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Quality Based Procedures –
A Collaborative Approach
November 7, 2014
Summary – NHS Quick Facts
6 Sites
441 Acute Beds
43,950 Urgent
Care Centre Visits
141 Mental Health Beds**
35,300 Inpatient
Separations
115 Long-Term Care Beds
249,100
Outpatient Visits
195 Complex Care Beds
7,910,000 Diagnostic Tests
(Lab, Medical Imaging)
2,500 Live Births
151,160 Emergency
Visits
20 Operating Rooms
$470M Budget
Data Based on 2013/14 Projected Volumes
** Including Addictions & Withdrawal Management beds at PCG [35] & 4 Adams St. [32]
41,680 Surgical
Procedures
Quality Based Procedures – A Collaborative Approach
November 7, 2014
Data Quality Committee
• Purpose:
– The NHS Data Quality Committee was created to
oversee matters related to data quality to ensure
appropriate reporting of NHS activity and results to
ensure optimal reporting for funding formula,
benchmarking and public reporting.
• Executive sponsor is CFO
• Committee reports to Clinical Ops/Quality committee
• Membership includes representatives from Finance &
Decision Support, Health Information Management &
Patient Registration, ICT, DI/Lab, ad hoc nursing,
physicians etc.
Quality Based Procedures – A Collaborative Approach
November 7, 2014
Number of Sub-working Groups
Team Approach
• Health Information Management
Documentation/Coding
Nursing
DI/
LAB
• GI Endoscopy
• Patients Registration/Accounts
Receivable/Health Information
Management
Physicians
Patient
Regis’n
ICT
HIM
Quality Based Procedures – A Collaborative Approach
November 7, 2014
Health Information Management Documentation/Coding
• Focus on ensuring NHS activity appropriately
reported for weighted activity through coded data for
HBAM and QBPs
• Focused on drivers of weighting methodology
• Engaged consultant to review potential opportunities
• Clinical Documentation and coding practices are key
Cost per
Weighted Case
$$/Case
Expenses
=
=
Weighted Cases
Weights
Quality Based Procedures – A Collaborative Approach
November 7, 2014
HSFR Weighting Methodology
Acute Inpatients (DAD):
Patient Characteristics
1. Age
2. MRDx
3. Interventions
HIG
Group
and
Base
Weight
HIG Weight Adjustment Factors
1.
Short length of stay
2.
Referral to home care
3.
Treatment in a special care unit
4.
5.
Intervention Events
Flagged Interventions (14 items)
Final
HIG
Weight
Day Surgery & ED (NACRS):
Patient Characteristics
1. Age and Sex
2. Main Intervention
3. Main Problem
4. Anesthetic Technique
5. Visit Disposition
CACS
Group
and
Base
Weight
Weight Adjustment Factors
Investigative Technology:
1.
Computed Tomography
2.
Magnetic Resonance Imaging
3.
Nuclear Medicine
4.
EEG
5.
Stress Test
6.
X-ray and Ultrasound
Final
Weight
Quality Based Procedures – A Collaborative Approach
November 7, 2014
A
QBP Review by Physician
• DQ Reviews (QBP type 1
vs MRDx)
• Reviewed the HIG
Drivers by physician by
QBP
Observations:
•
•
•
•
•
•
Physician Documentation – “Postop. anemia”
Home with Home Care
Anesthetic Technique
Flagged Interventions
Special Care Unit Days
Ventilation Days
# cases
HIG Weigted Cases
Avg HIG
RIW Weigted Cases
Avg RIW
Avg Age
0-364 d
1 to 17 y
18 to 59 y
60 to79 y
80+ y
total # Complications/Comorbidities ignored in HIG
Anaemia unspecified
Acute posthaemorrhagic anaemia
Benign hypertension
Hypokalaemia
Haem & haematoma comp a procedure NEC
Infection following a procedure NEC
Vascular comp following a procedure NEC
Congestive heart failure
Urinary tract infection site not spec
Atrial fib unspec
Pneumonia unspecified
B
C
74
51
50
109.53
83.64
74.77
1.48
1.64
1.50
110.95
81.77
75.46
1.50
65
1.60
70
1.51
69
0
0
20
49
5
0
0
7
37
7
0
0
8
37
5
6
24
64
24
11
1
5
1
1
1
3
1
2
1
2
1
1
Flagged Interventions
Vascular access device
1
1
0
1
1
0
Out of Hospital Interventions
Deaths
Transfer to/from other acute hospital
0
0
1
0
0
0
0
0
1
ALOS
% ALC days included in above
ALOS excluding ALC
25% Expected ALOS
# Short Length of Stay added for HIG (under 4 days)
3.73
5.37
4.62
0.7%
7.7%
4.3%
3.70
4.03
4.96
7.11
4.42
3.74
0
0
0
63
39
42
85%
76%
84%
0
2
1
1
69
3
1
4
39
8
2
33
15
7
8
5
63
39
42
# Disharge to homecare added for HIG
# Disharge to homecare added for HIG - % of total cases
# Treatment in Special Care Unit added for HIG (ICU, PCU,
CCU included and telemetry not included)
Anaesthesia Type
combined general with regional
spinal
general
epidural
Discharge Disposition
Discharged home (no support service required)
Discharged to home or a home setting with support services
(senior's lodge, attendant care, home care, meals on wheels,
homemaking,
housing,
etc) institution (includes
Transferred
tosupportive
an acute care
inpatient
other acute, sub-acute, acute psychiatric, acute
rehabilitation, acute cancer centre, acute pediatric centre
etc)
Transferred
to continuing care (a facility that provides
continuing supervisory care by medical and allied medical
staff)
1
3
1
4
2
Quality Based Procedures – A Collaborative Approach
November 7, 2014
Test Scenarios for Each QBP
Scenario 1
Scenario 2
Scenario 3
Scenario 4
Total Knee Replacement
RIW:
1.5227
HIG Weight:
1.5138
ELOS:
4.6
HIG ELOS:
4.4
25%
3.8
Disposition:
Home
Total Knee Replacement
RIW:
1.5227
HIG Weight:
1.5138
ELOS:
4.6
HIG ELOS:
4.5
25%
3.8
Disposition: Homecare
Total Knee Replacement
ICU Days *1
Respiratory Failure (Type 2)
Insertion of PICC
RIW:
2.4606
HIG Weight: 2.1402
ELOS:
9.5
HIG ELOS:
10.8
25%
6.0
Disposition: Homecare
Total Knee Replacement
ICU Days *1
Respiratory Failure (Type 2)
Insertion of PICC
RIW:
1.1748
HIG Weight:
1.5015
ELOS:
9.5
HIG ELOS:
10.7
25%
3.8
Disposition: Acute
CMG: 321 Unilateral Knee
Replacement
CMG: 321 Unilateral Knee
Replacement
HIG ELOS ^.1
CMG: 321 Unilateral Knee
Replacement
CMG: 321 Unilateral Knee
Replacement
RIW & HIG weight decreased
25% decreased but not ELOS and
HIG decreased by .1
Quality Based Procedures – A Collaborative Approach
November 7, 2014
Key Findings
• Home Care Services
– Consultant report for home care services were reported well
compared to province, found small margin of missed records
• No single source documentation within chart– various
forms/processes
• One consistent process is CCAC Homecare Consult Order
in PCI
• Investigating with ICT if possible for CCAC to enter order
in PCI notifying NHS that patient has been “accepted”
(currently only acknowledgement of Referral order
receipt) – assist with coding and also CCAC process for
follow up
Quality Based Procedures – A Collaborative Approach
November 7, 2014
Key Findings - NACRS – Day Surgery and ED
• GI Endoscopy QBP – Separate DQ group - focused on “specialized
procedures” since there was decrease in volume of cases
–
–
–
–
–
Random audit performed at each site “endoscopy alone”
Coding was at a high level of accuracy
Went back to physicians to ensure “Specialized procedures” were not being missed
Nursing Documentation was an issue, went back to nursing to heighten awareness
Updated “Endoscopy form” – clarification and additional check boxes to capture
specialized procedures
• Regional Conscious Sedation Form for ED cases – standardized at all sites
• Under reporting of DI procedures for ED visits approx. 5%
– Compared ITS DI procedures to WinRecs coded DI interventions
– Process for accessing scanned record reviewed with HIM’s to ensure appropriate
capture of DI visits (PCI vs medical record form)
– Second audit 4.9% - drilled down to HIM coder level
– ICT to develop flag that will interface to abstracting module to alert coders that a
DI procedure was performed
Quality Based Procedures – A Collaborative Approach
November 7, 2014
Key Findings Continued
• Anesthetic type (day surgery & QBP knee replacement)
– Documentation discrepancy between OR case record, anesthetic
record and physician dictated operative report
– Coders use unique Case Record vs Anesthetic record to obtain
anesthetic technique
– Anesthetic record will be used as source document
• Flagged Interventions
– ED face sheet updated to include central line (CL)
– Standardized ICU flow sheet across sites which includes key
flagged interventions (CL, Mechanical Ventilation)
– Developed cross-verification process between ED and inpatient
coders to ensure flagged intervention is captured which has positive
impact on weighted case
– Review with Chief of Radiology potential for standard verbiage
when reporting CL placement
Quality Based Procedures – A Collaborative Approach
November 7, 2014
Key Findings Continued
• Special Care Unit Days
– Consultant report identified NHS below peers
• review of MIS/CIHI definition for capturing ICU/step down
units occurred – SCS PCU changed to align reporting - updated
report identified NHS in line with peers for fiscal 2013-14
• ICT will interface ICU flag from Meditech to abstract to alert
coders
• Ventilation Days
– Comparison of WinRecs data with CCIS data for missing Vent days
• Found less than 10 case discrepancy and mostly vents after
surgery SCS
• Recovery Room record will be used as well as first
documentation noted on ICU flow sheets – two source
documents
Quality Based Procedures – A Collaborative Approach
November 7, 2014
Other Initiatives
• Sepsis post-admit vs pre-admit co-morbity
– Review of CIHI’s new In-Hospital Sepsis indicator
showed high results for post-admit sepsis
•Chart review conducted
•Physician interpretation of “sepsis” was an issue
– terms used interchangeably
•Monthly chart review process – includes
Infectious Disease physician, Regional Sepsis
Coordinator and HIM staff
•Standard Generic Coding query for physicians
which includes clinical criteria for sepsis
Quality Based Procedures – A Collaborative Approach
November 7, 2014
Patients Registration/Accounts Receivable/Health Information Management
•
Key Fields HBAM/QBPs
– Data of Birth
– Responsibility for Payment (Ontario)
– Province Issuing Health Card (ON)
– Valid Health Card Number/version code
– Geographic Information – Postal Code/Residence Code
• Ensure any Meditech updates to the above fields from BAR &
ADM are fed to Abstracting
– Edits interface through Meditech until abstract is saved at the time of
coding.
– Issue is after the abstract is coded changes are not updated
• Current manual process in place to check for changes and manually update
• ICT writing report to automatically notify HIM when key fields updated
– Error in Meditech with updates to address/postal code not updating
demographic data, mismatch of address & residence code – worked with
ICT to correct
– Recurring patients not updated with key fields (especially CKD)
Quality Based Procedures – A Collaborative Approach
November 7, 2014
Key to Success - Collaborative Approach
• Patient Registration
• Decision Support/Finance
• Health Information Management
• Information Technology
• Diagnostic Imaging
• Nursing
• Physicians
• Regional Sepsis Coordinator
Quality Based Procedures – A Collaborative Approach
November 7, 2014
Next Steps
• Patient Registration Education Day
• Physician and HIM sepsis education
• Two new Data Quality Analyst Positions
(NACRS/DAD)
• Increased education with physicians on QBP and
documentation
• Continue monthly QBP Committee with HIM
representation
• Continue monthly DQ Reports (CCIS/WinRecs
ventilation cases, RFP)
• Continue monthly DQ Reviews (QBP type 1 vs MRDx)
• Pilot site MOHLTC Data Quality Culture Survey
Quality Based Procedures – A Collaborative Approach
November 7, 2014