The OIG and Health Record Review

1. The OIG and Health Record Review Monday August 9, 2010 Julie Watrous Christina Hrynio

2. Objectives for Session Participants will understand: Overview of the Office of Inspector General Medical record review requirements Health Information Management-related results from Combined Assessment Program reviews Tips for success

3. OIG Overview Administration: receives and tracks hotline complaints, follows up on open recommendations Audit and Evaluations: conducts national financial reviews and Veterans Benefits Administration evaluations Criminal Investigations: conducts criminal reviews Health care inspections

4. Office of Healthcare Inspections Hotlines - individual complaints specific to individual facilities National reviews � many or all facilities reviewed Combined Assessment Programs - Review each facility every 2.5 years Community Based Outpatient Clinics � Review two CBOCs per facility CAP

5. �Patient's history is insignificant with only a 40 pound weight gain in the past 3 days.�

6. Medical Record Review 6 Requirements for quality review/audit Joint Commission RC.01.04.01 VHA Handbook 1907.01 Yes, you must track delinquent records! You spend considerable time and effort on this, and most places do it really well. That�s not what I�m going to talk about today.Yes, you must track delinquent records! You spend considerable time and effort on this, and most places do it really well. That�s not what I�m going to talk about today.

7. Joint Commission 7 RC.01.04.01 The hospital audits its medical records Changed from closed record review to chart checks during tracers Evolution from prescribed list to whatever is meaningful to the organization Define criteria, number of charts, frequency

8. RC.01.04.01 Element of Performance 1. The hospital conducts an ongoing review of medical records at the point of care, based on the following indicators: Presence Timeliness Legibility Accuracy Authentication Completeness of data and information

9. �The patient was to have a bowel resection. However, he took a job as a stockbroker instead.�

10. VHA Handbook 1907.01 HIM must define, develop, in conjunction with facility QM initiatives, ensure that health records are reviewed on an ongoing basis at the point of care by people who document in the record based on organizational defined indicators that address the following�.

11. VHA Handbook 1907.01 (cont) Presence Timeliness Readability Quality Consistency Clarity Accuracy Completeness Authentication

12. �The patient�s bladder was then emptied and sent to the postoperative recovery room in stable condition.�

13. VHA Handbook 1907.01 (cont) Results of record reviews, findings from record completion monitors, and monthly delinquent record statistics must be reported at least quarterly to the facility health record review committee, or its equivalent, as outlined in the facility By-laws

14. VHA Handbook 1907.01 (cont) A representative sample of charts from each service or program, inpatient and outpatient, must be reviewed to ensure adequate, timely, complete, and properly-authenticated documentation is being accomplished in accordance with all of The Joint Commission standards and VHA policy

15. VHA Handbook 1907.01 (cont) This committee provides oversight and coordination of the review process(es), assists with developing indicators, decides how often reviews will occur, receives and analyzes reports, decides what and when focused reviews are to be implemented, and documents follow-up for outliers until improvement reflects an acceptable level or rate

16. �She is quite hard of hearing. In fact, she can't hear at all in the left eye.�

17. Oversight Review Results OHI: reviewed since 1999 on Combined Assessment Programs with Medical Record findings in 2002, 2003, 2004/5, 2008 and 2009 The Joint Commission: of 17 recent sites, 4 RFIs related to medical records, 1 Requests For Information in RC.01.04.01 Systematic Ongoing Assessment and Review Strategy: findings related to Medical Record documentation at 10-26% of sites, data trending at 44%, and committee structure at 71%

18. �On the second day knee was better; on the third day it had completely disappeared.�

19. Interpretation of Requirements Ongoing record review by clinicians Include quality, accuracy Sample all services and programs Results reported quarterly to a committee Committee provides oversight Develops indicators Defines frequency Acts on outliers

20. Performance Improvement Cycle Gather data Analyze data for trends Compare with goal/target/benchmark Identify strong, specific corrective actions Implement actions/changes Evaluate effectiveness of actions/changes

21. Examples No ongoing record review process No frequency specified Number of records not defined Record reviews show problems with several items, but no action taken Actions are taken for an identified problem, but no follow through for effectiveness

22. Other Documentation Issues Documentation required by VHA, facility policies and/or The Joint Commission standards (partial list): Assessment of pain level Assessment of skin for pressure ulcers Discharge planning Advance directives Informed consent

23. Health Information Management Practice Brief #7 Provides excellent guidance re: health record review Types of review Sample tools Data collection tools Web based review tool Paper based review tool Monitoring schedule Clinician review form Sample data dictionary Resources

24. Copy and Paste Issue Handbook 1907.01: a policy that ensures the elimination and/or judicious use of this electronic functionality must be developed at each facility. This policy needs to be strictly enforced Recommendation: FY08- ensure that medical records are monitored for inappropriate use of the copy and paste functions and that the VA Office of Information and Technology consider this project to be a high priority

25. Examples History and Physical: female exam on male patient and vice versa Progress notes: same note verbatim day after day Procedure note for wrong patient

26. Health Information Management Practice Brief #9 Guidance - the copy and paste functionality Local policy requirement VHA Handbook 1907.01 Monitoring process requirement Monitoring frequency Minimum number of records Quarterly reporting � oversight review Sample tools policy samples report samples appropriate versus inappropriate use examples case scenarios

27. Tips for Success Work with Quality Management to coordinate/consolidate reviews Peer review (protected and reviews by peers) Utilization review VA National Surgical Quality Improvement Program VA Nursing Outcomes Database Use Health Information Management practice briefs

28. �Patient has two teenage children, but no other abnormalities.�

29. Objectives Covered Overview of the Office of Inspector General Medical record review requirements Health Information Management-related results from Combined Assessment Program reviews Tips for success

30. Closing Summary 2 huJ issuz 4 HIM C&P monitord Ongoing record review � integrate sampL ll services n progs GathA data analyze trendz � compare W goal Oversyt committee Rslts rptd 1/4ly Identify tuff corrective actions Eval effectiveness Two huge issues for HIM Copy and paste monitored Ongoing record review � integrate with other reviews, facility QM initiatives - Sample all services and programs - Gather data - Analyze trends and compare with goal/target compliance - Oversight committee Results reported quarterly Identify strong corrective actions Evaluate effectiveness of actions until acceptableTwo huge issues for HIM Copy and paste monitored Ongoing record review � integrate with other reviews, facility QM initiatives - Sample all services and programs - Gather data - Analyze trends and compare with goal/target compliance - Oversight committee Results reported quarterly Identify strong corrective actions Evaluate effectiveness of actions until acceptable

31. FY11 Combined Assessment Program Criteria Copy/paste process Health record review process Oversight committee Result analysis Action items for outliers � follow up Sample each service/program during each 12 month period Documentation review Present Authenticated Complete

32. Questions

33. Contacts Christina.Hrynio@va.gov Julie.Watrous@va.gov