by editor | Mar 22, 2023 | Human Resources, Interdisciplinary Team
How can your hospice organization find out what your employees are thinking? How do you know if your employees are satisfied? Dissatisfied? How do you know if employee satisfaction varies across different agencies in your organization? Do you have a systemic problem in one of your agencies? Is one of your regions better or worse than the others?
Using employee surveys to measure employee sentiment
Hospice organizations typically conduct employee surveys to try to dig into this information. Employee surveys are prepared by the corporate office and survey the entire organization – that is – all hospice agencies across the entire organization. The surveys are typically conducted no more frequently than once per year and involve significant planning and cost. A survey response rate of 70% is considered a good response rate.
Organization may also conduct more targeted “pulse surveys” – to gather the employee sentiment on a targeted issue. Pulse surveys are run more frequently, and a 50% response rate is considered a good response rate.
Using public data sources to measure employee sentiment
However, there is another valuable source of employee sentiment that is often overlooked by hospice organizations: both current and former employees post valuable company reviews on public employment websites. These reviews provide valuable and actionable insight that can be used to monitor employee sentiment, detect trends over time, identify differences between agencies or regions in the organization and a wealth of other useful information.
How can information from public websites be used?
How can a review from a public website be used to provide insight to a hospice agency? Let’s examine some reviews to see what insight can be gained.
Data points that we can gather from this review are the following:
- Rating: 5 star
- Employment status: current
- Date of review: March 10, 2023
- Type of employment: per diem
- Job role: Home recovery RN
- Location: Marshfield, WI
- General comments: supportive management
Here is another review:
Data points that we can gather from this review are the following:
- Rating: 5 star
- Employment status: former
- Date of review: April 10, 2017
- Type of employment: contractor
- Job role: data entry
- Location: Brentwood, TN
- General comments: excellent company to work for
Here is a third review:
Data points that we can gather from this review are the following:
- Rating: 3 star
- Employment status: former
- Date of review: August 1, 2021
- Type of employment: full time
- Job role: Patient care coordinator
- Location: Vestavia Hls, AL
- General comments: management does not respond to input
How can the data be stored so maximum value can be extracted?
A hospice agency should store the data in a database format – either in a database or in a spreadsheet – so that maximum value can be extracted. By storing the data in this manner, metrics of interest and can be created. Performance over time can be monitored. We provide an example below. Suppose the three reviews above are for three different locations for the same hospice organization – one for an agency located in Marshfield, WI, one for an agency located in Brentwood, TN, and one for an agency located in Vestavia Hls, AL. The data can be stored in a spreadsheet as follows:
Additional columns in the spreadsheet can be added to provide additional information. For example, categories of interest may be:
- classify the employee type by categories such as clinical, corporate, office team, etc.
- classify the city / state by regions in the organization.
As the number of rows in the spreadsheet grows patterns can be identified and valuable metrics can be created and monitored – in time and over time.
Where can you learn more?
by editor | Jan 29, 2023 | Human Resources, Interdisciplinary Team
Maslow’s hierarchy of needs is a theory that can be used to provide leaders and organizations with guidance on how to motivate employees. But what is this hierarchy and what is Maslow’s theory?
What is Maslow’s Hierarchy of Needs?
Maslow developed his theory on the Hierarchy of Needs in the 1940s. The hierarchy suggests that people are first motivated to fulfill basic needs before they move on to more advanced needs.
The theory states that there are five fundamental human needs that can be represented as a pyramid. Each of the five needs builds on the prior need. Individuals want to meet needs at a lower level before progressing to needs at a higher level.
The highest-level need in Maslow’s hierarchy is self-actualization, where an individual achieves self-fulfillment.
How does Maslow’s Hierarchy of Needs relate to leadership?
A good manager understands this hierarchy of needs and leads his team so that he is meeting each employee at the employee’s current level of need while simultaneously encouraging the employee to continue to move up the pyramid so that the employee eventually achieves self-actualization. In the workplace, self-actualization translates to an employee’s desire to maximize his potential at work.
What are the levels of the hierarchy?
In Maslow’s hierarchy, Level 5 is the lowest level and Level 1 is the highest level. An individual or employee will start at a lower level and move up levels as he tries to achieve the highest level in the hierarchy.
Level 5: Psychological needs – survival
This is a most basic need for survival. Employees at this level want to feel secure that they have a steady income.
Level 4: Safety and security
Managers and leaders need to make employees feel secure. Some managers do not realize this and think that employees will work harder if they are “kept on their toes.” But this strategy usually fails. Rather than working harder, employees become obsessed with job security.
- How can a leader make employees feel secure?
- Communication: Share the big picture with employees.
- Clear rules: Employees should know where they stand at all times
- Be supportive: Support employees if they are struggling or if they fail
- Be consistent: Be the same every day
- Be fair
Level 3: Belonging (social needs)
Employees enjoy a team environment and a social workplace.
- How can a leader create a social environment and a feeling of belonging?
- Conduct team meetings
- Create an area where people can gather, e.g., for coffee
- Encourage a feeling that people are a part of the team
- Organize social events outside of work
Level 2: Esteem/status
Employees want to be noticed, on occasion, and to stand out for their accomplishments and for what they do better than others. People like to feel important, occasionally.
- How can a leader meet this need of employees to feel important?
- Give employees regular recognition
- Spend time with employees
Level 1: Self actualization
Self-actualization is maximizing an self-fulfillment where an individual discovers his potential and uses his skills to the utmost. This is the highest level of Maslow’s hierarchy, where employees are maximizing their potential at work.
- How can a leader help employees maximize their potential?
- Give employees ownership of tasks or projects
- Empower employees
- Help employees find ways to advance in their careers
What defines a great organization?
Maslow believes that in a great organization, employees will be at the level of self-actualization. That is, all employees must achieve Level 1. For employees to achieve Level 1, leadership must support employees through all the lower levels of the hierarchy. The pyramid will crumble if employees are lacking the supporting levels.
Further, leadership must make it possible for employees to achieve self-actualization. Employees need to be trained, to acquire new skills, and to have an environment where they gain a sense of satisfaction. A good leader will learn his employees’ potential and create an environment where people are trusted, can flourish, and are given important tasks to complete. A good leader will create an environment where employees can achieve self-actualization.
Where can you find more information?
by editor | Jan 29, 2023 | Billing, Documentation - Nurses, Hospice 101 - Aides, Hospice 101 - Chaplain, Hospice 101 - Nurses, Hospice 101 - Office Team, Hospice 101 - Social Workers, Intake, Rules and Regulations - Nurses, Rules and Regulations - Office Team
What is the False Claims Act?
The False Claims Act (FCA) was established in 1863 during the Civil War to combat fraud and abuse perpetrated by suppliers of the federal government. At that time, the law was referred to as “Lincoln’s Law.”
The FCA has evolved significantly in recent years and is now one of the main tools used by the government to fight fraud. The FCA penalizes individuals or entities that submit fraudulent claims to the government, cause fraudulent claims to be submitted, or conspire to submit fraudulent claims.
One of the noteworthy provisions of the FCA is the qui tam provision, also known as the whistleblower provision. The qui tam provision allows private citizens, also referred to as “relators”, to report details of alleged fraud to the government. The whistleblower “stands in the shoes” of the government to prosecute the claim. This action benefits the government and the taxpayer as well as potentially the relator, who may receive a share of what is recovered.
How does the FCA relate to a hospice agency?
The False Claims Act allows hospice agency employees, patients, families of patients, or any individuals with alleged knowledge of fraud or abuse by the agency to report the behavior. Under the qui tam provision of the FCA, the relator may be entitled to a percentage of recovered funds.
What are different types of false claims?
A claim is a request for money made to the government. A false claim is money that is obtained from the government due to false or fraudulent claims. False claims include claims where the service
- Has not been provided
- Is already included as part of a different claim (i.e., double billing)
- Is not coded correctly
- Is not supported by the patient’s medical record
Claims may also be false and are covered under the FCA if they result from a referral made in violation of the Federal Anti-kickback statue (Stark Law).
The False Claims Act also includes payment from the government based upon false certification.
False claims include claims that the hospice agency should have known were false or fraudulent.
What is a claim that a hospice agency “should have known” is false?
The FCA expressly includes claims that a hospice agency “should have known” were false or fraudulent. “Should have known” means deliberate ignorance or reckless disregard of truth. As such, a hospice agency cannot avoid liability by simply ignoring inaccuracy in their claims. Examples of “should have known” include:
- Ignorance of billing rules, i.e., lack of knowledge of the rules
- Failure to act on consistent trends that are indicative of inaccurate billing
- Failure to act on inaccuracies or system errors identified by outside or internal auditing teams
- Failure to correct inaccurate billing (impacting either past or future claims)
A hospice agency must understand the rules and take proactive measures — such as conducting internal audits within the organization — to ensure compliance and accurate billing.
How can False Claims Act matters be initiated?
There are two ways that FCA matters can be initiated:
- Initiated by the government: When a FCA matter is initiated by the government, this type of matter typically starts with an audit or an investigation by the government. The government would determine that there is a false claim made to it and would initiate a matter, usually by a subpoena or civil investigative demand (CID). The government would issue the CID directly to the hospice agency. CID is a form of subpoena that requires the hospice agency to engage in one-sided discovery. That is, the hospice agency is required to produce documents demanded, respond to interrogatories, and provide sworn oral testimony. However, the hospice agency may not conduct any discovery.
- Qui tam matter: this type of matter is initiated by a whistleblower, also known as a “relator,” typically through the filing of a sealed lawsuit in a federal district court. The hospice agency does not know about the qui tam lawsuit since the lawsuit is initially served on the government. The case remains under seal while it is investigated by the government.
What is the qui tam process?
Qui tam actions are initially filed under seal. That is, only the US Attorney and some members of the Department of Justice (DOJ) have knowledge of and access to documents related to the case. The relator serves the complaint on the government together with a written disclosure of all material evidence.
The purpose of the sealed qui tam action is to allow the DOJ time to evaluate the relator’s allegations and for the DOJ to decide whether it would like to take over primary responsibility for prosecuting the case. If the DOJ decides to take over primary responsibility for the case, the DOJ is said to “intervene.”
The complaint remains under seal for 60 days during which time the DOJ investigates the relator’s allegations. This 60-day period can be (and typically is) extended. In fact, the government may spend months – or even years – investigating the case.
While the DOJ conducts its investigation, it may issue a Civil Investigative Demand (CID). This form of subpoena requires the defendant (the hospice agency) to engage in one-sided discovery where the hospice agency must produce documents, respond to interrogatories, and provide sworn oral testimony, as demanded. The CID is “one-sided discovery” because the hospice agency may not conduct any discovery.
If the government decides to intervene, the government is then responsible for litigating the case and files its own complaint instead of the complaint that was filed by the relator. The relator remains a party to the complaint.
If the government declines to intervene, the relator may proceed in her own name subject to the government’s right to dismiss the claim or to intervene at a later date.
Whether or not the government decides to intervene, the government remains the real party of interest. (As a reminder, the relator is only “standing in the shoes” of the government.) As such, the government must agree to any decisions on the case. The relator may not agree to dismiss or settle the case without the government’s approval.
What are the key phases in a False Claims Act investigation?
- Phase 1: FCA investigation is triggered. Triggers may include:
- Qui tam (whistleblower) lawsuit
- Call to OIG hotline
- Information identified during audit or claim review
- Complaints
- Data mining
- Phase 2: Formal investigation launches. Investigation may involve:
- Review of corporate filings
- Interview current or former employees
- Review financial records
- Electronic surveillance
- Physical surveillance of employees or of company premises
- DOJ civil investigative demand (CID), or the like
- Government search warrant or raid
- Phase 3: Litigation or resolution
Who are common whistleblowers?
Anyone can be a whistleblower and anyone may report alleged fraudulent activity to the government. The most common relators are:
- Business partners
- Current or former employees
- Competitors
- Patients
- Individuals who mine CMS data to identify anomalies/FCA claims
How can a hospice agency reduce the chance of qui tam lawsuits?
Any complaints or concerns that are raised – by employees, vendors, patients, or competitors, or any other individuals should be investigated and treated with concern as these have the potential to reveal compliance issues that need to be resolved by the hospice agency.
Employee complaints – whether from departing or active employees – are often an excellent source of information on potential compliance issues. A hospice agency should have a clearly established method – that is clearly and often communicated to employees – for employees to raise concerns. It should also have an organized process to diligently investigate and address any concerns raised by employees.
- Internal complaints:
- There must be an organized process – that is communicated regularly to employees – for employees to raise concerns
- All concerns must be investigated
- Have a plan to address any issues that are identified
- Take any necessary corrective actions
- Follow up with the individual who raised the complaint
- Provide training, as needed
- Departing employees
- Treat employees fairly as they leave
- Conduct exit interviews to identify any potential compliance concerns – investigate any issues that may be identified
- Potential releases (e.g., recovery from FCA claims)
Employees must feel that there is a process for raising concerns and that their concerns are heard. Employees should not fear retaliation for raising concerns. A hospice agency should be diligent and careful to respond to all employee complaints that are raised internally or to any complaints that are raised when employees leave the organization.
What are the financial benefits of avoiding FCA violations?
False claims act matters can be quite costly for a hospice organization. In addition to returning the payments associated with the false claims identified and incurring the costs associated with attorney fees to defend the matter, the hospice agency potentially faces the following significant costs:
- Treble damages: The FCA has a treble damages provision which provides that a hospice agency that is found to have violated the FCA statute may be liable to pay three times the amount of the actual false claim amount
- Penalty per claim: Under the FCA, a civil penalty may be assessed for each false claim that is submitted. The civil penalty dollar amount per claim has increased with inflation and currently may be as much as $23,000 per claim.
Where can you find more information?
by editor | Jan 29, 2023 | Compliance and Regulatory - Directors, Metrics and KPIs
Why is data valuable?
Like all other business decisions, a hospice marketing plan must be data driven. More progressive hospice agencies have increasingly begun to understand the value of many types of data in supporting business decisions. This includes internal data such as patient EMR data, financial data including general ledger revenue and expense data (at various levels of aggregation), and quality data. It also includes external data such as publicly available claims data, cost report data, and referral data.
This article published in June 2021 discusses how hospice agencies are using data analysis as a tool to gain an edge over competitors when engaging with potential referral sources. The discussion focuses on use of data analysis to identify which physicians represent referral sources that are more likely to produce (higher quality) referrals. This 2016 NHPCO article discusses the use of hospice metrics as a marketing tool. For example, a hospice agency can share statistics on reduction in hospital admissions for its patients in hospice compared to hospital admissions prior to hospice admission. Other metrics on cost of care or patient satisfaction are of interest, depending upon the referral source.
What data is valuable for designing a marketing strategy?
A hospice should gather data so that it can develop a complete picture of the customers that it serves. It should analyze its patients – including referral sources and patient attributes such as patient diagnosis, length of stay, and patient demographics. Referral sources can be analyzed at different levels of aggregations such as geographic location, facility type, physician type, and physician name. Analysis of hospice patients should be compared to analysis of data for the entire market (in the relevant geographic region). This can help a hospice agency identify where it may have strengths or weaknesses and contribute to its marketing strategy.
Analyze the data: gain input from multiple sources
When analyzing the output of the data analysis, the hospice agency should solicit input from multiple sources in the organization. Combining different perspectives on the data such as input from the executive, marketing, and clinical teams will provide a more holistic view and a more accurate assessment of the current marketing performance and how the go-forward marketing strategy should be designed.
How can the data be analyzed?
The simplest method for analyzing the data is to use Microsoft Excel. Excel is widely used in most organizations, so gaining access to this software should not be difficult. With relatively simple commands, one can analyze data and create charts to visualize the results of data analysis. Another benefit of using Excel for data analysis is that a lot of educational material is available on the Web to answer any questions that you may have about using Excel – in case there are data analysis functions that you want to learn more about.
What other information may be relevant to developing a strategy?
Patient data and claim data are historical data that are important inputs to a developing a marketing strategy. A hospice agency should also analyze forward-looking data as well as more general information such as:
- What are hospice market trends in the geographic region?
- How competitive is the marketplace and are there expectations for change in competition in the near term?
- How well is the role of hospice understood by communities in the geographic region?
- Is the use of hospice accepted by communities in the geographic region?
- Is hospice understood by the medical community in the geographic region?
- What are the demographics of your geographic region and are they expected to change in the near term?
Combining analysis of historical and forward-looking data and soliciting input from team members with different perspectives such as operational, clinical, and marketing will help a hospice agency develop an effective marketing plan.
Where can you find out more?
Using hospice metrics for marketing
by editor | Jan 29, 2023 | Compliance and Regulatory - Directors, Hospice 101 - Aides, Hospice 101 - Chaplain, Hospice 101 - Nurses, Hospice 101 - Office Team, Hospice 101 - Social Workers, QAPI, Regulatory Compliance
What is the governing body?
In accordance with the Conditions of Participation, a Medicare certified hospice agency must have a governing body. The governing body has ultimate responsibility for the hospice agency, including legal and financial authority. Medicare Conditions of Participation require that the governing body is informed of the ongoing activities at the hospice agency, including patient care delivery issues and all QAPI activities. The governing body must also appoint a qualified hospice administrator – a hospice employee with the necessary education and experience – who is responsible for hospice daily operations.
The governing body must meet at least quarterly and must maintain written minutes of its meetings.
There are two Conditions of Participation – 418.100 and 418.58 – that relate to the hospice governing body.
Condition of Participation 418.100
This Condition of Participation defines a standard that the governing body is responsible for management of the hospice agency, including its fiscal operations, provision of services, and continuous quality assessment and performance improvement (QAPI) efforts. The governing body also assumes full legal authority of all hospice operations. It further specifies that the governing body should appoint an administrator that reports to the governing body and who is responsible for hospice agency daily operations. The hospice administrator must be a hospice employee and must have necessary training, education, and experience. CMS does not specify the process by which an administrator should be selected by the governing body. If a hospice agency has multiple locations, the governing body is responsible for administration, supervision, and services for all locations as well as for any arranged services.
Condition of Participation 418.58
This Condition of Participation discusses requirements of a hospice agency’s QAPI program. The governing body must ensure that the hospice agency maintains and implements an ongoing quality improvement and patient safety program. Program performance must be monitored on a regular basis. Further, the governing body must ensure that one or more individuals are selected to lead the organization’s QAPI efforts.
The hospice agency’s organization documents must specify that the hospice governing body is responsible for the QAPI program. Additionally, the governing body specifies the frequency of data collection and level of detail of data collected by the QAPI program.
Are there any state regulations?
State hospice licensure regulations may impose additional requirements on the hospice governing body. They may also have specific requirements on the administrator that is selected by the governing body. A hospice is required to meet the most stringent requirements (whether state or federal).
Surveyors will check that all conditions are met. A hospice agency should maintain evidence of the governing body’s role and activities. Governing body authorizations and activities should be documented in governing body meeting minutes, company organization documents, and company policies and procedures.
Where can you find out more?
CMS Conditions of Participation – Governing Body
