Update on the Guide to Review of Quality of Care Issues for Physician Reviewers

1
Update on the Guide to Review of Quality of Care
Issues for Physician Reviewers

• Mary D. Giammona, MD, MPH
• Medical Director
• MBP QIOSC

2
Overview

• Review of Current Status
• Updates to Guide
• Brief summary of reported experience
• Discussion re implementationincluding QIPs
• Questions

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Review of Current Status

• Intro for Case Review Managers
• Intro for Physician Reviewers
• Response Determination Categories
• C Categories
• Possible Actions

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Review of Current Status

• Examples
• Quick Reference Guide
• Flow Charts
• Self-Test
• References

5
Key Update Points

• In the Intro for Physician Reviewers (PRS)
• More emphasis on how this process is NOT the same
  as the old levels of past SOWs
• Focus is on quality improvement
• Stresses the importance of the PR role

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Key Update Points

• In the Intro for Physician Reviewers (PRS)
• This new process may appear similar to the
  assigning of levels that occurred in earlier
  scopes of work. However, because the focus in
  the 7SOW is quality improvement, the new process
  is quite different and not the same at all as the
  process of the past, for it is looking at
  categories and improvement, rather than focusing
  on severity of concern.

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Key Update Points

• As any of you who are longstanding Physician
  Reviewers for the PRO/QIO program probably
  recall, the old process of assigning levels of
  severity was extremely unpopular in the medical
  community.

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Key Update Points

• That is why it is so important to stress that,
  while perhaps having some similarities
  structurally to that old process, the new process
  is very different. The emphasis now is on ways
  to work with physicians and practitioners in our
  communities so together we can improve the
  quality of care for our Medicare beneficiaries.

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Key Update Points

• C Categoriesthe examples
• C12- Apparently did not provide appropriate
  personnel and/ or resources.
• This category is used for lack of sufficient
  staff to handle patient load lack of
  credentialed staff for provision of offered
  services equipment unavailable to carry out
  treatment plan.
• Example a patient who undergoes a thyroidectomy
  without sufficient blood products available in
  case of hemorrhage.

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Key Update Points

• Applying CategoriesExamples
• Guidance in the intro to focus on the point of
  the questions, rather than getting lost in the
  details
• We understand that, in particular, Physician
  Reviewers in specialty areas may have additional
  questions about some of these vignettes.
  However, please try not to get distracted by the
  details of the vignettes instead, try to focus
  on the overall message that the example is trying
  to convey.

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Key Update Points

• Applying CategoriesExamples
• Example 1
• A son is concerned that a surgical error
  occurred during his 74-year-old mothers recent
  foot surgery. She has had repeated stasis ulcers
  that are non-healing. According to the record
  review, amputation of the right foot was
  recommended after vascular studies demonstrated
  severe ischemia not amenable to other treatment.
  Intraoperatively however, the left foot was
  removed in error.

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Key Update Points

• Applying CategoriesSelf-Test
• Question 5
• A 51-year-old patient with AIDS went to the ER
  complaining of profuse diarrhea. The ER
  physician hydrated the patient, performed a stool
  culture, ordered the culture results to be
  forwarded to the patients primary care physician
  and began presumptive treatment. The culture
  result came back positive for Campylobacter.
  Neither the patient nor the physicians was
  notified. The patient subsequently developed
  sepsis and was later admitted.

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Key Update Points

• Applying CategoriesSelf-Test
• Question 5Answer
• Decision
• Step 1 Care could have been better
• Step 2 Care failed to follow generally accepted
  guidelines or usual practice.
• Step 3 C.06 Apparently did not appropriately
  assess and/ or act on laboratory tests or imaging
  study results.

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Key Update Points

• Applying CategoriesSelf-Test
• Question 5
• Recommendation/ Action
• Recommend that provider develop and implement a
  QIP. The ER physicians care is not at issue.
  However, a QIP is required from the hospital to
  ensure that appropriate procedures are in place
  to notify a patient, and the appropriate
  physicians, with positive laboratory results as
  soon as they become available.

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Summary of Current Experience

• Received responses from 12 QIOs that had begun
  distributing the materials
• Variety of training methods in the works
• Mail-out of the Guide
• Use of the recorded WebEx training
• Teleconference training
• In-house (in-person) training

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Summary of Current Experience

• Two responses indicated that a few areas were
  revised to meet the needs of their PR community
• Some of the instructions, and examples
• When these are available, we will share on the
  QIOSC web site

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Summary of Current Experience

• California Experience
• Mailed out 340 packets with intro letter and
  request for evaluation to be returned
• After 1 week, received 15 of responses
• Overall acceptance and indication that Guide was
  useful for training
• Some concern re C categories
• Liked the examples and self-test

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Implementation Issues

• CRIS Questions
• Complicated to update PRAF, but are looking at it
• May use same PRAF and have a second sheet with
  the RDCs while CRIS is being updated
• Samples developed by QIOs will be posted on QIOSC
  web site when available

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Implementation Issues

• Issue of Severity
• Reminder anything considered gross and
  flagrant by a PR is just one step of the
  processthe usual QIO pathway (review by
  committee, etc.) makes the final determination
  re possible sanction activity
• For the middle categories, we will be working on
  developing additional examples to help clarify
  the differences further

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Implementation Issues

• QIP Requests and Monitoring
• Likely that this approach will lead to additional
  QIP requests
• When to request? Whenever a system or pattern of
  practice appears to be at fault.
• Could be either a hospital or health plan (more
  likely) or a practitioner

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Implementation Issues

• QIP Requests and Monitoring
• Can list any issues that need to be addressed
  (e.g. that were specifically mentioned by the PR)
  to guide the involved provider/practitioner
• Based on the response, can then determine the
  time for follow-up (e.g. 3 months, 6 months)

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Implementation Issues

• Sample Letters
• The QIOSC has been developing sample letters for
  QIP requests and follow-up
• After CMS approval, we will put these on the
  QIOSC web site

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DISCUSSION

• Comments about implementation
• Questions?