Auditing the Quality Data

1. Auditing the Quality Data AHIA NW Regional Conference Seattle, Washington May 7, 2010

2. 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

3. 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

4. What? (Scope) • Medicare IP Core Measures • Adverse Event Reporting • Physician quality reporting (PQRI) • Organizational incentives—focus on quality outcomes

5. How? (Methods) • Abstracted data • Extracted reports/data from clinical and financial systems • Spreadsheets/End user computing • Workflows—how does the data get reported?

6. Who? (Auditees/Clients) • Board/Executive Management • Management • Quality, Finance, Careline management • Public data sites

7. When? (Audit Plan) • Prior to: • Results leaving organization • Public posting • Surprises to constituents

8. 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

9. IP Core Measures • Carolyn Barton

10. Medicare Inpatient Core Measures Swedish 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

11. Medicare Inpatient Core Measures Swedish 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

12. 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”

13. 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

14. 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

15. 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)

16. 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

17. Audit Plan • Lessons learned • See Appendix A • Template – Audit of Quality Measures • Comprehensive risk area list • Overview of data collection process • Quality measure sample (SCIP) • Measure comparison – CMS vs. TJC

18. Auditing Adverse Event Reporting • Elizabeth Masnari

19. 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.

20. 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.

21. Auditing Adverse Event Reporting • 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.

22. Auditing Adverse Event Reporting • Risks – • Patient Safety • Legal • Compliance • Financial • Reputation

23. Auditing Adverse Event Reporting Audit program objectives: • Adverse events are properly identified & timely reported. • Root-cause analysis are performed & action plans are created in a timely manner. • Appropriate process changes & control measures are implemented & functioning as intended to reduce risk of future events.

24. Auditing Adverse Event Reporting • Timely identification & reporting • Organizational policies & procedures • Staff awareness & training • “Comfort” in reporting – fear of consequences • Logging and evaluating of events • Comparison of events log against patient claims • Compliance with external reporting requirements

25. Auditing Adverse Event Reporting • Root Cause Analysis (RCA) & Action Plans • Standard template & procedures • Competency & training of those responsible for RCA • Authority given & access provided to the RCA team • Communication of the RCA results & action plan across the organization • Monitoring implementation of the action plan

26. Auditing Adverse Event Reporting • Process change implementation • Authority to implement process changes and controls • Timely implementation of process changes • Monitoring of compliance with new processes • Reporting on compliance • Post implementation review – did the action plan reduce the risk of reoccurrence?

27. Physician Quality Reporting Initiative • Catherine Wakefield

28. 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.

29. 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

30. 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

31. 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

32. 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

33. 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)

34. 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

35. 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

36. Contact Information Carolyn Barton, CHC Director, Corporate Compliance, Internal Audit & Privacy Swedish Medical Center 747 Broadway Seattle, WA 98122 Office: 206-215-2605 carolyn.barton@swedish.org Catherine Wakefield, CPA, CIA, CHC, FHFMA Vice President, Corporate Compliance and Internal Audit MultiCare Health System 737 Fawcett, PO Box 5299  MS 737-2-CCIA Tacoma, WA 98415-0299 253-459-8002   Catherine.wakefield@multicare.org Elizabeth Masnari, CPA Regional Director of Audit Services - WA/MT Providence Health & Services 2001 Lind Ave. SW Renton, WA  98057 425-687-3650 elizabeth.masnari@providence.org