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

4/2/2015 1

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

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Presentation Objectives

• 1. Identify Division of Public Health (DPH) and
• ther 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

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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

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4/2/2015 2 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)

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Children and Youth Branch Accountability & Improvement Strategies

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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

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4/2/2015 3 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)

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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

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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

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4/2/2015 4 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

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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

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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

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Local Accountability & Improvement Strategies

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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

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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

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4/2/2015 6 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

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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

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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

Resource: Child Health & PHNPDU internal Audit Assessment Tools

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4/2/2015 7 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

Resource: Child Health & PHNPDU internal Audit Assessment Tools

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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

Resource: Child Health & PHNPDU internal Audit Assessment Tools

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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

• rientation & communication processes

Root cause analysis resources: 5 Whys and Fishbone Diagram

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4/2/2015 8 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

Resource: The Improvement Model-Institute for Improvement at www.ihi.org

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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

• f improvement opportunities

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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

• pportunities)

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4/2/2015 9

Assessment of Local QI Process

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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?

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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?

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4/2/2015 10

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?

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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?

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Summary of Key Messages

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4/2/2015 11

Summary of Key Messages

O Compliance with EBS requirements

improves health outcomes—our ultimate public health goal

O There is increased accountability for local

agencies to build the capacity needed to assure compliance with regulatory requirements

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Summary of Key Messages

O QI strategies support identification and

resolution of identified issues

O Must identify and understand the problem to

solve it

O Key stakeholders are critical to defining the

problem, developing and implementing solutions

O Ongoing monitoring is required to assure

compliance

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Summary of Key Messages

O Agency infrastructure and communication is

critical to preventing and resolving non- compliance

O Assure requirements are understood by all

staff and providers

O Orientation and ongoing communication

O Policies and procedures are updated,

meaningful, and implemented

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4/2/2015 12

Resources

O Regional Child Health Nurse Consultants http://www.ncpublichealthnursing.org/CHNCMap0 92214.pdf O PHNPDU Nurse Consultants http://www.ncpublichealthnursing.org/NurseCons1. pdf O The Improvement Model; Institute of

Healthcare Improvement

www.ihi.org

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Resources

O DPH Audit tools & Instructions

Including the CH Internal Audit Assessment Tool http://www.ncdhhs.gov/dph/wch/lhd/cyforms. htm

O PHNPDU Documentation & Coding

Guidance

See Documentation & Coding section for audit tools and archived training webinar http://publichealth.nc.gov/lhd/

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Questions & Comments

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