98 Tips for Getting Started

30 Tips for Educating Staff

  You have been asked by your facility’s administrative team to train a staff for the new wound center that is to open in a few short weeks or even months. The following are tips for educating your staff.

  1. Staff members hired for hospital outpatient wound centers are often pulled or transferred from the acute care setting — clinicians who enjoy caring for patients with wounds who have worked with the general hospital population, not exclusively with wound patients. This can present challenges in the educational process.

  2. Hiring an experienced wound care practitioner will require specificity in outpatient clinic training.

  3. A systematic approach to staff training can result in a positive outcome for the staff, clinic and most importantly patients.

  4. Staff should be knowledgeable regarding basic general care as well as assessment, treatment, and documentation specific to wound management.

  5. Patients receiving care in an outpatient clinic will require full nursing or physical therapy assessments.

  6. In the clinic, staff can rely only on what they are told and by what they observe in the hour or so the patient is present—unlike in a hospital where a constant monitoring system is in place. The clinician must learn to interpret subtle signs.

  7. In assessing wounds, standardization and accuracy among staff members are imperative. Clinicians need to be proficient in recognizing the signs and symptoms of basic and atypical types of wounds that may present in the clinic. 8. All clinical staff members should be knowledgeable regarding pressure ulcers (including staging), arterial ulcers, venous insufficiency ulcers, diabetic neuropathic ulcers, and burns as well as ulcers related to shear, friction, and moisture.

  9. Ulcers should be accurately staged and described in all documentation, including appearance of wound bed and periwound tissue, anatomic location, odor, and pain level, as well as color and consistency of exudate.

  10. Patients come to wound centers expecting state-of-the-art wound treatment. Many have exhausted all other options in treating chronic wounds before coming to the clinic.

  11. The ability to appropriately select and apply dressings are two of the most basic skills staff members should possess.

  12. Dressings that are conducive to a patient’s lifestyle and that can be easily changed by the patient, caregiver, or home healthcare (HHC) provider need to be selected.

  13. Because the patient is not in a clinic every day, the dressing application needs to be easily duplicated by the person who actually applies it.

  14. Staff must be well trained in applying various types of compression therapies, wound cleansing, offloading techniques, and debridement as well as in the adjunctive physical modalities offered at your facility, including ultrasound treatments, pulsed lavage with suction, electric stimulation, negative pressure wound therapy, biotherapy, vasopneumatic compression, ultraviolet therapy, and monochromatic infrared radiation.

  15. The clinicians providing certain treatments must be credentialed or certified.

  16. Physical therapists do not need to learn infusion therapy and nurses do not need to pass competencies on e-stim but both clinician groups should be aware of what the other has to offer and support their efforts.

  17. Documentation is critical in all healthcare settings but must be “spot on” and specific to diagnosis when working in the outpatient clinic, both to meet regulatory guidelines and to ensure the payment that sustains operations.

  18. If the clinic is a ‘stand-alone’ (not hospital-owned) facility, the only way to survive is to make sure that income exceeds expenditure (ie, create a profit).

  19. Current payment systems mandate appropriate documentation to support the care rendered for patients per diagnosis. Simply documenting treatment of a “wound” will not guarantee reimbursement for the assessment and treatment of clinic patients.

  20. Reimbursement rates differ according to treatment—eg, dermal substitutes, negative pressure wound therapy, and debridement. Conflicting documentation (eg, differing extremities, numbers of wounds, measurements, or diagnosis) will almost guarantee no reimbursement for that visit.

  21. Paper documentation can be more labor-intensive in the long run and prove ineffective in terms of tracking outcomes and benchmarking. In addition, handwriting is conducive to mistakes when being re-read, this is often the case when physicians dictate from staff or their own notes.

  22. Multiple electronic documentation systems are available that help eliminate these problems and offer national benchmarking, trend reports, tracking statistics, and updates that keep pace with changing reimbursement guidelines.

  23. Staff members need to understand the nuances of care outside the walls of their own facility. Dressing selection must be tailored not just to the patient’s needs, but also to what will be available from various home healthcare agencies and long-term care facilities.

  24. Staff members need to understand how supplies are provided and how to work with the company (including completion of all pertinent paperwork) to ensure timely delivery of correct products to your patient.

  25. Continuity of care improves if clinic practitioners have a basic understanding of skilled nursing facility (SNF) and HHC reimbursement issues.

  26. Outpatient care should include referral to and use of other community services. Everyone in the clinic should be familiar with local transportation companies, durable medical equipment (DME) companies, orthotists, prosthetists, physician’s offices, labs, and other hospital departments.

  27. Beyond the clinic’s profit/loss statement, knowledge of the reimbursement system will help clinic staff navigate payment issues that include patients who need but cannot afford compression hose or advanced dressings.

  28. Most importantly in an outpatient setting, staff members need to realize that they can only control limited chapters of a patient’s life. In an outpatient clinic, one can help provide the best care possible and instruct the patient on a healthier lifestyle. However, if the patient refuses or is unable to follow practical healthcare advice, the clinician must let go.

  29. Nurses and therapists need to know what is and what is not within their control. This is often the most difficult lesson to learn in the outpatient wound center.

  30. Staff education must be an ongoing task. Wound care changes rapidly, clinically, and logistically. Membership in wound care organizations, continuing education programs, online education, journal articles, collegial relationships with other wound care professionals, and ongoing dialogue between staff, physicians, and patients will help keep staff up-to-date and aware of changes in the healthcare climate.

34 Tips for taking the Clinic from Concept to Care

  Wound management crosses all disciplines from physical therapy to plastic surgery and includes podiatry and dermatology. The following are tips for taking the clinic from the concept phase to the care phase.

  1. Studies suggest that patient outcomes are better when care is provided in an environment of focused expertise.

  2. A systematic approach to wound care leads to superior clinical outcomes, positive revenue streams, and well deserved community accolades. These centers generate income for the hospital via tests and procedures.

  3. The wound center addresses inpatient wound care challenges, helping decrease runaway wound-related expenditures.

  4. A hospital has the potential to reduce inpatient length of stay and address a significant unmet need in the community when a wound center is established.

  5. Preparation and planning can lead to frustration and failure. However, careful planning and early investment in resources can lead to success.

 6. From the beginning, there must be buy-in both from the professionals who approve plans and budgets and those who take the plan to the hospital’s Board of Directors—many of whom are leaders from the community that you will serve.

  7. The hospital’s CEO and CFO should be well informed of the options for program development and become champions of the cause.

  8. Include medical staff as well as the marketing team with ideas about future internal and external marketing needs. They are the resources that will plant informational seeds in the community, identify potential referral sources, and ascertain the perception of need in the medical community.

  9. Knowledge of the demographics of the community based on known epidemiological data can assist in projecting the potential needs. Additionally, knowing the current diagnostic trends in the inpatient population (ie, diabetes, cardiovascular disease, patients admitted with wounds) can help predict potential wound care needs.

  10. Determine proximity to other medical services, patient access, visibility, options for expansion, cost per square foot, and the challenges for equipment installation (eg, hyperbaric chambers).

  11. Find out if there are other similar outpatient programs in the community. What are their strengths and weaknesses? Will the clinic compete for the same patients and physicians?

  12. Evaluate the service area mix, starting with the postal codes for your patients. Hospital marketing can help assess primary and secondary service area populations to allow staff to estimate payor mix.

  13. The clinic space must include individual treatment rooms with sinks, adequate front office space, offices, waiting area, clinical workspace, a dictation area, storage areas, and clean and dirty utility rooms.

  14. Podiatry chairs or stretchers, Mayo stands, visitor chairs, and either installed or mobile lighting are the minimum for a properly equipped treatment room.

  15. At a minimum, the center must have hand-held Dopplers and cameras. Transcutaneous oximetry or skin perfusion systems must be securely stored—if possible, installed on carts. Specialty equipment such as low-frequency ultrasound or pulsed lavage may be added later.

  16. Plan for instrumentation such as curettes, forceps, scissors, rongeurs, tissue nippers, and the like. Determine whether reusable or disposable equipment would be more effective, depending on your resources.

  17. Copier(s), fax machine(s), locking file storage, desks or cubicles, phones, and all other essential office needs must be considered. “Point of service” electronic documentation will require a computer in every room.

  18. Determine how walk-ins, registration, insurance verification, money collection, check-in and check-out processes, billing reports, payroll and time sheets, and end of month reporting will be handled.

  19. Privacy policies. HIPAA guidelines must be established and enforced.

  20. Assess what dressings are currently stocked in the hospital.

  21. Decide who will maintain par levels? By what mechanism will supplies be assessed and shelves be stocked? How will the inventory database be maintained?

  22. Also decide how will pharmaceuticals be handled? Who will maintain this information? Who will reorder pharmaceuticals? Consider topical and injectable anesthetics, topical creams, debriding ointments, steroids, and antifungal agents.

  23. Establish arrangements for and documentation of clean utility, dirty utility, housekeeping, and biohazard waste removal. Establish a plan in writing for the physical path that waste will take to exit the building.

  24. Is there a physician champion already involved? Physician staff recruitment should commence with great care. Ideally, a full-time Medical Director who has a passion for wound healing and can assist in attracting other multispecialty physicians should be identified.

  25. The ideal situation would involve hiring nurses and therapists with wound experience but this is not always feasible or possible.

  26. Hiring in staff from other specialties—eg, critical care or the emergency room brings in skill sets that can enhance the knowledge level of the entire staff.

  27. A thorough understanding of federal and state regulations, Joint Commission requirements, and coding and billing guidelines is essential to the financial health of the center.

  28. Documentation must include patient consent for treatment and photography, an initial visit and history form, regular clinic encounter and wound assessment forms, and a clinic charge form.

  29. Physician reimbursement is controlled by complex regulations from the Centers for Medicare and Medicaid Services (CMS). CMS details the specific documentation required to achieve different payment levels for initial and follow-up visits.

  30. The key consideration in selecting an electronic documentation system is its level of functional and semantic interoperability.

  31. Planning to open a wound clinic is a massive undertaking that can cause one to lose sight of the goal—to improve the care of patients with nonhealing wounds.

  32. The visual nature of healing wounds provides an emotional reward often lacking in other disciplines.

  33. Grateful patients—often elderly and in need of emotional support—find themselves uniquely attached to the wound center caregivers who often spend more time with them than any other clinicians.

  34. The wound center program must be financially successful if its mission is to be realized.

34 Tips for Evaluating Your wound Clinic Operations

  After a seemingly interminable amount of time, the wound center is open. The staff is seeing patients and helping them with their chronic wounds. Everything is going well.

  Or is it? How is the wound center really doing? The following are tips for evaluating your clinic’s operations.

  1. Determine whether the center is providing evidence-based wound care and, if so, whether outcomes are comparable to local and national standards and results.

  2. Evaluate how patients perceive the provision of care.

  3. Ascertain whether or not the clinic is financially healthy.

  4. Determining whether the staff is practicing evidence-based care is fairly easy. Most wound centers treat patients based on protocols or algorithms. If current wound care practices in the center follow evidence-based protocols, the staff should be providing quality patient care.

  5. Assessing how patients are responding to treatment depends on how the center tracks patients. If you have an electronic medical record (EMR), outcomes data are available at the touch of a button on the computer. If a computer database of some type is not available, chart review will be necessary.

  6. Healing rates, complication rates (such as infection), amputation rates, and other data should be evaluated for each major wound type treated in the center.

  7. Once collected, the information should be compared to national standards and randomized, controlled clinical trial results for the particular wound type being treated.

  8. If the center’s outcomes are comparable to published data, pat staff on the back—then try to better the figures.

  9. If the center’s outcomes do not quite measure up, do not presume staff are treating the worst patients on the planet. Use this as an opportunity to evaluate the treatment regimens and techniques in order to improve outcomes.

  10. Evaluate the satisfaction levels at the wound center. This may be the most critical area to evaluate.

  11. Three factors should be addressed: A) satisfaction of the staff working in the center, B) satisfaction of the patients receiving the care, and C) satisfaction of the referring physicians. Each is equally important and must meet high standards if the wound center is to function successfully.

  12. Satisfaction of the staff working in the center is crucial to success. If the staff are not happy in their jobs caring for patients with wounds, the entire care process can be slowed or stalled. The provision of efficient wound care depends on each staff member knowing his/her task and being willing and eager to perform it. Disgruntled or envious employees compromise the wound center atmosphere.

  13. Everyone in the center must be dedicated to making the wound center operate smoothly. For any operation to work efficiently, every staff member must be committed to doing whatever it takes to make the organization function.

  14. The next group that must be satisfied with provision of care is the patients. People receiving a medical treatment have the most relevant perspective of success (of that treatment). If patients are not satisfied with the care they are receiving or if they are not pleased with the way they are receiving the care, they will not cooperate with care plans or disappear.

  15. Patients notice how people do their jobs as well as the attitude that they are performed. They notice whether staff treat one another with professional respect. They are particularly aware of how staff address patients—whether patients are respected as individuals with medical problems or herded through the office for a dressing change and out the door.

  16. Many wound clinic patients have chronic problems and may be in the clinic’s care for a long time.

  17. Patients want to understand their problems and be involved in the development of their plans of care. It is extremely important for the care giver to address the patient’s concerns in words he/she can understand, answering questions such as, what is this wound or condition? What can I expect from the treatment? What should I look for when things are not right?

  18. The patient’s ability to participate in his/her care will greatly enhance his/her satisfaction with the wound center, the treatment, and the staff.

  19. Every year or so have patients fill out a patient satisfaction questionnaire. Many are available but it is also possible to develop a customized survey.

  20. An often forgotten group whose satisfaction with the center’s program is most important is the referring physicians. Many patients seen in the wound center come as a result of a direct physician referral. It is imperative to inform these physicians of your treatment plans and outcomes.

  21. Send a letter to the referring physician and the patient’s primary care physician (if different) after the first visit and after the patient is healed.

  22. If the patient needs to be referred to another specialist, the referring physician and the primary care physician are notified and asked to whom they would like the patient referred.

  23. If the patient needs hospitalization, these physicians are again notified and given the opportunity to participate in the care while the patient is in the hospital.

  24. The need for thorough and frequent communication between the wound center and the referring physician cannot be overemphasized. A satisfaction questionnaire sent to the referring physicians also might be a good idea.

  25. Remember, if referring physicians are not kept informed about their patients, they may not refer any other patients to your wound center.

  26. The bottom line on a balance sheet is not only a reflection of the financial viability of the center. Wound care is a volume business—ie, the center must see a certain number of patients to create a positive cash flow. The bottom line number of patients that must be seen will depend on the center’s overhead: salaries, rent, utilities, cost of supplies, and other expenses.

  27. Financial success is difficult to attain if professional charges are the sole source of income. Generating a facility charge when a procedure (eg, debridement) is performed is fiscally more helpful (although this is not possible unless the center is an outpatient department of a hospital).

  28. Some excellent centers around the country providing evidence-based wound care are not associated with hospitals, but “independence” seems to require an extra measure of diligence and financial savvy. This makes providing wound care for all patients who come to the center a more significant challenge.

  29. A wound center can help itself financially by performing “extracurricular” procedures in the center. Vascular evaluations with Doppler and TcPO2 studies and measurement of ankle-brachial indices (ABI) can generate charges for the center and enhance the bottom line.

  30. Initiate a program to provide the clinic’s own outpatient IV antibiotic therapy. This will allow patients to come to a familiar location for their IV antibiotics and give wound center staff the opportunity to keep a close eye on the patient’s wound.

  31. Other outpatient services such as an outpatient ostomy clinic could be located in the wound center, providing quality patient care while maximizing the expertise of the wound center staff and facility.

  32. Another important consideration regarding the wound center’s financial health is whether the center is a part of the hospital. The additional referrals to the hospital from the wound center for laboratory evaluations, microbiology, x-rays, nuclear medicine scans, MRI scans, arteriograms, and even admissions add to the hospital’s financial viability. The wound center should keep track of these visits for administrators to consider when evaluating the financial value of the wound center to the hospital.

  33. Wound centers treat a sometimes forgotten group—ie, patients with chronic, hard-to-heal wounds. Patients also know that if they develop a wound complication during their treatment in the hospital they will not have to go elsewhere for care.

  34. If the staff provides good, evidence-based care, demonstrate concern for patients and their problems, and are diligent/resourceful stewards of the clinic’s resources, the center can be professionally and financially successful.