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Auditing the Quality Data. AHIA NW Regional Conference Seattle, Washington May 7, 2010. Agenda. Overview—The Why, What, How, Who, When and more Medicare’s IP Core Measures Adverse Event Reporting Physician Quality Reporting Performance Incentives Q&A. Why? (Objectives). - PowerPoint PPT Presentation
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Auditing the Quality DataAHIA NW Regional Conference
Seattle, Washington
May 7, 2010
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Agenda Overview—The Why, What, How, Who,
When and more Medicare’s IP Core Measures Adverse Event Reporting Physician Quality Reporting Performance Incentives Q&A
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Why? (Objectives) Quality data is publically presented—transparency
Comparative reporting Patient choice for quality (and cost) Risk to reputation Marketing
Tied to payment—False claims Tied to performance incentives—accurate reporting Reliance on electronic record or abstracted data
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What? (Scope) Medicare IP Core Measures Adverse Event Reporting Physician quality reporting (PQRI) Organizational incentives—focus on quality
outcomes
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How? (Methods) Abstracted data Extracted reports/data from clinical and
financial systems Spreadsheets/End user computing Workflows—how does the data get reported?
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Who? (Auditees/Clients) Board/Executive Management Management Quality, Finance, Careline management Public data sites
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When? (Audit Plan) Prior to:
Results leaving organization Public posting Surprises to constituents
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Auditing Quality Data IP Core Measures—Carolyn Barton, Swedish Adverse Event Reporting—Elizabeth Masnari,
Providence PQRI and Incentive Plans—Catherine Wakefield,
MultiCare Stories Risks Take-aways
Sources of data for Quality information Audit templates Lessons Learned
IP Core Measures
Carolyn Barton
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Medicare Inpatient Core MeasuresSwedish acute care Dependent on clinical documentation About 40% of data elements extracted from
systems 60% human judgment to populate remaining
elements About $ 3M/yr in additional Medicare
payment
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Medicare Inpatient Core MeasuresSwedish acute care 12 month rolling average data on public
website 2 hours to verbally explain the complex
process Used to use internally created algorithms Late coding and demographic changes impact
process Lots of hand-offs between systems and people
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Care Measures Four categories
Surgical Care Improvement Project (SCIP) Heart Attack (Acute Myocardial Infarction) Heart Failure Pneumonia
Record population algorithm for each Multiple data elements for each Quarterly/monthly sample sizes based on “N”
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Process of Care Measures IP discharges by quarter, may gather monthly Based on Medicare provider number Determine case population and calculate
sample size required Abstract data elements from medical record Submit data elements to CMS via QIO Receive Measure Set Category Information
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CMS Validation Algorithm Result Measure Set Categories
B = Doesn’t fall into set D = Falls into denominator only E = Falls into numerator and denominator
E/E+D B – Not part of the data set for this measure E – Good news, the higher the better D – Bad news, the lower the better; didn’t capture
the quality indicator
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CMS Validation Process Case Detail Report 5 cases per provider number per quarter Full paper chart must be submitted Must have a 80% individual case reliability
rate There is an appeal process Significant delay (4/2009-6/2009 available on
3/22/2010)
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Major Risk Areas Clinical documentation insufficient Timing and accuracy of coding Abstracting errors System extract errors for discrete data elements Determining population and sample size accurately Meeting submission schedule Follow-up on quality variances identified
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Audit Plan Lessons learned See Appendix A
1. Template – Audit of Quality Measures
2. Comprehensive risk area list
3. Overview of data collection process
4. Quality measure sample (SCIP)
5. Measure comparison – CMS vs. TJC
Auditing Adverse Event Reporting
Elizabeth Masnari
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Auditing Adverse Event Reporting National Quality Forum (NQF) – “Never Event” references
a particularly shocking medical error that should never occur. http://www.psnet.ahrq.gov/primer.aspx?primerID=3
The Joint Commission requires hospitals to report “Sentinel Events” defined as an unexpected occurrence involving death or serious physiological or psychological injury or risk there of. http://www.jointcommission.org/SentinelEvents/ NQF has identified a list of 28 “Never Events” Categories: Surgical, product or device, patient protection, care
management, environmental, and criminal. Though rare, 71% of events reported to the Joint Commission over
the past 12 years were fatal.
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Auditing Adverse Event Reporting Most frequent “never events” reported to Joint Commission
in 2008 (5632 total events reported as of 12/31/2008) Wrong-site surgery (13.2%) Patient suicide (12.4%) Op/post op complication (11.2%) Medication errors (8.7%) Delay in treatment (7.8%) Patient falls (6.1%)
Some States mandate reporting – Wash, Oregon, Calif. In 2007, CMS announced that Medicare will not pay for
treatment of many preventable errors including Never Events.
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Providence Health & Services includes 27 hospitals located in 5 Western States (California, Oregon, Washington, Montana and Alaska).
Audits of Adverse Event Reporting are being performed in all states during 2010.
Focus is on acute care facilities.
Auditing Adverse Event Reporting
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Risks – Patient Safety Legal Compliance Financial Reputation
Auditing Adverse Event Reporting
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Audit program objectives:
1. Adverse events are properly identified & timely reported.
2. Root-cause analysis are performed & action plans are created in a timely manner.
3. Appropriate process changes & control measures are implemented & functioning as intended to reduce risk of future events.
Auditing Adverse Event Reporting
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1. Timely identification & reportinga) Organizational policies & procedures
b) Staff awareness & training
c) “Comfort” in reporting – fear of consequences
d) Logging and evaluating of events
e) Comparison of events log against patient claims
f) Compliance with external reporting requirements
Auditing Adverse Event Reporting
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2. Root Cause Analysis (RCA) & Action Plansa) Standard template & proceduresb) Competency & training of those responsible for
RCAc) Authority given & access provided to the RCA
team d) Communication of the RCA results & action
plan across the organizatione) Monitoring implementation of the action plan
Auditing Adverse Event Reporting
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3. Process change implementationa) Authority to implement process changes and
controls
b) Timely implementation of process changes
c) Monitoring of compliance with new processes
d) Reporting on compliance
e) Post implementation review – did the action plan reduce the risk of reoccurrence?
Auditing Adverse Event Reporting
Physician Quality Reporting Initiative
Catherine Wakefield
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Physician Quality Reporting Initiative http://www.cms.hhs.gov/PQRI The 2010 PRQI consists of
175 individual quality measures. 13 Measure groups
Eligible professionals (EP) can submit data on individual quality measures or on measures groups through claims or a qualified registry.
CMS is working toward qualifying EHR products for the purpose of submitting extracted data.
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Criteria for Claims-based Reporting of Individual Measures At least 3 PQRI measures, for 80% of
applicable Medicare Part B Fee for Service (FFS) patients for each EP
Criteria for Claims-based Reporting of Measures Groups
One measures group for 39 Medicare Part B FFS patients of each EP
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Incentive Payment Group Practices that satisfactorily submit data
on quality measures can qualify to earn a PQRI incentive payment of 2% of the group practice’s total estimated allowed charges.
Coming soon—No reporting Reduced payments
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PQRI Made Simple (per CMS) Data collection sheets (one per patient) Data to claim form (new codes for inclusion
on claims—no charges) Electronic data collection
Test, test, test For all, documentation is critical—the
medical record must contain the documentation to support the reported data
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Risks and Issues Accuracy and integrity of collected data
Incentives to document for payment purposes Complexity of reporting--# of measures, new codes,
mapping into claims system Cost of manual abstraction and input for billing
purposes For electronic systems, selection of measures to
minimize/eliminate manual processes—risks of system build/mapping
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MHS Lesson System upgrade with changes to PQRI fields Modifier not included (8P—not assessed,
reason not specified) (test, test, test!) All claims reported tobacco use Patient complaints (tobacco use showed on
EOB) CMS does not accept corrections Letter to patients (risk to reputation)
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Quality and Performance/Incentive Comp Plans Quality objectives must be actionable,
measurable, and auditable Each measure should include only one metric The methodology must be clear and easy to
understand or recipients might not know what to do to earn incentive
Periodic reporting on progress throughout year
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Data collection and management Manual? Spreadsheet? (audit for spreadsheet errors,
design errors and hidden worksheets, rows and columns)
Electronic downloads? (accuracy of data download, subsequent manipulation)
Reporting—timely, audited
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Contact Information
Elizabeth Masnari, CPARegional Director of Audit Services - WA/MT
Providence Health & Services2001 Lind Ave. SWRenton, WA 98057
Carolyn Barton, CHCDirector, Corporate Compliance, Internal Audit & Privacy
Swedish Medical Center747 Broadway
Seattle, WA 98122Office: 206-215-2605
Catherine Wakefield, CPA, CIA, CHC, FHFMAVice President, Corporate Compliance and Internal Audit
MultiCare Health System737 Fawcett, PO Box 5299 MS 737-2-CCIA
Tacoma, WA 98415-0299253-459-8002
