QIO Journey to Improving EMTALA Reviews

1. QIO Journey to Improving EMTALA Reviews Illinois and Iowa Beneficiary and Family Centered Care Follow us on Twitter: @QualityNet11 Tweet with our conference hashtag: #QualityNet11 QualityNet Conference | Baltimore, MD December 13 – 15, 2011

2. Patient Stories

3. CMS Identified Quality Concerns with EMTALA Review • Incomplete or insufficient completion of the EMTALA Physician Review Worksheet • Outcome questions answered with little or no rationale or justification supporting decisions • Inconsistent understanding and application of CMS definitions • Medical Screening Exams • Emergency Medical Conditions • Stabilization • Transfer • Appropriate Transfer

4. CMS Identified Concerns, cont. • Physician reviewer with possible conflicts of interest • Physician reviewer stating personal opinions about whether EMTALA was violated • No evidence of any internal quality assurance of subcontractor medical reviews • Undocumented conversations during formal 60-day review hearings • Deemed off the record • May have influenced the review

5. Root Cause Analysis • Problem • Inadequate EMTALA review and/or physician documentation to support EMTALA decisions • Four task areas • Review the 5-day and 60-day processes and procedures • Revise and implement physician reviewer and staff training • Revise IFMC IQC protocol and increase monitoring of EMTALA review outcomes, process and clinical decisions • Increase the number of Iowa physician reviewers Board Certified in Emergency Medicine to conduct EMTALA review

6. Improving Our Outcomes All the pieces and how we put them to work for us Follow us on Twitter: @QualityNet11 Tweet with our conference hashtag: #QualityNet11

7. Processes and Procedures • Updated our procedure to ensure • Physician reviewer evaluates all documentation submitted by CMS • No off the records breaks in 60-day transcripts • No conflicts of interest • Physician reviewer instruction memo includes definitions • Management assignment for all EMTALA reviews

13. Physician Reviewer and Staff Training • CMS Chief Medical Officer conducted training for our physician reviewers • Assigned a Physician Champion in EMTALA review • Emphasized review expectations and EMTALA terminology • Required staff to attend training

14. Internal Quality Control • Updated our IQC protocol • Review validity of the physician reviewer decisions on all cases • Ensure all rationales are supported with evidence-based sources • Conduct inter-rater reliability • Discontinue use of physician reviewers who do not meet expectations

15. Physician Reviewer Recruitment • Identified physicians through multiple resources • Developed talking points for recruitment • Ensure physician reviewers meet CMS requirements • Complete biennial certification

16. Final Outcome • Success of our internal procedure • Quality of our reviews • Quality of our physician reviewers • Lessons learned • The entire journey is full of them!

20. Contact Information • Jeanne Bridgewater • jbridgewater@iaqio.sdps.org • Thérèse Canaday • tcanaday@iaqio.sdps.org • Special thanks to Derek Robinson, MD • CMS Region V CMO This material was prepared by IFMC , the Medicare Quality Improvement Organization for Iowa, under contact with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 10SoW-IA-BFCC-11/11-027a