondents who identified these barriers, quality experts assert they are not insurmountable.

"Actually, I view most of them as excuses rather than barriers," says Patrice L. Spath of Brown Spath Associates, Forest Grove, OR. "An example would be documentation. What will happen when we start getting paid based on how well we document charts? Hospitals have already spent quite a bit of time and money to address concurrent documentation enhancement to make sure they are documenting not just the right pneumonia, but including the organism, or if a patient has respiratory failure, making sure the code is properly documented so they will get a higher reimbursement."

The "documentation" referred to in the issue brief, she explains, involves issues such as smoking cessation counseling at the time of discharge. "If we can fix documentation for one reason, why can't we fix it for another?" she poses.

This carries over into physician involvement, and ultimately, resources, Spath says. "We should be setting priorities for what doctors ought to be involved in," she insists. "A lot of money has been spent on getting doctors trained to document correctly for higher reimbursement, but we don't seem to do it for higher quality care. If documentation, for example, is linked to payment — which it eventually may be — we will work a little harder to make sure things are documented the way they should be."

Accountability, ownership required

In addition to making these issues priorities, Spath continues, there are two other keys to improving compliance. "Yes, it does require, number one, that senior leaders and medical staff leadership say 'This is a priority,'" she observes. "Second, there needs to be a system of accountability. Senior leaders can't just say 'Nurses, you write this, docs, you write this,' and then never measure and monitor — or not have consequences when they don't to it."

She likens the situation to the improved DRG system. "The doctors do the records more quickly so they get paid quicker; it was a priority, and they put some teeth into it," she explains.

The third key, she says, is that compliance needs to be seen as an issue that everyone owns. "What I found interesting was, one of the questions was about whether the hospital lacks enough staff trained in QI," she observes. "The thing is, the QI staff doesn't own this issue; they don't own the responsibility for ensuring that patients get good, quality care. That's owned by the nurses, the physicians, the respiratory therapists, and so forth. In other words, it takes a team; it takes everyone having ownership."

For example, she notes, in some hospitals, case managers have become involved in aspects of ensuring proper documentation. "They are not process owners but members of the team who have some accountability," she notes.

One thing quality managers can do, says Spath, is to keep these issues in front of senior leaders — both medical staff and administration. "The comparative data are being shared with the public, so you can constantly remind them if your facility is not looking as good as everyone else," she suggests, "And that might prompt them to change their priorities. That's the first step; if they do not view this as a priority, the QI person will be running around trying to do it all by themselves."

Once priorities have been set and people have ownership, Spath continues, "The quality managers might be the ones who facilitate the group of people who get together and talk about how those priorities are going to be addressed."

Improving communication

At Palomar Pomerado Health in San Diego, Opal Reinbold, chief quality officer, says resources were not a problem when she joined the organization a year ago, but communication clearly was.

"There was not a clear understanding on the part of clinical staff in terms of what needed to be documented," she recalls. "I would fairly consistently run into nurses who said, 'I did that documentation; the quality people are collecting the data wrong.' The quality people, of course, said they weren't."

When they all sat down together, she says, there was a huge "Aha!" moment. The nurses who thought they were documenting what they should realized they weren't, and the quality people said they were looking for the documentation in the wrong places. "When you have 300 pages of instructions around what needs be documented, it's hard," Reinbold concedes. "People are not clear on what needs to be documented in order to get credit."

After the meetings, she says, "The nurses began documenting better and the quality people knew where to look. Everyone agreed to document in the same space at the same time, and we're trying to build some 'locks' in our system so that you can't go on with documenting until these sections are filled in."

One of the problems with physician involvement, she says, is that "people thought these were the quality department's initiatives," reinforcing Spath's point about ownership.

"They now realize these are research best practices, and eventually there will be pay-for-performance for physicians as well as hospitals," Reinbold says. "It's a shift in point of view we are helping the physicians understand through physician champions who are showing them how much better outcomes are, and how [compliance has] really made a big difference."

In the case of smaller community hospitals where it's hard to see every physician, Reinbold recommends "very strong partnerships with nursing and physicians, using standardized order sheets placed on the record by docs — with nurses checking and reminding them. In our case, case managers are involved, too."

At Calvert Memorial Hospital in Prince Frederick, MD, case management is intimately involved with compliance issues, says Jennifer Stinson, RN, CCM, director of case management.

The case management model

"Documentation goes hand in hand with physician involvement," she asserts. "And the degree of physician involvement depends a lot on the culture of the physician staff; some welcome change and some fight it all the way."

At Calvert Memorial, they have changed to what Stinson calls "a physician-centered case management model." This means that every physician is assigned a specific case manager, so they form a partnership. "Usually what happens is we allow the case manager to pick the physician they want to partner with; they contact them and set up a time to perhaps talk over the phone daily, or, if they are around later in the day, they can meet up in the unit and round with the physician," she explains.

Were there some physicians no case manager wanted as a partner? "We do have some challenging physicians," Stinson says, "But the case managers took them on as challenges. They have partnered with them and formed good relationships; we've seen not only financial improvement with utilization, but quality improvement as well."

The doctors have really taken to this initiative since it was introduced in January. "We've received nothing but positive input," she says.

The case manager, Stinson continues, is in a unique position. "Sometimes they are the only constant; you have different nurses on every shift, and docs may trade off, too," she notes. "The case manager has the unique ability to see globally what's going on with the patient."

Calvert has a clinical documentation improvement committee to help ensure compliance. "We use queries – little sticky notes put on charts — that are very diagnosis-specific," Stinson says. "For example, if a patient has anemia, we have a 'sticky' for the doctor to document if this is chronic or post-op. The post-op anemia generates a better payment, but you have to have the documentation there."

The staff are very data-driven, she adds. "They want data before they address any change," she says. "One thing we look at in documentation is case mix index — and it has been steadily going up."

Data also can be valuable in benchmarking your compliance against other facilities, says Reinbold. "We use Premier's data systems, and as part of that we have been participating in their demonstration project," she notes. "That has really helped us. There was a lot of focus and energy around this P4P pilot project in our organization, and a lot of energy came out of the quality department."

The good news, she says, is that their data look good. "We view it off the CMS web site, and have done spread sheets of our performance against all other hospitals in San Diego; we see how we're doing as the public might see it, as part of the demonstration project."

Reinbold says her system "looks good," although in some cases they are at 97% with certain indicators – which is not in the top two deciles (required for financial rewards).

"It's not just the data we're concerned about," she adds. "Our motto is, 'Every patient, every time, gets best practice care."

For more information, contact:

Opal Reinbold, Chief Quality Officer, Palomar Pomerado Health, San Diego, CA. Phone: (858) 523-9492. E-mail:

Patrice L. Spath, Brown Spath Associates, P.O. Box 721, Forest Grove, OR 97116. Phone: (503) 357-9185. E-mail:

Jennifer Stinson, RN, CCM, Director of Case Management, Calvert Memorial Hospital in Prince Frederick, MD. Phone: (410) 535-8217. E-mail: