Warning: Doctors' orders can cause problems

Here's how two agencies got delays under control

It's one of the worst ways to find out you have a problem: The Joint Commission surveyor comes in and finds something wrong where you didn't know a problem existed. That's exactly what happened to Rachel Ibarra, RN, BSN, compliance manager at Dallas-Ft. Worth (TX) Medical Center Home Health Department. The surveyor sent by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in Oakbrook Terrace, IL, noticed that physician orders weren't getting signed and returned in a timely manner.

Not only was the problem brought to her attention in an uncomfortable way, but it was one of the toughest kinds of problems to deal with. "Once those physicians' orders leave us, [the situation] is out of our control. We had to find a way to bring that control back to us."

Ibarra isn't alone. Irene Kangas, CHHE, president of Genesis Home Health and Hospice in Flint, MI, had a similar problem with recertifications. Both knew that the only way to solve the problem was to make the process quick and smooth when the orders were in their hands, and politely push the physicians to sign the orders and return them quickly.

Doctors' orders often took well over 30 days to return, Ibarra says. "The thing is, for Medicare, a verbal order is fine," she notes. "But for JCAHO, we have to orders back in 30 days. The priority before was that as long as we had the order in time for billing, then there wasn't a problem. But that's not so."

Ibarra started a process that has virtually eliminated the problem. The first step was to cut down the time the agency had the orders by as much as possible. Nurses went to an inservice that reminded them that when there is a verbal order, they need to get a written order quickly.

Schedulers also were brought into the picture. Now, when a nurse calls in with a verbal order, the scheduler writes it in a log. When a written order is received, the log line is checked off. "Before, no one checked to see if an order was ever written," Ibarra says. "Now it's really clear if we got it or not."

For Kangas, the problem was so significant that there were up to 50 outstanding recertifications at any one time from a patient load of about 8,500 visits per month. She attacked the problem by bringing in her clerical team and flowcharting the current process. The agency then set a goal of getting their 485s out within five days of admission.

Immediately, there was a snag. "Physicians said there was no way they could do that if there was a weekend," Kangas recalls. "We had to change it to five working days."

Other administrative functions were also studied. For example, was it possible for one person to review the forms instead of two? Kangas and her team even looked at whether something really had to be copied. By taking these steps at their ends, both Ibarra and Kangas report that they have successfully limited the impact of the physicians' delays in getting forms back to them.

The next step was to keep track of what orders were outstanding and go after them, says Kangas. Genesis Home Health and Hospice flags recerts that haven't been returned weekly for follow-up calls. If necessary, a duplicate is sent out. Kangas also has relied on her courier to develop a good working relationship with the physicians' office staffs. "She can go in and schmooze and get things moving again."

Kangas admits there is an element of pussy-footing around with the doctors, of not wanting to push them too hard or offend them in any way.

However, Ibarra has been more forceful in dealing with physician offices. She sends a memo letting them know it is a compliance issue. "We don't want them to think we are just bugging them," she says. "Then, if it still doesn't come back, we ask them if faxing is easier than sending it. Or, as a last resort, we'll send a field nurse who is in that area to pick it up, or a records person will do it."

Kangas is pleased that the agency successfully slashed its outstanding recerts from 50 last summer to 11 in April, but continues to tweak the process. "We're still working on this," she says. "It's a constant challenge for us. But if you listen to your staff and to their questions about why they are doing something, you can often find new ways to streamline. Those questions should get you thinking. After all, the staff know the work best."