No one plans to design or implement a broken process or workflow, yet over time even the best of plans can suffer from numerous leadership or staffing changes, failure to keep policies updated and lack of simple observation.

Finding out during a survey that the policy has not been updated or the staff are not following a newly released CMS requirement is not the best time to make important decisions. Short-term solutions may get your facility through the immediate crisis but in the long term may create more problems and work for the team.
When working closely within the policies and procedures that are not efficient or overwhelming, staff may develop workarounds or eliminate critical steps that are passed on to the next new hire. It is critical that leadership not only observe the daily workflow, but they must also listen to genuine concerns expressed by those staff members required to follow the policy and process.
Below are five signals that alert leaders to take a closer look or ask for outside assistance.

1.    Repetitive Findings

A system, process or workflow that continues to repeat itself may have various causes and reasons. The range of these causes and/or reasons may be extensive and may at one time have been resolved but the solution may no longer meet the current needs, or the original solution may have only been a temporary fix when the issue really required a more strategic assessment. Reoccurring issues may be a signal that the Quality Assurance and Performance Improvement (QAPI) is not based on root-cause analysis, improvement is not data-driven or the timeline to audit or observe was not extended for the appropriate amount of time for real change to take place.

For example: During the QAPI meeting the Infection Preventionist states that Urinary Tract Infections (UTIs) are up. In this instance the QAPI committee does not really have enough information to move forward with anything more than a general conclusion of what to do. Therefore, the Director of Nursing (DON) does an in-service to remind the staff to offer fluids with every patient interaction. Unfortunately, this is another temporary fix.

A better study would report the problem using data, for example the patients with UTIs have increased from 10% last month to 50% this month; the steps taken to understand the root cause; what was implemented to negate the root cause; how it will be monitored; and expected results, such as new UTIs on C-hall for the next month and each subsequent month for three months.

Building a strong QAPI program that is based on data is not always a familiar process in many organizations. Leaders may not have the time to work closely with the Interdisciplinary Team to help them build their studies in a measurable, data-driven manner that promotes improvement or addresses variations in quality program measures. 

2.    Assessments Are Late

Occasionally there may be instances where either a Minimum Data Set (MDS), a Nursing Assessment such as the tool used to assess fall risk or a Care Plan is not completed on time. Regardless of why patient assessments of any type are late, it may become a big problem very quickly. Those closest to the problem are the best to understand the reasons for late assessments; for example, the MDS Coordinator knows that she is late due to Interdisciplinary Team Members not completing their information on time, a sudden influx of admissions or assisting with direct care and becoming so overwhelmed with the number of late assessments she doesn’t have time to address the underlying reason or reasons. Nurse leaders may also find themselves immersed in the day to the point they do not have the time or energy to dig deep into a problem. Direct care nurses facing unexpected patient needs may simply run out of time to complete the assessments assigned.

A process review conducted by someone outside the team who has no bias may have more insight into why assessments are late, provide options to improve processes and work with the team on how to implement changes.

3.    Reimbursement Does Not Reflect Patient Acuity

The facility is taking more clinically complex residents than ever; unfortunately, the needle is not moving when it comes to reimbursement. More direct care nurses and direct care givers are desperately needed but the budget does not allow for additional hires. An impartial Minimum Data Set audit will begin to identify where gaps are occurring. Gaps may appear at any point from preadmission to discharge. To minimize the impact of gaps on correctly reporting the patient acuity through the MDS all systems and processes must be assessed using comprehensive measures. Using an impartial set of eyes to observe, audit and evaluate where the gaps exist provides the facility with an understanding as to why the reimbursement needle is not moving and will assist the facility to develop a plan to close gaps.

4.    Quality Programs Do Not Reflect the Care and Services Provided

The MDS data that drives reimbursement and impacts on the Survey Quality Measures, Five-Star Rating, Quality Reporting Program Measure and SNF Value Based Program may create a conflicting picture of the facility. Balancing quality with reimbursement is not always easy; for example, a high acuity patient dynamic may increase reimbursement while negatively impact quality measures. In either situation a thorough, open-minded assessment of the day-to-day process and workflow is beneficial. As leaders understand where conflicts exist, they can proactively focus day-to-day care delivery more effectively.

5.    One Person Is the Process

Workflows, processes, systems and quality care can fail when there is only one person who owns it or has been delegated to it. Many of these areas that impact patient care cannot depend on only one owner. This is probably the hardest gap to identify because it does not become evident until the owner is no longer available, and it can appear at a most inconvenient time. A surveyor identifying the current process does not match the procedure written in the policy and determines this has caused patient harm is not the time to realize only one person knew what the policy stated or the process changed but the policy was not updated accordingly. Someone unfamiliar with your facilities’ policies and procedures observing real-time implementation is able to identify gaps between the care the policy states is to be delivered versus what is actually being delivered. 

Conclusion

Persistent findings, late assessments, reimbursement concerns, poor quality outcomes and overreliance on a single individual are all signs that a workflow may need closer examination. An objective, outside perspective can help organizations identify hidden gaps, strengthen compliance, improve quality outcomes and create more efficient and sustainable processes. For more information on our clinical consulting services, or to schedule a free consultation, contact us here. 

Richter partners exclusively with long-term post-acute care providers to deliver tailored, high-impact solutions across clinical, financial and operational domains. Our team of more than 90 healthcare consultants brings real world industry expertise to help leadership teams improve compliance, strengthen financial performance, optimize revenue cycle management, streamline EHR and PointClickCare systems and manage Medicaid eligibility with confidence. Acting as a trusted extension of your organization, we provide personalized guidance, expert-led enablement and end-to-end support that reduces complexity while driving measurable growth. With a focus on sustainable outcomes that strengthen clinical quality, financial stability and operational efficiency, while reducing risk and advancing resident care excellence, Richter empowers skilled nursing communities, senior living providers, home health and hospice organizations to achieve long-term success in today’s complex healthcare landscape.