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 1
4 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 Child Health Monitoring Process based on continued findings &our QI process Our goal is to develop a CAP which will resolve the issues and an infrastructure to prevent future noncompliance 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 5 Child Health Monitoring Process based 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 6 2
Child Health Monitoring Process based 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 7 Child Health Monitoring Process based on continued findings & our QI process 8 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 9 Child Health Monitoring Process based 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 3
Monitoring 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 Tools & 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/positionstatements-decision-trees/rn-position-statement.pdf Audit/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 4
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 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 5
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 6
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 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? 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 7
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 webpage Public Health Nursing & Professional Development Nurse Consultants: http://www.ncpublichealthnursing.org/nurse-consmap.pdf Audit/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 Findings QI 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 8
Next Steps if Findings QI 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 Visit Outcome Goal: Optimal Health Literacy Registration Eligibility CA or RN Check-in Provider Assessment & Plan of Care RN or Provider Discharge Check Medicaid status prior to or at registration to avoid Eligibility step Give parent BF forms to complete prior to seeing Provider Vital signs Measurement & plotting Assure Dev screens, HX & pre-visit forms are complete (no need to review with parent) Review HX, previsit, Dev screens, measurements, & share with parent Exam Plan of Care Brief education Reminder re next WCC Lab if indicated Limited process steps & messengers Focus on provider as priority messenger Provide immunizations, more extensive education Coordinate referrals & FU Reminder re next WCC Opportunity for compliance cues Traditional Fishbone Example RESOURCE: http://www.ihi.org/resources/pages/tools/causeandeffectdiagram.aspx 9
Fishbone & Process Diagram Mom of 2 year old has concern regarding child s hearing Model for Improvement What are we trying to accomplish? (AIM) 29 How will we know that changes are an improvement? (MEASURES) Act Plan What changes can we make that will result in an improvement? (IDEAS) Study Do Test Ideas & Changes with Cycles for Learning and Improvement PDSA Cycle Use the PDSA cycle to test changes Generating Ideas Resource: http://www.centerforpublichealthquality.or g/index.php/theqitoolbox/qi-project- profile-tool/workplace-organization/94- step-by-step-guide/170-ideas Act What changes are to be made? Adapt? Or Abandon? Next cycle? Study Complete the analysis of data Compare data to predictions Summarize what was learned Plan Objective of cycle Questions/predictions Plan to carry out the cycle (who, what, where, when) Do Carry out the plan Document problems/unexpected observations Begin analysis of data 10
31 Change Process Performance New Status Quo Status Quo-Baseline Time Resistance Chaos Transforming Ideas Integration Communicate impetus to change Reinforce messages with multiple & varied communication processes, policy & procedures, & progress data feedback Expect resistance during embedding process 31 Putting It All Together QI Approach & Resources AUDIT FINDINGS DPH Audit Tools & Instructions HCBG NCBON Guidance Agency Policy & Procedures ROOT CAUSE ANALYSIS 5 Whys Fishbone Fishbone Process Agency QI resources CAP DEVELOPMENT Improvement Model PDSA Agency QI Team RCHNC CHANGE COMMUNICATION Change Process IHI Spreading Change NCCPHQ Spreading & Sustaining Change CAP RESOLUTION DPH Audit Tools & Instructions HCBG NCBON Guidance Agency Policy & Procedures ONGOING MONITORING Improvement Model Agency QI infrastructure Communicating, Spreading, Sustaining Change How to Improve: Institute for Healthcare Improvement http://www.ihi.org/resources/pages/howtoimprove/default.aspx Communicating for Change: Institute for Healthcare Improvement http://www.ihi.org/resources/pages/changes/communicationstr ategiesforspreadingchanges.aspx Spreading & Sustaining Change: NC Center Public Health Quality http://www.centerforpublichealthquality.org/index.php/theqitoolb ox/qi-project-profile-tool/workplace-organization/94-step-bystep-guide/172-spread-and-sustain 11
Alleghany Alexander Mecklenburg Montgomery Richmond Scotland Granville Washington a 10/13/2014 Cherokee Graham REGION 1 Clay Swain Macon 1 Haywood Jackson Linda Harrison linda.harrison@dhhs.nc.gov Phone: 828-369-6940 Cell: 828-342-4265 REGION 2 Madison Buncombe Henderson McDowell Polk Rutherford Watauga Caldwell Burke Ashe Wilkes Catawba Lincoln Gaston Cleveland NURSE CONSULTANT Debra Patterson (CH Program only) debra.patterson@dhhs.nc.gov Cell: (336) 239-9852 REGION 3 Melody McCune melody.mccune@dhhs.nc.gov Phone: 336-940-2358 Cell: 704-662-2108 Child Health/Care Coordination for Children Consultation & Technical Assistance- Effective April 1, 2014 3 4 5 6 7 2 Iredell Surry Yadkin REGION 4 CARE COORDINATION FOR CHILDREN (CC4C) PROGRAM MANAGER (CC4C program only) Cheryl Lowe cheryl.lowe@dhhs.nc.gov Cell: 336-813-2068 STATE CHILD HEALTH Jean Vukoson jean.vukoson@dhhs.nc.gov Cell: 919-609-2904 Davie Rowan Cabarrus Union Stokes Forsyth Davidson Stanly REGION 5 Anson Rockingham Guilford Randolph Caswell Alamance Moore Orange Durham Chatham Lee Hoke Person Robeson Child Health: Stephanie Fisher Stephanie.fisher@dhhs.nc.gov Office: 919-266-9524 Cell: 252-571-2387 CC4C: Melody McCune Melody.mccune@dhhs.nc.gov Office: 336-940-2358 Cell: 704-662-2108 Harnett Cumberland Wake Franklin Johnston Sampson Bladen Columbus Warren Wayne Brunswick REGION 6 Nash Wilson Duplin Pender Hanover Northhampton Halifax Edgecombe Greene Lenoir Pitt Craven Jones Onslow 8 Hertford Bertie Martin Stephanie Fisher stephanie.fisher@dhhs.nc.gov Office: 919-266-9524 Cell: 252-571-2387 REGION 7 Lynette Robinson lynette.robinson@dhhs.nc.g ov Office: 252-223-2016 Cell: 252-514-5905 Gates Beaufort Chowan Pamlico Tyrrell Hyde REGION 8 Tara Lucas r Dare tara.lucas@dhhs.nc.gov Cell: (919) 624-6652 BEST PRACTICE NURSE CONSULTANT Debby Moyer Debby.moyerl@dhhs.nc.gov Cell: 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 debby.moyer@dhhs.nc.gov Jean Vukoson, State Child Health Nurse Consultant jean.vukoson@dhhs.nc.gov 12