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Radiology Administrator's Compliance & Reimbursement Insider, June 2008

Radiology Administrator's Compliance and Reimbursement Insider, June 1, 2008

Inside:

Take care of the needs of your aging work force

Target safety issues to ensure older workers’ well-being

CAD device approval process scrutinized

Don’t let chart errors lead to further medical mistakes

HIPAA compliance Q&A

Take care of the needs of your aging work force

American productivity will likely depend on the efforts of workers aged 50 or older, according to a new policy brief released by the Boston College Center on Aging & Work.

This is particularly true in the healthcare industry, says Kenneth Mitchell, PhD, vice president of health and productivity development at Unum, an employee benefits and disability insurance company in Columbus, OH.

Despite the fact that the baby boomer generation is reaching retirement age, many boomers expect to remain in the workplace, says Mitchell, who led the study “Health and Productivity in the Aging American Work Force: Realities and Opportunities.”

“By 2014, the 55-plus age group will possibly constitute
21% of the work force,” says Terry Jo Gile, MT(ASCP), MA, Ed, The Safety Lady^®, a healthcare safety expert in North Fort Myers, FL. They will remain in the work force in order to retain their incomes, their health benefits in addition to Medicare, and their contact with close colleagues.

With the high number of boomers in the retirement age bracket and fewer new hires available to take their place, it’s important to keep current, experienced staff members happy. Plan to keep senior staff members engaged and productive. Such engagement leads to higher job satisfaction, says Mitchell. The experience your senior workers bring to your facility can be invaluable, Gile adds.

Tips to accommodate older workers

Below are some general ways to keep boomer staff members on board:

➤ Examine risk factors for employees. Your imaging facility should identify and reduce risk factors, says Mitchell. Look at absenteeism in your facility and the reasons for it. While examining patterns of lost time in the Unum disability database, Mitchell found that 75% of employees on long-term disability were older than 40. Musculoskeletal ailments and cancer claims represented the most common reasons for absenteeism for workers in that age group, Mitchell says.

➤ Set policies that invite and reward worksite
flexibility. Once you have a sense of risk factors and lost-time patterns, develop policies and practices that keep the worksite flexible, Mitchell says. Strategies such as flexible extended leave policies and transitional work help keep employees productive during a medical predicament. This flexibility will allow your facility to adjust to employees’ common day-to-day impairments as well as catastrophic health issues.

Be sure to address job satisfaction for all workers, as workers who have low job satisfaction are more likely to stay off work. For example, some imaging companies with multiple facility locations allow staff members to transfer during the winter months to facilities located in warmer climates in order to accommodate their needs, says Mitchell.

➤ Reward employees for accepting responsibility for personal well-being. A healthy work force reduces lost time and healthcare costs, says Mitchell. You may be able to increase your staff members’ well-being by simply encouraging healthier lifestyle choices. Consider offering discounts for fitness programs, smoking cessation courses, on-site screening programs, or other
items.

➤ Offer support services for the care of family
members. Boomers often find themselves caring for three generations of family—parents, children, and sometimes even grandchildren. Employers need to understand the importance of the work-life balance, says Mitchell. For example, some hospitals have child care and elder care facilities.

➤ Promote generational equity. Reduced productivity due to ailments concerns more than just the over-60 age bracket, says Mitchell. Foster open communication among workers on sensitive issues such as salary and contributions to the workplace regardless of age. Workplaces have been seeing greater amounts of age-related discrimination complaints in the past five years, says Mitchell.

➤ Monitor programs. You should monitor all of your programs to ensure that they are working for your employees, says Mitchell. Ask staff members to complete regular reviews of the systems you put in place. This can be done in survey form or via confid-ential hotlines.

Editor’s note: For more information, visit Boston College’s Center for Aging and Work Web site at www.agingandwork.bc.edu.

Insider sources

Terry Jo Gile, MT(ASCP), MA, Ed, The Safety Lady^®, 4085 Hancock Bridge Parkway, Suite 111–129, North Fort Myers, FL 33903, 877/894-7004; tjgile@worldnet.att.net.

Kenneth Mitchell, PhD, vice president, health and productivity development, Unum, Return to Work Programs, 445 Hutchinson Avenue, Suite 240, Columbus, OH 43235, 800/282-4656; kmitchell@unum.com.

Target safety issues to ensure older workers’ well-being

The lack of a safety plan to meet older workers’ needs could cost facilities more later in the form of workers’ compensation claims.

In some cases, if an older worker’s safety issues rise to the disability level—meaning the problem substantially limits a major life activity—your facility may have a legal obligation under the Americans with Disabilities Act to reasonably accommodate that staff member.

Terry Jo Gile, MT(ASCP), MA, Ed, The Safety Lady^®, a healthcare safety expert in North Fort Myers, FL, discusses a few safety issues older workers face and some ways to address these challenges:

➤ Improving lighting. As employees age, proper lighting becomes more important. Staff members need more light to see, says Gile. Lighting is extremely important for all workers in an imaging facility. In general, a person aged 50 or older needs two to three times the amount of light in his or her work space compared to younger workers, says Gile.

Proper task lighting plays an important role in radiology safety. Elimination of glare helps, as do consistent light levels. Ambient light or daylight can be used when available. Task lighting should be no more than three times brighter than ambient light, says Gile.

Flat computer screens are helpful in eliminating glare and easing eyestrain. Employees can also turn off overhead lights or remove fluorescent bulbs to reduce light. In a four-bulb light fixture, remove the middle two bulbs if possible. Also, if bright fluorescent light causes difficulties, older workers can wear visors, says Gile.

➤ Coping with eyesight problems. As the eyes age, vision becomes less clear. Reading small fonts becomes difficult, even with the right glasses. To help older workers who may have trouble seeing small fonts, you should:

• Have a magnifying glass available for reading small print
• Add color contrast
• Use primary colors (blue, yellow, and red) for signs (pastels often cannot be discerned by older employees)
• Use a font size of 14 points or larger for e-mails and memos

➤ Preventing computer vision syndrome (CVS). CVS results from spending a large amount of time working at a computer terminal, says Gile. Common symptoms include:

• Eyestrain
• Blurred vision
• Dry, irritated eyes
• Double vision
• Headaches

Symptoms may occur due to prescription eyewear not designed for computer use, Gile says. Users without appropriate eyeglasses may try to compensate for blurred vision by leaning forward or tipping their heads back to look through the bottom portion of their glasses. Both actions can result in sore necks, shoulders, or backs, Gile says.

Most glasses or contact lenses do not correct the intermediate zone of vision at all, says Gile. Reading glasses correct near vision only and bifocals correct only near and far vision. Even lenses that do correct the intermediate zone, such as trifocals and progressive lenses, direct only a small portion of the lens to the intermediate zone and are not sufficient for comfortable computer work.

Computer glasses make a world of difference, says Gile. They correct blurred vision and relieve symptoms such as eyestrain and burning sensations. Encourage employees to visit an eye care professional regularly and to inform their physician about computer-related eyesight strain. Staff members can also use desktop software applications that enlarge the contents on the screen. This makes reading easier and reduces eyestrain.

➤ Preventing nighttime blindness. A monitor po-sitioned too close to a worker may contribute to nighttime blindness, particularly in older workers, says Gile. This condition makes focusing at regular or far distances difficult after a long day of up-close reading.

Gile recommends lowering computer monitors and tilting the screen upward. It is easier for employees to read at a lower height because it allows a more natural focus. Also, train employees to practice the 20/20/20 rule. Every 20 minutes, they should take a 20-second break to focus on a spot 20 ft. away. It gives the eyes a break and allows them to readjust to a distance beyond the screen.

➤ Avoiding falls. Accidental falls are hazardous for aging workers. Preventing falls isn’t just something to worry about with patients; it’s also something for radio-logy administrators to address with their workers. Skid-resistant floors that have some cushioning are helpful
in avoiding falls, as is eliminating clutter.

➤ Preventing back injury. Employers cite back trouble as the most frequent injury requiring days away from work, according to the Bureau of Labor Statistics. So make back injury prevention a priority, especially considering the current environment of rising workers’ compensation costs and reduced productivity. Sitting down for long periods can cause or aggravate back injury.

➤ Adjusting ergonomics. Task chairs that have a minimum of four-way (and preferably six-way) adjustability are best. The back of the chair should be able to move to 110º. In a slightly reclined position, the chair has a more positive effect on the body, reducing seated muscle activity and disc pressure in the lumbar region, says Gile.

The top of the monitor screen should be at eye level and directly in front of the worker, with the distance from your eyes and the screen between 18 and 26 inches, she adds. Screens that swivel horizontally and tilt or elevate vertically are ideal because they allow the monitor to move into a comfortable viewing angle and help avoid glare. This is especially helpful for employees who wear bifocals.

➤ Avoiding carpal tunnel syndrome (CTS). CTS is one of the most common job-related injuries, and if not properly treated, it can cause irreversible nerve damage and permanent disability of varying degrees, says Gile.Frequent breaks and changes of position may help avoid repetitive motion problems such as CTS. Instead of a 15-minute break every four hours, try a five-minute minibreak every hour to allow stretching of the muscles.

➤ Alleviating fatigue. Many radiology facilities must operate 24 hours per day. Employees on the night shift have an increased risk of cardiovascular disease, gastrointestinal disorders, obesity, diabetes, and sleep apnea, according to a 2004 study by Circadian Technologies in Stoneham, MA. Night shift workers are also prone to high absenteeism, turnover, on-the-job injuries, and technical errors.

Gile cites a 2006 study published by the American College of Occupational and Environmental Medicine in which 38% of employees experience low levels of energy, poor sleep, or a feeling of fatigue. The study says fatigue is more common in women, in workers over the age of 50, and in jobs with decision-making responsibility.

Encourage employees who work the night shift to buy black-out drapes and wear sleep masks at home so that they can sleep during the day. In addition, 20 minutes of aerobic exercise before work can help employees wake up, feel energized, and keep their hearts in shape.

➤ Helping stress. The long hours and high attention to detail needed in radiology work can raise stress levels, and
older workers can be more prone to ill effects from stress.

Eliminate clutter and reduce noise in your facility to cut down on stress for older workers, says Gile. Allow frequent breaks and encourage additional hydration to make older workers more productive. Tell employees to follow the
three Bs to lower their stress levels:

• Take frequent breaks
• Blink often to moisturize the eyes
• Remember to breathe

Tip: Talk to your older staff members, says Gile, and ask them what can be done to make their job more comfortable. Often, they will offer a simple and easy-to-adapt solution that will help others in your facility.

Technology watch

CAD device approval process scrutinized

An FDA panel conducted hearings on computer-aided detection (CAD) systems in March. The panel focused on the science behind evaluating CAD effectiveness and FDA approval for the devices, says John Smith, Esq., a healthcare attorney with Hogan & Hartson, LLC, in Washington, DC. The FDA wants input from the panel and the public in preparation for drafting guidance to describe the types of data necessary to characterize CAD performance for future marketing applications. As of now, there is no projected date for the guidance. Watch future issues of RACRI for updated information.

The FDA panel didn’t reach any firm conclusions during the hearings, “so consensus is elusive right now,” says Smith. Also, keep in mind that the panel is advisory, and the FDA could release guidance that does not comport with panel findings.

FDA evolves CAD regulations

Today, there is increased scrutiny of CAD, says Smith. In part, this is because the FDA is broadening the scope of what it considers a CAD. The FDA panel represented the largest panel ever convened for such a hearing, Smith adds. Members of the panel expressed agreement on the benefits of CAD in aiding with diagnosis. The FDA has turned its attention to this technology, based on recent reviews—both positive and negative.

For example, study results of colon CAD systems are encouraging. In two studies presented in March at the 2008 European Congress of Radiology, investigators tested colon CAD schemes for their ability to find flat lesions, which are typically difficult to detect. But questions remain about the effect of false-positive CAD detections on reader performance and variations in flat-polyp morphology.

The FDA has approved some CAD technology in the past few years, including:

• The Kodak Mammography CAD engine (2004)
• Medicsight ColonCAR 1.2.1, to be used with CT virtual colonoscopy (2006)
• PET VCAR (volume computer-assisted reading), a PET/CT software package to assist in diagnosis, staging, treatment planning, and monitoring
  (2007)

Panel probes CAD methodology

At its March meeting, the FDA panel discussed questions on general methodologies for CAD, including using CAD to aid with clinical decision-making, testing the devices, accounting for statistical bias, and assessing CAD safety and effectiveness.

Following the general discussion, the panel discussed and made recommendations about future CAD devices for radiological imaging of mammograms, chest x-rays, and CT images of the lungs and colon. These discussions included how the different types of CAD devices are used, as well as the literature published regarding these devices.

Before you give up on CAD, consider the following advice while assessing implications of future guidance on your practice:

Keep using current CAD devices. The hearings have little effect on current devices, says Smith, so if you are currently using CAD devices in your practice, keep using them.

Use CAD with clinical data. To continue to improve your practice, research how CAD devices can help achieve these improvements. Don’t let the forthcoming guidance delay steps you can take right now.

Examine vendor review processes. Much of the debate centered around questions of what represents good science in evaluating CAD, so it’s possible vendors will have to go through a more rigorous review process for devices not yet approved.

Insider source

John Smith, Esq., Hogan & Hartson, LLP, 555 Thirteenth Street NW, Washington, DC 20004, 202/637-5600; jjsmith@hhlaw.com.

Don’t let chart errors lead to further medical mistakes

Tragedies such as wrong-site surgeries can take a healthy kidney and leave a cancerous one: this happened recently at a St. Paul, MN, hospital. Such events can happen even if the facility follows The Joint Commission’s Universal Protocol™. So what can a radiology administrator do?

Radiologists and radiology departments can take steps to avoid these terrible errors, says Alice G. Gosfield,
Esq., a healthcare attorney and consultant at Alice G. Gosfield & Associates, PC, in Philadelphia. If the radiology department errs, even the best efforts afterward to follow protocols may not prevent a disaster. Surgical teams should review diagnostic images (x-rays, CTs, MRIs) to confirm the surgical site before surgery.

Follow Joint Commission protocol

Every Joint Commission–accredited hospital has had to comply with surgical safety protocols, including the Universal Protocol, since 2004. The current protocol applies to every surgery and to any other invasive procedure with more than minimal risk.

Currently, the protocol calls for three steps:

1. Review documents. In the preoperative area where the patient is interviewed, the preop nurse uses a PDF to confirm that the patient is who they say they are, using the patient’s date of birth or medical record number. The operating room personnel must ensure that the anticipated procedure is consistently documented in various areas of the chart. The nurse should ask the patient to confirm his or her name, the procedure, and the site of the surgery. Several staff members, including a preop nurse and an anethesiologist, should repeat this confirmation.

2. Reconfirmation. Before entering the operating room, the doctor must meet with the patient, reconfirm the surgery and site, and then write his or her initials on the surgery site.

3. Timeout. Doctors must hold a timeout immediately before the procedure. At this point, the entire team steps back and reconfirms that this is the right patient, the right procedure, and the correct site.

For further clarifications, review The Joint Commission (formerly JCAHO) implementation expectations below.

Closing the loophole

But in the case of the St. Paul hospital, the Universal Protocol left a loophole: The chart was incorrect from the beginning. A mistake in the chart made several weeks earlier became accepted as accurate. Although the investigation is ongoing, it’s possible the original scan might have been mislabeled, says Gosfield. The radiology department may have marked the image incorrectly, making it appear that the cancerous growth occurred in one kidney when it actually occurred in the opposite organ, she says. In this situation, radiology departments must safeguard the process by labeling the image the right way.

There are several places in the labeling process where errors might occur. For example, if the radiologist saw the tumor in the right kidney but misspoke and indicated the left kidney, the transcriptionist would not know the difference.

The transcriptionist also could have simply made a typographical error and typed “left” instead of “right.” Perhaps one of the physicians taking care of the patient mistakenly documented the wrong kidney, which then was promulgated in the chart.

In any case, there was an error, and as a result, even the patient became misinformed, as he or she would likely have been queried several times as to which kidney was to be removed.

Make sure your radiology department strives for accuracy when labeling images.

Insider source

Alice G. Gosfield, Esq., Alice G. Gosfield & Associates, PC, 2309 Delancey Place, Philadelphia, PA 19103, 215/735-2384; agosfield@gosfield.com.

Review standards to prevent wrong-site surgery

The following is a review of the implementation expectations for preventing wrong-site, wrong-procedure, and wrong-person surgery. These guidelines provide detailed implementation requirements, exemptions, and adaptations for special situations, and are reprinted from the Joint Commission (formerly JCAHO) Web site.

Preoperative verification process

Verification of the correct person, procedure, and site should occur (as applicable) at the following times:

• When the surgery/procedure is scheduled
• At admission or entry into the facility
• When the responsibility for care of the patient is transferred to another caregiver
• When the patient is involved, awake, and aware
• Before the patient leaves the preoperative area or enters the procedure/surgical room
• Prior to the start of the procedure, ensure availability and review of the following:
• Relevant documentation (e.g., H&P, consent)
• Relevant images, properly labeled and displayed
• Any required implants and special equipment

Marking the operative site

Once the patient and procedure are confirmed, use the following steps to indicate the correct site for the surgery:

Make the mark at or near the incision site. Do not mark any nonoperative site(s) unless necessary.

The mark must be unambiguous (e.g., use initials or “yes” or a line representing the proposed incision; consider that “X” may be ambiguous).

The mark must be visible after the patient is prepped and draped.

The mark must be made using a marker that is sufficiently permanent to remain visible after completion of the skin prep. Adhesive site markers should not be used as the sole means of marking the site.

The method of marking should be consistent through-out the organization.

At a minimum, mark all cases involving laterality, multiple structures (e.g., fingers, toes, lesions), or multiple levels (e.g., spine). Note: In addition to preoperative skin marking of the general spinal region, special intraoperative radiographic techniques are used for marking the exact vertebral level.

The person performing the procedure should mark the site.

If possible, marking must take place with the patient involved, awake, and aware.

Final verification of the site mark must take place during the timeout.

A defined procedure must be in place for patients who refuse site marking.

In some situations, you don’t need to mark the site as listed above. Such situations include the following:

Single organ cases (e.g., cesarean section, cardiac surgery)

Interventional cases for which the catheter/instrument insertion site is not predetermined (e.g., cardiac catheterization)

Teeth—indicate operative tooth name(s) on documentation or mark the operative tooth (teeth) on the dental radiographs or dental diagram

Premature infants, for whom the mark may cause a permanent tattoo

Timeout immediately before the procedure

The timeout must be conducted in the location where the procedure will be done, just before starting the procedure. It must involve the entire operative team, use active communication, be briefly documented—such as in a checklist (the organization should determine the type and amount of documentation)—and must, at the least, include:

• Correct patient identity
• Correct side and site of procedure
• Agreement on the procedure to be done
• Correct patient position
• Availability of correct implants and any special equipment or requirements

The organization should have processes in place for reconciling differences in staff responses during the timeout.

HIPAA compliance Q&A

by Mary D. Brandt, MBA, RHIA, CHE, CHPS

Q: Do HIPAA regulations forbid employees from accessing their own records? For example, could a hospital employee look at the results of his or her recent radiology test?

A: The HIPAA privacy rule does not prohibit healthcare organization employees from accessing their own records. In fact, the privacy rule gives individuals the right to access their personal health information (PHI). However, your organization’s policies may regulate this practice.

Many healthcare organizations have written policies that prohibit employees from using electronic health records to access their own PHI. Instead, they require employees to request access to their PHI through the health information management department, just as any other patient would be required to do.

Q: Does HIPAA require that we block facility telephone numbers from appearing on caller ID when calling patients or their families?

A: The privacy rule doesn’t specifically require you to do so, but HIPAA does require covered entities to take reasonable steps to protect their patients’ privacy.

You may not want to block your facility’s number, because many individuals don’t answer calls when numbers don’t appear on their caller ID. Instead, consider having only the telephone number appear without your facility’s name attached. Alternatively, you could have a generic term or name such as “clinic” or “healthcare facility” appear with the phone number instead of your treatment facility’s actual name.

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