1. HRID, ESRI, Dublin, July 2008 Audit of Coded Patient Data

2. HRID, ESRI, Dublin, July 2008 Audit Background information Who will perform coding audits? How to conduct a chart based audit Coding Audit Software Audit software in Ireland

3. HRID, ESRI, Dublin, July 2008 Background “Quality, as it applies to coded data, means the performance of the coding function is accomplished at the highest level of accuracy and of efficiency possible” Ref: Quality Control Issues, Vicki L. Rogers, Effective Management of Coding Services, AHIMA, 2002. Audit is a method to improve data quality for all those involved in HIPE.

4. HRID, ESRI, Dublin, July 2008 Background Audit Function Perform chart-based audit Scrutinise national data Develop audit software Training based on audit findings Local involvement in process Encourage audit in hospitals Track & record all audit activity

5. HRID, ESRI, Dublin, July 2008 Background Comparing original coding to re-abstracted coded data Casemix funding has placed the emphasis on quality accurate data Audit is a method of establishing data accuracy Audit can identify factors that affect data quality

6. HRID, ESRI, Dublin, July 2008 Background Why audit? Focus on data quality – data must be accurate and fit for use Meeting deadlines is not sufficient – accuracy is the key factor Quantity not at the expense of quality Data scrutinised by audit to improve quality

7. HRID, ESRI, Dublin, July 2008 Background Benefits Understanding and application of coding guidelines Cleaner data Ongoing improvement in data quality Maintain improvement & high standards Ownership of data quality

8. HRID, ESRI, Dublin, July 2008 Who Will Perform Coding Audits?

9. HRID, ESRI, Dublin, July 2008 Who Will Perform Coding Audits? Skills required: Independence Knowledge Practice due care & diligence Enforce recommendations Analytical Good communication skills Maintain Confidentiality

10. HRID, ESRI, Dublin, July 2008 Who Will Perform Coding Audits? Internal and External Auditor –Work with hospital staff –Input into training and development –Encourage staff to be involved in the audit process –Follow up on recommendations Position of trust and authority

11. HRID, ESRI, Dublin, July 2008 Who will Perform Coding Audits? Skills Required: –Re-abstraction Coding Skills Knowledge of DRGs and Coding Guidelines Knowledge of medical record systems and layout –Report writing Analysis of data Presentation of results Finding & recommendations –Ability to report results to management, clinicians and coding staff

12. HRID, ESRI, Dublin, July 2008 Who will Perform Coding Audits? Options: Coding staff perform audit re-abstraction Visit different hospitals Analysis and Report prepared separately Or All stages of audit completed by an auditor from recoding through to report and feedback

13. HRID, ESRI, Dublin, July 2008 Who will Perform Coding Audits? Decide on roles: –Roles may change depending on scale and focus of audit. –A particular expertise may be required –Audit may highlight contentious issues –Report may not be favourable to management, clinicians or coding staff Need for flexibility while maintaining high standards

14. HRID, ESRI, Dublin, July 2008 Administrative Issues Who can request an audit? Hospital participation – required or voluntary Access to charts – are there restrictions? Can hospitals respond to audit findings? Responsibility for implementation recommendations

15. HRID, ESRI, Dublin, July 2008 Summary Ongoing audit development process Process adapts to subject of audit Flexibility of process Training for audit role Short Course in Clinical Coding Auditing La Trobe University, Melbourne. Who does what?