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Transcript of Excellent Healthcare, Clinical Currency Air Force Medical Operations Agency 2012 TMA DQ Course 1...
Excellent Healthcare, Clinical Currency
Air Force Medical Operations Agency
2012 TMA DQ Course
1
AFMOA/SGAR
Current as of 10 May 2012
Excellent Healthcare, Clinical Currency
Air Force TMA DQ Course Break-Out Session Overview
Organization
Why Data Quality?
MTF Engagement
Guidance
DQ Assurance Team
CHCS Provider File
Metrics
Other DQ Efforts
DQ Review List/Statement Guidance & Completion
eDQ
2
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ORGANIZATION
3
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Organization
AFMOA (Execution)
Chief, Financial Performance Data Quality Program Manager
AF Data Quality Manager Program Analyst
Data Quality SME/DBA
Data Quality SME
HAF/SG8Y (Policy)
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Organization
5
SGA
SGAIInfo Services
SGALMed Logistics
SGAPManpower
SGARResource Mgt
SGATHealth Benefits
SGAX**Readiness
MEPRS DQ UBO
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Readiness
AFMOA Strategic Alignment
6
GoalsRebuild inpatient
platforms to provide clinical
currency needed for readiness,
GME and warrior care
Medical Home to provide efficient, patient centered
health care
Sustain clinical currency for
readiness beyond what our
platforms can provide
Standard processes where
needed to improve quality
and reduce waste
VisionWorld-class healthcare for our beneficiaries anywhere, anytime
Mission
Support development and oversee execution of Air Force Surgeon General Policies
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Provide Comprehensive DQ Program Management to all AF MTFs
Provide reach-back support to MAJCOMs and DRUs
Our Mission
7
AFMOA Data
Quality
Air Force MTFs
DRUs
MAJCOMS
Standardize methodologyEvaluate processesReduce variance
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DQ Program Manager
DQ Program Analyst DQ DBA/SME DQ SME
Data Quality (DQ) Roles and Responsibilities
- Focal point for MTF’s DQ Mgmt
Control Program/DQ Statement - Teams to provide policy/MTF’s
business practice improvements- Biometric data consultant- Measures MTF/AFMS DQ performance & influences change- Trains MTF DQ Managers
- Provide CHCS Database Admin SME support -- ID & assist MTFs correct: (Provider File errors, Hospital Location Files, site definable MEPRS tables, etc.) - Create CHCS restrictions/business rules to promote
standardization- Develop CHCS training guides to promote MTF DQ - Provide Ad Hoc report assistance to support MTF’s - Perform MTF site visits to provide on-site technical
assistance- Manage performance metrics to validate improvement
efforts Mission: - Provide Comprehensive DQ
- Program Management to all MTFs
- Provide reachback support to MAJCOMs and DRUs
Key Objectives:- Standardize Methodology- Evaluate Processes- Reduce Variance
Future Initiatives:- Consolidation - Shape MHS/AFMS DQ
efforts
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WHY DATA QUALITY?
9
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Data Quality Integrated Approach
10
MEPRSPersonnel
Workload
Financial
UBOOther Health
Insurance
Eligibility
Demographics
CodingSIDR/SADR
MSDRG/RWP
RVU/CPT
Patient
&
Provider
Completeness
Timeliness
Accur
acy
Data Quality
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Why is Data Quality Important?
Monitor efficiency of the healthcare system
Prospective Payment System (PPS)
Base Realignment And Closure (BRAC)
Medicare Eligible Retiree Health Care Fund (MERHCF)
MTF Business Plans
Provider/Clinic Workload Productivity
Reimbursements (TPC, Coast Guard, NOAA…etc)
Enable the Leadership to make informed decisions
11
For these reasons, it is vital your data accurately reflect work performed in your MTF!
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What could go wrong?
12
Air Force
MDR
M2
WWR(Count Visits)
EAS IV“Eligible” EncountersCPT Codes Units of Service
WAMCount Visits & Raw Services
SADRCAPER(Encounters)
TPOCSBillableEncounters
PDTS
Worldwide Workload Report
Standard Ambulatory Data Record
EAS Repository
EAS IVExtract
MHS Data Repository
MHS Mart
Service Repository (BDQAS)
Pharmacy Data Transaction System
Pop HealthPortal
CCE
Coding Compliance Editor
ClinicalData Mart
TRICAREOps Center
Interface Errors
DoD/VA FHIE/BHIE SHARE
ADMSADR 1/SADR 2
Essentris
CCQAS
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MTF ENGAGEMENT
13
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MTF DQ Engagement
One-on-One Support
Telephone and E-mail: [email protected]
Defense Connect Online (DCO) & optimize use of Vector Check
MTF-AMFOA DQ Teleconferences Every Other Month PACAF, CONUS, USAFE (schedule on Vector Check) DCO used to conduct meetings and take attendance Business and training conducted at each meeting
Site Visits
AF portion of the TMA DQ Course
Other Conferences/Forums
14
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Defense Connect Online
To become a registered user visit: https://www.dco.dod.mil
Link to meeting will be sent via email/calendar request
Share screen capability to maximize training
Chat capabilities to ask questions to all or individuals
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Vector CheckYour DQ Toolkit
Announcements
Calendar
Contacts
FAQs
Documents
Electronic Data Quality Application (eDQ)
Subscribe to Alerts!
16
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Vector CheckGaining Access
17
Your Vector Check account is linked to your Knowledge Exchange (Kx) account
If you don’t have a Kx account, create one at https://kx.afms.mil Click:
If you have a Kx account, verify your e-mail address is correct (then WAIT 24 Hrs prior to signing into Vector Check). Click:
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Vector CheckGaining Access
18
After you have been granted a Kx account (this may take up to 24 hours), navigate to Vector Check at: https://vc.afms.mil
The first time you visit the Vector Check site, you will be redirected to a registration page. The form will be pre-populated. Verify and submit the information.
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Vector CheckUpdating the RM Master Roster
Update your POC information on the RM Master Roster at: https://vc.afms.mil/AFMOA/SGA/SGAR/Lists/Resource%20Management%20Master%20Roster%20Updates/Summary%20View.aspx
Select “New” to add a new POC, or select “Actions / Edit in Datasheet” to edit POCs. The contact information for these positions must always be kept current: MDG CC MDG Deputy CC MDSS Commander Administrator RMO RMO NCOIC DQ Manager DQ Alternate
19
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Vector Check DocumentsTraining Material on VC
Review training materials posted on Vector Check “Alerts, Timeliness and Accuracy, and TUG”
Pathway: Vector Check > AFMOA > SGA > SGAR > SGAR – Data Quality > Documents > Training > Administrative
All DQ Review List and Statement Training Slides Pathway: Vector Check > AFMOA > SGA > SGAR > SGAR –
Data Quality > Documents > Training > DQ Review List and Statement Training Slides
Review the latest DQ Teleconference Notes Pathway: Vector Check > AFMOA > SGA > SGAR > SGAR –
Data Quality > Documents > Data Quality Meeting Minutes-Notes
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GUIDANCE
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Overview
DoDI 6040.40 DQ Mgmt Control (DQMC)
Procedures DQMC Review List Data Quality Statement Annual Updates – TMA Led Recommends Data Quality
Assurance Team (DQAT) Composition
22
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Health Services Inspection (HSI)
2012 HSI Checklist, OM.3.2.2
The Data Quality Assurance Team (DQAT) met monthly: Completed DQMC Review List Briefed Executive Committee
on all Review List performance that was not compliant
There was evidence corrective action plans were created, monitored and progressing to address non-compliant or underperforming DQMC items
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Health Services Inspection (HSI)
2012 HSI Checklist, OM.3.2.2
Documents Required for Review:
Current and past year’s
DQM reports
DQAT meeting minutes
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DQ ASSURANCE TEAM
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DQ Assurance Team
The Data Quality Assurance Team (DQAT) or other designated structure met during the reporting month to complete the DQMC Review List.
26
DoDI 6040.40 Recommended Team Composition:
• DQ Manager• Directors of Clinical Activities• MEPRS/EAS Coordinator• Budget/Accounting• Medical CIO• Health Information Manager• CHCS Administrator• Group Practice Managers• Patient Administration
Additional team members recommended in Data Quality Team User’s Guide:
• Coder/coding auditor• AHLTA Trainer• Ancillary services representative• Defense Medical Human Resources
System – internet (DMHRSi) personnel (i.e., DMHRSi Manager, contract liaison, civilian liaison, volunteer liaison, and Command Support Staff (CSS) personnel)
• UBO Manager• Clinic support staff representative• Resource Management Flight CC
Red indicates required members when AFI 41-120 is published
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DQ Assurance Team
• Provider file clean-up and maintenance• TMA coding audit• MEPRS ASD reconciliation• DMHRSi program• DD Form 2569 collection process
Provide oversight for:
Develop DQ initiatives
• Ensure there is cross-talk• Recommend at your next DQ meeting, that everyone goes around the room and
understands why they are a member of the team• What role they have in DQ• What ideas they have to make the team (ultimately your MTF) better
Communication:
• File/Table updates, Clinic/Provider profiles• Appointment standardization
Proper CHCS File/Table set up
• Account Subset Definition (ASD) Table Reconciliation• Inappropriate MEPRS Codes
Assigning Workload to the Proper MEPRS/FCC Codes
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DQ Assurance TeamInitiatives - Interest Items (cont)
• Verify Eligibility in DEERS• Gather/Verify Demographics and OHI
Patient Registration/Admissions/Front Desk Duties
• Documentation must record what actually occurred• Ensure Accuracy/Completeness• TMA Annual Coding Audit tracking
Coding
Patient safety
CHCS Training
Accountability
• Include critical data elements• Correct critical data elements
Improve data accuracy
Capture workload and revenue opportunities
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CHCS PROVIDER FILE
29
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CHCS Provider File Report Cards
30
IMPACT76% decrease in the number of Provider File errors across AFMS since Nov 09
ACTIONS
Centrally produced MTF report cards; refined focused approach
Created a library of training materials to correct backlog
and prevent errors
Partnered with Pharmacy community (point of entry
for most external providers) to focus on prevention
Conducted Focus site visits to provide training and
obtain buy-in
ISSUES
Impacts REVENUE, WORKLOAD, PATIENT SAFETY and DATA INTEGRITY
Lack of expertise, ownership and guidance to resolve and prevent provider file errors
PROCESS
Eliminate CHCS Provider File error backlog and prevent future errors across AFMS
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Primary Effects of CHCS Provider File Errors
Revenue
Patient Safety
Data Integrity
Workload
31
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CHCS Provider FileContinuity Guide
32
• Comprehensive reference for issues related to CHCS provider file maintenance
• Nearing completion – release date TBD
• Includes step-by-step guidance to correct errors
• Recommendations for provider file management
• Includes helpful resources
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Provider File Report Card
33
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Provider Details Report
34
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Outside Provider Entry Checklist
35
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METRICS
36
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DQ Performance Metrics
37
https://vc.afms.mil/AFMOA/Matrix/default.aspx
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DQ Performance Metrics
38
http://www.tricare.mil/ocfo/mcfs/dqmcp/metrics_reports.cfm
https://vc.afms.mil/AFMOA/SGA/SGAR/SGARDQ/Documents/Forms/AllItems.aspx
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AF DQResults
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DQ Statement Signed by?
42
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Provider File Progress Metrics
43
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Workload Guidelines Sample
- Supplements AF Coding Guidelines- Published by AF Coding Experts- MHS Coding Guidelines, inpatient and outpatient, dated 1 January
2011http://www.tricare.mil/ocfo/bea/ubu/coding_guidelines.cfm
Encounter Activity
Provider Type
Provider Specialty
Code
MEPRS Code for
Time Capture
MEPRS Code for Workload
Count/Non-Count
Indicator
Patient Encounter Business Rules
Coding Required
Billing Required
Nutritionist/Dietitian
Privileged Provider
704 – Dietician/Nutritionist
B*** B*** Count Registered dieticians or licensed nutrition Professionals are responsible for providing medical nutrition therapy (MNT).
Yes Yes
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OTHER DQ EFFORTS
45
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Support Provided
Correct CHCS patient registration errors for all Air Force MTFs
Primary Care Manager Information Transfer (PIT) Errors
Correct Patient Registration Errors (FY11-558K Patients)
Merge CHCS Duplicate Patients
Identify AHLTA Multiples and Log MHS tickets
Subject Matter Expertise Support
Partner with DoD to develop policies and processes to reduce patient registration errors
Identify and correct systemic issues, which contribute to the duplication of clinical records and put patient safety at risk
AFMS Record Reconciliation Initiative
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Support Provided
47
Training
Conduct Pt Reg, PIT Error, Duplicate Patient training at MTFs, Conferences, DCO Connect, etc.
Phone consultations as needed
Enterprise Health Data Optimization System (eHDOS) Reports
Summary Reports by MAJCOM and MTFs on Vector Check
Users with Registration Capability
Number of New Patients Added to CHCS with Critical Errors
Number of Potential CHCS Duplicate Patients
Number of Patients with Patient Category Mismatches
Number of PIT Errors
Managed Care File/Table Concerns Affecting PIT Errors
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AFMOA Data Quality Vector Check
48
MTF Reports are posted to the AFMOA Data Quality Vector Check monthly
Menu path: Vector Check-AFMOA-SGA-SGAR-Data Quality-Documents-Patient Registration MAJCOM_MTF Reports
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AFMOA Vector Check-The MATRIX
49
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DQ REVIEW LIST/STATEMENT GUIDANCE & COMPLETION
50
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TUG
51
Primary AF-specific DQ guidance
Clarifies questions on the DQMC Review List
Includes formulas, background information, and how to get the data
Available on Vector Check
Share with the DQAT
Discuss at your DQ meeting to ensure it is read and understood by those answering DQ statement and review list question
Organization mirrors the review list
Updated during the year as needed
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TUG: Six Linked Worksheets
52
Click the options box and select "enable this content"
Tab 1: Forward
Tab 2: TUG Contents Filtered & Linked
Tab 3: TUG
Tab 4: TUG Appendix
Tab 5: DQ Review List
Tab 6: DQ Statement
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TUG Contents
The following is provided for each review list and statement question:
Performance threshold
Calculation (if applicable)
Details (may include “step-by-step” guidance)
Process
Additional Information
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DQ Review List/StatementReminders
Refining/expanding beyond DQ statement…TUG
Internal tool to assist in identifying & correcting financial & clinical workload data problems
DQMC Review List requires all supporting summary documentation kept on file for 5 years
Monthly Requirement
All variances on the REVIEW LIST should be briefed with DQ Team and Executive Committee
MTFs need back up plans for Data Quality and all other areas that support completing the Review List
eDQ is based on the Review List
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DQ Statement Due Date
25th
DUE THE LAST DUTY DAY OF THE MONTH
Day One – Notify RMO
Day Two – Notify MDSS/CC
Day Three – Notify MDG/CC
Aggressive follow up if late:
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DQ Review List Comments
Evaluate all comments non-compliant Review comments to ensure complete and concise Problem, corrective action plan, ECD required Do not use “I”, “AFMOA”, “John Doe”, etc… Do use functional area, ie. DQ Manager, Coding Auditor,
AFMOA Coding… If stating contractor, system or AFMOA has impacted a metric
negatively, require back up documentation These comments will be validated before approved
Review comments with Contracting Officer Representative (COR) (if comment provided by contractor) for comments requiring further clarification
Comments included on your MTF Statement are posted word for word on TMA and vector check websites
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DQ Review List DQ Assurance Team Meeting
Question A.3: The DQ Assurance Team or other designated structure met during the month to complete the DQ Management Control Review List (recommend attaching meeting minutes)
Date Completed: __________
Data Month: ______________
YesNo
(comment required)
N/A(not appropriate for this
question)
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DQ Review List DQ Assurance Team Meeting
Question A.4: The DQ Manager briefed last month’s Data Quality Management Control Review List, and Financial and Workload Data Reconciliation and Validation results to the MTF Executive Committee
YesNo
(comment required)
N/A(not appropriate for this
question)
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DQ Review List TMA DQ Course
Question A.7a: TMA Data Quality Course (DQ Manager in the last three years)?
YesNo
(comment required)
N/A(not appropriate for this
question)
Recommend using the A.7 a-c to highlight training needs to your MTFs leadership
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DQ Review List Negative Findings
Question A.8: Was there evidence in meeting minutes or other sources of corrective plans, of appropriate resourcing and actions to follow-up on the previous month's negative findings?
YesNo
(comment required)
N/A(not appropriate for this
question)
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DQ Review List Rejected Data
Question B.4: Were all rejected data corrected and retransmitted? (As applicable.)
YesNo
(comment required)
N/A(Only use when no rejected data needed to be corrected
or retransmitted)
h) TPOCS – File Upload Status Report
g) MEPRS (EAS) - Error Correction Unit
e) DMHRSi - 100% Timecards approved?
d) CHCS - PIT Errors
c) CCE - ADM SADR/TPOCS Extract Status Display & CCE Interface Error Report
b) AHLTA - AHLTA ADM Exceptions Report
a) ADM - ADM SADR CAPER Error Report
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DQ Review List/StatementEnd of Day
Question B.5.a. (DQ Statement question 1a): In the reporting month (include only B*** and FBN* accounts): a) What percentage of appointments were closed in meeting your “End of Day” processing requirements, “Every appointment – Every day?”
Source: BDQAS
≥ 97% ≥ 80% but < 97%(comment required)
< 80%(comment required)
Number of closed CHCS appointments
Total CHCS appointments for the month
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BDQAS
Biometric Data Quality Assurance Service (BDQAS) is a source for many DQ statement questions (https://bdqas.afms.mil/)
Updated on the 10th or 11th for non-EAS data
EAS data on BDQAS is updated between the 16th and 20th
If EAS transmission did not occur on-time, questions that are applicable to EAS must be manually calculated and annotated on the review list
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BDQAS
DQ Review List / Statement Report data is found here:https://bdqas.afms.mil/data_metrics/data_metrics.htm
Metrics you can drill down to clinic level and get AFMS rankings
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DQ Review List Monthly Statistical Report
Question B.5.c: Were all workload discrepancies on the CHCS Monthly Statistical Report corrected prior to processing the WWR and WAM files?
YesNo
(comment required)
N/A(not appropriate for this
question)
MINI_CAPER_DQ adhoc – Use frequently throughout the month to encourage correcting workload in a timely manner
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MINI CAPER DQ REPORT
Designed to help Medical Treatment Facilities (MTFs) identify and correct patient appointment workload discrepancies prior to running the MSR
Some examples on how to utilize report: Appts Closed at EOD (B.5.a) Workload Count By Provider Type (B.5.c) Ensuring Providers Sign T-cons and Encounters on Time (B.6.a) Determining whether the “ADMIN” status is properly utilized
(B.5.d) Report generates a significant amount of appointment data, it can
also be used for statistical analysis.
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DQ Review List ADMIN Closed
Question B.5.d: Do you have a process or policy in place to ensure the appropriate use of using "admin" when closing encounters in CHCS?
NOTE: Administratively closing an appointment is as if the appointment never existed. "Admin" should be used for one of the following reasons: Training and Testing purposes Duplicate encounters Appointment created in error
YesNo
(comment required)
N/A(not appropriate for this
question)
# of admin closed appointments: ______
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DQ Review List/StatementOutpatient Timeliness
Question B.6.a (DQ Statement question 2a): What percentage of Outpatient Encounters, other than APVs, has been coded within 3 business days of the encounter?
Source: BDQAS
≥ 95% ≥ 80% but < 95%(comment required)
< 80%(comment required)
Sum of Non-APV CAPER Encounters Coded W/in 3 Business Days
Sum of Non-APV Daily Outpatient Workload Reports (DOWR)
Nurses and Techs with “count” encounters will negatively impact metric; FY12 data has 32K encounters with incorrect workload
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DQ Review List/StatementAPV Timeliness
Question B.6.b (DQ Statement question 2b): What percentage of APVs have been coded within 15 days of the encounter?
Source: BDQAS If non-compliant, a time study is required each month until
compliant Where are your delays?
Transcription
Records
Provider
Coder
≥ 95% ≥ 80% but < 95%(comment required)
< 80%(comment required)
Sum of APV CAPERs Coded W/in 15 Calendar Days Sum of APV DOWR
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DQ Review List/StatementInpatient Timeliness
Question B.6.c (DQ Statement question 2c): What percentage of Inpatient records have been coded within 30 days after discharge?
Source: Run “Inpatient Timeliness” ad hoc found on BDQAS
If the MTF lacks a coder, the numerator will be “0” and the denominator will be taken from the WWR Total Dispositions
≥ 95% ≥ 80% but < 95%(comment required)
< 80%(comment required)
Total # of Records CodedWWR Total Dispositions
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DQ Review ListCCE
B.7.a: What percentage of encounters had an encounter coding status of “Completed” for the data month?
Source: CCE
≥ 95% ≥ 80% but < 95%(comment required)
< 80%(comment required)
This question measures CCE utilization. Due to the AF coding model, AF MTFs will have a low percentage for this question.
Denominator
Numerator
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DQ Review List/StatementReconciliation
Question C.1.a (DQ Statement question 3a): Was the monthly MEPRS (EAS) financial reconciliation process completed, validated and approved by the MTF Resource Manager (i.e., AF Budget Officer or Analyst prior to MEPRS monthly transmission?
Source: MEPRS Manager and RMO Office
EAS Transmission does not impact this question.
YesNo
(comment required)
N/A(not appropriate for this
question)
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DQ Review List/StatementReconciliation
Question C.1.b: Has the MTF used the Workload Generation Controller (WGC) in CHCS to generate their WWR and WAM files?
Source: MEPRS Manager
YesNo
(comment required)
N/A(not appropriate for this
question)
WGC process is an 11 step process
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DQ Review List/StatementMEWACS
C.1.d. (DQ Statement question 3b): Were the data load status, outlier/variance, WWR-EAS IV, and allocations tabs in the current MEWACS document reviewed and explanations provided for flagged data anomalies?
Source: MEPRS Manager
C.1.d.1 through C.1.d.4 must be answered
If you reviewed tabs on MEWACS, C.1.d.1 - C.1.d.4, regardless of anomalies, ANSWER YES
YesNo
(comment required)
N/A(not appropriate for this
question)
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MEWACS:http://www.meprs.info
Will be required to register to access
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Select:Data Load StatusSummary OutliersWWR/EAS IV OutliersAllocation Test
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AFMOA MEPRS Dashboard
Launched MEPRS Dashboard Oct 2009
Objectives: Identify variance Evaluate processes Provide training
Measures: 20 Key data points with supporting detailed reports
Controls: 1 or 2 standard deviations Upper-Lower controls
Visibility: Resides on Vector Check – Enterprise-Wide Access https://vc.afms.mil/AFMOA/SGA/SGAR/SGAR_MEPRS/default.aspx
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AFMOA MEPRS Dashboard Nellis AFB, Nov 2009
Validated
Error
Error
Error Error
Error
Errors
Research
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AFMOA MEPRS Dashboard Nellis AFB, Apr 2010
Research
Corrections Pending
Corrected Corrected
Corrected
CorrectedCorrected
Validated
Research
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C.1.f. (DQ Statement question 3c): For DMHRSi, what is the percentage of submitted timecards by the suspense date?
=100%< 100%
(comment required)
C.1.g (DQ Statement question 3d): For DMHRSi, what is the percentage of approved timecards by the suspense date?
DQ Review List/StatementTimecards
Number of Timecards Submitted On-time Total Number of Timecards for an MTF
Source is MEPRS Manager
Number of Timecards Approved On-time Total Number of Timecards for an MTF
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C.1.f. (DQ Statement question 3c) For DMHRSi, what is the percentage of submitted timecards by the suspense date? Source is MEPRS Manager?
Number of Timecards Submitted On-time
315
320Total Number of Timecards for an MTF
Denominators (bottom numbers) should be the same
Remove the following statuses NULL NOT SUBMITTED REJECTED WORKING
Remove all personnel who did not work during pay period
C.1.g. (DQ Statement question 3d) For DMHRSi, what is the percentage of approved timecards by the suspense date? Source is MEPRS Manager
Number of Timecards Approved On-time
310
320Total Number of Timecards for an MTF
Cannot be greater than C.1.e.
Remove the following statuses NULL NOT SUBMITTED REJECTED WORKING SUBMITTED
Remove all personnel who did not work during pay period
Remember, comments are required if under 100%
DQ Review List/StatementTimecards
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DQ Review List/StatementTimecards
Timecard compliance and EAS transmission
Pay period ends
Timeliness Timecard submission
Timeliness Timecard approval
Member PCS’d
Rejected timecards corrected
DQ Statements due to AFMOA
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DQ Review List/StatementTimecards
Timecard compliance and EAS transmission
Pay period ends
Timeliness Timecard submission
Timeliness Timecard approval
Rejected timecards corrected
DQ Statements due to AFMOA
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DQ Review List/StatementCHCS Duplicate Patients
Question C.2. a. (DQ Statement question 10) Use CHCS during the data month to identify duplicate patient registration. For CHCS or AHLTA hosts only, what was the number of potential duplicate patient registration in the data month for all MTFs under the host? (NOTE: Only Host sites report up.)
Source is Internal Process
Report RanReport Not Ran
(comment required)If you are not a host site,
LEAVE BLANK
Run the CHCS standard report – “Potential Duplicate Patient Search”
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Run Time Statistical Report Validate the accuracy of the potential duplicate patients being
reported Provide Summary Documentation (5 year requirement) Detailed Results w/out Protected Health Information (PHI) Identifies if Potential Duplicate’s are resolved
The sum of these 4 columns is the potential duplicate number reported on the DQ Statement
DQ Review List/StatementCHCS Duplicate Patients
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Total # of potential duplicate patients
Must add up to the total listed above
Pre-populated with DMIS ID(s) and MTF(s) associated with host site
DQ Review List/StatementCHCS Duplicate Patients
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Potential Duplicate Report
Run the Registration report
Run for the entire data month
Run this report no earlier than the first day after the data month
Identify, Exclude, and/or Merge potential duplicates
Provide DQ Manager the potential duplicate number(s) by unresolved, identified, excluded, and merged
Run Time Statistical Report
Use this report as summary documentation
Provides results of the Potential Duplicate Report
Run this report for the first day after the data month to present
This report captures WHEN the potential duplicate report was ran and the results
The numbers in the unresolved, identified, excluded, and merged columns are all to be reported on the DQMC Review List & Statement
DQ Review List/StatementCHCS Duplicate Patients
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DISCLAIMER: We know this is not catching all duplicate patients. Do not use this to gauge the health of your patient file on your CHCS platform. Would recommend on occasion running the “ALL” report and Registration report. However, for DQ reporting purposes, the Registration report number is what should be on the Statement.
Just because DQ is asking for the Potential Duplicate Patient Report, does not exclude a facility from running the required monthly PIT Error Discrepancy Report and working them separately. Two different requirements and two different problems. Might see some crossover that the same patient’s are on both
reports, but this is normal
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Patient Duplicate Reporting
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DQ Review List/StatementEAS Transmission
Question C.3.a (DQ Statement question 4a): MEPRS/EAS (45 days)
Source: MEPRS Manager
EAS transmission should not occur until 100% timecard compliance is achieved, per AF/SG policy letter
YesNo
(comment required)
N/A(not appropriate for this
question)
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MEPRS Transmission (C.3.a)
Request summary documentation of timely submission Email is generated when MEPRS Transmission occurred Ensure transmission occurred on or before the 45th calendar
day after the data month
When reviewing BDQAS data, if the numerator for C.9.c is not available, MEPRS Transmission was not timely
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DQ Review List ADM SADR/CAPER Errors
Question C.4.a: Check the ADM SADR/CAPER Error Report?
YesNo
(comment required)
N/A(not appropriate for this
question)
Question C.4.b: Correct the errors listed on the report?
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DQ Review List/Statement Coding Accuracy Calculation
Use the following formulas for:
Q5b-d (Internal Process)
6b-d (Audit Tool)
7b-c (Audit Tool)
ICD-9:# of correct ICD-9 codes
Total # of ICD-9 codes
E&M: # of correct E&M codes
Total # of E&M codes
CPT: # of correct CPT codes
Total # of CPT codes
*Note: The denominator for all categories should include codes identified by the auditor.*Note: If your MTF doe not have a coder; the numerator will be 0 and the denominator will be 30
*Note[p1] : The denominator for all categories should include codes identified by the auditor. [p1]#134, 135, 136
The Service Headquarters will determine the specific random sample to be audited.
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Inpatient Coding/Rounds
Must audit a minimum of 30 records
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Question # Numerator Denominator %
5a(MS-DRG)
Medical Severity
Diagnosis Related Group
30 30 100%
5b (E&M)Evaluation & Management
29 30 97%
5c (ICD-9)Diagnosis
25 25 100%
5d (CPT)Procedure
35 40 88%
MS-DRG and E&M denominators must
No good indicator for CPT
Expect ICD-9 codes to be higher
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Availability (Outpt/APV)
If the documentation is available; however, the patient’s outpatient health record is not available, the “record of the encounter” is available for audit
Calculated from the records audited by coding auditor
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Availability and E&M denominators should match or be close
No good indicator for CPT
Expect ICD-9 codes to be higher than E&M
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DQ Review List/Statement DD Form 2569 Availability
Question C.8. (DQ Statement questions 8a (Inpatient), 8c (Outpatient), 8e (APVs)): What percentage of completed and current (signed within the past 12 months) DD Form 2569s (TPC Insurance Info) are available for audit?
Source: UBO Manager
Number of Complete and Current DD Form 2569s Available
Number of Non-Active Duty Records available from Audit
≥ 95% ≥ 80% but < 95%(comment required)
< 80%(comment required)
If you do not have a coding auditor, an alternate method is provided in the TUG
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Roles and Responsibilities2569 Pull List/Audit
Coding Auditor - COPY and PASTE the encounters from CARS then paste in a word document in a landscape format
UBO Manager - Exclude all the active duty member’s and audit ALL non-active duty members Do not alter list Auditing only 30 is not
acceptable
DQ Manager - Provide a listing of non-active duty members to UBO Manager using alternate method only when there is not a coding auditor
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2569 DQ Review List/Statement Questions
C.8.c. What percentage of completed and current (signed within the past 12 months) DD Form 2569s (TPC Insurance Info) is available for audit (non-active duty encounters only)?
Number of complete and Current DD Form 2569s Available
95
100Number of Non-Active Duty Non-APV
Records Available from Audit
Searching for a patients 2569 information in Mini Registration is incorrect and should not be used to conduct the audit
C.8.d. What percentage of available, current and complete DD Form 2569s is verified to be correct in the Patient Insurance Information (PII) module in CHCS?
Number of DD Form 2569s Correct in PII Module in CHCS
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95Number of Available, Current and Complete
Non Active Duty DD Form 2569s available from the Outpatient – Non APV 2569 Audit
The numerator in C.8.c. becomes your denominator in question C.8.d.
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DQ Review List/Statement Workload
C.9.c. (DQ Statement question 9c): Comparison of reported workload data.
Number of MEPRS visitsNumber of Kept Appts (count only)
≥ 95%≥ 80% but ≤ 95% or
≥ 105%(comment required)
< 80%(comment required)
Source: BDQAS
If EAS was not transmitted on-time, manually calculate numerator
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DQ Review List/Statement Rounds
Question C.5.f-h (DQ Statement questions 5b-d): Coding Accuracy of Rounds
Question C.9.e (DQ Statement question 9e): Comparison of reported workload data
Source: M2 and WWR
Number of “A***” CAPERS completed by attending provider or service (FCC=A***)
Number of Sum WWR (Bed Days + Bassinet Days + Dispositions)
≥ 95% ≥ 80% but < 95% < 80%
≥ 80% ≥ 110% < 80%
Questions C.5.f-h
Question C.9.e
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Rounding
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Per AF DQ TUG: Percentages must be reported to one decimal point. Rounding of actual performance calculations beyond one decimal point is prohibited.
This means if percentage is 94.9% for the questions where compliance is 95%, a comment will be required and question is non-compliant
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EDQ
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eDQ Documents
104
Vector Check URL: https://vc.afms.mil
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eDQ Documents
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eDQ Availability
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Comments & Space Limitations
Limited to 1,000 Characters
Limited to 1,000 Characters
Limited to 1,000 Characters
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Take Aways
Data Quality is much more than the DQ Statement
Data must be:
Front-end processes are CRITICAL to back-end success
ANALYSIS OF DATA
DMHRSiENGAGED DQ TEAM
PROVIDER F
ILE
ASD RECONCILIATION
2569 COLLECTION
APPT STANDARDIZATION
BUSINESS PLANS
CODING
CAPERS
ADM
END OF DAY
AND MUCH, MUCH MORE!
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Group Email Box: [email protected]
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AFMOA DQ Point of Contacts
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Summary
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Organization
Why Data Quality?
MTF Engagement
Guidance
DQ Assurance Team
CHCS Provider File
Metrics
Other DQ Efforts
DQ Review List/Statement Guidance & Completion
eDQ
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Questions?
Data Quality Program Office