Audit: University of Iowa ‘Home Hemophilia Program’ lacks ‘governance and oversight’

IOWA CITY — University of Iowa Health Care is creating a new task force to review and revise the governance and management structure of its 7-year-old “Home Hemophilia Program” after auditors found “weaknesses“ and “ongoing concerns.”

“The HHP does not have a clear governance and oversight structure for administrative, operational, and financial processes, resulting in inconsistent and ineffective execution of the program,” according to an internal audit that reviewed the program’s operations between July 2022 and September.

“Through multiple interviews with the assigned program leadership and the program’s nurses, it was determined that no clear expectations of program oversight and ownership currently exist.”

The university in 2017 started its Home Hemophilia Program — the state’s only program providing specialized blood disorder care in a patient’s home — as a joint effort between its departments of pediatrics and pharmaceutical care, according to the audit.

Pediatrics was charged with operational oversight, while pharmacy provided funding “through revenue generated from the prophylactic drug, Factor, used to treat these patients in their homes.” The program — which tasks three nurses, supervised by a pediatric nurse manager, with providing home care and education — also gets support from the UIHC Hemophilia Treatment Center.

That center serves more than 400 pediatric and adult patients suffering from bleeding and clotting disorders, offering “state-of-the-art comprehensive clinical care, education to patients and their families, and accessibility to clinical research projects.”

‘Risk of financial loss’

But an audit of the home-based program found a “lack of clear leadership.”

“The HHP does not have any established policies or procedures for execution of critical processes, increasing the risk of negative impacts to patient care,” according to the audit that found the program has been without any formal or informal standard operating procedures or policies for years.

Specifically, the program lacks operating procedures for nurse travel, nurse expectations with patients and documentation.

“Due to a lack of formally documented expectations, inconsistencies in accountability and operations for the community nurses were observed,” according to the audit, citing for example variances in vehicle use and travel reimbursement.

“The HHP does not have defined expectations for the travel reimbursement process, increasing risk of financial loss and delays in payout.”

When auditors reviewed travel logs for the program’s three nurses from November and December 2023, they found 10 inconsistencies from among 64 encounters — including discrepancies within the electronic medical record system, Epic.

“The inconsistencies include lack of notes within Epic, no encounter documented in Epic, or date discrepancies between travel logs and Epic encounters,” according to the audit. “Accurate documentation of patient care being provided and when they are traveling to patients is crucial to the operation of the program.”

Auditors found the program lacks an “appropriate” travel reimbursement approval process and does not have a systemic process for documenting patient encounter types. A review of 12 visits from January 2023 to March found inconsistencies in how the nurses logged and labeled visits — making it hard to monitor patient-visit volumes.

“Additionally, patient progress is not able to be tracked through their care plans in an efficient manner,” according to auditors. “As such, the metrics for both the volume of HHP patients and number of visits that were completed by the community nurses could not be accurately determined.”

During the same time period — from January 2023 to March — investigators also evaluated the nurses’ clinical notes and found no oversight regarding timely completion and signing of patient charts. Of the 1,323 signed clinical notes reviewed, 31 percent were completed eight or more days after the date of service, and two went unsigned for over 100 days.

“The timely completion and signing of patient charts are critical to the accuracy and completeness of patient records and care plans, and to reduce potential delays in identifying future care needs,” according to the audit, which reported UIHC was responsive and committed to implementing fixes by early in 2025.

UIHC ‘action plan’

In response to the internal auditor findings, UIHC told The Gazette it is "committed to providing the highest quality care for our patients.“

“We welcome the recommendations from the Board of Regents audit and are implementing those recommendations to strengthen the management of the Home Hemophilia Program, which provides access to critical care for people with bleeding disorders.”

Specific fixes it promised the regents include establishing a task force to review and revise the existing memorandum of understanding used to create the program — a group that will include representation from pediatrics hematology and oncology, pharmacy and the Hemophilia Treatment Center.

By establishing a revised governance structure, the university will document policies, create workflow processes and reconcile travel logs, among other things.

“(Standard operating procedures) will be developed and documented by the HHP’s leadership and staff,” according to UIHC’s response. “These will include scheduling practices, travel expectations, charting requirements and expectations, and specific home care policies. An individual from the program will be assigned responsibility to the policies to ensure timely completion and appropriate documentation.”

Comments: (319) 339-3158; vanessa.miller@thegazette.com