Becker's Clinical Quality & Infection Control

19 Executive Briefing Sponsored by: The Case for Simplification: How Hospitals Can Get Clinicians Back to the Bedside T asked with the need to comply with a vast body of chang- ing regulations and the ever-shifting payer requirements for maximum reimbursement, hospitals have implement- ed a heavy load of clinical and operational policies in the name of compliance. As a result, clinicians are burdened with an enormous number of administrative tasks. These expectations, however well intended, actually place healthcare organizations at greater regulatory risk, reduce physician, nurse, and patient satisfaction and negatively impact quality and safety. A 2016 study published in the Annals of Internal Medicine found for every hour physicians worked directly with patients, they spend about two hours on reporting and desk work. A 2016 Mayo Clinic Proceedings study found clinicians who use electronic health and medical records and computerized physician order entry report lower levels of job satisfaction and higher rates of burnout compared to clinicians who use paper. The days of paper documentation may soon be in the past, leaving many in the industry wondering how to mitigate burn- out while also complying with CMS conditions of participation, as well as reporting requirements that ultimately dictate reim- bursement. Steven Bryant, president and CEO of The Greeley Company, a healthcare consulting, education and professional services provider, says the key to getting clinicians back to the bedside is to simplify expectations: get rid of unnecessary complexity in the documentation process. "We have seen universally that hospitals' EHRs are so robust and overcomplicated that they deprive clinicians of adequate time to assess and evaluate their patients," says Mr. Bryant. "Regulations and reporting requirements are fairly cut and dry, but hospitals' own efforts to be compliant are overly complex. There's a real irony there." Hospitals serve a lot of masters, but are often their own strictest taskmasters. It is the tendency of hospital leaders to think more is better when it comes to creating policies to ensure compliance with regulatory requirements. Therefore, hospitals' internal policies are often much stricter and more complex than federal, state and accreditation standards. This unnecessary complexity stems from healthcare professionals not fully understanding a standard's intricacies, according to Mr. Bryant. "What many healthcare leaders don't understand is that they must always comply with the strictest of the mix of federal, state, accreditation and internal policies," says Mr. Bryant. "When internal policies are drawn up and compounded to meet, but actually far exceed, federal or state requirements, they set a bar so high that it is hard to reach consistently, which then leaves a facility out of compliance. We have seen hun- dreds of facilities get into hot water with CMS because they can't meet their own impossible standards, but they would have met the federal requirements for Medicaid or Medicare reimbursement." In hospitals it is not uncommon to see a 20-page policy to address a single issue. "Greeley's position is that healthcare organizations should never exceed a federal, state or accreditation requirement unless the added process enhances quality, safety or revenue. But they almost always do," Mr. Bryant adds. "Exacerbating this challenge is the inherent misalignment between the overstated policy, actual clinical practice and EHR documentation expec- tations. The time spent serving this many masters is time taken away from direct patient care." How The Greeley Company gives time back to clinicians The Journal of Nursing Care Quality published a 2016 study that found nurses spend nearly 33 percent of their time inter- acting with technology. Approximately 11.5 percent of their time was spent documenting information into the EHR and only 7.2 percent was spent on patient care and bedside tasks. Mr. Bryant shared this example: CMS details the expectations for the management of patients in restraints in its Condition of Participation: Patient's Rights. CMS also requires hospital accreditors such as The Joint Commission to only hold hospi- tals who utilize accreditation for deemed status purposes to the federal restraint requirements. In practice, many hospitals still require physicians to reorder medical restraints every 24 hours or every calendar day. In fact, the CMS changed the ordering requirement years ago. While a physician or other licensed independent practitioner must initially order the restraint, the reorder frequency is up to the hospital to decide. Greeley recommends that the initial order remain in effect until the patient no longer meets restraint cri- teria. Greeley offers a model policy that has been adopted by facilities across the country. Beyond the order is the frequency nurses are expected to doc- ument a restrained patient's ongoing status. While nurses are

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