Skip to Main Content
Thought Leadership

A Zero Percent Error Rate: An Inspiring Story on How To Get There



November 09, 2022
Listen to the podcast

Related Industry:


Related Service:

Hospice & Palliative Care 


Husch Blackwell’s Meg Pekarske is joined today by Mary Kay Tyler, Chief Quality and Compliance Officer of Hospice of the Western Reserve, who shares strategies for achieving the elusive goal of improved clinical documentation. As Mary Kay discusses, you start with what can make the biggest impact. For general inpatient care (GIP), that is often physician and nurse practitioner (NP) documentation. Meg and Mary Kay discuss how she leveraged her electronic medical records (EMR), fostered buy-in, cultivated accountability, and remembered to listen throughout the process. We encourage you to take notes—you won’t want to miss any of these helpful tips.  

Read the Transcript

This transcript was auto-generated using Adobe Premiere Pro.

00:00:05:00 - 00:01:07:09
Meg Pekarske
Hello and welcome to Hospice Insights, The Law and Beyond where we connect you to what matters in the ever changing world of hospice and palliative care. A Zero Percent Error Rate: An Inspiring Story on How You Get There. I'm thrilled today to be joined by Mary Kay Tyler, chief quality and compliance officer at Hospice of the Western Reserve. She shares strategies for achieving the elusive goal of improved clinical documentation. As Mary Kay discusses, you start with what can make the biggest impact for GIP That is often physician and peer documentation. We break down how she leveraged her EMR, fostered by end and cultivated accountability And remember to listen throughout the process. Now go get a pen. You won't want to miss any of these helpful takeaways. Mary Kay, you're one of my favorite people. I'm so glad that you're here. So thank you for taking the time to share what what are really helpful insights. So.

00:01:08:07 - 00:01:09:13
Mary Kay Tyler
Well, I'm happy to be here.

00:01:10:06 - 00:02:36:02
Meg Pekarske
So you and I did a little pre-planning on on the session. And, you know, I came up with as you were explaining all of the things you have done internally, sort of broke things down into sort of six different buckets. And I think for for our listeners this is so helpful because everyone is dealing with it could be a number of teepees at the moment. And you have CPI audits and all these other things right? And so you feel buried and then you're supposed to be making improvements and how do you do that? And so when you and I were were talking, what really struck me was just you know, breaking it down and focusing on the things that matter. Right. Because going and telling people, like be better doesn't really move the bark and you really moved the bar and made meaningful difference. And so wanted to to share some of those those secrets and magic or whatever. So the first thing that struck me was I call it the biggest bang. You can't do it all at once. Who do you focus on first? And so in the intro, I talked about positioning and PS and you and we're talking about GIP documentation. In particular, but you really found that those were the professionals on the team that could have the biggest impact, right?

00:02:36:03 - 00:04:15:10
Mary Kay Tyler
Right. Really looked at when I sit down and do a summary, where am I looking for that summary information? And so I thought, well, I you know, I first look at the physician or NP documentation. Obviously got to review the entire chart, but that was my starting point. So I worked very closely with our chief medical officer. And underneath the quality team, we do have our computer education team, our clinical software team. So by putting those two groups together really worked on how can we improve the documentation by our physicians and nurse practitioners to really paint the picture better. I mean, obviously, we all believe that we're providing the right level of care. We just need to have that documentation that demonstrates that. And our physicians, you know, bought into that because we were you know, we sat down not just with the medical director but a couple key physicians who are in our inpatient facilities and said, okay, this is why you this patients here. Tell me more about it. And you could pull out from their conversation that there was a lot more behind their decision that was in their documentation. So now, okay, we got to get that documentation and did it with real patients at the real time. You know, right now this patients here, tell me why, hey, look at your documentation from yesterday. That really doesn't tell me what you just told me. Yeah, let's go over it. And we set down really word from word to try to give them some better key phrases to use.

00:04:15:14 - 00:06:15:16
Meg Pekarske
And I think that's so important because right. Sometimes we get wrapped up on doing everything all at once and everything needs to be perfect. And what we're trying to do is move the mark. And so I totally agree with you. It's like, well, what did the physician say? Or the NP, that's the first thing you're going to jump to. So of course, if you're trying to improve documentation, isn't it focusing first on those people? But I really because. Right, everyone could improve their documentation. Nursing as chaplains. Maybe, maybe chaplains don't need to prove their documentation. They're usually really robust, but most people could. And just that drumbeat of, oh, just be better and we're going to break down what better is. But I think that that was a really helpful insight of who am I going to focus on first because they're going to make the biggest difference. Like could they make a 50% difference in the overall if we're looking at the overall quality of the documentation supporting the level of care, the physician and P and then the second you mentioned this is and it's the second point on my list was leveraging your EMR, so. Right. So many fabulous things about EMR. And there's many things that are real frustrating. And in our operational series, we're talking about EMR glitches because I feel like we're constantly dealing with some pretty big EMR glitches. But speaking on the plus side, there's a lot of things you can do to customize your EMR to make information easier to be comparative for physicians and other things so that they can look at things. Right. We say we want clinicians to be comparative but, you know, if they have to go through 10 million screens to get there, is that really going to be very helpful and are they really going to do it? So can you share some tips you did with your EMR?

00:06:16:04 - 00:07:52:15
Mary Kay Tyler
Sure. One of the things to reduce having to click from one screen to the other to get information was to add a plan of care summary section. So our EMR, you are able to bring elements forward so you would need an EMR that can bring some. So we customized bringing that section forward. So whoever was seeing the patient. Yes, one provider saw the patient on Monday and maybe there is a different provider that comes for day two of GP. They would see that brief summary of the plan of care and it would have a date and the physician's initials at the end of it. And then when they did their documentation they would then put that brief and it's usually only one to two sentences. It's not, you know, really a lot of work for them to do, but it is a free narrative that they can add. And then when you're looking at it, you see that running summary each day. Now we ran up to if someone's in GP for a very long time, we do have to start deleting some of the first entries, but really to teach people maybe it's 5000 characters that's in that field. So that has been very helpful to really get a sense of, Hey, what have we've been working on for the last three days? And this is the new change on day four that has it different. So I think that was a very helpful.

00:07:53:12 - 00:08:31:15
Meg Pekarske
Well, and when you say care plan, right? It is like the critical document, but oftentimes you don't see care planning just change or not as often as I think ideally you want. So how do you tell the story? It's hard to say, oh, these things are going on, but not a lot has changed because you have to find the changes through the individual clinical notes as opposed to the care plan, which is the overarching thing. So that's really interesting. So so was that based on feedback that you got from this outreach with your physicians about, well, I'd like you to be more comparative and.

00:08:33:01 - 00:09:14:12
Mary Kay Tyler
It was based on the feedback and the fact that we had a couple providers, you know, that would just come in for a day to cover when someone was off. And so we made sure we not only talked to the providers that are normally there, but the ones that were covering and said you know, how are you struggling with knowing what you need to know about the patients? And that did was brought forward by the people that don't spend a lot of time in the unit. Hey, I would like a really quick summary. And, you know, I do look at the other documentation, but probably not as thoroughly as I don't have time. Yeah, yeah, yeah. There's a limited amount of time for all of us.

00:09:15:06 - 00:09:33:19
Meg Pekarske
Which bleeds into this third point, which is it takes a village compliance, right? You are not just one person. I mean, you have a team of people, but still. Right? I mean, you're a really large organization I mean, how many hospice patients do you have?

00:09:33:19 - 00:09:39:22
Mary Kay Tyler
We have 1300 hospice patients.

00:09:39:23 - 00:09:45:18
Meg Pekarske
1300 hospice patients? Okay. And how many units do you have? GIP units.

00:09:46:13 - 00:09:47:21
Mary Kay Tyler
Four GIP units

00:09:48:07 - 00:10:09:06
Meg Pekarske
So obviously you and your compliance team can't just will this to happen, right? So you really need to get other people to buy into it to carry water for you. And so it can't just come from on high from compliance because we know that that fails, right? You're just saying.

00:10:09:06 - 00:10:10:08
Mary Kay Tyler
It certainly does.

00:10:10:19 - 00:10:31:11
Meg Pekarske
So so how did you approach this differently under the sort of guise of it takes a village when you decided to to say, okay, I'm going to take GIP and this particular goal in mind, how did you approach it differently then maybe something else you have in the past?

00:10:31:23 - 00:12:55:02
Mary Kay Tyler
I think our physicians and nurse practitioners we've cultivated over the last couple of years really keeping them informed on what's going on. You know, what what CMS is looking at, what OIG is looking at, and they really have and that's why regular attendance at their staff meetings, it may only be 10 minutes in their staff meeting, but it really and getting the Pepper report out to all of them. Since we are a large institution, it can't just be let's get it to leadership in the CMO. It needs to get to the ground level. So we've cultivated that over the last couple of years. And so for this what we decided we'd leveraged a reporting system that we have that takes information out of our enemies are and can create reports for us. And we designed a report that gave us every day the CMO myself, our CEO and our chief clinical officer get a report of all the patients in CHIP for greater than five days. That report is then sent to whoever's at the units and the expectation is there to respond to that email to the chief medical officer just defining why their patients still in GP. Just once again it is a quick sentence. It's not a narrative. We're talking three or four words, sub Q medications being used, a new symptom of agitation, whatever that is, and it's justified or their response is, hey, we're changing them to routine home care today or your reports wrong. They changed a routine home care over the weekend. Oh, see what's wrong with your report? So, you know, we have found some other interesting things in doing that, but that's really given the ownership back to the actual providers who are making that decision. Once again, stressing, we believe they're making the right decision. Let's just have some transparency to that decision for leadership to see and then for us to feel more secure. That has really been helpful and I think they bought into it very well. I mean, we didn't get any pushback like, oh, you're just watching us or.

00:12:55:11 - 00:12:56:00
Meg Pekarske
Yeah, yeah.

00:12:56:00 - 00:13:35:07
Mary Kay Tyler
There was really no negative but we had these conversations, but we didn't just do it. We talked through it. What do you think about this? How would that work? And they were all very receptive and I'm talking both physicians and nurses because we don't every day we don't necessarily have a physician at our unit. It may be an MP. Yeah, and then in our unit, that's a little larger. We made one person the contact, even though there may be two providers that day and then that way it was very clear they know who supposed to do that. They weren't. Oh, is he doing it today or is she doing it today? Wasn't that confusion?

00:13:35:11 - 00:15:07:02
Meg Pekarske
Well, I think what you say about sharing compliance things regularly. So it's not just Mary Kay says this, right? This is what the government's concerned about. And this is. And so there's by and right, every job, every person's job has a compliance element to it. Right? So it's not a department. It is really an obligation of everyone. And so I think pulling that through into if I'm going to have a compliance initiative of improving documentation, that sort of it takes a village because and I do think you need to deal with this whole compliance fatigue or improvement fatigue. People get like, oh, you keep asking me do more and more and more. And I think, you know, my reflection is you're talking is you focused on pretty, pretty I don't want to say small things, but. Right. It's not like write two paragraphs every day about why the person is eligible. It's like we're carrying through this care plan thing. And then with your five day report, you're not expense expecting them to like over respond. Right. Because we expect they they do have their eye on the ball and that they can very quickly say, yeah, this is why this person I know they're on day six of GIP, but they need it because and then they fill in that sentence as opposed to making it you know I want you know this beautiful narrative.

00:15:07:19 - 00:16:38:13
Mary Kay Tyler
And I think that that was key that we were realistic in what we were expecting people to do. Yeah. And our we didn't make these changes. We had the we have a new CMO who's been here just a year now, but he actually got experience using our EMR and he still does it on a regular basis when he's covering it. The same with myself, really trying to keep up. Now, usually they have to fix some of my documentation. I do make sure the team does get a little nervous. But anyway, still being experienced and being able to really talk realistically. There's another section of there note that is pre populated so they can click which the symptoms are and we added some very important narrative to those. And I'll just give you one example medication adjustment requiring 24 sevenths skilled nursing monitoring which cannot be managed in the home setting zoom by adding cannot be managed in the home setting or some variation of that. I think that it put a lot more weight and statements and then you know their summary may then say you know change you know increased medication frequency to Q one hour something like that but some of this they can easily click which is helpful also.

00:16:38:21 - 00:17:53:21
Meg Pekarske
That is is so helpful. I was just emailing a client about reviewing some GP examples and I feel like a read part of the guidance about one GP is appropriate but then not paying or being as attentive to the second half, which is it cannot be managed in another setting. Right. And like hitting that home is that just about the pain in symptom management and it's like and it can't be managed anywhere else but yeah, right. And I think that that sometimes documentation just really says, well they have this condition and they're getting I.V. medication. So of course then it's like, well, you still need to say more like could we try something else? Ah, so I think that that's really smart and really helpful. So then and you talked a little bit about this. And so the fourth thing on my list was how to build accountability and the role of leadership. And it sounds like so you do all this proactive staff and you do this with your EMR. And so is the accountability piece really in those for people who are on over five days, this leadership report, is that where the accountability comes in that.

00:17:54:05 - 00:19:21:07
Mary Kay Tyler
Yeah, I really I not that the ones for less than five days are, you know, and the appropriate level of care. But yes, I think the the providers realize that they are going to need to respond to that email. I have to say there's the 100% response sometimes it's a little later in the day than we'd like but we usually get hey I'm swamped emails coming. Yeah there's an email that that's coming out and so really 100% compliance with them responding to it and and knowing that you know we're there's an important reason for why we're asking this question. And then we did share with them when these changes resulted in a substantial decrease. I mean we went to a zero error rate and we had double digit era. You know, I don't want to say exactly how high it was, but it was high. Yeah. And really made sure that they were thanked for that and that we've continued to make modifications as they've brought them forward. And I think that they I really do think that the providers feel that it's a joint effort and this is a team approach. They do know that nursing's next on the list. Yeah. To improve it. I think, you know, we've also gotten their input. What would you like to see in the nursing documentation that's going to help you.

00:19:21:16 - 00:21:34:00
Meg Pekarske
You beat me to it. The fifth point I had on my list as the balancing doing with listening and reevaluate regularly because right, we just need to begin and then valid, you know, evaluate whether or not that was helpful. Right? And if you found out everything you just did, was it moving the marker, abandon it, right? Start with something else, get feedback. Why did that not work? You know, I just because sometimes I think we get scared if I put a lot of time into doing this and I thought it was going to work and and then just working harder on the same thing and it's like I got a I got to get feedback and I got to, you know, hear from others because what I thought was going to work isn't really moving the mark. Now, you nailed it to me to have a 0% error rate, I mean, is remarkable. And kudos, like you said, not just to the compliance team, but all of your providers and let's just say it's not that care was any different or that people were eligible. It's just connecting those dots in a more clear way. Which I think really when your audience for this documentation is a reviewer who may not. Well, we'll never see this patient may not have tons of familiarity with hospice, right. Like you need to leave them and connect the dots. And so it's a real test I made to, I think, building your idea with input on the front end and then reevaluating it again with those same people about what's working and what's not working. And you had the good fortune that, wow, out of the gates. You got a lot of movement, positive movement, and so so then the the last thing I had on my list was persistence, right? Because have we solved this problem forever? Right. Like, who knows? Who knows? Right. And so it's probably worth it because like, when do you stop sending the emails for the patients on day five? And do we find that forever?

00:21:34:10 - 00:22:50:04
Mary Kay Tyler
I we're going to keep it for a while. You know, we really don't see it as a burden. No one is complaining that it's a burden right now. So as long as the scrutiny now we may have to add, you know, other things to that. Yeah. You know, so if we identify another area and and things kind of stay quiet in the Gap area a year from now, maybe. Yeah. You know, we would focus on something else. And one of the things that I'm kind of focusing in on, and I know this is off subject is, yeah, those sorts of terminal illness because you sit in team and you listen to what they're saying and then I go and look at the cert and I'm like, hmm, you know, you really provided some good education, Dr. Smith, and I don't see it in your cert and you know, we got to somehow get that information because once again, the reviewer could not may have no medical knowledge and need to get that to them. So we'll probably keep it for another year. And if things quiet down will change the focus. We don't want to overwhelm and have two things at the same time.

00:22:50:04 - 00:25:43:17
Meg Pekarske
But yeah, but I think that it is really important in terms of trying to figure out the disconnect sometimes. And because I've done a lot of documentation training in my, my day and I feel like the audience is really important, like who are you writing this for? And I think they think they're right in it for their so for like the physician that comes on tomorrow. But it's like you're really writing this for some third party reviewer three years from now who may look at this right? And so it's got to stand on its own, right? And so it's got to give enough color. But sometimes I think giving folks perspective on who is the audience for your documentation, because that may lead you to use less shorthand like a lot of physician notes have lots of shorthand. I mean, now when people can type, I think it's a little bit better. But still there's a lot of medical language and things that people don't necessarily understand because another physician is not really going to be reviewing this, right? It's going to be a clinician who may or may not have any hospice experience. So, you know, and ultimately, if you have to peel it, you're going to go to the administrative law judge who is a lawyer and knows nothing about medical staff. Right. So and I think it's an important skill for and we talk about physicians having to expand their role as being advocates, right? Because so often you have to appeal cases and your physicians need to feel comfortable looking at it from another perspective because when they have to look at documentation from three years ago and scratch our head and be like, okay, why did I think this? I wish I wrote more, right? Like right. So I think for both the perspective of who your audience is, but also this five year rule, like I this document has to stand up, you know, five years from now that I can know why I did what I did and all of that stuff, because it is really that contemporaneous documentation that's going to be the most persuasive then me saying five years later while this is what I was thinking. But as I documented so so that persistence I think is is really helpful and great to know that that you're not running into that fatigue where people are just like, I'm going to just piece out because you just keep asking more and more of me and I want to spend time caring for my patients and not do all of their stuff. And but I also think seeing that it was so successful and resulted in a 0% error rate on GIP, I mean, that's remarkable. That's huge.

00:25:44:07 - 00:26:02:00
Mary Kay Tyler
Yeah, it certainly is. And I do think as you've said, a couple of times, the buy in and working with the providers was was key. We didn't just hand them something that yeah, the quality team came up with you know, because that those interventions almost always fail.

00:26:02:00 - 00:26:05:06
Meg Pekarske
So we learn from mistakes. Right.

00:26:05:06 - 00:26:06:13
Mary Kay Tyler
I certainly have.

00:26:07:19 - 00:26:31:14
Meg Pekarske
Because I do think it's like, well, this makes sense to me and compliance, but a blending of what do you look for when you write a summary and then partnering with the people who are documenting and say, here's what I need, here's what you do, how can we blend these together? And really make a difference? But well, I told you, you should frame that letter.

00:26:32:04 - 00:26:36:19
Mary Kay Tyler
Yes, I think. And I'm keeping it in my office.

00:26:36:23 - 00:27:07:01
Meg Pekarske
Exactly, because it is just a wonderful story. And I think that, you know, you're still providing the great care, but the more you can connect the dots and make it really clear for reviewers to say, oh, yeah, these symptoms cannot be managed in another setting because and then they are answering that question in their documentation and not just in a esoteric way, like that's in the back of my mind. But you're really completing a sentence that that has that built in.

00:27:07:11 - 00:27:08:00
Mary Kay Tyler

00:27:08:10 - 00:27:27:21
Meg Pekarske
Awesome. Well, this was an inspiring story to me, and because I feel like people always like to hear happy endings, obviously, but also just something meaningful that you did that made a difference in harnessing your EMR, which it sounds like played a really big role in terms of...

00:27:27:21 - 00:27:28:14
Mary Kay Tyler
Certainly did.

00:27:28:15 - 00:27:35:21
Meg Pekarske
...what you're able to accomplish. So yea to EMR is they have tons of value if we can use them correctly.

00:27:36:06 - 00:27:37:21
Mary Kay Tyler
Certainly do. Thank you.

00:27:38:03 - 00:27:47:00
Meg Pekarske
I so appreciate you taking the time to share all of your insights. This is an incredible story and I think really great takeaways for our listeners. So.

00:27:47:10 - 00:27:48:12
Mary Kay Tyler
All right. My pleasure.

00:27:53:10 - 00:28:09:05
Meg Pekarske
Well, that's it for today's episode of Hospice Insights, The Law and Beyond. Thank you for joining the conversation. To subscribe to our podcast, visit our website at or sign up wherever you get your podcasts. Till next time, may the wind be at your back.