Child Health Monitoring Quality Improvement...
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10/13/2014 1 CHILD HEALTH MONITORING & QUALITY IMPROVEMENT RECOMMENDATIONS Debby Moyer, Best Practice Unit Nurse Consultant Jean Vukoson, State Child Health Nurse Consultant Training Objectives • Provide best practice recommendations to improve local internal audit and QI processes to assure compliance with: • Current Health Check Billing Guide (HCBG) requirements for preventative services • CMS billing & coding guidance for E&M services • NC Board of Nursing licensure requirements for nurses (scope of practice compliance) Background & Current Context • Interagency Memorandum of Understanding (IMOU) with DMA to provide monitoring for clinical services provided by LHDs • IMOU requires report of monitoring findings • Corrective Action Plans (CAPs) and resolution • External monitoring every three years & additional assessments by regional consultants • QI approach to identifying and resolving identified non-compliance issues
Transcript of Child Health Monitoring Quality Improvement...
10/13/2014
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CHILD HEALTH MONITORING & QUALITY IMPROVEMENT
RECOMMENDATIONS
Debby Moyer, Best Practice Unit Nurse ConsultantJean Vukoson, State Child Health Nurse Consultant
Training Objectives
• Provide best practice recommendations to improve local internal audit and QI processes to assure compliance with:• Current Health Check Billing Guide (HCBG)
requirements for preventative services• CMS billing & coding guidance for E&M services• NC Board of Nursing licensure requirements for
nurses (scope of practice compliance)
Background & Current Context
• Interagency Memorandum of Understanding (IMOU) with DMA to provide monitoring for clinical services provided by LHDs
• IMOU requires report of monitoring findings • Corrective Action Plans (CAPs) and resolution
• External monitoring every three years & additional assessments by regional consultants
• QI approach to identifying and resolving identified non-compliance issues
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Child Health Program Review Trends
• Increase in Corrective Action Plans (CAP) due to non-compliance with HCBG requirements• Increase in reports to Medicaid
• Increase in documentation indicating practice outside nursing scope in all programs• Increase in reports to NC Board of Nursing
• New monitoring and consultative follow-up model developed in response to trends
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Child Health Monitoring Processbased on continued findings &our QI process
• Our goal is to develop a CAP which will resolve the issues and an infrastructure to prevent future non-compliance
• The BPNC will: • Train agency staff in audit tools and documentation
expectations• Provide the agency a summary of the findings at the
audit debrief• Immediately share the findings summary with the
RCHNC• Provide instructions for starting root cause analysis in
preparation for CAP development
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Child Health Monitoring Processbased on continued findings & our QI process
• The RCHNC will:• Work with the agency to develop a CAP based on
root cause analysis• 5 Whys & Fishbone Diagram
• Focus is on system change vs education only• Map & assess clinical process (check-in to
discharge) to identify areas for revision or addition of compliance cues
• Develop/revise clinical policies and procedures & standing orders to support compliance
• Orientation & ongoing training of staff to assure embedding of compliance
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Child Health Monitoring Processbased on continued findings & our QI process
• The RCHNC will:
• Continue focus and technical assistance on effective internal audit & QI processes• Provide staff training on HCBG and billing & coding requirements
• Share/train on QI resources and processes
• Work with the agency to develop effective CAP to resolve findings within 90 days
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Child Health Monitoring Processbased on continued findings & our QI process
• CAPs must be resolved in 90 days from development of the CAP as demonstrated by follow-up audit by the BPNC
• The health director and DON will be involved in CAP requirements
• If the agency is not able to demonstrate compliance with HCBG requirements in 90 days, the findings will be discussed with Division management for a plan for next steps
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Child Health Monitoring Processbased on continued findings & our QI process
• Program Review Findings Report• The Best Practice Unit Nurse Consultant is providing quarterly Audit Findings Report(without county names) in the NCAPHNA Children & Youth report
• LHDs are urged to establish processes for review of the report, comparison to internal audit findings, and communication of reminders with local staff
• REVIEW HANDOUT
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Getting StartedMonitoring Requirements
• The Consolidated Agreement Requires all LHDs to perform an internal audit in all programs at least annually
• Best practice recommendation: • at least every six months
• more frequently with new HCBG requirements or new providers or clinical staff• weekly for three months to ensure guidance is embedded in practice
Getting StartedTools & Resources
• DPH Audit Tools & Instructions: http://www.ncdhhs.gov/dph/wch/lhd/cyforms.htm
• HCBG: http://www.ncdhhs.gov/dma/healthcheck/index.htm
• PHNPDU Documentation & Coding Guidance & E&M Audit Tool: http://publichealth.nc.gov/lhd/
• RN Scope of Practice Guidance:http://www.ncbon.com/myfiles/downloads/position-statements-decision-trees/rn-position-statement.pdf
Getting StartedAudit/QI Teams
• Multidisciplinary Audit Team:• QI expert• Program Content expert• Clueless individual
• Multidisciplinary Child Health QI Team:• Responsible for building infrastructure to support
compliance & development of CAP if findings• Provider• Clinical and administrative support staff• QI expert
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Getting StartedCompleting the Audit
• Gather tools• Audit tools & instructions• Current HCBG• E&M audit tool & guidance
• Randomized list of visits, including visits from each provider
• Encounter form or crystal client ledger or other billing documentation for the visit
• RN scope of practice guidance from NC Board of Nursing and PHNPD
• Use a patient identifier to allow review of the chart later. DPH uses Initials/DOB/DOS
• Record the initials of the provider—assure that records are reviewed for all providers
Getting StartedCompleting the Audit
• Review the record (hardcopy or electronic) for the requirements on the DPH audit tool—using the instructions as a guide
• The DPH audit tool supports compliance with HCBG requirements and programmatic requirements
• The audit team must have a content expert on agency policy and procedure and licensure requirements
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Getting StartedCompleting the Audit
• Does record meet audit requirement based on the instructions? If team needs clarity, refer to the HCBG
• REVIEW ACTIVITY• STEP 1: Review Instructions
• STEP 2: Review HCBG to clarify requirements
• STEP 3: Review billing document
• STEP 4: Review agency policies and procedures or licensure requirements
AUDIT TOOL INSTRUCTIONS
HCBG
2013 HCBG
AUDIT TOOL INSTRUCTIONS
HCBG
2013 HCBG
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Getting StartedCompleting the Audit
• Health Check Billing guide requirements must be documented regardless of source of payment. Staff should have a clear understanding of the policies and procedures for documentation; policy should support documentation that staff have reviewed and understood the agency’s policies and procedures.
• Did documentation demonstrate agency policy and procedure?• Clinical discipline accountability met
• Agency assessment & documentation standard met
• Date of Service (DOS) on all record components
Getting StartedCompleting the Audit
Agency policy & procedure continued:• Did documentation demonstrate RN scope of
practice compliance?• Is there documentation of consultation & referral for all
abnormal findings or deviation from expected care response identified by the RN?
• Is there clear delineation between RN documentation and NP/PA/MD documentation to demonstrate appropriate RN scope of practice?
• Do agency nursing standing orders meet NCBON guidelines & does documentation demonstrate compliance?
Getting StartedCompleting the Audit
• Review the record (hardcopy or electronic) for the requirements on the DPH audit tool—using the instructions as a guide
• Were all components of the visit reported or billed correctly?
• For clarification: refer to pages 85-87 2013 HCBG
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Getting StartedCompleting the Audit
• Agencies providing primary care services (sick visits) should also audit for appropriate Evaluation and Management (E&M) coding
• RESOURCES:E&M Audit Tool & Training: http://publichealth.nc.gov/lhd/Resources under the Documentation and Coding section of the webpagePublic Health Nursing & Professional Development Nurse Consultants: http://www.ncpublichealthnursing.org/nurse-cons-map.pdf
Getting StartedAudit/QI Teams
• Multidisciplinary Audit Team:• Clueless individual• QI expert• Program Content expert
• Multidisciplinary Child Health QI Team:• ROLE: Responsible for building infrastructure to support
compliance & development of CAP if findings• Provider• Clinical and administrative support staff• QI expert
Next Steps if FindingsQI Approach
• Root cause analysis: • What system processes defaulted to the error?• How can system processes support compliance?
• System processes to be assessed:• Work flow (front desk to discharge)• Policies & procedures, standing orders• Communication structure & processes• Orientation, competency assessment, ongoing training
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Next Steps if FindingsQI Approach
• Review 5 Whys HANDOUT• How does clinical process impact outcome?
• What other questions would you have asked?
• Have you used the 5 Whys to identify root causes for other identified issues?
Best Practice Well Child Visit Flow
RegistrationEligibility
CA or RN Check-in
Provider Assessment
& Plan of Care
RN or Provider
Discharge
Lab if indicated
Provide immunizations, more extensive education Coordinate referrals & FUReminder re next WCC
Vital signsMeasurement & plottingAssure Dev screens, HX & pre-visit forms are complete (no need to review with parent)
Review HX, pre-visit, Dev screens, measurements, & share with parentExamPlan of CareBrief educationReminder re next WCC
Check Medicaid status prior to or at registration to avoid Eligibility stepGive parent BF forms to complete prior to seeing Provider
Opportunity for compliance cues
Limited process steps & messengersFocus on provider as priority messenger
Visit Outcome Goal: Optimal Health Literacy
Traditional Fishbone Example
RESOURCE: http://www.ihi.org/resources/Pages/Tools/CauseandEffectDiagram.aspx
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Fishbone & Process DiagramMom of 2 year old has concern regarding child’s hearing
Model for ImprovementWhat are we trying to accomplish?
(AIM)
How will we know that changes are an improvement?
(MEASURES)
What changes can wemake that will result in
an improvement?(IDEAS)
Act Plan
Study Do
Test Ideas & Changes with Cycles for Learning and
Improvement
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PDSA Cycle
Act Plan
Study Do
• Objective of cycle• Questions/predictions• Plan to carry out the cycle
(who, what, where, when)
• Carry out the plan• Document
problems/unexpected observations
• Begin analysis of data
• Complete the analysis of data
• Compare data to predictions
• Summarize what was learned
• What changes are to be made?
• Adapt? Or Abandon?• Next cycle?
Use the PDSA cycle to test changes
Generating Ideas Resource:http://www.centerforpublichealthquality.org/index.php/theqitoolbox/qi-project-profile-tool/workplace-organization/94-step-by-step-guide/170-ideas
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• Communicate impetus to change• Reinforce messages with multiple & varied
communication processes, policy & procedures, & progress data feedback
• Expect resistance during embedding process
Status Quo-Baseline
Resistance
Chaos
Transforming Ideas
Integration
New Status Quo
Time
Performance
Change Process
Putting It All TogetherQI Approach & Resources
AUDIT FINDINGSROOT CAUSE
ANALYSISCAP
DEVELOPMENT
CHANGE COMMUNICATION
CAP RESOLUTION
ONGOING MONITORING
• DPH Audit Tools & Instructions
• HCBG• NCBON Guidance• Agency Policy &
Procedures
• Improvement Model
• Agency QI infrastructure
• Improvement Model
• PDSA• Agency QI Team• RCHNC
• Change Process• IHI Spreading
Change• NCCPHQ Spreading
& Sustaining Change
• 5 Whys• Fishbone• Fishbone Process• Agency QI
resources
• DPH Audit Tools & Instructions
• HCBG• NCBON Guidance• Agency Policy &
Procedures
Communicating, Spreading, Sustaining Change
• How to Improve: Institute for Healthcare Improvementhttp://www.ihi.org/resources/Pages/HowtoImprove/default.aspx
• Communicating for Change: Institute for Healthcare Improvementhttp://www.ihi.org/resources/Pages/Changes/CommunicationStrategiesforSpreadingChanges.aspx
• Spreading & Sustaining Change: NC Center Public Health Qualityhttp://www.centerforpublichealthquality.org/index.php/theqitoolbox/qi-project-profile-tool/workplace-organization/94-step-by-step-guide/172-spread-and-sustain
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ance Durham
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Chow
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Child Health/Care Coordination for Children Consultation & Technical Assistance- Effective April 1,
2014
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33 44 55 66 77
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REGION 1
Linda Harrison [email protected]: 828-369-6940Cell: 828-342-4265
REGION 3
Melody McCune [email protected]: 336-940-2358Cell: 704-662-2108
REGION 2
Debra [email protected]: (336) 239-9852
REGION 6
Stephanie [email protected]: 919-266-9524Cell: 252-571-2387
REGION 4CARE COORDINATION FOR CHILDREN(CC4C) PROGRAM MANAGER(CC4C program only)
Cheryl [email protected]: 336-813-2068STATE CHILD HEALTH NURSE CONSULTANT(CH Program only)
Jean [email protected]: 919-609-2904
REGION 5
Child Health: Stephanie [email protected]: 919-266-9524Cell: 252-571-2387
CC4C: Melody [email protected]: 336-940-2358Cell: 704-662-2108
REGION 7
Lynette Robinson [email protected]: 252-223-2016Cell: 252-514-5905
REGION 8
Tara [email protected]: (919) 624-6652
BEST PRACTICENURSE CONSULTANT
Debby [email protected]: 919-218-2945
Questions and Comments
• Please type your questions into the CHAT Box• If you have questions after the training, please contact your RCHNC or • Debby Moyer, Best Practice Nurse Consultant
• Jean Vukoson, State Child Health Nurse Consultant
