Creating an Environment for Quality: Educating Tomorrow s Doctors Today on the Role of the QIOs

1. Creating an Environment for Quality: Educating Tomorrow�s Doctors Today on the Role of the QIOs Jeffrey Deitch, DO, ABQAURP, Medical Director Thomas D. Leyden, Senior Director, Marketing and Business Development February 25, 2004

2. 2 Hypothesis � circa 2000 Residents and medical students are open to learning and a great audience to educate on quality improvement and the role of medical review in quality assurance Educating residents and medical students can help a QIO down the road: Recruiting for quality improvement projects Conducting medical review Decreasing unnecessary admissions Decreasing poor documentation

3. 3 Hypothesis � circa 2000 Offers an indirect pathway to their mentors Allows us to get residents/students involved when they step into the health care arena on Day One, as practitioners Students are a �captive audience� with brains like sponges. The Graduate Medical Education (GME) program gives us an opportunity to expose the students and their institutions (universities and hospitals) to QIO programs

4. 4 Findings � circa 2005 GME program can broaden the exposure of the QIO. Helps create an �Environment for Quality�. Helps further erase any inappropriate perceptions of the PRO program Gets a QIO�s foot in the academic door. These relationships can help us with current projects as well as business development opportunities (i.e., CMS special studies and grants) Opens up the door for QI project recruitment as well as access to future physician reviewers

5. 5 Benefits to the QIO Great practice and experience for staff presenters to present in a friendly atmosphere. Teaching is a great way to really understand your subject Good outlet for new staff orientation and education. Education session provides each side of the organization (QI and review) an opportunity to learn about each others work and understand the big picture on how projects and tasks interrelate GME program lends to many of our QIO initiatives including shared learning, physician education �Creates an Environment for Quality� and positive marketing of the QIO program

6. 6 Lessons Learned about Residents/ Med Students Understand very little of business of health care Unaware of the state and federal laws which govern medicine 3 day admits EMTALA, their risk, and hospitals risk Evaluation and Monitoring (E&M) coding Hospital-Issued Notice of Non-Coverage (HINNs) QIO role and our role in assisting patients. Knowing this can diffuse problems in the doctor/patient relationship

7. 7 Lessons Learned about Conducting a GME Program Can�t teach the entire QIO program in a � day session. Instead, provide a high level overview of fundamentals of medical review, quality improvement, and how they can build off each other

8. 8 Lessons Learned about Conducting a GME Program Started with an academic approach. To keep students awake and increase involvement, we moved to a �hands-on� approach to give real life experience and medical review practice It is important to include examples of quality improvement projects into the session. Focusing solely on review, even though that is the section we have found they get the most out of, only perpetuates old perceptions of the role of the PRO Stick to discussing the Medicare QIO program! State government contracts, independent review, etc. only confuse the issue

9. 9 Lessons Learned about Conducting a GME Program Used real charts blinded for patient confidentiality, looked at: Admission appropriateness DRG validation Hard for them to grasp how the principal diagnosis impacts payment Don�t understand appropriate documentation of diagnosis and how that relates to billing Lack understanding of complications and co-morbidities impact on DRG assignment Quality of care issues

10. 10 Strategies for Conducting Split sessions into smaller, more manageable buckets of time Allow for �hands-on� time Use real life examples Give students more credit than they deserve Give them an opportunity to think on their own and they will brainstorm the obvious solution

11. 11 Typical Agenda Introduction & Overview (Medical Director and Marketing) Welcome and overview Introduction to QIO services Overview of QIO projects Introduction to QIO Quality Improvement Project (QI Project Manager and Project Coordinator) Overview of 1 project from project inception to current status/completion

12. 12 Typical Agenda Introduction to Medical Record Review (Medical Director and Review Manager) �Hands-on� review of ER and Inpatient cases, particularly: Admission denial vs. approval DRG validation Quality of care issues EMTALA (Medical Director) Summary and Program Evaluation (Medical Director and Marketing)

13. 13 Tools Provided to GME Students PowerPoints of the presentations �Change in the Quality of Care Delivered to Medicare Beneficiaries, 1998-1999 to 2000-2001� (JAMA Vol. 289, No 3, 1/15/03, authors: Jencks; Huff; Cuerdon) Coding Guidelines and Documentation Tips for Physicians Compare Care brochures HINN Prompter

14. 14 Tools Provided to GME Students Inpatient Documentation Prompter Medicare.gov brochure Michigan Seniors, Medicare and MPRO �Role of the QIO� (written by the Center for Medicare Education)

15. 15 Tools NOT Provided to GME Students Any review cases, charts, etc. � All are returned to MPRO upon the end of the class

16. 16 Roles of QIO Staff Medical Director � Leads training, reviews cases, gets the involvement of students in the �hands-on� review Marketing Lead � Facilitates the event, provides a high level overview of the QIO program, links the QIO to the community, connects resource needs with resources Review Manager � Ancillary support for medical review segment. Able to discuss the details associated with HINNs, sanction activity, quality improvement plans, special projects Coding Compliance � Reiterates the importance of coding guidelines, link between documentation and coding

17. 17 Key Messages Medical Review � Plays an important part in the health care community. Review is not a punitive function, used for teaching and improving quality of care. We reiterate that the integrity of system works best with peer-to-peer evaluations (i.e., matched specialties) Quality Improvement � Success of QI projects begin with careful analysis of the data, development of the quality improvement project, and collaboration with health care providers. Understand the role of data in quality improvement. Get involved in QI projects now!

18. 18 Key Messages Coders, Documentation, and Coding Coders can not INTERPRET medical information or CHOOSE a diagnosis. They must have documentation that is available that clearly states a definitive diagnosis MPRO drives home the concept of generally accepted documentation guidelines (i.e., what goes in a good note) Coders are not the enemy, be nice to them. They are trying to understand what services were delivered so they can code most appropriately

19. 19 Key Messages Coders, Documentation, and Coding (cont) If a procedure or diagnosis is not documented on the chart, it did not happen. If the writing on the chart it illegible, it is difficult to assign a DRG code EMTALA � Make sure the patient has been seen by the physician and that �hands have been laid on the patient�. Patient needs to be stabilized before being transferred to another hospital

20. 20 Future Directions Have conducted classes for: Students preparing to be Physician Assistants, Medical Assistants, and Nurse Practitioners, Pharmacists, and Registered Health Information Technicians (RHITs) Looking to expand our education program

21. 21 Future Directions Presently Pursuing: American College of Physicians, MI Chapter Eastern Michigan University (RNs) Madonna University (RNs, NPs, PAs) Michigan Osteopathic Association Michigan State University College of Michigan (Dos, RNs) Michigan Academy of Family Physicians National Institute of Technology (CNAs)

22. 22 Future Directions Presently Pursuing (cont): Red Cross (CNAs) Schoolcraft College (RNs) University of Detroit Mercy (RNs) University of Michigan Medical School (MDs, RNs) Washtenaw Community College (RNs)

23. 23 Future Directions Ultimate Goal In addition to supporting HCQIP and medical review tasks, supports Task 2 Creating an Environment for Quality in 8SOW Link up the 3 main medical schools (1 is clinically-based, 1 is research-based, and 1 is diversity-based) with ancillary educators so they can all interact at one forum and discuss quality improvement and the role of the QIOs. This can add a worldly dialogue that will help us create an open and responsive environment for quality

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