From Registration to Accounts Receivable – The Whole Can of Worms 2007 UBO/UBU Conference 1 Briefing: Fishing for Data Quality Date: 20 March 2007 Time:

2007 UBO/UBU Conference From Registration to Accounts Receivable 2 Objectives By the end of this presentation, you will: Describe the origin and goals of Six Sigma Identify how Six Sigma is used in healthcare and other industries Define the DMAIC process and use the steps in your day-to-day operation Locate tools to help you begin exploring data quality opportunities

2007 UBO/UBU Conference From Registration to Accounts Receivable 3 Intro to Six Sigma

2007 UBO/UBU Conference From Registration to Accounts Receivable 4 Intro to Six Sigma

2007 UBO/UBU Conference From Registration to Accounts Receivable 5 Case Study The Defense Health Program (DHP) performance plan requires that the number of Work Relative Value Units (RVUs) per Full-time Equivalent (FTE) provider per 8 hour day in primary care clinics meet or exceed 14.5

2007 UBO/UBU Conference From Registration to Accounts Receivable 6 Case Study

2007 UBO/UBU Conference From Registration to Accounts Receivable 7 DMAIC – Define Opportunities A defect is a) anything out of the scope of customer specifications b) decreases customer satisfaction c) does not fulfill functional/technical requirements A unit is something that is measurable or observable whether it is a physical product or some process with specific start and stop times An opportunity is a measurable or observable chance of not meeting the required specification or having a defect. A defect can have more than one opportunity to occur but each opportunity for that defect is independent of the other opportunities

2007 UBO/UBU Conference From Registration to Accounts Receivable 8 DMAIC – Define Opportunities Defect: Failing to meet the benchmark of 14.5 Work RVUs per FTE primary care provider per 8 hour day Unit: Work RVUs Opportunity: Each FTE primary care provider

2007 UBO/UBU Conference From Registration to Accounts Receivable 9 DMAIC – Measure Performance

2007 UBO/UBU Conference From Registration to Accounts Receivable 10 DMAIC – Measure Performance

2007 UBO/UBU Conference From Registration to Accounts Receivable 11 DMAIC – Analyze Opportunity Defect: Failing to meet the benchmark of 14.5 Work RVUs per FTE primary care provider per 8 hour day Unit: Work RVUs Opportunity: Each FTE primary care provider – Incomplete coding of SADR – Provider hours not recorded or attributed to a non- primary care MEPRS code – E&M codes downgraded by AHLTA – Interpretation of MEPRS business rules

2007 UBO/UBU Conference From Registration to Accounts Receivable 12 DMAIC – Improve Performance Test all of the opportunities discussed, one at a time, to see where the process actually requires improvement Incomplete coding of SADR – Training for providers and coders – Automated solutions, such as CCE Provider hours not recorded or attributed to a non-primary care MEPRS code – Training for providers – Automated solution that links provider clinic time to patients E&M codes downgraded by AHLTA – Correct programming so system picks up on the language necessary to assign correct E&M code Interpretation of MEPRS business rules – Training for providers and coders

2007 UBO/UBU Conference From Registration to Accounts Receivable 13 DMAIC – Control Performance Monitoring Plan – Control plan in place for sustaining improvements (short- and long-term) Process Standardization – New process steps, standards, and documentation are ingrained into normal operations Documented Procedures – Operating procedures are consistent – Knowledge gained on process is shared and institutionalized Response Plan – Response plans established, understood, and deployed Transfer of Ownership (Project Closure) – Transfer ownership and knowledge to process owner and process team tasked with the responsibilities Six Sigma DMAIC Quick Reference - Control Phase By Patrick Waddick

2007 UBO/UBU Conference From Registration to Accounts Receivable 14 DMAIC – In Class Example Define: Measure: Analyze: Improve: Control:

2007 UBO/UBU Conference From Registration to Accounts Receivable 15 Tools – MEPRS Web Portal

2007 UBO/UBU Conference From Registration to Accounts Receivable 16 Tools – MEPRS Manual M DoD M – Provides Tri-Service guidance to all MEPRS reporting MTFs / DTFs – Contains policy and guidance for implementation of MEPRS program Chapter 1Background Chapter 2Chart of Functional Cost Codes Chapter 3Manpower & Expense Assignment Chapter 4Reporting Requirements Chapter 5MEPRS Issue Process AppendicesAcronyms, Definitions, Guidelines for reporting FTE

2007 UBO/UBU Conference From Registration to Accounts Receivable 17 Tools – MEPRS Manual M C Ambulatory Procedure Unit (APU) DGA FUNCTION: The Ambulatory Procedure Unit (APU) provides pre-procedure and post-procedure care, observation, and assistance for patients requiring short-term care of less than 24 hours. Same Day Surgeries (SDS) or also known as Ambulatory Procedure Visits (APVs) are performed in a specialized area such as an APU, surgical suite, or extended care area. Refer to DoD Instruction (reference (c)) for further guidance. An APU is a location where the staff provides a centrally managed and coordinated program of nursing assessment and care planning; hospital or unit orientation; pre- procedure and discharge teaching; post-procedure monitoring; clinical and administrative interviews; initiation of procedural records and physician orders; and other functions, as appropriate. Therapies and functions include: nursing assessment; case management; pre-operative teaching; providing necessary written instructions to the patient by registered nurses; parenteral fluid support; administering pre-procedure and post-procedure medications; discharge teaching; obtaining ordered pre-operative laboratory tests and radiology results; and scheduling patients for arrival time for surgery. NOTE: MEPRS uses a fourth level B**5 code to identify an APV. The B**5 codes are linked to an APU (DGA) subaccount. The "5" in the fourth position indicates an APV performed in the APU, and the "**" coding indicates the clinical service performing the APV. For example, an APV performed by a Dermatology Clinic (BAP) provider will be recorded as BAP5. COSTS: The APU work center shall be a subaccount that includes all expenses incurred in operating and maintaining the function, such as expenses for personnel, supplies, travel, and any other expenses identified directly in support of APU activities. Total expenses shall ultimately be assigned through an expense allocation process to a B**5 account associated with an Ambulatory Care (B) final operating account. SERVICE UNIT: Minutes of service. Raw count is the number of patients. ASSIGNMENT PROCEDURE: Total expenses shall be assigned based on the ratio of minutes of service performed for each receiving account to the total minutes of service performed. Excerpt from Chapter 2

2007 UBO/UBU Conference From Registration to Accounts Receivable 18 Tools – MEWACS

2007 UBO/UBU Conference From Registration to Accounts Receivable 19 Tools – S2M3

2007 UBO/UBU Conference From Registration to Accounts Receivable 20 Tools – S2M3

2007 UBO/UBU Conference From Registration to Accounts Receivable 21 Tools – HSI Human System Interface

2007 UBO/UBU Conference From Registration to Accounts Receivable 22 Tools – HSI Human System Interface

2007 UBO/UBU Conference From Registration to Accounts Receivable 23 Tools – HSI Human System Interface

2007 UBO/UBU Conference From Registration to Accounts Receivable 24 Summary You can now: Describe the origin and goals of Six Sigma Identify how Six Sigma is used in healthcare and other industries Define the DMAIC process and use the steps in your day-to-day operation Locate tools to help you begin exploring data quality opportunities