Hospital near-death experience
An organization's fight for survival after CMS decertification
After reading this article, you will be able to:
- Describe where an organization's goals can be counterintuitive to quality
- Discuss leadership's role in decertification
- Identify ways nursing staff are key to recertification
- Discuss physician involvement in rescuing the facility after CMS decertification
The threat of loss of accreditation is one that keeps survey coordinators and hospital leaders awake at night, but for most hospitals, it's more of a bogeyman than an actual threat-there are many stages an organization must go through and fail before their accrediting bodies slam the hammer down. However, a recent case of decertification and recertification by Medicare stands as a cautionary tale for hospitals across the country to never lose sight of the goals of quality and safety.
Compass Clinical Consulting, an independent consulting group, recently had the experience of helping one hospital recover from the rare event of decertification from CMS. (For the privacy of the organization, the hospital's name has been omitted from this article.)
"How we got here is pretty straightforward," says Kate Fenner, RN, PhD, managing director of Compass Clinical. "It was an organization with a very strong leader, and they were focused on entrepreneurship and building the base of the organization."
The organization had been fairly aggressive in acquisition and reservice, and its board of trustees was on board with this concept. An unintentional downside to this approach, however, was the neglect of day-to-day clinical operations, says Fenner.
"They got very involved with growth-it became their mantra," she says. "But making certain that their core business was well served did not hit high on the radar. Board meetings were dominated by financial discussions, acquisition discussions, real estate, and building, with little to no discussion about clinical quality or issues going on at the hospital."
This lack of attention to clinical operations did not go unnoticed. Physicians became concerned-so much so that one physician submitted a complaint to CMS, bringing the state survey office in. The physician's fears turned out to be legitimate, and the organization received an immediate jeopardy finding.
Too little too late
CMS wanted an action plan on how the deficiencies it found would be addressed. Amazingly, the board did not even know about the immediate jeopardy finding, says Fenner. Instead, the CEO-that same leader who had led the charge toward acquisition and growth-delegated addressing the CMS finding to the chief nursing officer (CNO), who was an interim CNO at the time.
"She did her best," says Fenner. But despite the CNO's efforts, CMS came back in and found the facility still out of compliance.
"The second immediate jeopardy had a tight timeline on it," says Fenner. "Their CEO chose to say, 'You can't do that to us.' Well, they can! CMS is like the IRS-they have a lot of power. And this was a legitimate clinical concern."
Despite this, the state government gave the facility another opportunity to save itself-the surveyors even chose to stay in the area over a weekend, coming back on Sunday night, to give the organization one more chance to clean up and comply.
"At this point they received notice of decertification," says Fenner, whose organization was brought in to help. "I wish they'd called us a week or two earlier."
Precipitation of the event
So what was happening at this hospital to bring it to this point? A complete lack of attention to the clinical side of things, says Fenner.
"I think what happens in cases like this is that leadership assumes that it's being attended to," she says. "Many leaders are not clinicians, and what we do in the areas of safety and quality can appear incredibly boring-wash your hands, two identifiers, the Universal Protocol™. This is not glamorous."
Nonclinicians assume these steps are being taken care of-but that's not the case if no one is paying attention to them, says Fenner.
There were several core issues that helped bring this organization's quality challenges to a head. First and foremost, there was a horrendous turnover rate in the nursing staff, as well as a high use of traveling and agency nurses.
What's more, the facility's temporary staff was being overseen by an interim CNO.
"If everyone is a temp, who owns this process?" says Fenner.
Further complicating matters was how the hospital handled its medical staff. "They had a superb medical staff, incredibly well trained, and they were kept completely out of medical operations," says Fenner. "There was not a tight relationship between quality, clinical, leadership, and staff. If you don't have all the players on the same page, it's hard to flow in the right direction."
Getting back on track
Step one was to bring the board up to speed. Fenner and her team called them almost immediately.
"At this point, the board had a mess and the CEO retired. They appointed an interim CEO, someone who hadn't been part of the problem," she says.
Next, Fenner's team warned the board that it was pointless at this juncture to try to litigate or appeal.
"There are no appeal mechanisms once you've been decertified," says Fenner. "There were opportunities earlier on, but once it's happened, it's done. It's like receiving a ruling."
So the task was set: The organization was not seeking to overturn the decertification. Instead, it was seeking recertification.
The organization would need to be surveyed from stem to stern-including areas that were not touched in the initial problems examined-and as such, it was very possible that more issues might be found.
"Everybody has to be dressed for the prom, so to speak," says Fenner.
The organization assembled a team from all areas of the hospital and put together a quality process because it had not been doing much in terms of data collection.
"And then we were to look at them until we could convince the state survey office they were ready," says Fenner.
In nothing short of a miracle, the organization was recertified in 110 days. "It usually takes a year or more," says Fenner.
But those 110 days were painful-that's almost four months with no Medicare reimbursement and almost no commercial payers. As Fenner describes it, "It's a near-death experience."
What went right
There were a few factors that came into play to make the recertification happen in such short order.
"First and foremost, the medical staff. They were chagrined when this happened. Most of the surgeons couldn't practice there. They couldn't admit patients there," says Fenner. "There was a mad scramble for privileges in other hospitals in the area. They were motivated and talented and got behind the effort with 100% enthusiasm."
Remarkably, out of the roughly 120 physicians practicing at the hospital, the organization lost only five or so during the decertification period. Despite taking an income hit and having every reason to worry about themselves first, the vast majority of the hospital's physicians put their shoulder to the wheel and helped push the facility toward recertification.
Secondly, the board had their wakeup moment. They saw where they had gone off course and worked to correct the problems. Their attitude, says Fenner, was to get it done, whatever it took.
Thirdly, the community itself got behind the facility. "The community was superb. They wanted their hospital to survive," says Fenner.
The interim CEO had great outreach skills and went to every rotary club, every church group, and anyone who would listen to keep them in the loop about the status of the hospital. There was even a prayer meeting at the hospital to pray for its survival.
Finally, there was a relentless drive to make the changes that needed to be made, whether they were personnel or policy based.
"They swapped out a couple of key people who couldn't get with the program quickly enough," says Fenner.
The required changes were mostly met with enthusiasm. As Fenner notes, no situation like this can be entirely rosy, and there were outliers, but the vast majority of staff approached the recertification process with a can-do attitude.
The nursing staff culture at the organization had to change for the transformation to be complete. For better or for worse, though, when the facility's occupancy dropped by 90%, there was no longer a need for traveling or agency nurses. This allowed the organization to start from scratch with a core of its own employees.
"They made it a priority to keep as many of their full-time employees as possible," says Fenner. "Their inpatient nursing care was that core."
After recertification was obtained, the facility began opening units based on a well-oriented, full-time dedicated staff.
"By the time the hospital was back up to speed, they had no need for travelers," says Fenner.
When patients are in the hospital, they see physicians on an episodic basis, but they see nurses all the time-as a result, a solid nursing staff is crucial, says Fenner.
"When my own family needs care, I look at nursing," she says.
One of the things that occurred during the recertification process was a raised awareness of the importance of the staff nurse. Educating staff nurses, orienting them, communicating with them so that they could do their jobs effectively-all of these things became a priority, says Fenner.
"The hospital did have to pay attention to building from the ground up a real system of clinical measurement," says Fenner. "How many meds are not given on time, how many pressure ulcers we see, falls and near misses-they really hadn't collected real data."
And this data forms the building blocks of clinical quality, she says.
"Basic, mundane, boring data tells you everything about the core of your business," says Fenner. "The core of the business is not how well you are doing [financially], though I never question the need for good margins. But great margins while providing mediocre care means you're in the wrong business. The goal is to give quality care and have money to build toward the future."
But where did it all begin?
There are some key lessons to take away from this near-death hospital experience. First, the fundamental ingredient to any hospital's success is leadership-not just at the top, but in individual units as well.
"We had a lot of good people in a very siloed organization," says Fenner. "They didn't share problems, and they didn't have the data to drive improvement or tell you how fast you were going."
The recertification process was a flash of clarity that signaled the need for change-and the hospital, thankfully, chose to change in the right direction, she says.
Also, there was no malicious intent behind the conditions leading to decertification, explains Fenner.
"My experience is that in 99% of cases, they want to see the right thing happen," she says. "You don't find evil intent. They just didn't know how to reach out for help."
The cost of this process was perhaps the greatest lesson. The organization had to burn through its reserves, keeping its doors open with just five patients in the hospital. This led the organization to embark on a strategic affiliation.
"They went from an independent community hospital to a system hospital. They are now part of a good system, with access to other benefits-but the hospital, had this not happened, was a growing organization ready to thrive," says Fenner.
And despite the nightmare of having survived decertification, good things came from this event.
"The community still has its hospital, the doctors still have a place to practice, people can still work there, and they avoided the loss of the economic engine that would have been lost if the hospital closed," says Fenner. "They stayed the course."
Lastly, there is a lesson in this story for hospital leadership across the country.
"The core business of a hospital is not margin or growth, it's clinical care," says Fenner. "And if you're giving good clinical care, you'll get your margin and growth. If you don't pay attention to the basics, you open yourself up to all kinds of trouble."
- Board meetings focused on financial health, business deals, and cost-cutting measures instead of quality-of-care data and concerns
- The CEO was extensively involved in outside organizations, but had little time for internal operations oversight
- Alienation and deteriorating relationships between medical staff and leadership led to distrust and ineffective communication
- Unstable nursing leadership led to inconsistency in the course of direction and detachment from the organization's core business-patient care
- Significant turnover as nursing staff resigned or retired led to high use of agency and traveling staff to fill vacancies with little or no orientation and supervision
- Create a plan that is realistic and patient-centered
- Involve your board-now and always
- React quickly
Compass Clinical Consulting. "Hospital Near-Death Experience: How Medicare Termination Can Push Your Hospital to the Brink of Closing." Retrieved from: www.compass-clinical.com/hospital-near-death/neardeath-2.