Collaboration on Quality Assurance Site Visits for Texas Vaccines for Children Providers

1. Collaboration on Quality Assurance Site Visits for Texas Vaccines for Children Providers Jack Sims Texas Department of Health (TDH) and Pam Mathison Texas Medical Foundation (TMF) National Immunization Conference March 18, 2003

2. Objectives of this Presentation • Describe the development of the TVFC program collaboration between TDH and TMF. • Identify the tools developed for use in conducting and managing TVFC quality monitoring site visits. • Identify the outcomes of the TVFC collaboration

3. TMF Overview • Private non-profit organization (1971) • Physician directed • Not a government agency, but is contracted with the Centers for Medicare and Medicaid Services to provide quality improvement and peer review services

4. TMF Overview • Quality Improvement Organization (QIO) for Medicare in Texas • Improve overall quality of care for beneficiaries • Quality improvement projects • Protect the Medicare trust fund • Hospital Payment Monitoring Program • Protect beneficiaries by addressing special cases • Beneficiary Outreach and Helpline

5. Brief TMF Overview • Other services • Independent Review Organization • Education and Training • Consulting Services and Special Contracts

6. History of TVFC Contract between TDH and TMF • CDC grant with TDH requires a combined site visit and CASA at 25% of enrolled TVFC private providers • 2% of enrolled private providers had a combined visit done during 2000 • 25% had a site visit without a CASA

7. History of TMF TVFC Contract • December 2000: TDH Immunization staff met with TMF staff to discuss preparation for CDC grant application • September 2001: contract between TDH and TMF was finalized for TMF to conduct site visits from September through December

8. Fall 2001 • September: • Revision of instructions • Compilation of resources for reviewers • Hiring and training of reviewers • Between October 9 and December 31: • 354 site visits completed by TMF reviewers • Only private physician offices • Specific areas of the state

9. TVFC Contract for 2002 • March 2002: contract finalized for March through December 2002 • Expansion of assigned areas of the state • Additional tasks during the site visit • Delivery of TVFC Provider Tool Kit (as of 3/02) • Completion of re-enrollment (as of 9/02)

10. TVFC Contract for 2002 • Expansion in types of sites visited: • Private physician offices • Public and private hospitals • Public and private schools • Federally Qualified Health Centers • Migrant and Rural Health Centers • 831 site visit reports submitted to TDH

11. TVFC Contract for 2003 • 2003 – expansion to statewide • Projected completion of 2700 site visits

12. Collaborative Relationship between TDH and TMF • Agreement on quality assurance concepts • Ongoing clarification of: • Circumstances specific to clinic sites • Decisions regarding how to answer site survey items for specific clinic situations

13. Collaborative Relationship between TDH and TMF • Communication processes to involve health department staff at all levels • Adaptation, revision and/or responsiveness by TMF as CDC and TDH needs arise

14. TVFC Quality Assurance Concepts • Assure that the items reviewed are important and clearly written • Assure that the instructions reflect: • CDC program regulations and protocol • TDH program regulations and protocol • Federal law • State law

15. TVFC Quality Assurance Concepts • Assure that the instructions are clear for determining how to complete the review tools • Access and make available resources for reviewers and clinic staff • Encourage an open and evolutionary process

16. Development of Training and Resource Tools for TMF Reviews • Confirmation letters developed, to fax or mail to scheduled sites • Explains relationship between TMF, TDH, and TVFC • Explains purpose and elements of site visit • Includes scheduled site visit date and time

17. Development of Training and Resource Tools for TMF Reviews • Confirmation letters includes specific information for pulling records for mini-CASA record review • Definition of active client and • Birth date range for 12-35 month-olds OR • Up to age 18 for TVFC eligibles if clinic does not see children under three years old

18. Development of Training and Resource Tools for TMF Reviews • Confirmation letters include: • List of items for the clinic to have ready during the review • List of items from site survey tool • Pre-populated Re-Enrollment Forms (since September 1, 2002)

19. TVFC Resource Notebook for TMF Reviews • Provider Site Visit Protocol • CASA Instructions • Instructions for Completion of the Immunization Record Review Tool • On-site Evaluation Report Instructions • TVFC Provider Re-enrollment Guidelines

20. Development of Training and Resource Tools for TMF Reviews • Provider Site Visit Protocol – • Roles of TMF Reviewers and local and regional health department staff • How to handle scheduling issues • Notification from reviewer to TMF when a site visit is scheduled

21. Development of Training and Resource Tools for TMF Reviews • Provider Site Visit Protocol • What supplies and materials reviewer needs to take to the site visit • Submission of site visit results to TMF

22. Development of Training and Resource Tools for TMF Reviews • CASA Instructions • Clarified what sections of CASA would be used for TVFC site visits • Identified which input criteria would be used for TVFC site visits • Extracted information from Help section of CASA program • Clarified what constitutes a valid vaccination date

23. Development of Training and Resource Tools for TMF Reviews • Paper version of CASA input screen • Developed for use in the event of a computer failure • Instructions are the same as for the computer input

24. Development of Training and Resource Tools for TMF Reviews • Immunization Record Review Tool Instructions (IRRT) • Clarified instructions to include objective criteria for determining a “yes” or “no” • Identified which items on the IRRT correspond with items on the On-Site Evaluation Tool

25. Development of Training and Resource Tools for TMF Reviews • On-site Evaluation Report (site survey) Instructions • Clarified objective criteria used to determine “yes” or “no” response to items that did not have definitive criteria • Provided sample questions for every item that had “interview” as one of the Review Criteria

26. Development of Training and Resource Tools for TMF Reviews • On-site Evaluation Report Instructions • Gathered and provided additional resources in page protectors in 3-ring Resource Notebook • Referenced in instructions for each item • Also used as as potential educational tool and resources for clinic staff

27. Development of Training and Resource Tools for TMF Reviews • On-site Evaluation Report Instructions • Resource Notebook Materials include: • TDH literature, forms, and website information • CDC literature and resources • Immunization Action Coalition materials • List of TVFC contacts for local and regional health departments

28. Development of Training and Resource Tools for TMF Reviews • Vaccine Gain/Loss Calculation Table – modifications • Several revisions throughout the contract

29. Development of Training and Resource Tools for TMF Reviews • Authorization letter for each reviewer • On TMF letterhead • Identifies specific individual as a reviewer for TMF/TDH/TVFC • References TMF Confidentiality Policy

30. Changes in Tools • Provider Site Visit Protocol • Expanded with more information on scheduling site visits • TVFC Provider Tool Kits • Available for delivery by TMF reviewers

31. Changes in Tools • On-Site Evaluation Report • Some items rewritten to improve clarity and focus. • Some items rewritten to expand information gathered. • Some items added due to changes in CDC reporting data elements.

32. Changes in Tools • On-Site Evaluation Report Instructions • Added instructions regarding use of computerized tool. • Added sample corrective action statements for each item.

33. Changes in Tools • On-Site Evaluation Report Instructions • Revised resources available for each item to reflect those in the TVFC Provider Tool Kit • Removed resources from the Resource Notebook if included in Tool Kit • Included sample completed On-Site Evaluation Report

34. Changes in Tools • Site visit tools developed as software tools, with implementation in March 2002 • On-Site Evaluation Report • Immunization Record Review Tool • Vaccine Gain/Loss Calculation Table • Computerized tool only contains TVFC items from a larger quality assurance monitoring tool.

35. Electronic Tools • Brief demo of: • On-Site Evaluation Report • Immunization Record Review Tool • Vaccine Gain/Loss Calculation Table

36. Changing Roles for Health Dept. Staff as of Sept. 1, 2002 • Conduct site visits only at WIC clinics, local and regional health department clinics, and selected other sites • Continue with recruitment and training of new providers • Continue to provide ongoing support of current providers

37. Changing Roles for Health Dept. Staff as of Sept. 1, 2002 • Provide follow-up on every “no” response on site survey reports within: • 5 days for refrigeration issues • 10 days for anything else except non-critical items and immunization rate • 6 months for immunization rate below Texas’ NIS coverage level

38. Key Results • Percent of Private Providers with Site Visit and CASA Completed *projected

39. Key Results • Refinement of the content of the site visit tools • Clarification of instructions for completion of the tools • Increase in resources available to the reviewers and to the TVFC providers

40. Key Results • Development of an electronic site visit tool, for ease in data collection and analysis • Incorporation of re-enrollment of providers during the site visit

41. Key Results • Change in responsibility of local and regional health department staff • Plans for development of a web-based system to allow health department staff at all levels to have access to information regarding the status of site visits and site visit results

42. Key Results • Plans to develop reports based on site survey results • Compare results of specific clinic from year to year • Compare one clinic to all clinics in the city/ county/region/state • Compare composite data from cities/ counties/regions

43. Key Results • Plans to develop specific/targeted training based on data from site surveys

44. Key Results • Feedback from reviewers • Reviewers like the focus on education, rather than auditing. • “I reviewed this office last year and it was a mess….What a tremendous improvement this year!!”

45. Key Results • Feedback from clinic staff • “…the review was so very helpful in the office learning what we should be doing…I really needed someone to tell me specifically what I needed to correct in my office.” • “The actual visualization of the clinic allows the auditor to assist the clinic in more efficient operations to meet all state requirements.”

46. Ultimate Outcomes • With time, we hope to see: • More satisfied providers who continue to re-enroll • Improved immunization and vaccine management practices, i.e., more “yes” responses on the site survey tool • Higher immunization rates

47. Questions???