Presentation Objectives 1. Identify Division of Public Health (DPH) - PDF document

4/ 2 /2015 Implementing Strategies to Improve Child Health Monitoring & Quality Improvement 2015 Spring Child Health Regional Meetings Debby Moyer, Best Practice Unit Nurse Consultant Jean Vukoson , State Child Health Nurse Consultant 1 Presentation Objectives 1. Identify Division of Public Health (DPH) and other resources to support comprehensive medical record audit for and compliance with regulatory and licensure requirements 2. Implement quality improvement strategies to identify and resolve identified non- compliance issues 2 Quality Improvement & Health Outcomes O The audit process is designed to improve care and health outcomes by identifying processes which do not support evidence-based strategies (EBS) and provides a structure for making improvements O The Health Check Billing Guide (HCBG) and programmatic requirements are based on Bright Futures which are evidenced-based recommendations O Compliance with the requirements demonstrates EBS and billing requirements 3 1

4/2/2015 Quality Improvement Process O The QI process includes: O IDENTIFICATION (via audit) O DEFINING THE PROBLEM (via root cause analysis) O DEVELOPING & TESTING SOLUTIONS O Demonstrated RESOLUTION OF PROBLEM O CONTINUOUS MONITORING (via audit & data analysis) 4 Children and Youth Branch Accountability & Improvement Strategies 5 Children and Youth Branch Compliance Accountability O DPH Interagency Memorandum of Agreement (IMOA) requires C&Y staff to monitor local health departments to assure compliance with Health Check Billing Guide (HCBG) and Centers for Medicaid and Medicare Services (CMS) O This is accomplished via external audit and QI consultation processes 6 2

4/2/2015 Children and Youth Branch Compliance Accountability O External monitoring occurs every three years for low risk agencies O Audit process determines compliance with O HCBG requirements (preventative visits) O CMS billing requirements (Evaluation & Management visits) O State licensure requirements (NC Board of Nursing (NCBON) RN scope of practice) O Programmatic requirements (Title V/Activity 351) 7 Children and Youth Branch Compliance Accountability O Corrective action plans (CAP’s) are developed when non-compliance is identified O CAP must be resolved in 90 days O Consultative support to agency to resolve CAP O Failure to comply with HCBG/CMS or programmatic requirements may result in payback situation to Medicaid or loss of Title V funds 8 Current Context for Compliance O Over last 2 years, DPH has seen an increase in paybacks to DMA and reports to NCBON regarding scope of practice issues (all programs) O Based on these findings, the program has implemented multiple strategies over the last year to support improvement in health care delivery and compliance with the regulatory compliance 9 3

4/2/2015 Children and Youth Branch Quality Improvement Process O The QI process includes: O IDENTIFICATION of non-compliance O DEFINING THE PROBLEM or reason for non- compliance O DEVELOPING & TESTING SOLUTIONS O Demonstrated RESOLUTION OF PROBLEM O CONTINUOUS MONITORING to assure compliance and prevent non-compliance 10 Children and Youth Branch Quality Improvement Strategies O Frequent updates regarding HCBG requirements and scope of practice issues and audit findings O Regional meetings, NCAPHNA reports O Written summary of findings provided at the external audit debrief O Focus on root cause analysis and PDSA cycles in the CAP process 11 Children and Youth Branch Quality Improvement Strategies O Training for RCHNCs on root cause analysis and QI strategy O Training for LHDs on audit process and revision of DPH tools for external and internal monitoring O Continued focus on building local QI/QA infrastructure to support improved care and compliance 12 4

4/2/2015 Local Accountability & Improvement Strategies 13 Local Compliance Accountability O Visits which do not meet HCBG/CMS requirements should not be billed to Medicaid, or Title V funds used to support the service for non-Medicaid clients O The programmatic requirement is that all child health services meet the HCBG/CMS requirements 14 Local Compliance Accountability O Activity 351 Child Health Agreement Addenda (AA) spells out the requirements for service provision and infrastructure to support quality services and meet funding requirements O Failure to consistently meet Activity 351 requirements may result in reduction in funding 15 5

4/2/2015 Local Compliance Accountability O Internal monitoring must occur annually, at a minimum O Audit process determines compliance with O HCBG requirements (preventative visits) O CMS billing requirements (Evaluation & Management visits) O State licensure requirements (NCBON RN scope) O Programmatic requirements (Title V/AA) O Agency policies and procedures to support care & compliance 16 Local Quality Improvement Process O Does your QI process include the following strategies? O IDENTIFICATION O DEFINING THE PROBLEM O DEVELOPING & TESTING SOLUTIONS O Demonstrated RESOLUTION OF PROBLEM O CONTINUOUS MONITORING 17 Assessment of Local Quality Improvement Process O IDENTIFICATION of non-compliance issues O Recommended audit frequency O Use of DPH audit tools & instructions for preventative and problem visits O Child Health (CH) program audit tools O Public Health Nursing & Professional Development Unit (PHNPDU) tools for evaluation and management services 18 Resource: Child Health & PHNPDU internal Audit Assessment Tools 6

4/2/2015 Assessment of Local Quality Improvement Process O IDENTIFICATION of non-compliance issues O Link audit to billing process to assure all requirements are met O Review encounter form & billing statements O PHNPDU Documentation & Coding Guidance O Audit team trained in recommended CH program audit process 19 Resource: Child Health & PHNPDU internal Audit Assessment Tools Assessment of Local Quality Improvement Process O IDENTIFICATION of non-compliance issues O Audit team includes content expertise: O Clear understanding of Child Health Program/Bright Futures/HCBG requirements O Clear understanding of NCBON RN scope of practice O Clear understanding of agency policies and procedures to assure that practice follows policies/procedures 20 Resource: Child Health & PHNPDU internal Audit Assessment Tools Assessment of Local Quality Improvement Process O DEFINING THE PROBLEM O To solve the problem you must first understand the real or root problem O Requires stakeholder involvement to understand current care processes O Root causes most often system issue, not people or training issue O Internal policies & procedures including orientation & communication processes 21 Root cause analysis resources: 5 Whys and Fishbone Diagram 7

4/2/2015 Assessment of Local Quality Improvement Process O DEVELOPING & TESTING SOLUTIONS O Communication structure to support communication of findings, improvement process, & accountabilities O Stakeholder involvement in developing and implementing possible solutions O QI expert available to assist with developing, implementing, and evaluating possible solutions Plan-Do-Study-Act (PDSA) cycles 22 Resource: The Improvement Model-Institute for Improvement at www.ihi.org Assessment of Local Quality Improvement Process O Demonstrated RESOLUTION OF PROBLEM O Internal audit to assure resolution O Customer satisfaction surveys to assure improvement in services O CONTINUOUS MONITORING O Ongoing external audits and data review to assure ongoing compliance and identification of improvement opportunities 23 Assessment of Local Quality Improvement Process O Does your QI process include the following: O IDENTIFICATION (ongoing external audits) O DEFINING THE PROBLEM (DPH and local root cause analysis) O DEVELOPING & TESTING SOLUTIONS O Demonstrated RESOLUTION OF PROBLEM (reduction in audit findings & CAPs) O CONTINUOUS MONITORING (ongoing external audits and data review to identify improvement opportunities) 24 8

4/2/2015 Assessment of Local QI Process 25 Table Discussion Worksheets at each table Based on the findings scenario provided: O What processes and tools would you use to identify the root causes? 26 Table Discussion Worksheets at each table Based on your root cause analysis: O What processes and tools would you use to identify possible solutions or PDSA cycles to test? 27 9

4/2/2015 Table Discussion Worksheets at each table Now that you have selected possible solutions: O What organizational structure should be in place to develop, successfully implement, and resolve the CAP? 28 Table Discussion Worksheets at each table Based on the Child Health Internal Audit Assessment Tool and today’s presentation: O What challenges do you see to implementation of the recommended monitoring and corrective action strategies? 29 Summary of Key Messages 30 10