The role of staff in meeting quality metrics

In the current world of medical reimbursement, a doctor’s revenue is often tied to quality. Insurance companies will pay bonuses to doctors for better care. To obtain these extra monies, however, practices need to meet certain metrics that are designed to provide a higher quality of patient care and decrease costs. Meeting these quality metrics requires the help of the entire office staff, not just the physicians. Our office is currently revising our job descriptions, because everyone’s job is changing.

So what are some of these quality metrics that an office might chase? Currently, our office can receive bonus dollars if we can convince a percentage of our age-appropriate patients to get their colonoscopies and mammograms. There is also money available if we can convince patients with diabetes to undergo yearly urine tests for microalbumin.

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Another quality metric involves getting our patients with diabetes to have hemoglobin A1C levels under 8.0%, blood pressures less than 130/80 and LDL cholesterols of under 100. If we can get all three of these reports on a percentage of diabetic patients to meet our goals, then we earn substantial bonuses.

An additional quality issue, albeit one much easier for our office to obtain, is screening every patient over 65 for falls. If we can document that we have asked a certain percentage of our patients this question, we can make more money.

There are many barriers to fulfilling our quality requirements, including lack of time in an office visit, noncompliant patients, and medication costs. But the availability of trained staff to help pursue quality should not be one of them.

Our office has been slowly evolving staff responsibilities to handle the onslaught of data entry, phone calls, letter mailings and information tracking we are required to handle.

Our receptionist doesn’t just answer phones and schedule appointments, for example. With the advent of electronic health records (EHR), the changes to front staff duties has been substantial. With no paper charts to file and search for, the front staff seems to have more downtime than  the nursing staff. We decided, therefore, to assign much of the audit/quality improvement work to the front staff. We now have an audit specialist working ‘upfront.’ She is in charge of pursuing quality by tracking patients on the audit list to be sure they meet the required goals.

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If a patient hasn’t had her mammogram, she sends a letter or an email via the electronic portal. If a patient isn’t at goal with his A1C, she generates a new telephone message and sends it to the patient’s physician. The physician then has the option of reviewing the medications and deciding if pushing the dose or adding medications would be appropriate for the patient.

Often in a given office encounter, the physician does not have adequate time to address every issue. If a patient presents with acute depression because his or her spouse just died, it is not necessarily the right time to say, “I see your diabetes isn’t to goal, let’s increase your medication.”

Next: How bonus payments are awarded

When, as a team, we meet the quality guidelines and receive a bonus, we award the audit specialist a bonus as well. She has a vested interest in performing well.

Not all of the audits and quality goals are appropriate for front office staff to handle. Some of the metrics are better pursued by a member of the nursing staff with a clinical background. We are participating in a program that rewards us financially for improving our coding by adding the high-risk codes that doctors sometimes neglect to enter during the office visit. For example, many of our patients have chronic kidney disease stages I to IV, but our doctors were not remembering to include that information at least once a year during a visit. Certainly, the physicians were considering it, because with any medication prescribed the glomular filtration rate needs to be taken into account.

If the patient presents with a urinary tract infection, and an antibiotic was recommended, you can be sure that the doctor was adjusting the antibiotic if the kidney function was down. By including these codes, the patient’s risk assessment factor (RAF) will be higher, because he or she is a more complex patient. The RAF is important, because more money is allocated for more-complex patients, so insurance companies need to know who requires a more intricate level of care. The nurse assigned to this audit needs to go through past office visits and document for the insurer whether the coding is still pertinent.

Again, if we receive a bonus for this work, we make sure to give our nurse a portion of it. This lets her know we appreciate her hard work and motivates her to keep it up. It also makes more sense for the nursing staff to ask the question regarding falls in the over- 65 group. because it is asked as part of obtaining patient vital signs. When the clinical staff brings back a patient, staff members  enter information regarding fall risk into the computer at the same time they are entering  blood pressure data. This allows for an easy capture of a quality measure.

Gone are the days of the vital signs being just blood pressure, pulse and temperature. Our vitals now include fall risk and smoking behaviors which a clinical staff member obtains before the doctor even enters the room. So the job description of the nurse is also expanding to include data entry.

Acquiring much of the quality metrics and audit information requires a team effort. Job descriptions have changed and the entire staff needs to work together to earn the bonus money. By assigning our detail- oriented existing staff to work the audits, we have been moderately successful in maintaining a reasonable income. All of this work is not just for the money. It would only be worth it if it improved our patient care.

The bottom line is that this effort does advance the health of our patients. The entire office can be proud and satisfied at the end of the work day, if we know our patients are getting the best possible care.

Lori Rousche, MD, is a physician owner in TriValley Primary Care, a seven-office primary care group in southeastern Pennsylvania. She has been practicing family medicine for 22 years.