1. 2010 UBO/UBU Conference Title: Data Integrity Breakouts (Navy) DQ – FY11 DQMC Guidance Speaker: Colleen Rees & Team Session: T-4-0850

2. Objectives Overview of the Navy Medicine Data Quality Management Control Program Orientation of the eDQ Discuss FY11 DQMC Guidance Policy and Expectations 2

3. 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 3

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 4

5. DQMC Program Components Critical MTF Staff: – Commanding Officer / ESC, Data Quality Manager, Data Quality Assurance Team (DQAT) 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 5

6. 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 6

7. The Review List 7

8. 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 8

9. The eDQ Mechanism for Capturing and Reporting the CC Statement Automatically Populates 17 Questions – Can only be changed via TT, when local results more than 2 % point All Commands Must Accomplish POMI section 9

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14. Highlighted Changes in FY11 DMHRSi: 100% compliance (or provide an appropriate justification) to process in EAS DD Form 2569: Sample separate from Coding audit; only includes Non-AD records 7 POMI questions added (Navy Medicine unique) Non-Compliant metrics must use standard format in comment section Regional and Service level metrics based on raw data – Larger MTFs have greater impact on average 14

15. 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 (10 th calendar day) – Revised statement will need to be re-signed by CC DQMC submissions are reviewed by senior leadership at all levels, including the Region, BUMED, & TMA 15

16. End of Day Question 1 on the DQ Statement Almost always compliant Continues to be measured because it is a key step for complete/timely coding of encounters Although not measured in the metric, correct EOD processing includes assigning appropriate provider 16

17. Coding Timeliness Question 2 (a - c) on the DQ Statement Compliance timeframe depends on encounter type: – Outpatient = 3 Business Days – APV = 15 Calendar Days – Inpatient = 30 Calendar Days The Navy Data Quality DRG data extract is required to be transmitted with the SIDR DQ Hint: Question 2c should always be less than or equal to Question 9b 17

18. MEPRS/EAS & Subsystems Question 3 (a - d) on the DQ Statement Financial Reconciliation (3a) is always “yes” unless BUMED specifies otherwise MEWACS (3b) monitored closely by TMA – Must be reviewed monthly, even if current data month not transmitted; if reviewed, answer is “yes” – If there are outliers, actions to correct, or explanation for anomaly, must be documented in comments Starting in FY11, DMHRSi 100% compliance = 100% – All outstanding timecards must be explained in order to obtain approval to process 18

19. Transmission Timeliness Question 4 (a - d) on the DQ Statement Compliance based on product – MEPRS = 45 calendar days, but the 15 th of following month to determine compliance – SIDR = 5 business days, BUMED requires 4 calendar days – WWR = 10 calendar days, BUMED requires 4 calendar days – SADR = 1 calendar day DQ Hint: Question 4a compliant if EAS successfully transmitted by 15 th ; confirm via EAS IV Repository. Suggest sending prior to 15 th in case transmission fails 19

20. Coding Compliance Questions 5 (a - d), 6 (a - d) and 7 (a - c) on the DQ Statement Minimum sample size of 30 encounters (or all cases for month if less than 30) E&M, CPT, and ICD-9 compliance calculations based on # of codes, not # of records There should be a direct correlation between reported compliance and error reason codes reported in the Coding Summary Report DQ Hint: Monthly audits must be performed; if late, the metric = 0% (not N/A). When audit completed, results must be changed in the eDQ and Regional DQMC Manager must be informed of update 20

21. DD Form 2569 Question 8a through 8e, covering Inpatient, Outpatient and APV on the DQ Statement Minimum sample size is 30 Non-Active Duty records Process is owned by the MTF UBO function A Navy Medicine 2011 Focus Area DQ Hint: The numerator for the first question (complete/current) is always the denominator for the second question (PII) 21

22. System Workload Comparisons Question 9 (a - e) on the DQ Statement Question 9a through 9d can not be reported above 100%, the eDQ modifies the metric appropriately If EAS is not transmitted by the eDQ freeze date, the WAM must be used to calculate those metrics DQ Hint: Question 9b should always be greater than or equal to Question 2c 22

23. AHLTA Penetration Question 10a on the DQ Statement Starting in 2011, metric compliance changed from 80% to 95% 23

24. Duplicate Patient Records Question 11a on the DQ Statement Only MTFs that are CHCS hosts report this metric Metric is based on 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

25. 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 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 25

26. 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

27. 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 – 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 27

28. 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

29. Q&A Questions? 29