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 2

Why Have a Program? Mandated: DoDi Funding Prospective Payment System (PPS) Medicare-Eligible Retiree Health Care Fund (MERHCF) Budgeting Business Planning Congressional Inquiries Business Case Analysis Special Studies 3

Significant FY12 Changes New DQMC Review List Process Complete Migration to the SharePoint DQ Community Site Centralized Coding Audit Pull Lists Changes in MEPRS (EAS) Processing DQMC Review List Briefing FOR OFFICIAL USE ONLY 4

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. 5

DQMC Program Components Critical MTF Staff: Commanding Officer / ESC, Data Quality Manager, Data Quality Assurance Team (DQAT) 6 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 7

The Review List 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 8

Commander’s Statement Overview 19 Questions, 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. 9

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

End of Day 11

Coding Timeliness 12 Outpatient = 3 Business Days APV = 15 Calendar Days Inpatient = 30 Calendar Days

Coding Timeliness 13 Outpatient = 3 Business Days APV = 15 Calendar Days Inpatient = 30 Calendar Days

MEPRS/EAS & Sub Systems 14 DQMC Submissions are reviewed by senior leadership at all levels, including the Region, BUMED & TMA

MEPRS/EAS & Sub Systems 15

Transmission Timeliness 16 MEPRS = 45 Calendar Days SIDR = 5 Business Days* WWR = 10 Calendar Days* SADR = 1 Calendar Day * Navy Medicine = 4 Calendar Days

Coding Compliance 17

Coding Compliance 18

Coding Compliance 19

Coding Compliance 20

DD Form 2569 FY 2010FY 2011 Minimum Sample Size = 30Minimum 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 21 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 22 A - D: 103% = 97% E: 103% = 103%

AHLTA Penetration 23

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. 24

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. 25

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 26

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 27 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. 28

FOR OFFICIAL USE ONLY 29 NME NMW NCA NMSC Regional Points of Contact

FOR OFFICIAL USE ONLY 30 Government POC CAI Team BUMED Points of Contact

Questions FOR OFFICIAL USE ONLY 31