Building a Suspension Bridge: The QI and Case Review Connection

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Building a Suspension BridgeThe QI and Case
Review Connection

• Linda Moore, RN
• Collins Gibson, MS

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History

• During the 7th SOW, CCME participated in the Best
  Practice Methods Special Study
• 5 QIOs SC, AZ, CO, MD, WA
• Replicate a common set of protocols covering the
  spectrum of QIO activity from recruitment to
  intervention to internal team-building
• Great success

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Background

• This same process was used for our IPGs in the
  8th SOW.
• Can these protocols work for case review
  activities?

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HPMP Special Project

• Decreasing Coding Errors and Inappropriate Higher
  Weighted DRG Adjustments
• This project focused on working with ten
  hospitals to implement processes to assure
  correct coding and prevention of payment errors.

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Plan

• Work with hospitals to eliminate coding errors
  and inappropriate submission of HW DRGs
• A systems approach will be utilized in which
  hospitals will be asked to do
• root cause analysis of their errors
• assessment of their current work processes
• development of a plan of action

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Plan Part 2

• We not only want to encourage elimination of
  errors during the adjustment coding/claims
  submission, but also for any initial claims.

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How

• Modeled after processes tested during the Best
  Practice Methods Special Study.
• The design includes various QIO activities,
  including
• Recruitment
• Provider relationship nurturing and maintenance
• System change to improve care and support of
  provider data collection
• Peer-to-peer sharing

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Recruitment Protocol

• Identify pool of target hospitals
• Partner recruitment
• Statewide notification
• Recruitment letter mailing
• Follow-up contacts
• Obtain commitment

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Participants - Anchors

• Good recruitment is important
• Asked 10 hospitals to participate
• Kick-off call to outline
• Project goals
• Project outline
• CCME roles
• Hospital requirements

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Relationship Protocol

• Assess the relationship
• Schedule face-to-face meeting(s) with
  participating hospitals
• Understand each hospitals culture
• Plan for turnover

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Environment - Towers

• One of learning and sharing similar to that of
  the Communities of Practice
• Will lead to rapid improvement in the areas of
  focus through informal sharing of
  improvement processes to include lessons
  learned, barriers, and successes
• Collaboration will be in the form of
  teleconferences, face-to-face meetings, and email

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System Change Protocol

• Assessment of each hospitals program (by
  hospital and QIO)
• Schedule and prepare for face-to-face visit with
  each participating hospital
• Conduct site visit with each hospital
• Debrief after site visit with each hospital
• Provide comments and suggestions once activity
  report is received
• Contact hospital at least monthly to support data
  collection and system modification

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Implementation Cables, Hangers

• Abstraction of records already
  denied to identify root causes
  for errors by the QIO and
  the hospital
• Assessment of their current work
  processes by the hospital
• Face-to-face visit with hospital to discuss
  findings of abstraction and assist with
  development of interventions

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Implementation Part 2

• Request monthly activity report updates
• Provide comments and suggestions once activity
  report is received
• Contact hospital at least monthly to support data
  collection and system modification

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Hospital Peer-to-Peer Sharing

• Harvest and share best practice ideas
• Identify state high performers
• Consider if the QIO has any additional knowledge
  about which hospitals are likely to have best
  practices to share
• Share documented best practice ideas
• Share success stories with hospitals during
  on-site visits, and/or when providing other
  technical assistance

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Best Practices - Deck

• Meeting with partners (SCHA, SCHIMA) and Best
  Practice hospitals
• Learn processes that are working from Best
  Practice hospitals in order to assist 10
  participating hospitals

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Results

• Baseline FY 2005 DRG change rate was 13.1
• For 3 months of intervention (February April
  2007) DRG change rate was 7.7
• So far for FY 2007 DRG change rate was 4.3

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Hospital Lessons Learned

• It takes a village! While the coder assigns the
  codes external factors affect claims submission
• Query practice
• Definition of complete documentation
• Pressure to drop bills
• This project brought together all entities
  involved to take action to lower the occurrence
  of HW DRG submissions.
• Coding error redefined Not just when coder
  assigns an incorrect code, but also when coder
  lacks sufficient physician documentation.

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More Hospital Lessons Learned

• Definition of a complete medical record Means
  truly everything. Coders need the discharge
  summary and responses to physician queries prior
  to coding the record.
• Setting the stage for the coding community with
  present on admission (POA) and MS-DRG More
  documentation is necessary!
• Must look at process to understand process
  Hospitals with little to no HW DRGs evaluated and
  monitored their submissions, whereas, those in
  the project accepted it as an allowed practice
  but had never evaluated why it was happening.

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QIO Lessons Learned

• The Best Practice Model works! This QI technique
  works whether the quality improvement focused on
  clinical care or billing processes.
• The Hawthorne effect is still alive and well!
  Although this project focused on ten hospitals,
  statewide change was realized.
• Partners are invaluable. The support of the SCHA,
  the FI/Compliance Officer group, and the SCHIMA
  strengthened the project outreach and success.

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Suspension Bridge QI Process

• Need all parts for a workable bridge
• Need all processes for a successful project

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Questions ?

• Linda Moore, RN
• Manager, Federal Programs and Services
• lmoore_at_scqio.sdps.org

Collins Gibson, MS Research Analyst cgibson_at_scqio.
sdps.org
The Carolinas Center for Medical Excellence 246
Stoneridge Drive, Suite 200 Columbia, SC
29210 803-251-2215
This material was prepared by The Carolinas
Center for Medical Excellence, the Medicare
Quality Improvement Organization for South
Carolina, under contract with the Centers for
Medicare Medicaid Services (CMS), an agency of
the U.S. Department of Health and Human Services.
The contents presented do not necessarily
reflect CMS policy. 8SOW-SC-HPMP-08-1