The Core Competencies of a Hospital Medicine Practice … · 2018-04-05 · Contents 1 Overview ... Member Elda Dede MPA University of Kentucky Health Care ... The foundation of any

Introduction and Background1

The Core Competencies of a Hospital Medicine Practice Administrator Updated: March 2018

Contents 1

Overview .....................................................................................................................3

Business Operations .................................................................................................5

Financial Management .............................................................................................9

Grants Management .................................................................................................13

Human Resources ......................................................................................................17

Information Management ........................................................................................21

Organizational Governance .....................................................................................25

Patient Care System ...................................................................................................29

Quality and Process Improvement ..........................................................................33

Risk Management ......................................................................................................37

Cont

ents

2

Thomas Jefferson

Nothing can stop the man with the right mental attitude from achieving his goal; nothing on earth can help the man with the wrong attitude.

Steven Covey

We need to have business leaders who live by deep, strong principles.

In 2011, the Society of Hospital Medicine's (SHM's) Practice Administrators Committee developed a white paper that documented the critical knowledge, skills and attitudes of a hospital medicine practice administrator to serve the following purposes: • Educate new hospital medicine practice administrators about their roles and responsibilities • Broaden the skill set of existing hospital medicine practice administrators • Help employers of hospitalists create job descriptions for hospital medicine practice administrators

The 2017-2018 committee decided to review and update the core competencies content and would like to thank the original team: Ajay K. Kharbanda, Kristi Gylten, Glenn Appelbaum, Deborah Haywood, Michael Brown, Roberta P. Himebaugh, Patrick Devereux, Amit Prachand, Kimberly Dickinson, Allen J. Schmalzer, Bradley J. Eshbaugh, Joanne M. Weissberger, Barbara J. Fry, Joseph Miller and Vicki-Lynne Gloger.

We hope with our combined efforts that this document will continue to provide value to the hospital medicine community. The 2017-2018 committee includes the following:

Position First Name Last Name Designation Company NameBDLSN Howard Epstein MD, SFHM PreferredOne Health PlansChair Roberta Himebaugh MBA, SFHM TeamHealth Hospital Medicine

Member Bishara Bates MHA, SFHM Johns Hopkins MedicineMember Elizabeth Canan MHA Mayo ClinicMember Elda Dede MPA University of Kentucky Health CareMember Lauren DeFrates MS Ochsner

Member Bradley Eshbaugh MBA, FACHE, FACMP, FHM INDIGO Health Partners

Member Rodney Hollis MHA Eskenazi HealthMember Stephen Keiser MHA Northwestern Medical Group

Member Tiffani Panek MA, SFHM CIMS-Johns Hopkins Bayview Med Ctr

Member Erin Yarbrough MBA University of Alabama at Birmingham (UAB) Hospital

Staff Patrick Vulgamore MPH Society of Hospital Medicine

Overview

Overview 3© 2017 The Society of Hospital Medicine

The foundation of any successful career begins with bringing the right attitudes to the job. As a hospital medicine practice administrator, you must have a strong set of guiding principles upon which to effectively build your core competency knowledge and skills.

As a hospital medicine practice administrator, you must:

Strive for personal excellence… • Maintain your poise and composure under pressure • Be flexible and adaptable • Accept responsibility and accountability for your actions • Solicit feedback and pursue ongoing education, growth and improvement

Communicate effectively… • Exercise persistence, assertiveness and confidence combined with diplomacy and tact • Establish strong working relationships with all stakeholders • Promote an environment of trust and respect • Recognize the importance of strong public relations

Adhere to the highest ethical standards… • Be the paradigm of operational excellence in your institution and within the

hospital medicine community • Be a role model of conduct, displaying honesty and transparency in all your activities • Create an environment of fairness and equity • Encourage and embrace diversity

Focus on governance… • Attend to critical issues while maintaining the ability to plan for the long term • Create an environment that promotes innovation and positive change • Adhere to principles of data integrity, security and confidentiality • Recognize that organizational structures and governance tend to be fluid

and evolutionary

Develop others… • Encourage, motivate and inspire those around you • Recognize efforts and achievements of others • Share credit – shine the light on the work and contributions of others

Attitudes and Principles

Attitudes and Principles4


Business Operations

Business Operations

IntroductionThe competency of Business Operations encompasses many domains such

as business development and strategic planning, regulatory compliance

and risk management, and group structure oversight and improvement.

Hospital medicine practice administrators must have an in-depth knowledge

of healthcare administration and medical group management, an awareness

of the current market and trends in the field, and strong analytical skills.

Effective business operations management requires not only technical

knowledge but also strong organizational relationships and the ability to

envision the “big picture.” Hospital medicine groups rely heavily on their

practice administrators to help them to be nimble in the fast-paced and

ever-changing world of hospital medicine, and to successfully bridge the gap

between high-level strategic planning and tactical implementation of day-to-

day processes that are sustainable, compliant and fiscally sound.

Business Operations6

Knowledge

• Understand the current state of hospital medicine and its history, and have a well-informed picture of the future landscape, including healthcare reform

• Recognize the market position, key strengths and challenges to determine the attributes that define the group

• Understand the nuances of applicable regulatory compliance requirements and how they impact operations

• Understand the legal implications of business arrangements commonly created in hospital medicine groups including provider service agreements, management service agreements, independent contractor definition and application related to labor laws

• Be familiar with the myriad patient-centered safety and quality initiatives common to the industry and within the hospital

• Be familiar with the key components of strategic planning, business planning, operational planning and creating SMART goals

• Understand the importance of maximizing all levels of stakeholder satisfaction throughout the organization

• Understand how the alignment and engagement of hospital departments has a positive impact on the hospital medicine group

• Understand and anticipate the need for expanded capital resources and know how to present the case for increased resources

• Understand essential operational metrics and their resultant impact on the group including but not limited to census, total encounters or visits, RVUs, length of stay, hospital readmissions, case mix index and the patient experience

• Understand the full scope of revenue cycle management, payor contract negotiation and subsidy requirements for the group

• Be familiar with the variety of scheduling and staffing options in hospital medicine groups• Understand how to implement a comprehensive and adaptable compensation and bonus

structure that appropriately aligns pay with performance and productivity• Understand strategic and business communications, marketing, financing options, public

policy/advocacy and public relations

Business Operations

Business Operations 7

Skills

• Clearly articulate a vision for hospital medicine that resonates with hospital administration, community hospital constituents and clinicians

• Craft business development strategies that support strategic growth and group branding initiatives

• Identify top metrics for the group and interpret and analyze information to effectively pinpoint areas that need improvement to shape the direction and goals of the group

• Routinely evaluate cost management strategies for efficiency and effectiveness, including lean principles

• Direct and participate in the development of organizational and group goals and assign responsibility and accountability

• Create goals that reflect the mission, vision and values of the group, and ensure that group goals align with the overall organizational strategy

• Communicate consistently, clearly and concisely with each level of the organization• Effectively manage and monitor partnerships and affiliations• Raise group visibility within the community and in the catchment area• Regularly evaluate group structure, including staffing, scheduling and compensation models, for

efficiency and efficacy• Ensure adequate infrastructure and resources to meet the operational goals of the group• Ensure provider contracts are current and accurately reflect provider activities including but not

limited to teaching, assistant and associate professorships, and leadership roles• Create systems that ensure timely provider credentialing, billing enrollment and onboarding• Integrate ethics into provider’s professional goals, performance appraisals and financial incentives• Oversee the compliance of the group in:

- Training and safety requirements- Documentation and resource utilization- Compliant billing procedures - Ethics and professional behavior

Business Operations

Business Operations8

Introduction and Background11 Introduction and Background11

Financial Management

IntroductionFinancial management systems are an integral part of the core

competency for a hospital medicine practice administrator.

Clinician reimbursement is primarily received through third

parties such as Medicare, Medicaid and other insurance companies.

The rules and regulations for appropriate and compliant billing

procedures are complex. In addition, clinicians are not always

facile in financial management and will rely heavily on the

practice administrator in this area. Because of the unique role that

hospitalists play in the management of patients, it is important

for the practice administrator to have a strong knowledge base

of hospital reimbursement and how clinical documentation and

group performance can impact hospital reimbursement.


Financial Management10

Knowledge• Understand, in depth, issues facing hospital medicine and healthcare in general (i.e., professional

services revenue, performance-based reimbursement, utilization issues, penalties, etc.)• Understand value-and performance-based reimbursement and relation to hospital medicine

outcomes• Understand hospital medicine’s role and ability to impact technical billing outcomes (focus is

currently on professional billing)• Understand hospital medicine’s ability to impact utilization within the institution (and related cost

savings)• Be familiar with ICD-10 – and the impact of transition from ICD-9• Be able to apply benchmarks and comparison analysis to assess how well the group is doing

compared to peers, opportunities for improvement/cost savings, etc.• Have a knowledge of reimbursement and its link to productivity to align revenue and compensation• Understand commonly used performance metrics including length of stay, readmission rates, etc.,

and the financial impact of such metrics on the hospital/facility and clinician • Understand the full scope of revenue cycle management, charge capture, and billing procedures

and processes, including a thorough knowledge of the clinicians’ CPT reimbursement system, as well as denials and impact of payor mix and associated reimbursement rates

• Be familiar with Medicare, Medicaid and other third-party (i.e., managed care plans) healthcare provider laws, rules and regulations

• Understand the nuances of accounts receivable management, collection procedures and processes, and laws associated with these activities

• Understand the financial information/reports necessary to evaluate hospital medicine groups• Know how to analyze the above-referenced financial reports to monitor group financial

performance• Be familiar with terms and conditions in clinician contracts, and monitor those contracts to optimize

payments to the group• Understand the preparation and monitoring of group budgets to achieve the group’s objectives• Understand the preparation and use of financial audits• Understand external controls necessary for effective cash management• Understand lending policies and procedures to effectively obtain outside financing for the group

should this become necessary• Understand the nuances of professional liability insurance to provide the group with adequate,

cost-effective insurance coverage• Understand payroll processes and procedures• Have a basic understanding of tax laws and their implication for hospital medicine groups• Have a basic understanding of new healthcare reimbursement models (accountable care

organizations, bundled payments, medical homes, etc.)• Have a comprehensive (working) knowledge of the financial industry and healthcare finance


Financial Management 11

Skills

• Ability to design compensation based on expected reimbursement from services rendered, hospital support or contract reimbursement

• Ability to work with dedicated financial professionals to produce working financial documents that are understandable and meaningful to the clinicians

• Ability to take complex financial data and simplify it for clinicians’ operational use• Ability to work with hospital administrative teams to align goals of group and facility • Experience translating process improvement, clinical outcomes and other performance-based

initiatives into financial terms to demonstrate the value of the hospital medicine group to hospital administration

• Experience developing financial proposals to secure the necessary programmatic resources within the institution

• Ability to calculate return on investmentt (ROI) and present it to hospital and group• Experience in developing and implementing changes in clinician compensation structure• Creative reporting and analysis

- Sample reports could include:- Individual clinician performance- Performance to quality metrics (group and hospital)- Length of stay and readmission- Business development reporting (sources of business)- Compensation analysis- Budgets and plans- Collections and accounts receivable- Third-party payor contracts analysis


Financial Management12


Grants Management

IntroductionAs the research interests of hospitalist faculty grow and funding

opportunities expand to support investigation into key topics

for hospital medicine and healthcare delivery, academic practice

administrators must be engaged in understanding the research

process and the intricacies of research administration to best

support their faculty. Key research topics for which hospitalist

faculty seek sponsorship in the form of grants include clinical

research (effectiveness of protocols), health service value and

quality improvement (readmissions interventions, impacts of

staffing models on patient satisfaction) and impacts of technology

on patient care (electronic health record [EHR] implementation).

Grants Management

Grants Management14

Knowledge

• Understand the general research process and the stewardship requirements driven by both the research sponsors and the home institution’s policies to support the faculty Principal Investigator’s (PI’s) successful execution of the grant award

• Understand the role of the PI, which may include the following:- Responsibility for the technical, administrative and fiscal management of the research project,

including subcontracts- It is important to acknowledge that grants are awarded to institutions, not to PIs;

a PI typically serves the role of being the institution’s project manager- Development of the research project- Reflecting accurate costs in proposal budgets- Ensuring costs are compliant with regulations- Providing sufficient time to process proposals- Disclosing and managing conflicts of interest/commitment- Complying with grant terms and conditions

• Understand the function of and develop a relationship with the various institutional-sponsored research groups (pre-award, post-award, compliance)

• Be familiar with the structure of local research administration expertise in the institution (typically within the Department of Medicine)

Grants Management

Grants Management 15

Skills

• Facilitate resolution of any potential barriers during the research (and the administration of research) process

• Be able to support faculty understanding of the entire research award process – from concept to award close-out. At a high level, the process consists of three elements:

- Pre-Award Administration- Proposal and Budget Development- Proposal Review, Approval, Submission, Processing

- Post-Award Administration- Award Acceptance and Account Establishment- Managing and Monitoring Projects

- Award Close-out

For specific information regarding research administration, visit the website of the National Council of University Research Administrators (http://www.ncura.edu/content/)• Maintain an interdependent relationship with PIs by providing administrative support on

sponsored projects. Support may consist of the following:- Completing appropriate forms- Developing budgets- Conducting quality assurance on proposals and sub-contracts- Submitting proposal to sponsor, when appropriate- Understanding of rules and regulations, including the “Uniform Administrative

Requirements, Cost Principles, and Audit Requirements for Federal Awards,” 2 CFR Part 200

- Monitoring financial and compliance controls for external funding- Coordinating communications to sponsors regarding changes in faculty effort,

personnel status and significant salary changes- Monitoring university communications for regulations, investigations and policies

related to effort reporting- Assisting in cases with high commitments of effort or other unique situations

• Assume a stewardship responsibility to funding agencies and the institution

Grants Management

Grants Management16


Human Resources

IntroductionThe job of human resources is to ensure that the organization

gets the most from its employees through assisting in the

establishment of successful teams, fostering of a productive and

supportive work environment, and providing clear pathways

for professional growth. The human resources function ensures

compliance with organizational and governmental laws and

policies and contributes to the organization by constantly

assessing the effectiveness of its departments and work groups,

and by sponsoring change. Key areas of focus include recruiting,

training and retaining employees; compensation and benefits;

employee development and engagement; employee relations

and performance; and compliance with health, safety and legal

requirements. It is a highly complex function, because it deals with

not just technical management issues but human ones as well.

Human Resources

Human Resources18

Knowledge

• Be familiar with the variety of models of staffing and scheduling structures in use at hospital medicine groups throughout the country and base design decisions off of established structures.

• Be aware of the assortment of methods available for recruitment of employees, including internal position postings, advertising in medical journals or on electronic career sites, etc.

• Understand the current market for hospitalist compensation and benefits as it relates to recruit-ment and retention of employees

• Understand the fundamentals of coaching, mentoring and adult-learner training strategies in guiding performance improvement of individuals and groups

• Be familiar with the available benefits that the organization offers, and when and how to access these benefits (e.g., family medical leave, short- and long-term disability, tuition benefits, etc.)

• Understand the importance of employee engagement in the success of a group, ensuring a focus on:

- Investment in employee learning and creating development opportunities- Creating autonomy and encouraging participation - Creating an environment where employees see their work as meaningful and worthwhile in

order to produce a culture of personal accountability and satisfaction• Understand the essentials of personality types, communication styles and conflict

management tools to effectively manage and supervise a group• Understand the fundamentals of creating high-functioning teams to bring diverse

groups of individuals together most effectively within the group • Be familiar with laws related to human resource issues including but not limited to

employee privacy, handling disciplinary and grievance issues, payroll and immigration• Be familiar with the mission, vision, values and goals of your institution• Implement and support talent development to ensure a productive workforce that

has the ongoing ability to meet changing job requirements• Be vigilant of burnout by recognizing signs and reacting accordingly to mitigate it• Ensure an effective succession plan is in place and review it annually

Human Resources

Human Resources 19

Skills

• Gauge labor needs on a continual basis to ensure sufficient and safe, but cost-effective, levels of staffing, including the consideration of alternate specialties or skills sets different from the current group model

• Work within the framework and payroll policies of the organization to devise strategic and creative compensation packages geared toward recruitment and retention of highly qualified employees

• Develop onboarding strategies designed to ensure thorough and efficient training of new hires and minimize downtime and non-productivity

• Clearly outline the duties of a position and expectations for performance, including skills, tasks and attitudes

• Perform regular informal review, as well as formal annual/semi-annual reviews, including assessment of job performance, setting goals for growth and improvement in the current position, and development of plans for career advancement beyond the current role including access to coaching and mentoring as needed

• Monitor employee morale and turnover rates on at least an annual basis and create programs to address concerns related to job satisfaction and retention

• Establish methods and pathways to communicate group and organizational needs and opportunities, and to encourage participation from all members of the team in these initiatives

• Establish practices and opportunities within your group to foster positive relationships, a strong sense of team and community, and collaboration with colleagues throughout the organization (e.g., group participation in charity work, multidisciplinary in-services and lunches, social events, etc.)

• Clearly communicate group and organizational processes for dealing with difficulties that may arise related to work performance, personal interactions with other employees and customers, etc., providing appropriate resources or disciplinary actions as needed in compliance with organizational and governmental requirements

• Serve as a role model for business ethics and be responsible for ensuring proper business ethics are applied and enforced within the group

• Ensure a balance between advocating for employees’ concerns and needs and protecting the organization and promoting its culture, values and goals

Human Resources

Human Resources20


Information Management


IntroductionInformation systems, whether automated or manual, are

a vital element of all organizations. They support the

organization’s daily operations and provide the data needed

for decision making. In healthcare organizations, information

systems have a unique importance because they support

the patient care process. The hospital medicine practice

administrator needs to take a leadership role in managing the

information systems resource, within the group itself, as part

of the broader hospital institution, and in relationship to the

systems of referring clinicians.

Information Management22

Knowledge

• Understand types of information technology (IT) systems and applications used in hospital medicine groups, including:

- Clinician group management and billing systems- Hospital administrative and clinical systems- Inpatient and outpatient electronic health record software

• Be familiar with vendor solutions for these systems• Understand how these systems interface and interact with one another• Understand the sources of information in the hospital and/or group (both systems

and people) to support analysis and reporting• Understand the systems and processes employed by office-based clinicians and

surgeons who refer patients to the hospital medicine group• Understand the issues and challenges of new system implementation and conversion of an

existing system, specifically as it applies to process redesign and data transformation

• Understand the Current Procedural Terminology (CPT) coding system, specifically regarding services related to admissions, discharges, inpatient visits and procedures performed by hos-pitalists

• Understand issues of data integrity, security and confidentiality according to the Health Insur-ance Portability and Accountability Act (HIPAA)

• Understand the definitions, regulations and reporting requirements of an information breach• Understand regulatory requirements for the prescribing, transmission and monitoring of pa-

tient medications• Understand reporting requirements for medical conditions as established by state

and federal Departments of Health• Understand requirements for disease, vaccine and other registries that require

clinician reporting• Understand federal and state requirements for biohazard and epidemic response

requirements


Information Management 23

Skills

Communication Systems• Establish secure communication systems for clinical and nonclinical staff to communicate

among themselves, with other hospital departments and with external healthcare providers and organizations

• Ensure good communication pathways through careful planning, selection of appropriate communication channels and a consistent professional message

• Oversee meeting management, including facilitation skills, agendas, decision-making processes and recordkeeping

• Foster ongoing development of effective interpersonal communication skills; build trust with other hospital departments and clinicians to ensure their support on issues related to systems planning, implementation, analysis and reporting

Information Systems Planning• Develop an effective information systems plan and budget (addressing both manual and technology

based systems) to support business needs and organizational goals, including an information system needs assessment

• Conduct cost-benefit analyses that justify the investment in new technology and systems• Conduct thorough review and evaluations of new software and hardware platforms to

support the effective use of group information• Document current and proposed systems and processes using flow charting and

documentation techniques• Together with other parties (e.g., hospital IT), ensure appropriate IT selection, procurement and

installation, including request for proposals, a selection committee, clinician buy-in, vendor relationships, contract negotiation and technical support

• Develop a plan to oversee database management and maintenance for systems internally maintained within the group

• Develop plans in conjunction with referral clinicians (primary care and subspecialty) to create/coordinate linkages for the hospitalist to use in obtaining patient records

Information Systems Implementation• Use effective coordination and project management skills to ensure effective technology

and systems implementation, including installation, training, work-flow redesign, process integration, reporting and ongoing support

• Ensure training and support for clinical and nonclinical staff• Gain clinicians’ acceptance of new information technology and systems, along with their active

engagement in implementationReporting and Analysis

• Develop and implement processes to provide reports to senior hospital leadership and other departments

• Develop and implement processes to provide data and reports that support internal group requirements (e.g., bonus calculations, staffing, etc.)

• Develop and implement processes to comply with mandated reports of specified patient issues to regulatory agencies

• Demonstrate data analysis skills


Information Management24


Organizational Governance


IntroductionOrganizational governance, comprising both people and

processes, plays a vital role in healthcare organizations. It

integrates the management team with the Board of Directors

to provide strategic direction and ensure the organization

fulfills its mission statement. Typically, the Board of Directors

consists of individuals with experience in multiple disciplines.

The Board is responsible for the principles and values that

guide the operating structure.

Often, an important priority for organizational governance is

accountability for regulatory compliance. While compliance

is essential, organizational governance should also focus on

identifying factors that affect an organization’s success or

failure. Specifically, in healthcare, improved outcomes must be

balanced with financial performance by the Board of Directors,

which establishes leadership and guides the overall direction

of the organization. Organizational governance can provide

the vehicle for monitoring and assessing risk, optimizing

performance, creating value and defining accountability.

Additionally, the Board can establish the framework for how an

organization influences its members, patients, customers and

other stakeholders to contribute to organizational goals.

Practice administrators link the group's day-to-day activities

with communicating and implementing the organization's

vision and policy objectives.

Organizational Governance26

Knowledge

• Understand the governance structure and roles/responsibilities of the Board of Directors, committees and management, including:

- Their roles, responsibilities, accountabilities and key success factors- Differentiation between issues that are the responsibility of the Board of Directors and is-

sues that are the responsibility of management- Realization that the Board of Directors alone bears ultimate responsibility, authority and

accountability for the organization• Be familiar with Robert’s Rules of Order• Be familiar with requirements for recordkeeping and documentation• Know how to develop plans and strategic initiatives• Be familiar with legal implications – accountability, liability, fiduciary responsibility and

regulatory considerations• Understand, define and enforce the ethical principles that apply to medical groups• Understand performance measurement, performance indicators and accountability• Understand the responsibility for defining the overall mission of the organization and

assuring that it is understood by management, staff and external audiences


Organizational Governance 27

Skills

Communications• Conduct Board meetings, including establishing an agenda and maintaining records • Facilitate Board-level discussion, build consensus and resolve conflicts• Establish a sub-structure to assure effective governance (Executive Committee, Board Committees,

etc.)• Establish clearly defined roles and functions of sub-structure to differentiate them from the

governing Board of Directors• Coach/train/orient Board members to be effective in carrying out their responsibilities

Monitor and Assess Risk• Create a forum that balances internal and external perspectives affecting the group• Assure oversight of group activities• Facilitate establishment of appropriate legal counsel• Encourage and lead participation in policy development at local, state and national levels• Assess the barriers and facilitating factors to effect change and incorporate those factors into a

strategic approach• Identify gaps in competencies and implement processes to address the gaps

Optimize Performance and Create Value• Optimize the relationships among healthcare value, quality and cost• Develop, monitor and maintain a set of group/organizational quality and client satisfaction measures• Create value through recognition and development of opportunities in the group• Make it an overarching obligation to ensure an organization’s resources and capabilities are

deployed for the benefit of the organization's stakeholdersContribute to Organizational Goals and Define Accountability

• Construct program mission, vision and value statements and articulate their message throughout the organization

• Develop strategic planning processes to establish group goals, determine accountability and identify indicators of achievement

• Ensure organizational and group alignment• Ensure alignment of executive and provider compensation plans with the organization’s strategic

goals• Develop a culture that embraces change and learning• Facilitate enhanced communication and transparency


Organizational Governance28


Patient Care System

Patient Care System

IntroductionPatient care systems entail designing business processes

to ensure safe, effective and efficient delivery of clinical

care. Hospital medicine groups are unique in that all

patient care is delivered in an inpatient environment

and, as such, group support staff may have little or

no face-to-face interaction with patients. Patient care

processes must be designed to support clinicians in

care delivery in acute care facilities and coordination of

transitions of care to the appropriate post-hospitalization

care providers. Group-level business processes must be

aligned with hospital/facility processes to ensure patient

safety, patient and provider satisfaction, optimal use

of institutional resources including provider schedule

efficiency, effective care transitions to the outpatient

setting and revenue cycle effectiveness.

Patient Care System30

Knowledge• Understand and explain business processes within the hospital medicine group and the hospital to ensure

alignment and integration of such practices, as well as safe, effective and efficient clinical operations

• Understand and apply the concepts of emerging models of healthcare delivery including patient-centered care, group redesign, etc.

• Understand, explain and monitor relevant patient outcome measures and quality of care metrics, as well as the impact on performance-based reimbursement models

• Understand, articulate and implement methods of effective patient, family and primary care clinician communication

• Understand the following:- Patient referral process- Patient education process and available resources to facilitate such education- Principles of clinical research studies- Institutional and programmatic patient flow process and volumes- Scheduling methodologies to optimize clinician staffing in periods of fluctuating volumes- Coverage models including backup and surge capacity options- Importance of confidentiality and compliance with the Health Insurance Portability and Accountability Act

(HIPAA)- Importance and implications of legislation and regulations affecting the practice of hospital

medicine- Importance of developing internal data tracking and reporting mechanisms to optimize resource utilization,

business operations and patient throughput (e.g., tracking volumes of Emergency Department admissions to enhance staffing levels at peak admission times to reduce patient wait times, etc.)

• Describe required system improvements needed to meet new healthcare legislation or public health guidelines and articulate programmatic and institutional impact of compliance and noncompliance

• Define and explain the role and value of hospitalists and hospital medicine groups; define metrics and develop scorecards to measure outcomes, identify trends and demonstrate value

• Understand and discuss commonly used hospital financial terminology, including but not limited to appropriate billing, coding and documentation; relative value units (RVUs); direct and indirect costs; average length of stay and case mix index

• Understand and define the components of a useful financial report

SkillsBusiness Processes

• Create work systems that connect the healthcare services and support processes to enable successful healthcare delivery. Link design of business processes at the group level to interface with facility processes to support effective and efficient clinical operations

• Understand the impact of facility-level clinical outcomes on provider outcomes with the aim of delivering services that lead to patient satisfaction and engagement

• Provide a focus and knowledge for providers and staff based on emerging healthcare trends

• Understand the impact of third-party payor contracts on hospital reimbursement and the implications of contract language on the hospital medicine group. Make recommendations for at-risk/quality metrics to managed care department/team negotiating on behalf of the institution

• Understand and identify opportunities to integrate clinical research at the facility level with clinician interests and individual leadership

Patient Care System

Patient Care System 31

• Understand and explain the potential impact of value-based initiatives on patient care, and expectations for individual hospitalists and hospital medicine groups

• Understand and explain patient satisfaction measures and scores, including HCAHPS, and relevance to hospital reimbursement

• Understand, explain and identify resources to stay abreast of and seek clarification on federal statutory restrictions on clinicians contracting with hospitals, third-party payors and groups. Possess adequate knowledge to guide and advise in-service line development and program growth initiatives

Patient Integration

• Design patient care support processes to meet operational needs for an environment where there is limited or no direct face-to-face support staff interaction with the patient

• Create processes (paper or electronic such as interface with facility IT department) to seek data from facility registration department or to have clinicians obtain patient demographic and payor information

• Establish a process to review facility paperwork for informed consent and approval for clinical outcomes; understanding treatment plan along with associated risk and anticipated outcomes; and patient educational material and delivery of such information

• Create a process for patient transition from acute setting to post-acute or back to primary care provider with regards to prescription and refill management

• Establish policy and procedures for termination of care and the patient relationship (additional caution to reflect patient status in the acute setting if the termination/transfer request is initiated by the patient or family)

Referral Management

• Create support processes to foster strong relationships with referring clinicians. Create effective communication processes using support staff and/or technology conforming to regulatory compliance associated with HIPAA and Stark

• Understand the referral process and payor requirements; decision regarding plan participation may be dependent on referring clinician payor distribution and facility participation

Provider Schedule/Patient Flow

• Understand development and communication of clinicians’ call schedule including managing call procedures for the group

• Understand and explain advantages of utilizing advanced clinician providers in a hospital medicine group

• Understand the impact of the different models of clinician compensation and incentives on patient care processes

Patient Registration

• Understand and develop effective patient registration process that may rely on facility registration process or information gathered by clinicians from other facility sources

• Understand group management software integration with facility system and/or charge capture system used by clinicians and/or data entry process from paper face sheets

• Understand and incorporate the necessary elements for effective and compliant billing, coding and revenue capture, audit and review, and process improvement in the design of patient care processes

• Understand compliance requirements associated with personnel files (e.g., The Commission and other regulatory agencies) to develop and implement a process to maintain compliant files especially in an environment where the group is a part of a hospital or integrated health system

Pharmaceutical Management

• Understand and describe the impact of medication formularies, utilization review requirements, third-party payor contracts and other policies impacting patient care

• Manage relationship with hospital pharmacy departments, pharmaceutical sales representatives and specialty clinicians who may control hospital formularies or access to certain medicines

Patient Care System

Patient Care System32


Quality and Process Improvement


IntroductionQuality and process improvement is the continual

monitoring and identification of opportunities for

improvement in both clinical and operational aspects.

The process also encompasses proactively pursuing

improvements by implementing policies and procedures

to maximize performance and optimize outcomes.

Areas of focus include, but are not limited to, patient

experience, patient safety and clinical outcomes, and

efficiency of clinical and operational services. Continuous

improvement requires a solid understanding of the

methods used in quality and process improvement, as well

as knowledge of the laws/regulations and quality

metric expectations affecting the hospitalist group.

Quality and Process Improvement34

Knowledge

• Understand the components of effective quality and/or process improvement programs used by healthcare entities (i.e., lean management, Six Sigma and total quality management)

• Be aware of the existing literature on quality and/or process improvement at other facilities and how to utilize this information in creation of best practices for your group

• Understand the components of evidence-based medicine and implementation of best practice tools, such as clinical pathways and protocols

• Understand laws, regulations and accreditation requirements relevant to the practice of hospital medicine, such as:

- Joint Commission on Accreditation of Healthcare Organizations (JCAHO)- Patient Safety and Quality Improvement Act- National Committee for Quality Assurance (NCQA)- Physician Quality Reporting System (PQRS)- Healthcare Effectiveness Data and Information Set (HEDIS)- Hospital credentialing and peer review

• Understand the Centers for Medicare & Medicaid Services’ Core Measures hospitalists are responsible for meeting (e.g., sepsis, DVT, medication reconciliation), know where to obtain hospital data and state/national comparison/benchmark data, and understand the implications of noncompliance with quality-related requirements

• Understand current policies and be aware of upcoming legislative changes related to medical record documentation and clinical reimbursement compliance

• Understand patient experience survey methodology and data and be aware of the utility, as well as the challenges, of applying this metric at both the group and individual level

• Be aware of key departments that provide resources for quality and process improvement projects – they may have existing QI initiatives underway

• Understand the principles of change management and how to successfully implement new programs within an organization


Quality and Process Improvement 35

Skills

• Ability to identify opportunities for quality and/or process improvement in clinical and operational arenas

• Ability to gather and analyze data through existing literature and related informational forums/resources, and synthesize this information into potential improvement pathways at your facility

• Ability to create an improvement project using the work-flow structures of lean, Six Sigma or other QI/PI project design, and successfully lead implementation of the project utilizing key principles of change management to ensure buy-in, support and sustainability

• Ability to function effectively as a leader or active participant of a multidisciplinary team, managing effectively both up and down within your organization

• Coordinate hospitalist improvement efforts with the efforts of other groups, such as Risk Management and QI/PI departments, to avoid duplication of effort and to ensure participation in these organizational programs as appropriate

• Monitor compliance and coordinate with organizational resources to implement group compliance with:

- Federal and state regulations related to quality and outcomes- Provider medical record documentation requirements- HIPAA regulations to ensure patient confidentiality- All state licensing and hospital credentialing- Medical record documentation

• Ability to use patient experience survey and other organizational data to develop action plans including, but not limited to, development of staff training or implementation of clinical pathways, protocols and order sets to improve patient experience


Quality and Process Improvement36


Risk Management

Risk Management

IntroductionRisk management is the process of identifying risks to

the hospital medicine group and proactively managing

such risks by implementing policies and procedures not

only to minimize exposure to these risks but also to set

up guidelines for how to handle such risks should they

develop. Such risks can be related to environmental issues

(physical workplace) or human behavior. Continual risk

assessment requires a solid understanding of the laws and

regulations affecting the hospital medicine group.

Risk Management38

Knowledge

• Understand possible adverse events and risk exposure- Patient care

- Negligence (breach of standard of care/reasonable person standards)- Medical error identification and prevention- Informed consent- HIPAA and patient confidentiality- Ethical issues (i.e., end-of-life care)

- Employment issues- Sexual harassment- Discrimination- Board of Directors’ fiduciary duty

• Understand and document compliance with hospital/health system policy, The Joint Commission, and state and federal laws related to notification of patients/families of adverse or potentially adverse events including medication errors, diagnostic errors and care delivery errors

• Understand hospital and/or health system’s process for patient notification of a HIPAA violation when a hospitalist patient is involved

• Understand impact of legal events on clinicians and the organization• Understand laws and regulations, whether federal, state or hospital, that are relevant to the

practice of hospital medicine, including but not limited to:- Emergency Medical Treatment and Labor Act (EMTALA)- Patient Safety and Quality Improvement Act- State licensing- Hospital credentialing, by-laws and peer review

• Understand the components of an effective compliance plan• Understand hospital/health system processes for compliance • Understand the impact of various types of disasters on the group, including but not limited to:

- Natural disasters (hurricane, flood, tornado, blizzard)- Fire- Bio-contamination- Mass shootings- Terrorist attacks

Risk Management

Risk Management 39

Skills

• Develop and implement a compliance program with the following elements:- Standards of conduct- Appointed compliance officer- Training

- Specifically, with respect to hospital and/or health system’s compliance initiatives (i.e., hand hygiene ) requiring annual compliance training

- Auditing- Ability for employees to report non-compliant activity- Disciplinary guidelines and corrective action initiatives

• Ensure compliance with federal and state regulations, including but not limited to:- U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG)- Clinician self-referral – Stark Law, anti-kickback law and antitrust- Centers for Medicare & Medicaid Services (CMS)- Health Insurance Portability and Accountability Act (HIPAA)- Occupational Safety and Health Administration (OSHA)- Centers for Disease Control and Prevention (CDC)- Employment laws and regulations

• Ensure compliance with provider billing and coding• Ensure compliance with legal requirements of recordkeeping, including record retention, storage,

retrieval and destruction• Obtain appropriate insurance coverage for the hospital medicine group that meets state

regulations and specific hospital/health system requirements- Professional liability- General liability- Property and casualty- Directors’ and officers' liability

• Ensure appropriate and timely response to subpoenas received by the group not only for medical records but also the group’s billing records, which requires establishing a process to direct patients to the hospital for medical records and a process for submitting the group’s additional billing records and notes

• Develop processes and policies for notification to insurance carriers that meet the carrier’s mandates as well as prudent business practice as related to adverse events, potentially adverse events and subpoenas

• Investigate all grievances, claims and complaints against the group, assessing legal ramifications using best practice information, relevant regulations and standards, and reasonable person standards

• Develop and use effective relationships with insurance brokers and legal counsel• Establish plan for disaster response and recovery to ensure continuation of group

- Ability to get critical staff to/from hospital- Protection and backup of group information (personnel files, patient information)

Risk Management

Risk Management40 © 2017 The Society of Hospital Medicine


Documents

The Core Competencies of a Hospital Medicine Practice … · 2018-04-05 · Contents 1 Overview ... Member Elda Dede MPA University of Kentucky Health Care ... The foundation of any