How Clinical Compliance Helps Your Agency Thrive
A Registered Nurse (RN) completes the scheduled initial assessment visit and the Plan of Care (POC) to the best of their ability. A week later, there is a devastating patient outcome. After a review, it’s clear the RN forgot to include interventions & goals associated with the patient’s newly prescribed medication and diagnosis. The patient had a history of low blood sugar.
The RN opened their software app and reviewed the POC and notes. They realized that they missed that the patient just started on Metformin, and being in a hurry the clinician forgot to include a check for blood glucose levels in the POC. As happens, in many agencies, QA didn’t have the chance to review the file so patient care was already in progress.
It’s essential that your software provides the tools to allow your agency to stay clinically compliant so that scenarios like this don’t happen.
What is Clinical Compliance?
Clinical compliance is ensuring that agency clinicians complete all of the treatment and care that is included in the POC. It’s crucial that clinicians check and double-check the POC and any change orders during every follow-up visit. Agencies will go to great lengths to ensure situations like those above don’t happen, but ultimately the success of the home visit requires compliance from the clinician and support from the software.
The second level of clinical compliance is timely Quality Assurance (QA) processing. The agency’s software must make sure that the clinician is documenting in all required areas to ensure quality patient care and in accordance with agency policy. If a patient doesn’t want to take their medication or perform the recommended physical therapy, etc., the clinician must report it. However, some software doesn’t require clinicians to document in accordance with the POC and later change orders. This makes it harder on QA because now they have to compare the current POC with the clinician’s notes line by line. Quality Assurance must make sure that the clinician didn’t skip over any of the treatments needed for the patient. If they do find errors, they must then reach out to the clinician and determine the reason for the error and/or request a correction.
Poor clinical compliance is, unfortunately, a common problem in many home healthcare agencies and results in unnecessarily high QA/administrative tasking and associated cost, reduced revenue, star ratings, and poor patient outcomes.
Take Control of Staying Compliant
When agencies want the best care for their patients, it starts with having software that works for the agency. The result is increased clinical compliance, incredible efficiency, and better outcomes for providers and patients.
Below are features that KanTime provides in support of clinical compliance:
- Agencies can set KanTime up to require all follow-up clinicians to document every intervention/goal during the visit. If one of the interventions or goals is not completed during the follow-up visit, the reason must be recorded or the note can’t be submitted.
- KanTime allows organizations to populate agency-recommended care plans with listed interventions and goals that are triggered based on the M00 question responses and patient diagnosis. This allows agencies to standardize their care based on the illness.
- KanTime provides a tab within the follow-up visit notes that includes all current medications for the patient updated by any medication change orders.
- In KanTime, all the documented treatments in the POC, as well as any submitted change orders during the episode, are transferred to the follow-up visit notes. The clinician doesn’t have to leave their notes to review the current POC as it is automatically populated to the visit notes.
Once the note is submitted, QA understands that the visit note wouldn’t be sent to them unless everything in the POC had been documented. If something wasn’t completed the clinician would have documented why treatment wasn’t done and it would be highlighted in red for QA’s immediate awareness. From there, QA can determine what the next steps would be on the note or if the POC has to be adjusted.
The clinician would have been able to see in their visit notes that the patient had started on a new type of medicine, and could have prevented a negative outcome with the help of KanTime.
Request a demo today to see how KanTime tackles compliance and does it right the first time.