Radiology Administrator's Compliance & Reimbursement Insider, August 2006

Once you understand the internal and external threats, match up your available resources with the potential pitfalls.

“It’s just like connecting the dots,” Murphy said.

Next, use the previous business experience of yourself and your team to evaluate lessons learned.

“I’m being sent to fly a mission in the middle of the night over the desert in the middle of a sandstorm,” said Murphy. “I’ve never flown over this particular area and I’ve certainly never flown through a sandstorm before, but other people have.”

Pick up the phone or, better yet, ask your staff, he said. Further, he suggested contacting related associations (e.g., the RBMA) for advice.

“Your associations have a wealth of knowledge to share. That’s what they are there for,” he said.

With the groundwork laid, you and your planning team can begin to brainstorm tactics and appropriate actions to implement your plan, such as the following:

You’re not done with the plan yet, said Murphy. With a draft in hand, it’s time to plan for contingencies.

“This is the time to decide what you will do if,” he said. “In the middle of a sandstorm flying straight toward the side of a mountain isn’t the time to plan for additional difficulties.”

No plan is perfect. If you think that you’ve thought of everything, you haven’t. Think about it some more and consider the worst case scenarios—then plan on them happening.

Finally, establish the W’s. Decide who will do what, when, where, and how, said Murphy.

Make sure that everyone on the team understands how their assigned tasks fit into the larger picture and make this mission manageable, he said.

Don’t forget to brief the staff, as well, Murphy said (see “Five steps to staff briefing for clarity” below).

Execute the plan

One you set the wheels in motion, make sure that everyone on the team stays focused on the task at hand.

Despite the hundreds of instruments on the flight panel in front of him, Murphy always paid attention to two things—the enemy and the ground.

“What do we focus on? There’s a lot going on it your cockpit, but if you don’t focus you’ll lose the fight,” he said.

The altimeter sits in the center of the instrument panel and is the largest of the plane’s instruments, he said. All pilots follow a specific pattern of rotation when eyeing their instrument panel.

No matter what instrument they check, pilots always return to the altimeter at the center of the panel.

“Your company’s overall goal should be at the center of your instrument panel, too,” Murphy said. “No matter what other problems, goals, or departments your instrument panel also contains, always keep your eye on the center goal.”

Debrief staff to learn from your mistakes

The debrief stage of Murphy’s flawless execution model also requires a culture shift.

In the Air Force, once a mission ends, the entire team enters the debriefing room, he said. As they enter the confines of that enclosure, everyone from flight sergeants to the commanding officer removes their rank—both mentally and physically.

“It must be nameless and rankless,” said Murphy. “Once you walk into that room everyone must be open to criticism, from the head of the company to the secretary.”

At the debriefing, staff must be able to respectfully share information so the next task, objective, and mission can be accomplished, he said.

“Your team must be able to say, without fear of retribution, ‘I’ve made this mistake and I’m going to fix it.’ It’s not who’s right, it’s what’s right,” Murphy said.

“That way everyone knows what went wrong and what went right, and everyone can work together to figure out a plan to overcome these difficulties next time,” Murphy added.

A cycle of success

The goal is accomplished and the team is debriefed. It’s time to get back out there, right?

No, said Murphy. “Go back and incorporate those lessons that you learned from your debriefing back into the plan.”

“You can change the culture of your organization,” Murphy concluded. “You can break the error chain. That’s how you can grow your business.”

Insider source:

Jim “Murph” Murphy, CEO of Afterburner, Inc., Seminars, 1503 B Northside Dr., Atlanta, GA 30318, 800/261-2912; murph@afterburnerseminars.com.

Fly clear of task saturation

So you’ve got a million things going on at once. That’s why you make the big bucks, right? That’s what Afterburner, Inc., Seminars CEO Jim “Murph” Murphy called “task saturation.”

“It’s a silent killer,” he said.

Murphy and fellow pilot and lecturer Yarmema “Yarko” Sos should know. They lost two friends, “two good fighter pilots who flew their planes into the ground,” Murphy said. “They weren’t bad pilots. They were good pilots who took their eyes off the ball and died.”

“I’m sure you all know of one or two businesses out there [that] were doing really well until some task-saturated manager flew it into the ground,” he said.

Generally speaking, people deal with task saturation in any number of ways. Some quit. Others compartmentalize. Some prioritize.

“You can quit,” said Murphy. “You can give up and go home or start over somewhere else. The other way we cope is by channelizing our attention. [For example], we focus on that one fish that’s close to the boat and ignore that school of fish swimming a few feet away.”

To illustrate their point, Sos and Murphy showed a simulated crash of a passenger jet in the Florida Everglades. During routine desent preparations, the crew discovered a broken landing light. Within minutes, everyone in the cockpit became focused—not on landing the plane—but on the landing gear light.

The captain told the copilot to put the plane on autopilot and help with the problem at hand. By focusing on the light—not on landing the plane—the crew became channelized, said Sos.

Although flying on autopilot at 2,000 ft. may be common practice for passenger jets, this plane’s autopilot mechanism automatically disengaged with any application of manual pressure. As the copilot leaned forward to work on the light, he inadvertently sent the plane on a slow and steady decline to its doom.

Avoid crashing your radiology business by maintaining focus on the central mission and continuously planning, briefing, executing, debriefing, and planning, said Murphy.

Insider sources:

Jim “Murph” Murphy, CEO of Afterburner, Inc., Seminars, 1503 B Northside Dr., Atlanta, GA 30318, 800/261-2912; murph@afterburnerseminars.com.

Yarmema “Yarko” Sos, Afterburner, Inc., Seminars, 1503 B Northside Dr., Atlanta, GA 30318, 800/261-2912; yarko@afterburnerseminars.com.

Five steps to staff briefing for clarity

With a business plan in hand, managers and staff may tend to move straight to implementation, but Jim “Murph” Murphy, CEO of Afterburner, Inc., Seminars in Atlanta, warned against this measure during the June Radiology Business Management Association’s 2006 Radiology Summit in Miami. Make sure that you review the plan and brief the staff, he said. Murphy used the letters in the word “brief” for a five-step process for this procedure.

Brief the scenario. What’s the big picture? Why are we here?

Restate the mission objective. Is it clear, measurable, and achievable, and does it support the overall organizational picture? “If not, go back to the drawing board,” said Murphy.

Identify threats and resources. Understand the obstacles that stand between your facility and your business’ success. Know what tools the organization possesses to battle these threats.

Execute appropriate tactics. Make sure that everyone involved knows who will accomplish what task by when and how.

Be Flexible and plan for contingencies. Flexibility is the key to success, and preparation is the key to flexibility, Murphy said.

Keep open policies to security concerns

You’re required to have an incident reporting and response policy in place, pursuant to section 164.308 (a)(6) of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) security rule. However, a formal avenue for employee feedback regarding the effectiveness of your security policies and practices may be elusive. The security rule does not explicitly require a formal complaint process, but it might be an implicit part of the risk management implementation specification [164.308(a)(1)(ii)(B)], says Reece Hirsch, partner at Sonnenschein Nath & Rosenthal, LLP, in San Francisco. “You don’t want to be in the position of having a paper trail that indicates that certain issues were brought to your attention [and not addressed].”

Make it clear that employees can share concerns about security policies or procedures. “It’s always best to handle things up front. If someone comes to you with a question or [worry], take that as a window of opportunity,” says Mark Eggleston, manager of security and business continuity at Health Partners of Philadelphia, Inc. The employee’s concerns might lead to a policy improvement or allow you to clarify a confusing aspect of policy for the individual. For example, employees often come to Eggleston with concerns about receiving unencrypted e-mails containing electronic protected health information (ePHI) from outside vendors or associates. Eggleston explains that although Health Partners’ policy requires encryption of outgoing e-mails containing ePHI, the HIPAA encryption standard is addressable, and other organizations may make different encryption decisions.

Health Partners’ formal policy also enables employees to report matters of corporate responsibility—including security-related issues—that they believe require investigations. The policy explicitly prohibits harassment or retaliation. These provisions are important, Hirsch says. “Send a message to the work force that complaints are appreciated, that it’s a legitimate process, and that there won’t be retaliation.”

And because employees may understandably be reluctant to point out organizational missteps, go further than a nonretaliation policy by making yourself visible and approachable to the work force. Employees will likely be a major source of security feedback—at Health Partners they’ve brought up concerns about access control and physical security, Eggleston says—but don’t overlook feedback from other groups.

For example, third parties (e.g., vendors) could point out problems in your security policies and procedures, Hirsch says.

Amend the policy to create a close working relationship between the security and privacy officer. “The security officer will recognize a security issue that’s underlying a complaint when the privacy officer might not have the same expertise and might not spot it the same way,” Hirsch says. “A lot of privacy and security issues can be closely intertwined.” n

Editor’s note: This article was first published in the HCPro, Inc., newsletter Briefings on HIPPA.

Ask the Insider:

Use appropriate orders for diagnostic radiology testing

Federal regulations guide test orders

Q: Where can we find the federal regulations regarding radiology orders in the hospital setting? My radiologist wants to see written documentation that states that he can add procedures to the referring physician’s orders if he deems them medically necessary.

A: Consult the Hospital Conditions of Participation, 42 CFR 482.26 atwww.access.gpo.gov/nara/cfr/waisidx_02/42cfr482_02.html, says Stacie L. Buck, RHIA, CCS-P, LHRM, vice president of Southeast Radiology Management in Stuart, FL.

Radiologist or referring physician

Q: Should we allow our radiologists to order additional tests without an order from the attending physician?

A: “The short answer is yes—if the additional test is medically necessary,” Buck says.

And, adds Stacy Gregory, RCC, CPC, of Gregory Medical Consulting Services in Tacoma, WA, a radiologist can only order additional tests in the hospital setting under certain circumstances, as outlined in 482.26.

There is a distinct difference between hospital and nonhospital regulations, says Buck. In the nonhospital setting, you can only order additional tests if one of the exceptions to the test order rules exists.

Hospitals should also address this scenario in their bylaws. If you can obtain an order from the referring physician, then do so, Buck says. “Remember, protocols are not allowed. Medical necessity always prevails. And be sure that everything is documented.”

Order errors

Q: Can the radiologist change the physician orders in the physician setting if they are clearly wrong according to the patient’s clinical signs and symptoms (e.g., clinical indications call for CT angiography rather than CT)? Does the ordering physician have to be notified or issue another order?

A: CMS’ ordering of diagnostic tests rule (Medicare Carriers Manual 15021, Transmittal 1725) provides for “clear error,” says Gregory.

The document states that “the interpreting physician may modify, without notifying the treating physician/practitioner, an order with clear and obvious errors that would be apparent to a reasonable layperson [e.g., x-ray of wrong foot ordered].”

This scenario may also fall under the “test design” exception to the rules for ordering diagnostic tests, Gregory says.

“Unless specified in the order, the interpreting physician may determine, without notifying the treating physician/practitioner, the parameters of the diagnostic test [e.g., number of radiographic views obtained, thickness of tomographic sections acquired, and use or nonuse of contrast media].”

Find diagnostic test supervision and ordering requirements for hospitals in 42 CFR.

Adequate orders in a hospital setting

Q: Can a radiologist in a hospital-based radiology department order additional radiology procedures if the requested scan would not provide the medical information necessary to help the patient?

A: “Yes, this is [appropriate] in the hospital setting,” says Gregory.

The radiologist should always try to consult with the referring physician. But in the interest of patient care, if additional/different procedures need to be performed, the radiologist may order and provide these services in the hospital setting “with a written order and medical necessity, of course,” she says.

Breast ultrasounds are an exception to that rule, warns Gregory. A radiologist cannot order a breast ultrasound on a patient presenting for a diagnostic mammogram. That order needs to come from the patient’s treating physician.

Q: For a mammography requiring further evaluation, should the referring physician provide a new order for ultrasound of the breast, or can the radiologist order the ultrasound based on findings? Does he or she need to write a new order or just dictate the need?

A: A radiologist can request that a screening mammography be converted to a diagnostic mammography, but he or she cannot order the breast ultrasound, Gregory says. The order for the breast ultrasound must be generated by the referring physician.

Q: Who should be listed as the ordering physician if the radiologist appropriately adds procedures—the radiologist or the original referring physician?

A: The radiologist, says Gregory.

Insider sources:

Stacie L. Buck, RHIA, CCS-P, LHRM, vice president, Southeast Radiology Management, 512 SW, St. Lucie Crescent, Stuart, FL 34994, 772/600-0324; stacie@southeastrad.com; www.seradmgt.com.

Stacy Gregory, RCC, CPC, principal, Gregory Medical Consulting Services, 4653 North Bristol St., Tacoma, WA 98407-2014, 253/566-2494; stacygregory@wamail.net.

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