2010 UBO/UBU Conference Navy Medicine DQMC Breakout Session FY11 DQ Guidance and FY12 Preview.

2010 UBO/UBU Conference

Navy Medicine DQMC Breakout Session

FY11 DQ Guidance and FY12 Preview

Objectives Overview of the Navy Medicine Data Quality

Management Control Program

Orientation of the eDQ

Discuss FY11 DQMC Guidance Policy and Expectations

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Why Have a Program? Mandated: DoDi 6040.40 Funding

• Prospective Payment System (PPS)• Medicare-Eligible Retiree Health Care Fund (MERHCF)

Budgeting Business Planning Congressional Inquiries Business Case Analysis Special Studies

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Significant FY12 Changes

New DQMC Review List ProcessComplete Migration to the SharePoint

DQ Community SiteCentralized Coding Audit Pull ListsChanges in MEPRS (EAS) ProcessingDQMC Review List Briefing

FOR OFFICIAL USE ONLY4

Navy Medicine DQMC FY11 DQMC Goals Improve data transmission metrics to meet deadline 100% for

10 of the 12 reporting months. Improve DD FM 2569 collection in all three medical record

categories. Achieve 95% in all DQMC Readiness Categories by the March

2011 data month. Region command DQMC submission will improve to be 100%

compliant 10 of the 12 reporting months.

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DQMC Program Components Critical MTF Staff:

• Commanding Officer / ESC, Data Quality Manager, Data Quality Assurance Team (DQAT)

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DQMC Review List: • Internal tool to identify and

correct financial / clinical workload data and processes

Monthly DQMC Commander’s Statement: • Monthly statement forwarded

through the MTF Regional Command to BUMED and TMA

The Data Quality Assurance Team

Meets Regularly With DQMC Manager Acts as Subject Matter Experts Identifies / Resolves Internal DQMC Issues Team Membership (minimum):

• MEPRS• Coding / PAD / Medical Records• CHCS, AHLTA, and ADM Experts• Physician / Provider Champion• Executive Link• Business Analysts

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The Review List

Leadership commitment and DQMC structure

Timely and accurate

distribution (EAS, WWR, SADR, SIDR,

DMHRSi)

Ensure accurate,

complete and timely data

into systemsIA, access

breach

Organizational Factors

Data Input

Data Output

Security

System administrator

ID, IT business

processes

System Design and Training

Leadership commitment and DQMC structure

Ensure accurate, complete

and timely data entry

into systems

Timely and accurate

distribution (EAS, WWR,

SADR, SIDR,

DMHRSi)

IA, access breach

System administrat

or ID, IT business processes

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Commander’s Statement Overview 19 Questions, 51 + 2 Individual Elements

Submitted monthly to BUMED via the Regional Commands (and sent to TMA via BUMED)

Signed and reviewed by the Commanding Officer

The month reported on the statement is two months behind the current month (April’s submission is for February data)

When a system-wide issue prevents completing an element of the eDQ, BUMED will provide a standard response for the MTFs to use.

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Things to Remember Accurate Data is essential

• Red is not bad, it identifies an issue that requires attention• Need to apply DQ to the DQ Statement

Comments are as important as the metric• Provides the information required to take action• Need to use the correct format

Incorrect submissions will be rejected• Delays reporting to TMA (10th calendar day)• Revised statement will need to be re-signed by CC

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DQMC Submissions are reviewed by senior leadership at all levels, including the Region, BUMED & TMA

End of Day

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94%

95%

96%

97%

98%

99%

100%

EOD

Goal (Compliance)

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

Oct 09 Nov 09 Dec 09 Jan 10 Feb 10 Mar 10 Apr 10 May 10 Jun 10 Jul 10 Aug 10 Sep 10

Inpatient (2C)

Inpatient (9B)

Goal (Compliance)

Threshold (Minimum)

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%


Outpatient (2A)

APV (2B)

Inpatient (2C)

Goal (Compliance)

Threshold (Minimum)

Coding Timeliness

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Outpatient = 3 Business DaysAPV = 15 Calendar DaysInpatient = 30 Calendar Days

MEPRS/EAS & Sub Systems

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99%

100%

101%


Financial Reconciliation (3A)

MEWACS (3B)

DQMC Submissions are reviewed by senior leadership at all levels, including the Region, BUMED & TMA

MEPRS/EAS & Sub Systems

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87.00%

89.00%

91.00%

93.00%

95.00%

97.00%

99.00%

OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP

Medical Center FY 2010 DMHRSi Statistics

NMC San Diego- Approval NMC San Diego- DQ NNMC Bethesda-Approval

NNMC Bethesda - DQ NMC Portsmouth-Approval NMC Portsmouth-DQ

60%

65%

70%

75%

80%

85%

90%

95%

100%


MEPRS/EAS (4A)

SIDR (4B)

WWR (4C)

SADR (4D)

Goal (Compliance)

Threshold (Minimum)

Transmission Timeliness

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MEPRS = 45 Calendar DaysSIDR = 5 Business Days*WWR = 10 Calendar Days*SADR = 1 Calendar Day

* Navy Medicine = 4 Calendar Days

Coding Compliance

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75%

80%

85%

90%

95%

100%

Oct 09

Nov 09

Dec 09

Jan 10

Feb 10

Mar 10

Apr 10

May 10

Jun 10

Jul 10

Aug 10

Sep 10

DRG

DRG (5A)

Goal (Compliance)

Threshold (Minimum)

Coding Compliance

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75%

80%

85%

90%

95%

100%

Oct 09

Nov 09

Dec 09

Jan 10

Feb 10

Mar 10

Apr 10

May 10

Jun 10

Jul 10

Aug 10

Sep 10

E&M

IPSR (5B)

Outpatient (6B)

Goal (Compliance)

Threshold (Minimum)

Coding Compliance

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75%

80%

85%

90%

95%

100%

Oct 09

Nov 09

Dec 09

Jan 10

Feb 10

Mar 10

Apr 10

May 10

Jun 10

Jul 10

Aug 10

Sep 10

ICD-9

IPSR (5C)

Outpatient (6C)

APV (7B)

Goal (Compliance)

Threshold (Minimum)

Coding Compliance

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75%

80%

85%

90%

95%

100%

Oct 09

Nov 09

Dec 09

Jan 10

Feb 10

Mar 10

Apr 10

May 10

Jun 10

Jul 10

Aug 10

Sep 10

CPT

IPSR (5D)

Outpatient (6D)

APV (7C)

Goal (Compliance)

Threshold (Minimum)

DD Form 2569

FY 2010 FY 2011

Minimum Sample Size = 30 Minimum Sample Size = 30 Non AD

Sample Tied to Coding Audit (UBU driven) Sample Separate from Coding Audit (UBO driven)

Hint: The Denominator for the Complete/Current = Numerator of PII

NO CHANGE

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DQMC Submissions are reviewed by senior leadership at all levels, including the Region, BUMED & TMA; These metrics are a 2011 BUMED Focus Area

System Workload Comparisons

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55%

60%

65%

70%

75%

80%

85%

90%

95%

100%


SADR/WWR (9A)

SIDR/WWR (9B)

EAS/WWR Visits (9C)

EAS/WWR Dispositions (9D)

IPSR/WWR (9E)

Goal (Compliance)

Threshold (Minimum)

A - D: 103% = 97%E: 103% = 103%

AHLTA Penetration

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75%

80%

85%

90%

95%

100%


AHLTA/Total SADRS (10A)

FY11 Goal (Compliance)

FY10 Goal (Compliance)

Duplicate Patient Records

Question 11a on the DQ Statement Only MTFs that are CHCS hosts report this

metric Metric is based upon all duplicate records on

the silo, including Army and Air Force Facilities Starting in 2011, all DMIS IDs included in this

metric must be reported in the comments section.

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0

50

100

150

200

250

300

350

Oct 08

Nov 08

Dec 08

Jan 09

Feb 09

Mar 09

Apr 09

May 09

Jun 09

Jul 09

Aug 09

Sep 09

DQ Hint: Sometimes, commands forget to select “yes” on the eDQ; if the answer is truly “no”, there must be a reason identified in the comments section.

Commander’s Acknowledgement

Question 12a on the DQ Statement This question is the linchpin in the Data Quality Program; it

certifies that the senior leader at the MTF is aware of what is going on and is taking steps to correct deficiencies.

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Operational Personnel Readiness

Questions 1 through 7 (a & b) on the DQ Statement These are Navy Medicine unique metrics All Commands must complete this portion of the eDQ The following systems are gauged for completeness and accuracy:

• MRRS• EMPARTS• FLTMPS• DMHRSi

Successful management of these systems are critical for military readiness; Navy Medicine goal is 95% compliance for all questions by the March 2011 data month

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Comments and Corrective Actions

All metrics that are non-compliant (less than 95% or 80% for 9e) require a comment

Starting in FY11, comment grouping not allowed Comments must be in correct format

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ITEM: 2a, TT# (if applicable), ISSUE: XX% encounters from ER did not meet the 3-day deadline due to staffing issue. CORRECTIVE ACTION: Effective 1 January, temporarily reassign military staff until civilian/contract hiring process can be completed. CORRECTION DATE: January DQS.

Commands that report a Metric that is non-compliant for 3 (or more) consecutive months must develop and report the status of a POA&M

Summary

It is important to understand both the current policy as well as the data that is being reported when accomplishing the DQMC CC Statement.

Monthly DQMC submissions are official reports that are reviewed by senior leadership at the Region, BUMED and TMA.

The comments provided within the submission are just as important as the metrics that are reported.

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• NME

• NMW

• NCA

• NMSC

Regional Points of Contact


• Government POC

• CAI Team

BUMED Points of Contact

Questions


2010 UBO/UBU Conference Navy Medicine DQMC Breakout Session FY11 DQ Guidance and FY12 Preview.

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