BY: DEBRA G. SALDI, M.S., RN, L.M.H.P. and ERICK L. HILL, Ph.D.
Health care reform, though a year or more from full phase-in, is already a fact of daily life for hospitals. It came early to our industry as the federal government stepped up pressure to standardize and upgrade our patient care and to track our progress by collecting and reporting all manner of patient data. Add now a new demand for hospitals that provide inpatient psychiatric care to provide statistics related to these patients.
Beginning later this year, all freestanding psychiatric hospitals and all hospitals with psychiatric beds that get reimbursed under Medicare's Prospective Payment System (PPS) must account for their patient care to the Centers for Medicare and Medicaid Services (CMS).
CMS will be holding these hospitals to a set of "core measures," or quality benchmarks, for inpatient psychiatric patients adopted in 2008 by the Joint Commission. The Joint Commission has published several of these core-measure sets in the past several years, mostly having to do with hospitals' treatment of patients with medical conditions like myocardial infarction, heart failure, stroke and pneumonia.
The psychiatric measures differ from the Joint Commission's other core-measure sets in a couple of significant ways. For one, they are not diagnosis-specific. For another, they are the only ones for behavioral as opposed to physical health.
In formulating them, the Joint Commission took a commendably deliberate, rigorous and collaborative approach, evolving them over several years of drafting, revising and testing. In the process, it listened to an 18-member panel of experts in the field plus, among other stakeholders, the National Association of State Mental Health Program Directors, the National Association of Psychiatric Health Systems and the American Psychiatric Association.
The results are the first widely recognized, evidence-based, national standards for quality, safety, consistency and accountability in the care of one of the most challenging and highest-risk groups of hospitalized patients: those with mental illness. And the mental health community generally welcomed them.
The Joint Commission stopped short of imposing the core measures, however. In 2011 it started requiring only freestanding psychiatric facilities to report their core-measure data as part of their accreditation process. For general hospitals with inpatient psychiatric units, the Joint Commission left reporting optional, and so it has remained.
Alegent Health — which merged in mid-2012 to form the Omaha, Neb.-based multi-hospital, multi-clinic Alegent Creighton Health — was in the latter category. It operates no freestanding psychiatric hospitals. Its inpatient psychiatric care consists of units in three general hospitals. With a total of about 200 beds altogetheitalicsr, it is one of the system's major service lines.
Alegent Health Creighton is totally committed to providing these services, despite low reimbursement rates that are driving similar units out of business nationwide. Alegent Health Creighton offers a full range of psychiatric services — inpatient care, along with emergency, outpatient and residential care — in keeping with its mission as a Catholic health care organization to continue the healing ministry of Jesus by serving the mental, physical and spiritual needs of all patients to the best of our abilities.
Alegent embraced the concept of psychiatric core measures from the beginning and took part in a pilot program as one of several sites nationwide to test and validate the measures as the Joint Commission began developing them in 2005.
Initially, five core measures were proposed. Finally, they became seven. As a test site, Alegent had a thorough education in the multiple challenges that go with implementing them. Though not required to do so, the system has continued to voluntarily comply with the core measures and submit its statistics to the Joint Commission.
Then, in October 2012, CMS announced it will start collecting psychiatric data measures from PPS-reimbursed psychiatric facilities in July 2013, retroactive to Oct. 1, 2012, discharges.
The announcement caught some hospitals off guard, without the proper practices or means to collect and report the required data in place. How, they wondered, could they possibly meet this year's looming deadline on what seemed like impossibly short notice? The key is to proceed with patience, deliberation and almost obsessive attention to detail in order to get up to core-measure speed.
As a guiding principle, Alegent Health Creighton adopted — and recommends — gap analysis, that is, constantly asking, What are the core measures asking of us that we aren't already doing? What steps must we take to become 100 percent compliant? This is the best way for hospitals to discover any significant differences between their current practices and those required for core-measure compliance. They will likely find, as Alegent Health Creighton did, that they have to make changes.
At Alegent Health Creighton, we learned that though we had been providing excellent care for our psychiatric patients, documentation of the core measure data was lacking. Thus, because we were not always doing everything precisely to core-measure specifications, we had to make adjustments.
Along the way, we overcame many inevitable technical as well as human obstacles.
We found, for instance, that the formats of many of our electronic medical records required major updating. Our information technology department redesigned them in order to capture the exact information in the exact ways the core measures required.
For an extra measure of certainty, we added an eight-tenths-time employee whose sole responsibility is chart abstraction — collecting core-measure data from patients' records, aggregating it and correctly formatting it.
Whether their records are electronic like ours or paper, hospitals just beginning to get up to core-measure speed can expect to confront these same challenges.
Some will face yet another technological hurdle: To make their CMS reports, all will have to use a CMS-approved software vendor or develop their own reporting systems. Alegent Health Creighton is fortunate in already having this capability.
While reprogramming our computers, Alegent Health Creighton was simultaneously reprogramming, so to speak, our staff of more than 200, including nurses, therapists, secretaries, technicians and physicians. All had something to learn. We introduced new employees to the core measures in their orientation sessions and met with existing employees in small groups and one-on-one, familiarizing them with the new procedures and documentations required by the core measures, each with multiple data elements.
Not surprisingly, some staff members showed some resistance as we put the psychiatric core measures in place. But because our hospitals had already implemented other Joint Commission core measures, employees were at least familiar with the concept and the critical importance of strict compliance.
We constantly emphasized — and continue to emphasize — the necessity of doing everything the core measures require, documenting all activities completely and reporting all data in the core measures' exact terminology. Everything must be done perfectly. Core measures make no allowance for error or omission.
The measures having to do with patient discharge have proved the hardest to follow. Discharge is always a busy time, with patients gathering their belongings, completing satisfaction surveys and reinforcing the learning about their medications. This is also when, according to the core measures, plans must be made for their follow-up care.
That's especially difficult in the cases of patients who leave the hospital against medical advice or are moving somewhere without an identifiable follow-up provider.
So far, CMS is demanding only that hospitals provide their psychiatric core-measure data. The agency has not yet established goals for the individual measures or consequences for hospitals that fail to collect and report their data. It's likely that CMS will eventually move to minimum acceptable standards and compulsory participation.
Of whatever kind, core measures are excellent evaluation tools for hospitals in general and in particular. They are helping to raise the quality of patient care at all hospitals and make it more consistent among them. Alegent Health Creighton looks to the core measures to show where and how to improve patient care and how we rate in that care relative to peers.
We have been especially eager to compare ourselves to others on the psychiatric core measures. The Joint Commission has only recently begun to release limited, relevant national data, but it has been enough to show that we are trending above average in almost all of these indicators. Still, we would like to know more. Unlike some of the reporting hospitals, Alegent Health Creighton's three inpatient psychiatric units care for all ages, children through geriatric patients. They vary greatly in their diagnoses and the severity of their symptoms. So far the Joint Commission has not released enough information to allow us to compare our results with those of other hospitals with similar patient populations.
Despite their limitations, we find the psychiatric core measures indispensible. We are constantly collecting and monitoring our data for indications of where and how we can raise our care to the highest possible level of excellence. As the core measures now help to remind us, that process is endless.
DEBRA G. SALDI is operations director, behavioral quality management services, for Omaha, Neb.-based Alegent Creighton Health.
IMPROVING CAREGIVER RESILIENCY AT LASTING HOPE
By Erick L. Hill, Ph.D.
Lasting Hope Recovery Center, located in Omaha, Neb., is one of three adult behavioral health inpatient treatment centers within the Alegent Creighton Health System. As the system strives to incorporate Centers for Medicare & Medicaid Services (CMS) core measures for inpatient psychiatric care, Lasting Hope also is focusing on promoting greater resiliency among clinical care providers.
As a freestanding, short-stay facility for patients in mental distress, Lasting Hope is a high-stress environment for caregivers, putting them at risk for burnout and compassion fatigue, and potentially compromising their ability to provide quality care. Care providers who are chronically stressed are more likely to make poor clinical decisions or commit clinical errors. Therefore, enhancing care provider resiliency enhances the quality of care.
In spring of 2011, Lasting Hope took part in a stress reduction study focused on supporting clinical nurses and nursing support staff to effectively manage stress in the workplace. Since that time, the 64-bed hospital has developed a series of services and supports for the clinical staff. Caregivers can attend workshops on compassion fatigue, learn self-help techniques and take advantage at regular intervals of a relaxation room — a gathering place stocked with stress-relieving tools such as exercise mats, electric massage chairs and meditation CDs. They are also encouraged to take part in Schwartz Center Rounds©, a peer-support program, and to use the HeartMath biofeedback program to monitor and reduce stress.
Lasting Hope's goal is to create a culture where care providers and people coping with stress are supported and encouraged to take responsibility for self-care. Workshops on compassion fatigue teach people the signs and symptoms of this stress-related disorder common to full-time caregivers and offer tips on how caregivers can better care for themselves. Schwartz Center Rounds©, a program that provides caregivers of different disciplines opportunities to come together to discuss emotional, social and spiritual effects of caregiving with supportive peers, have been shown to promote greater communication, teamwork and reduced stress in the workplace (www.theschwartzcenter.com).
HeartMath (www.heartmath.com) is another key component of Lasting Hope's resiliency program. A system of tools gathered in a software program developed in the early 1980s by researcher Doc Childre, HeartMath is designed to measure the effects of emotions on heart rhythms. The program helps people to assess and reduce their physical responses to stress with various techniques aimed at cultivating positive emotional states. Lasting Hope was able to make the program available to caregivers via computers in the relaxation room with an investment of less than $1,500 for software and accompanying workbooks. (HeartMath is available for a variety of age levels, and Lasting Hope, as part of its community benefit outreach, makes the program available to children in three Omaha public schools. The hospital pays the salaries of three behavioral therapists who are assigned to work full time with students in the schools, helping them to reduce school-related stress and take charge of their emotions using the computer biofeedback program.)
Although it is not yet possible to evaluate long-term effects of Lasting Hope's efforts to promote employee satisfaction and wellness, it does appear the hospital is moving in the right direction. In 2012, the hospital reported its highest employee engagement scores in four years (the time period in which the hospital has attempted measurements).
For those who work in health care, it isn't a matter of if, but when, a person's capacity to cope with stress and compassion fatigue will be tested. As organizational leaders, we owe it to our care providers to properly equip them with the skills and knowledge they need to proactively engage in self-care.
ERICK L. HILL is organizational and resiliency consultant, Lasting Hope Recovery Center, Omaha, Neb.
Copyright © 2013 by the Catholic Health Association of the United States
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