December 30, 2023 | Cathy Thomas Hess, BSN, RN, CWCN

3 Minute Read

The Power of Why: Create an Effective Wound Care Process

Work smarter, not harder, by defining a wound care process that supports sustained results across clinical, operational, and financial metrics

What is your why? Why do you do what you do? Why do you take one approach over another; purchase a particular product or service; implement a specific process? Those seem like simple questions, but when it comes to your wound care department or the business unit you serve, finding answers can be a difficult but necessary step for optimal outcomes and success. It’s important to try to define your wound care process. We start by asking why we’re able to determine if we’re on a path to success or if we can and should push the boundaries further. Answering the why is the first step in owning your process and understanding why simple changes can lead to achieving your goals, from improving patient satisfaction and outcomes to enhancing efficiencies.

To find out what you can do to answer your why, check out the following best practice tips developed by recognized industry experts. These are the key points that can become the blueprint for your success.

Why do we do what we do in a given workday?

People and workflows influence every action and interaction in the typical wound care department. They affect everything from coding, billing, and medical records to clinicians and providers’ cognitive workflows. Each of these maps to crucial elements within your documentation system. Producing the right combination of operational and clinical experience with the underpinning of a robust documentation system will create efficient business practices and optimal patient flow and care. You can determine the effectiveness of a workflow process with an informal internal audit. Steps to take include:

  1. Evaluate if accurate assessment, documentation and intervention processes have been reviewed and updated at least annually and ensure they are based on validated guidelines.
  2. Review all relevant guidelines, at least annually.
  3. Update your policies and procedures and your facility practices and workflows.
  4. Ensure workflows reflect your organization’s and the government body’s standards necessary for proper documentation and payment.
  5. Provide competency validation testing for your staff at least annually, to ensure proper practice standards and support for those policies.
  6. Invest time and expertise in developing appropriate workflows in your business.
  7. Verify and validate your staff’s understanding of each workflow and their associated documentation requirements. . . answer their why questions.

What will you get if such steps are taken? Quite a bit, including an increase in staff knowledge, which is vital to greater efficiency, improved clinical and operational outcomes, reduced errors, improved patient safety and satisfaction, and even better employee satisfaction as they become more skilled and invested in the process.

Questions about workflow

  • How often do you review your workflow?
  • How do you complete each step?
  • What tools and strategies do you need to complete these steps?

Why do we have certain products on our shelves?

What process goes into developing the formulary? It should be more than contracts, or because it’s a product the department has always used. Products should align with your preferences and your patient needs as well as your organization’s operational policies and processes. To answer those questions, consider clinically proven efficacy and cost-effectiveness, availability, ease of use, function, and direct costs.

Once the criteria for developing the formulary are established, the operational processes should be reviewed as well. First, design a supply management system that controls product use, internally or externally, to control costs and waste. Second, ensure you work with your revenue cycle management team to account for these products annually, if not more often. Last, and perhaps most important, bring your staff into the process. Get their input on preferences, needs, and experience with specific product lines. Once decisions are made, make sure they understand why specific products were chosen and how to use them to ensure optimal outcomes.

Operational processes for formularies

  • Align the product’s Healthcare Common Procedure Coding System (HCPC) codes within your Charge Description Master.
  • Define clinical and financial outcome data.
  • Document data for advanced critical pathways.
  • Improve product formularies, as well as patient and clinician satisfaction.
  • Validate contract fees with payers.
  • Comply with federal mandates.

Defining procedure and ensuring compliance

Do you know who your Medicare carrier is and their documentation requirements? When working in a wound care department, it’s the clinician’s responsibility to understand the rules and regulations that guide that department’s documentation processes. These roles are generated from your fiscal intermediary carriers, including Centers for Medicare and Medicaid Services (CMS), Medicare Administrative Contractors (MAC), and the Joint Commission. In short, performing procedures today involves clinical and operational oversight to ensure that they are clinically appropriate for the patient and will be compensated by the payer.

Once you’ve defined the procedures to be performed, take steps to ensure it is approved within your department and that it is placed within the charge master. Hand-in-hand with that step is including the proper HCPC codes. This is a critical step in the process as all services, including procedures performed and supporting diagnoses, need to be reported accurately and promptly. Coding has become complicated and can be confusing. However, it is also your responsibility to understand the processes for coding, billing and any payer-specific billing compliance requirements. The good news is once you do your homework and engage in the process, it becomes second nature.

Payment – The importance of compliance and medical necessity

Understanding medical necessity is an important step for your reimbursement. CMS clearly states the following: “…no Medicare payments shall be made for items or services that are not reasonable and necessary for the diagnosis, the treatment of illness or injury to improve the function of the malformed body member.” What Medicare is telling us is that the clinical documentation, diagnosis, and the current procedure codes that are reported must meet medical necessity, or the claim may be denied. Medical necessity is payer-specific, but most often those payers are following CMS, their NCDs or LCDs/LCAs.

It’s also prudent to be familiar with the managed care payer agreements, as well as their limitations. This understanding defines what documentation needs to be completed within the medical record, which serves as the source of truth for the patient encounter as well as payment for the service. Additionally, from an audit perspective, knowing the documentation elements required assists in determining the accuracy of the documentation and potentially discovering lost revenues. The documentation must adequately substantiate the services billed and identify medical necessity for the services rendered.

Wound care process: The thread that pulls it all together

A good wound care process brings documentation, staff efficiency, productivity and payment together. If your workflows are set up correctly, they’re going to detail your department’s key processes and determine the proper steps to eliminate redundancies and identify gaps in your practice. Process also impacts both compliance and payment. It affects everything from pre- registration to coding to medical records and billing and to denial management. Four specific processes lead to optimal documentation and drive compliance and payment. At Net Health, we define those processes by a proprietary acronym CORE:

  • C – Clinical
  • O – Operational
  • R – Regulatory
  • E – Economic

As a provider of specialty wound care, it’s your responsibility to define your practice’s specific needs. One way to do this is through the lens of smart workflows and process. The value of smart workflows and process is that you’re able to then manage and optimize those critical clinical, operational, regulatory and economic functions (e.g., CORE). Streamlining and improving these processes allows you to advance quality of care, patient safety and satisfaction while increasing process efficiencies. . .it becomes your recipe for success.

Why do we document what we do?

That’s perhaps one of the simpler questions to answer for a wound care department. Proper documentation guides appropriate treatment decisions. It’s a mechanism to evaluate the wound care process, offers support for reimbursement, and is the ideal defense for potential litigation. The documentation detailing the work performed becomes the source of truth for that patient encounter. Documentation processes need to be substantiated by identifying the medical necessity for the services rendered. This leads to improved compliance and, ultimately, more timely and accurate reimbursement. Periodic audits can help with this process. Audits serve as checks and balances oversight for documentation and billing – it is a priceless. function in your department. Consider deploying internal as well as external audits.

For an internal audit, define the specific issues, determine the appropriate sample size, establish an audit schedule, and perform the audit. Once completed, prepare a concise audit report, present the audit results to the relevant senior leadership and then develop a plan of action and perform ongoing monitoring. Ensure your audit becomes a tool for learning and process improvement. The external audit supports the overall compliance plan. Work with your compliance team to ensure the internal and external audits meet your facility’s expectations. Choose an outside auditor or consultant to conduct the process and report the results. And most of all, critically read the report results so it can make a difference in the clinical and/or operational outcomes for your facility.

Sample documentation checklist

  • Meet with select departments to review updates for pre-registration, coding, billing, medical records, and denial management.
  • Review and update the product formulary and technologies.
  • Know your facility’s accreditation standards and documentation workflows.
  • Manage through a comprehensive engine providing clinical, operational, financial, and marketing reports.
  • Implement Clinical Decision Support Alerts.
  • Participate in the Quality Payment Program.
  • Review and update signature requirements for your documentation process.
  • Ensure staff credentials and competencies are up to date as directed by your organization’s standards and compliance plan.

The power of why

Developing a wound care process to measure and manage your business is essential so that you streamline your resources, documentation, and payment. Once your core processes are defined, implement the six best practice points to work smarter, and drive substantial and sustained results in clinical, operational, and financial metrics across your business unit.

Last, to see a true understanding of your workflows and process, remember the power of your why, and the factors you’ve carefully analyzed to arrive at your decisions. When you take these steps, you will find yourself with a fresh perspective and a new path to innovate change.

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