All Entries in the "Consultants" Category

Thoughts on evaluating vendors/consultants

How can you tell which vendor/consultant will stand out from the crowd? A little self-preparation and planning can make a big difference.

A CDI Talk string discussed ideas for evaluating consultants—a conversation that didn’t gather much steam. So I thought I would throw some ideas out to CDI “blog-o-sphere” to discover what floats.

When considering whether to enter into a contract with a vendor or consulting firm, first determine if this particular entity’s culture and philosophy “matches” that of your own organization. Second, determine what services, products, and/or deliverables you need the consultant to provide. Third, do some legwork to obtain both direct and indirect referrals regarding the consultant’s performance. Be sure to contact referrals provided by the consultant and also gather others on your own through networking or by contacting facilities of similar size and make-up as yours.

Compatibility

You will likely be able to answer the first question, whether your philosophy the consulting firm’s philosophy match, only after several interactions between yourself and representatives from the consulting company, and by combining a number of sources. From my viewpoint, it is a crucial question but ultimately one that each program/organization really needs to answer for itself.

Of course, understanding whether your program is compatible with the philosophy/goals of the consultant also depends on whether you and your program staff have a solid understanding of trends in the CDI profession. Your CDI team and manager must possess a working knowledge of commonly accepted best practices and overall trends of CDI practice from a national perspective.

Frequently, facility leaders hire a firm to provide their facility with that level of insight. Of course, consultants travel the country working with diverse program types and sizes and can provide such overarching global perspective. However, comparing their perspective against your own awareness can foster interesting dialogues regarding program goals and parameters. From that position of self- and industry-knowledge, you (as the hiring agent) can consciously develop your own thoughts and positions and compare them against the particular consulting firm’s’s vision. Hmmm, already quite a bit of hard thought and work!

Products and services

Evaluate your CDI program and its interactions with other, related departments, to determine exactly what product and services you need.

Perhaps when you attended last year’s ACDIS National Conference, you saw a great demonstration of a new query software package. After further discussion, management at your facility wants to move forward with discussions regarding it and other similar products. As it turns out the vendor or consulting firm you remember from the conference not only provides a CDI-related query tool but other products and services as well. What should you do?

Again be aware of the scope and particulars of your facility’s needs. Then, ask different vendors a lot of questions. Keep a spreadsheet of the questions you’ve asked, how each vendor responded, and which vendor representative answered which question on what date.

Determine what tools or products will be provided (and whether the contract include periodic updates to these) such as:

• Hardware, software, or system integration
• Sample queries, policies, and procedures
• Physician education pocket cards, handouts, PowerPoint presentations, educational materials
• Reference books and additional education
• On-call services
• Periodic auditing
• Regular systems analysis and reporting
• Ongoing staff training

Once you’ve worked out the details of the services and products the consulting firm will provide, dig a little deeper to determine the scope and range of education the vendor will provide to your staff. After all it does no one any good to have a great gadget if no one knows how to use it. Ask:

• Will the vendor provide training to coders, CDI staff, physicians, and upper management individually?
• Will it tailor sessions to the needs of individual groups/departments?
• Will it guarantee the qualifications and expertise of its instructors? If your staff desires the specific qualifications of a particular individual to train your physicians be sure to include that in the contract.
• Will the organization gain the rights to the education materials or does the consulting firm retain them? Once the contract concludes will the facility need to develop its own educational program or query forms)?
• What forms of ongoing support and education will the vendor offer in the first few months and years?

Additionally, create a plan to evaluate the vendor’s effectiveness. Develop an implementation timeline and set reasonable deadlines for deliverables.

References

As I mentioned earlier, vendors/consultants should freely offer names of referrals of people and programs with which they have a positive working relationship. Be aware, of course, that these sources will most likely express glowing recommendations of the company with whom they are contracted. That’s to be expected. Everyone wants to put their best face forward. You wouldn’t tell a prospective employer to call an old boss with whom you’ve had an unresolved dispute, would you? Therefore, be sure to target your questions to these references to get the most well-rounded description of their experience. Ask:

• What was the highlight of your experience with this consultant/vendor?
• What part of the process would you do over differently? Why? And be sure to ask the individual how he or she would change his or her own behavior. What parts of the process do you wish the consultant/vendor would have handled differently? Why?

Armed with information and background from this exchange, solicit feedback from other peers to augment your research with an unbiased assessment. You may struggle to find a similar facility that also has experience with a given vendor. Use the networking available via ACDIS (e.g., local chapter members and meetings, ACDIS social media, and message boards). Also reach out to nearby facilities to see if they’d host you for an afternoon to give you a better picture of how they use the vendor/consultant product and services on a daily basis. These questions will likely be helpful even if your neighbors and peers have experience with different consultants. You can certainly learn broader lessons. Be sure to ask:

• How long have you worked with this vendor/consultant?
• Can you rate your overall experience on a scale of 1-10 (10 being the best)?
• What duties did the vendor/consultant include in your contract?
• What did the vendor/consultant do to understand your organization’s dynamics, culture, unique factors, etc.? What adjustments did it make to its proposal in light of that understanding?
• What was its strengths?
• What was its weaknesses?
• What tools did the vendor/consultant provide and how would you evaluate those tools (e.g., electronic programming, handouts and reference materials, educational sessions, manuals)?
• What level of ongoing support does the vendor/consultant provide?
• What type of data analysis or reporting did the vendor/consultant provide?
• What were the tangible and concrete results of the engagement?
• If you were to start over again, what aspects of the project or of the consultant engagement would you handle differently? Why?
• Going forward, what would you ask the vendor/consultant to change, add, stop, or maintain?

Final thoughts

Good consultants/vendors are experts who bring value to your organization. Don’t hesitate to ask questions, to tailor their offerings to your facility’s needs, or to try something a bit different, something your facility thinks might work better locally. Similarly, don’t hesitate to decide not to follow a particular piece of advice. Of course, proceed carefully, thoughtfully, and with discussion, but still, don’t hesitate to try!

At the end of the day, it is up to you and your organization to carry your CDI program forward so you need to be clear on what, why, and how you and your team plans to do things and be comfortable with that.

Policies and procedures:Where does your facility stand on compliance?

If you’ve spent any time on CDI Talk you will see that not every facility (or every CDI specialist, for that matter) subscribes to the same viewpoint when it comes to whose rules and regulations to follow for when implementing a physician query process.  Is this a problem?  It might be if your policy doesn’t clearly state what your position is and clearly define the roles of the person performing the query process.

From an outside perspective, auditors, such as the recovery audit contractors (RAC) or the Office of the Inspector General (OIG) do not care who authored the query.  What they do consider is whether a query is  compliant, based on the available information contained within the medical record and available guidelines.

What guidelines do auditors look to?  Well, right now, the most current guidelines have been published by the American Health Information Management Association (AHIMA), one of the four cooperating parties, along with the Centers for Medicare and Medicaid (CMS), the American Hospital Association (AHA) and the National Center for Health Statistics (NCHS).  These four parties govern revisions to ICD-9 codes, and are responsible for maintaining the integrity of the coding system.

We, at ACDIS, believe that the guidelines published by AHIMA in “Managing an Effective Query Process” and “Guidance for Clinical Documentation Programs” provide clear recommendations for those involved in the physician query process, regardless of professional background. During the 2010 ACDIS conference in Chicago, the ACDIS Advisory Board voted 12-0 to support basic tenets of AHIMA’s “Guidance for Clinical Documentation Programs.” (Read ACDIS Director’s Brian Murphy’s statement in the July edition of the CDI Journal.)

The AHIMA document  speaks to the issue of whether these published guidelines apply only to health information professionals:

“The guidance is relevant to all CDI professionals and those who manage the CDI function, regardless of the healthcare setting in which they work or whether they are AHIMA members.”

As one of the four cooperating parties, AHIMA is positioned as a governmental “expert” regarding the coding and billing function, and ACDIS feels that their recommendations should be taken seriously.

A recent question posted on CDI Talk asked for ideas on how to present information to the coding staff regarding their new established CDI program.  Several respondents provided ideas for topics.  One respondent mentioned that when discussing the query process  “they (the coders) need to know you are not restricted by the same regulations they are”. When I was a practicing CDI specialist this was the philosophy we had been taught to espouse by our consultants.  Eighteen months later our program was failing, and fast, due to the “us versus them” mentality this viewpoint created.  When I became the program manager my first order of business was to establish policies and procedures regarding the query process and ensure that the process was the same for both coders and nurses.

Why was this such a big deal?  Well, prior to this point the coders and nurses had been following different procedures and the goals of those processes and procedures were often at odds.   Having differing query policies gave coders the message that they were not “clinical” and therefore were inadequately equipped to write a coherent physician query—this was the area of  “expertise” of the nurses.

However, let’s look at the educational preparation of a coding professional.  Coders are required to take the same number of clinical science courses as their nursing counterparts, and in some cases, advanced training in anatomy, pathophysiology, and pharmacology.  The only difference between nurses’ and coders’ professional preparation is that nurses provide hands-on patient care while coders interpret (and learn to code) that care.

Another myth that must be dispelled is that CDI specialists are part of the “clinical team”.  When nurses become CDI specialists they are no longer part of the clinical team—they are now part of the revenue cycle.  While chart analysis and improvement of the documentation may have a positive effect on communication between caregivers (leading to improved patient outcomes), this is not the driving force behind the establishment of clinical documentation integrity/improvement programs.  CDI programs are chiefly implemented to achieve a return on investment— revenue.  If this was not the case CDI program reports would not include anything to do with MS-DRGs, case mix index (CMI), CC/MCC capture rates, etc.  All of these metrics have a direct link to revenue and every consulting firm provides these reports to their clients along with potential or realized financial gain.  If you don’t believe me, ask to see a copy of your most recent consultant’s annual CDI performance report. Some firms actually guarantee an increase in the CMI by offering a money-back guarantee as part of their contract.

I encourage everyone to look at their processes and determine whether they are inclusive—do your policies promote team collaboration and achievement of goals or do your processes emphasize that one group is “better” than the other?

NJ ACDIS offers summary of special guest event

by Melanie Halpern, RN-BC, MBA, CCDS, CCRA

Juanese Williams spoke to the NJACDIS meeting in March.

Editor’s note: The New Jersey ACDIS group brought healthcare fraud investigator Jua’nese L. Williams, PhD, MBA, BS, CPUR, IQCI, C-CDI, CPC, to its meeting in March at the New Jersey Hospital Association, in Princeton, NJ. In response to Williams’ lecture “Integrating Clinical Documentation and Medical Necessity to Successfully Navigate the 18 Federal Auditing Agencies and Contractors,” Halpern offers the following summary. Halpern is the  supervisor of clinical documentation and coding integrity at UMDNJ–The University Hospital, in Newark, NJ. Contact her at 973/972.3236 or by e-mail at halperme@umdnj.edu.

Dr. Williams was very knowledgeable. With Florida as her home state and the backdrop to the largest CMS fraud investigations in the country, if you need someone to give a convincing argument about the realities of recovering CMS funds to hospitals and physicians, she’s really good.

I thought her way of responding to participants’ questions was especially effective. With a look of endearment and tilt of her head, when asked things like, “We’re a comprehensive stroke center, and our protocols…” She would nod and say…”po? time to go!” (in other words, if your fancy protocol includes protocols for medications CMS auditors may not consider that administration a  medical necessity).

We learned a lot of other valuable information, as well.

1. NINN (non-coverage) letters: Starting April 1, 2010, as a CMS Condition of Participation, facilities need to give patients NINN (non-coverage) letters to alert them that CMS will not pay for procedures that fail the medical necessity litmus test. This topic was positioned as a community oOutreach education opportunity. According to Williams, that means facilities need to also educate the state QIO authority/arbiter, as well as hospital staff and patients.

2. Medicaid Integrity Contractors (MIC): The MICs’ scope of work is to oversee item #1 above as it relates to Medicaid claims. The MIC has authority to deny full claims, for which there is no federal appeal process for their decision. Hospitals would only be able to appeal the state portion of Medicaid payment, through a state-level proceeding. The MIC contractors are looking at 2005-2007 cases onsite (so there’s no opportunity to ‘pull together’ the records, and/or send/submit materials that may be missing).

In addition, MICs are looking at inpatient/outpatient claims, who then use that data mining to review physicians’ data. The MIC, if/when they suspect inconsistent documentation/treatments, are required by law to turn over the cases to OIG’s  Healthcare Fraud prevention and Enforcement Action Team (HEAT). Williams described such OIG investigations as “not a social visit.”

3.  Medicare Administrative Contractors (MAC): They control the dollars, Williams says. A MAC scope of review includes discrepancies between Part A and Part B, as it relates to Medicare whereas the MICs concentrate on Medicaid. MACs also focus on the documentation specificity to/from office to hospital. MAC can impose “prepayment” holds to providers (based on a bell curve, not necessarily any wrong doing). First MACs review the inpatient and office claims, then they determine the payment to provider, says Williams. NJ’s MAC is HighMark.

4. Audits related to Medical Necessity Claims: Hospitals should require pre-certification for elective surgeries (ie: when the doctor wants to schedule operating room time). Before a surgery date and time are set, facilities should require physicians to submit the patient’s office medical record to the hospital, so it can become part of the in-patient medical record. This is the only way a hospital can defend the medical necessity.

Specifically, AICD, TKR, and THR implants are the focus of this fraud investigation.  The patient’s care and treatment plan leading up to the supposed requirement of an implant must meet CMS specifications (ie, 30 second VT for AICD implant; failed NSAID treatment with bone pathology and significant ADL limitations for total knee and hip replacements). Otherwise the hospital is not able to defend the medical necessity for the elective surgery, and the full claim can be denied (or only ancillary services will be paid).

5. Audits concerning the “72 hour rule (window)”: There was a healthy discussion about hospital’s “billing rules” as being non-compliant either through bundling services that should be billed separately, over services that should be “carved out”. Williams recommended extreme caution for attempting to resubmit unbundled claims stating that such actions draw auditors’ focus to the entire case. From there, additional concerns regarding issues of medical necessity and DRG validation will become new focus of claim(s) reviews.

6. Audits of claims for observation vs. inpatient status: Medicare’s inpatient definition has two key parts, Williams’ says. They include the severity of the signs and symptoms exhibited by the patient at the time of admission and the medical predictability of something adverse happening to the patient.  Williams cautions that InterQual’s definition may not be good enough, for CMS to “capture data from the first 12 hours of admission to support inpatient…”

7. The CDI role in discharge documentation: Clinical documentation education efforts should include the discharge planning process: This point related to HINN letter for non-coverage, which specifically targets 30-day re-admissions to any facility. Williams stressed that documentation about the disposition facility (LTAC, SNF, etc) is vital.

The discharge plan must clearly be documented, including the need for continued therapeutic treatments, Williams says. If the family/patient disagrees with the plan or physician feels that by discharging patient there could be a safety issue, that needs to be well documented. Williams emphasized that this documentation should not be about the patient’s payment disposition, but about the quality of the care for the patient and the risk to patient by noncompliance. With such documentation provided then it is up to the QIO to argue the patient’s payment issues, or lack of non-acute care services available in the state.

8. PEPPER Reports: Williams suggested that these reports are very important to clinical documentation programs, because it specifies the top 10 DRGs the government identified as at high risk. CDI programs should review at least the last two PEPPER reports (Q3 ’09, published 2/25/10, and Q4 ’09, published 3/25/10) and compare the reports with their own facility data, Williams suggested.

9. The “bottom line” clinical documentation query: Williams suggested that the essential physician query as submitted by a CDI specialists should ask, “What is the medical necessity of this admission, and by what standards are you basing your judgment?”

10. Healthcare Integrity Triad: During her presentation, Williams included a slide which showed a triangle with the word “compliance” in the middle and at each corner the words: “clinical documentation,” “coding,” and “medical necessity.”

CDI resolution: Examine 2009 benchmarks for 2010 improvements

Are you like me and refuse to make New Year’s resolutions because you think you’re just setting yourself up for failure? Lose weight? Quit smoking? Exercise more? Spend less?

Let’s face it, you can’t just decide to change your life without having a plan for how it’s going to happen. I’ve found that making resolutions with a cocktail wienie in one hand and a glass of champagne in the other is not conducive to clear thinking. My resolution somehow turns into planning on how to win the lottery and retire!

On New Year’s Eve, however, I do find myself reflecting back on the previous year’s events and how

Time to do some retrospective analysis for CDI program enhancement.

decisions I made influenced those events. I also think about decisions that I made as a result of anticipated or unexpected events. So—what does this have to do with CDI?

January is a good time to look back at your results of the previous year and identify your strengths and weaknesses (or, as we say in consulting – “opportunities for improvement”). Take a look at the focus of your program and determine if you’re meeting your goals. Most organizations evaluate performance by looking at calendar year data, so set aside some time in January to run some reports and analyze where your program is at.

Editor’s Note: Read more of Lynne’s recomendations onthe ACDIS Web site Featured Article section. An archive of previously featured articles can be viewed by visiting www.cdiassociation.com and clicking on the Helpful Resources tab in the left-side navigation bar.

CDIP at the crossroads

The field of clinical documentation improvement has rapidly expanded into a burgeoning profession with strong potential and long lasting value for all healthcare providers involved in the care of the patient. The importance of and necessity for complete and accurate medical record documentation reflective of true patient acuity, risk of morbidity and mortality, and readmission cannot be over emphasized. There is almost always an opportunity to improve clinical documentation in any medical record chart from both a resource intensive reimbursement standpoint and quality of care and clinical outcomes standpoint.

But just as the profession is gaining momentum and increased recognition in the business facet of healthcare, we have reached a crossroads and may be going down the wrong path.

For those of us who have been in the clinical documentation improvement arena for a long time, it is eye-opening to view the advertisements and promotional materials for clinical documentation improvement projects readily available at trade shows and appearing in prominent trade journals. The common promotional theme is increased reimbursement for the hospital, which is not surprising given the fact these clinical documentation improvement programs are marketed strictly on the basis of “reimbursement enhancement.”

Let’s not kid ourselves, every healthcare expenditure that is not direct patient care related must provide for a reasonable chance of return on investment, contributing to the organization’s financial performance in some for or fashion, whether it be additional revenue or at least cost avoidance. But there has been some talk in the industry that some firms have worked into their CDIP contracts a guarantee of specified amount of increased reimbursement for the hospital with the implementation of their programs. 

The aftermath

Clinical documentation improvement programs can be structured to meet the documentation requirements required in the health record to financially sustain the hospital from a financial accounting and quality of care reporting perspective. How the program is structured can dictate success or failure in the rollout and acceptance of the program by physicians and other ancillary service providers.

In speaking with a fellow colleague recently, I heard a valid concern that is worth mentioning regarding where the CDIS profession is now, and where it may be going. Once again it may be going down the wrong route. My colleague pointed out that in some instances, the clinical documentation improvement specialists appear to be focusing on reviewing the record solely for identification and documentation of “missed CCs and MCCs,” almost as if they were “CC/MCC scroungers.”

The very idea of CDIPs being promoted primarily as reimbursement mechanisms perpetuates and drives the ever-increasing viewpoint of CDIS as CC/MCC identifiers. In order to be directed down the right path, we need to stay attuned to the mission of the profession, which is to affect positive change in physician’s patterns of clinical documentation over the long term through provisions and actions of continued physician education. This relentless pursuit of physician clinical documentation education embraces a holistic approach with an emphasis upon the direct correlation between clinical documentation and the continued business financial viability of the both the hospital as well as the physician. A primary focus upon “getting that CC/MCC” documented in the record represents a very small cross sectional piece of what the CDIS can fundamentally contribute to a successful program.

Looking to the future

A recent article caught my attention, certainly an interesting thought to consider as we are at the crossroad of our profession. Clinical documentation improvement efforts are episodic with a bent toward reviewing individual records and utilizing the clinical query process in striving for complete and accurate clinical documentation. In an article that appeared in the July/August 2009 Journal of Hospital Medicine entitled “Transitions of Care Consensus Policy Statement,” the American College of Physicians, Society of Hospital Medicine, and Society of General Internal Medicine convened a multi-stakeholder consensus conference in July 2007 to address the quality gaps in the transitions between inpatient and outpatient settings and to develop consensus standards for these transitions.

Over 30 organizations sent representatives to the Transitions of Care Consensus Conference. The Transitions of Care Consensus Conference made recommendations for standards concerning the transitions between inpatient and outpatient settings for future implementation. The American College of Physicians, Society of Hospital Medicine, Society of General Internal Medicine, American Geriatric Society, American College of Emergency Physicians, and Society for Academic Emergency Medicine all endorsed this document. You may read a summary analysis of this policy census statement through this link.  http://hospital-medicine.jwatch.org/cgi/content/full/2009/1009/1?q=etoc_jwhospmed

There are seven consensus principles and standards for managing care transition as follows:

1. Accountability
2. Responsibility
3. Coordination of care
4. Family involvement
5. Communication
6. Timeliness
7. National standards and metrics

While each of these standards embraces elements of clinical documentation, the last standard above speaks greatly for the ability of the clinical documentation improvement specialists to jump into the fray of clinical documentation and fulfill a much needed role of assisting in the formulation and development of standardized communication formats for care transitions that can be used for accountability and continuous quality improvement. Minimal required information in the transition record that the CDIS can help facilitate include principal diagnosis and problem list, medication list reconciliation, identification of the coordinating physician/institution, patient’s cognitive status, and test results and pending test results.

Which way?

We are at the crossroads of our profession in CDI. Which direction we decide to take will guide the ultimate success and future of the profession. Decisions made today will certainly impact all of us tomorrow and well into the future.

HCCA physician compliance and documentation initiatives

On a recent planning call regarding the 2010 ACDIS conference, participants requested a session about enlisting assistance from risk management and corporate compliance for CDI.   So, I was pleased to see our friend Betty B. Bibbins, MD, FACOG, CHC, C-CDI, president and chief medical officer of DocuComp LLC., listed as general session speaker at the Health Care Compliance Association’s Physician Practice Compliance Conference in Philadelphia, October 11–13. As ACDIS Director Brian Murphy, CPC, said when he heard the news “it’s really great to see the integration of CDI in various venues.”

Bibbins session,Clinical Documentation Improvement Programs and Physician Advisors: Working Together to Improve Effectiveness takes place Monday, October 12. During the session, she’ll discuss  the importance of CDI to physician practices within the inpatient and office settings and provide a basic overview of the goals and mission of CDI programs.

Teresa M. Bivens, CPC, CHC, deputy compliance officer at the University of Louisville/HSC, also offers a presentation to physicians regarding the importance of appropriate documentation titled The Lighter Side of Documentation. During her program, participants will play a game a real life clinical documentation “Mad Libs,” and she’ll explain how proper documentation can help keep government investigators at bay.

Breaking documentation bad habits

A documentation specialist and I were doing rounds on a unit one day when we ran into a physician who left a query unanswered.

The CDI whispered in my ear:

“I query him about this condition all the time and he usually writes it but I don’t get why he won’t write it without being asked first.”

The physician’s response was simply  “out of sight, out of mind.” After a lengthy discussion regarding long standing documentation habits, we realized that this physician wasn’t being non-compliant or difficult—he truly needed the constant reminders. He had developed a pattern of dictation he reverted to whenever looking at a patient’s chart and was in a time crunch.

So this begs the question, how do we change documentation habits and patterns? Do we have any real hope of changing them at all?

For many CDI specialists posting queries is not enough to change a physician’s documentation behavior. Probably the best answer to this question is to keep clinical documentation information  in front of physicians. Constant reminders through informational/educational opportunities that are updated monthly can be very beneficial. The format needs to be applicable to the physicians and can vary from hospital to hospital. I caution that once you establish a format be consistent in your approach.

Possible strategies include:

• monthly newsletters
• posters and flyers in the physician lounge
• cue cards that can be easily carried in a pocket and presentations at meetings

But probably the most beneficial method for providing support for documentation that reflects the severity of illness of the patient is for a CDI specialist to be visible on the units when the physicians are on the units. I can’t stress enough the need for personal one-on-one time with the physicians on the floor, the importance for a CDI specialist to be “in their face.”

Pick a CDI topic of the month and go with it. The information needs to remain simple and to the point so you don’t lose the interest of the physician. Again, time is money in their mind so they tend to be more accepting when you get straight to the point. And don’t be afraid to recycle what you’ve used in the past, as reinforcement of new habits is also very beneficial in supporting clear and consistent documentation.

After the consultants leave…what now?

Hey, you CDS with new programs out there! How’s it going? Are you sailing along on the smooth seas of phenomenal MCC capture rates or are you stalled in the doldrums? Are you asking yourself the following question: “What do I do now that the consultants are gone?

Been there. Done that …twice, in fact! Are you finding that the people at your hospital who decided that a CDI program was a good idea are now saying things like “the CMI doesn’t seem much different” or “where’s the money they promised us”?

Don’t feel bad. You didn’t do anything wrong. You’re just feeling the pangs of aftermath: the training and support is over and now you’re alone and administration doesn’t even know what you do, exactly.

First, who do you report to? Someone who actually knows from a hole in the ground, or someone who wouldn’t know an MCC if it bit them? This isn’t a silly question. If the person making the decisions doesn’t know what you’re REALLY there for, it’s going to be hard to succeed and grow your program. So, invite this person to come to your team meetings and be sure to share your successes and tell him/her how much more you can do with their active support. [more]