Navy Data Quality Management Control Program (DQMCP)

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Navy Data Quality Management Control Program
(DQMCP)

• DQMCP Conference Navy Breakout

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Dilbert on Data Quality
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DQMCP Components
Navy DQMCP Roles and Responsibilities
DQMC Process Flow and Deadlines
Commanders Statement
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DQMCP Components
MTF DQMCP Components

• Critical MTF Staff
• Commanding Officer / ESC, Data Quality Manager,
  Data Quality Assurance Team
• DQMC Review List
• Internal tool to identify and correct financial
  / clinical workload data and processes
• Monthly DQMC Commanders Statement
• Monthly statement forwarded through the MTF
  Regional Command to BUMED and TMA

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DQMCP Components
DQMCP MTF Teams

• 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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DQMCP Components
DQMCP Review List
Ensure accurate, complete and timely data
IA, access breach
Leadership commitment and DQMC structure
Timely and accurate
System administrator ID, IT business processes
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BUMED Program management, oversight, policy and
strategies.
Navy DQMCP Roles and Responsibilities
REGIONS Regional consolidation of Commanders
Statements, DQMCP coordination, issue resolution,
audits and training.
MTFs DQMCP execution, Review List, Commanders
Statement, CO briefs, and communication of issues
to regional representatives.
NMSC Systems execution, website maintenance /
development, and DQMCP support.
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Navy DQMCP Roles and Responsibilities
DQMCP Points of Contact

• Colleen Rees
• [phone]

• Zachary Feldman
• [phone]
• x 8287

• Consolidated Call Center
• [phone]

• Jessica Welty-Morse
• [phone]

• Pat Huston
• [phone]

• Nick Coppola
• [phone]

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NAVMISSA Consolidated Call Center
Navy DQMCP Roles and Responsibilities

• Who do I call?
• Toll Free 1-866-755-NAVY (6289)
• Commercial 304-367-9462
• E-mail navmed.callcenter_at_med.navy.mil
• How do I know the status of my problem?
• Broken functions to existing products are closely
  monitored by the NMSC DQMC Program Manager.
• Weekly status reports are posted to the DM
  SharePoint site for visibility.
• Your problem is not considered solved until you
  say it is solved.
• What if I have a new need or good idea?
• MTFs are encouraged to provide any proposed
  requirements or ideas for improvement to their
  Regional DQ Manager.
• BUMED and Regional DQ Managers will vote and
  prioritize items based on available resources.

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DQMC Process Flow and Deadlines
Recurring DQMCP Tasks
Annually
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DQMC Process Flow and Deadlines
DQMCP System Process Flow
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DQMC Process Flow and Deadlines
Reporting Timeframes for DQMCP
Timeframes may be updated as the year
progresses, be sure to obtain the most current
version from the BUMED Financial Guidance Portal
at www.navmedfinancial.org
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Commanders Statement Overview
Commanders Statement

• 11 Questions, 37 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 (Marchs submission is
  for January data)
• When a system-wide issue prevents completing an
  element on the eDQ, BUMED will provide a standard
  response for the MTFs to use.

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Commanders Statement Overview
Commanders Statement

• For any question where a difference between an
  MTFs submission and the automatic eDQ
  calculation is greater than 2, a NAVMISSA
  Trouble Ticket (and source for the local
  number) must be included in the comments section.
• MTFs are required to provide comments, an MHS
  Trouble Ticket and a POAM for actions being taken
  to resolve non-compliant (lt80) metrics and
  metrics that have significantly decreased (10 or
  more) from the prior month.

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Commanders Statement End of Day (EOD)

• Methodology
• Two timeframes
• Clinics with normal hours complete EOD by
  midnight
• 24 / 7 Clinics complete EOD by 0600 the next
  calendar day
• 1a - of Appointments Closed by midnight (or
  0600) / of Appointments
• Metric is dependent on the receipt of each sites
  DQMC Appointment Audit File

Auto-Populated by the NAVMISSA eDQ Local Data
Should be Calculated Using the BUMED Approved
CHCS Ad-hoc
NEW FOR FY10!
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Commanders Statement End of Day (EOD)
Note that the vertical axis on the historical
charts is adjusted to better display trends
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Commanders Statement End of Day (EOD)
NOLA transition impacted the file receipts at
NAVMISSA, inflating the calculation difference
(blue data points are adjusted to reflect actual
data received).
BUMED 2 Goal
NMSC and NAVMISSA Tiger Team On-Site
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Commanders Statement Coding Timeliness

• Methodology
• Compliance is determined by the number of
  business days between the appointment date and
  the date a SADR is transmitted.
• 2a - of SADRs coded within 3 business days /
  Total SADRs

NEW FOR FY10!
Auto-Populated by the NAVMISSA eDQ
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Commanders Statement Coding Timeliness
Note that the vertical axis on the historical
charts is adjusted to better display trends
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Commanders Statement Coding Timeliness

• Methodology
• Compliance is determined by the number of
  calendar days between the APV date and the date a
  SADR is transmitted.
• 2b - of APVs coded within 15 calendar days /
  Total APVs

NEW FOR FY10!
Auto-Populated by the NAVMISSA eDQ
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Commanders Statement Coding Timeliness
Note that the vertical axis on the historical
charts is adjusted to better display trends
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Commanders Statement Coding Timeliness
NOLA transition impacted the file receipts at
NAVMISSA, sites with transmission issues were
removed from the metrics on this slide
(retransmitting impacts the SADR Extract Date).
NMSC and NAVMISSA Tiger Team On-Site
Tiger Team impact on the calculations was minimal
as only a small percentage of SADRs fall on the
border of compliance where a methodology change
would have an influence. However, since January
2009 (FM4) sites have steadily been more
accepting of the eDQ calculation as sites are
educated on how to calculate the two metrics.
Also, the elimination of TCONs from the FY10
metric has reduced local variation.
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Commanders Statement Coding Timeliness

• Methodology
• Compliance is determined by the number of
  calendar days between the disposition date (E
  records) and the date a SIDR is coded (D
  records).
• Date coded is determined by the DRG assignment
  date transmitted to NAVMISSA in the DRG file.
• 2c - of SIDRs coded within 30 calendar days /
  Total SIDRs

NEW FOR FY10!
Auto-Populated by the NAVMISSA eDQ
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Commanders Statement Coding Timeliness
Note that the vertical axis on the historical
charts is adjusted to better display trends
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Commanders Statement MEPRS Reconciliation

• Methodology
• Both questions are answered Yes or No by each
  MTF.
• 3a Financial reconciliation must be completed,
  validated and approved prior to the monthly MEPRS
  transmission. BUMED policy is to answer Yes,
  since this process is performed by BUMED.
• 3b MTFs must review the current version,
  regardless of whether it matches the reporting
  month or not (this question should always be
  Yes).

NEW FOR FY10!
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Commanders Statement MEPRS Reconciliation
Note that the vertical axis on the historical
charts is adjusted to better display trends
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Commanders Statement MEPRS Reconciliation
NEW FOR FY10!

• Methodology
• Both questions are provided by BUMED.
• 3c - Timecards Submitted, Working,
  Rejected or Approved / Total Timecards on the
  BUMED DMHRSi Interim Report Date
• 3d Timecards Approved / Total Timecards on
  the BUMED DMHRSi Final Report Date

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Commanders Statement MEPRS Reconciliation
Note that the vertical axis on the historical
charts is adjusted to better display trends
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Commanders Statement Data Transmission

• Methodology
• All three measures are Yes or No and
  calculated based on the day the files were
  successfully transmitted to NAVMISSA, not when
  the transmissions were attempted.
• If 4a is No, questions 8c and 8d should use
  local WAM data.
• Note For 4b and 4c, compliance is measured by
  5th Business Day and 10th Calendar day for TMA
  reporting purposes.

NEW FOR FY10!
Auto-Populated by the NAVMISSA eDQ
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Commanders Statement Data Transmission
Note that the vertical axis on the historical
charts is adjusted to better display trends
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Commanders Statement Data Transmission

• Methodology
• SADR transmissions are reported as a percentage,
  since they are the only file transmitted multiple
  times in a month.
• Every DMIS (Parent and Child) should have a SADR
  file transmitted each day (even if the file is
  empty).
• Logic for sites (especially overseas) is based on
  time zones and CHCS ETU settings.

Auto-Populated by the NAVMISSA eDQ
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Commanders Statement Data Transmission
Note that the vertical axis on the historical
charts is adjusted to better display trends
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Commanders Statement Inpatient Coding Audit

• Methodology
• of correct DRG codes / Total of DRG codes

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Commanders Statement Inpatient Coding Audit
Note that the vertical axis on the historical
charts is adjusted to better display trends
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Commanders Statement Inpatient Coding Audit

• Methodology
• 5b of Correct EM codes / Total of EM
  codes documented and expected
• 5c of Correct ICD9 codes / Total of ICD9
  codes documented and expected
• 5d of Correct CPT codes / Total of CPT
  codes documented and expected
• Note The denominator is not the of IPS rounds
  audited.

NEW FOR FY10!
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Commanders Statement Inpatient Coding Audit
Note that the vertical axis on the historical
charts is adjusted to better display trends
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Commanders Statement Inpatient Coding Audit

• Methodology
• 5e of Available DD 2569s (completed and
  signed within the last 12 months) / of
  Non-Active Duty records audited
• 5f of Records from the numerator of 5e
  correct in PIIM / Numerator from 5e
• Notice that the basis for 5f is the number from
  5e that are completed and signed within the last
  12 months.

NEW FOR FY10!
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Commanders Statement Inpatient Coding Audit
Note that the vertical axis on the historical
charts is adjusted to better display trends
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Commanders Statement Outpatient Coding Audit

• Methodology
• Consists of 30 randomly selected records.
• If a record is documented as being checked out
  within the facility, it is counted as available.
  If a record is documented as being checked out to
  a patient, it is not counted as available.
• 6a of Available records / 30

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Commanders Statement Outpatient Coding Audit
Note that the vertical axis on the historical
charts is adjusted to better display trends
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Commanders Statement Outpatient Coding Audit

• Methodology
• 6b of Correct EM codes / Total of EM
  codes documented and expected
• 6c of Correct ICD9 codes / Total of ICD9
  codes documented and expected
• 6d of Correct CPT codes / Total of CPT
  codes documented and expected
• Note The denominator is not the of encounters
  audited.

NEW FOR FY10!
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Commanders Statement Outpatient Coding Audit
Note that the vertical axis on the historical
charts is adjusted to better display trends
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Commanders Statement Outpatient Coding Audit

• Methodology
• 6e of Available DD 2569s (completed and
  signed within the last 12 months) / of
  Non-Active Duty records audited
• 6f of Records from the numerator of 6e
  correct in PIIM / Numerator from 6e
• Notice that the basis for 6f is the number from
  6e that are completed and signed within the last
  12 months.

NEW FOR FY10!
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Commanders Statement Outpatient Coding Audit
Note that the vertical axis on the historical
charts is adjusted to better display trends
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Commanders Statement APV Coding Audit

• Methodology
• Sample size must be a minimum of 30 APVs (or
  100, if less than 30 APVs were completed).
• If a record is documented as being checked out
  within the facility, it is counted as available.
  If a record is documented as being checked out to
  a patient, it is not counted as available.
• 7a of Available records / 30 (or all APVs if
  less than 30)

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Commanders Statement APV Coding Audit
Note that the vertical axis on the historical
charts is adjusted to better display trends
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Commanders Statement APV Coding Audit

• Methodology
• Sample size must be a minimum of 30 APVs (or
  100, if less than 30 APVs were completed).
• 7b of Correct ICD9 codes / Total of ICD9
  codes documented and expected
• 7c of Correct CPT codes / Total of CPT
  codes documented and expected
• Note The denominator is not the of encounters
  audited.

NEW FOR FY10!
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Commanders Statement APV Coding Audit
Note that the vertical axis on the historical
charts is adjusted to better display trends
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Commanders Statement APV Coding Audit

• Methodology
• 7d of Available DD 2569s (completed and
  signed within the last 12 months) / of
  Non-Active Duty records audited
• 7e of Records from the numerator of 6e
  correct in PIIM / Numerator from 7d
• Notice that the basis for 7e is the number from
  7d that are completed and signed within the last
  12 months.

NEW FOR FY10!
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Commanders Statement APV Coding Audit
Note that the vertical axis on the historical
charts is adjusted to better display trends
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Commanders Statement Workload Comparison

• Methodology
• SADRs transmitted to NAVMISSA are used to
  calculate the numerator.
• WWR workload category Outpatient Visits is used
  for the denominator.
• The percentage should always be less than or
  equal to 100. If the percentage is greater than
  100, the number reported to TMA will be adjusted
  (i.e. 102 98)
• 8a - of SADRs (Count) / WWR Outpatient Visits

NEW FOR FY10!
Auto-Populated by the NAVMISSA eDQ
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Commanders Statement Workload Comparison
Note that the vertical axis on the historical
charts is adjusted to better display trends
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Commanders Statement Workload Comparison
NOLA transition impacted the file receipts at
NAVMISSA, inflating the COUNT and NON-COUNT
calculation difference (blue data points are
adjusted to reflect actual data received).
BUMED 2 Goal
NMSC and NAVMISSA Tiger Team On-Site
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Commanders Statement Workload Comparison

• Methodology
• SIDRs transmitted to NAVMISSA are used to
  calculate the numerator.
• WWR workload category Dispositions is used for
  the denominator.
• The percentage should always be less than or
  equal to 100. If the percentage is greater than
  100, the number reported to TMA will be adjusted
  (i.e. 102 98)
• 8b - of SIDR Dispositions / WWR Dispositions

Auto-Populated by the NAVMISSA eDQ
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Commanders Statement Workload Comparison
Note that the vertical axis on the historical
charts is adjusted to better display trends
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Commanders Statement Workload Comparison

• Methodology
• EAS Visits are pulled from the EAS repository by
  NAVMISSA.
• WWR workload category Outpatient Visits is used
  for the denominator.
• The percentage should always be less than or
  equal to 100. If the percentage is greater than
  100, the number reported to TMA will be adjusted
  (i.e. 102 98)
• 8c - of EAS Visits / WWR Outpatient Visits
• Note If an MTF answers No for 4a, MTFs should
  use WAM data.

NEW FOR FY10!
Auto-Populated by the NAVMISSA eDQ
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Commanders Statement Workload Comparison
Note that the vertical axis on the historical
charts is adjusted to better display trends
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Commanders Statement Workload Comparison

• Methodology
• EAS Dispositions are pulled from the EAS
  repository by NAVMISSA.
• WWR workload category Dispositions is used for
  the denominator.
• The percentage should always be less than or
  equal to 100. If the percentage is greater than
  100, the number reported to TMA will be adjusted
  (i.e. 102 98)
• 8d - of EAS Dispositions / WWR Dispositions
• Note If an MTF answers No for 4a, MTFs should
  use WAM data.

NEW FOR FY10!
Auto-Populated by the NAVMISSA eDQ
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Commanders Statement Workload Comparison
Note that the vertical axis on the historical
charts is adjusted to better display trends
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Commanders Statement Workload Comparison

• Methodology
• IPS Rounds are obtained from the MTF SADR
  Transmissions.
• WWR workload categories Dispositions and
  Occupied Bed Days are used for the denominator.
• 8e - of IPS Rounds / WWR OBDs Dispositions

Auto-Populated by the NAVMISSA eDQ
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Commanders Statement Workload Comparison
Note that the vertical axis on the historical
charts is adjusted to better display trends
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Commanders Statement Workload Comparison
NOLA transition impacted the file receipts at
NAVMISSA (blue data points are adjusted to
reflect actual data received).
BUMED 2 Goal
NMSC and NAVMISSA Tiger Team On-Site
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Commanders Statement AHLTA Utilization

• Methodology
• The Source System field in MTF SADR
  Transmissions is used to determine whether the
  encounter was created in AHLTA or another system.
  This is also the same field used in M2.
• This metric only needs to be above 80 to be
  green, since AHLTA is not designed for all
  clinics.
• 9a - of AHLTA Encounters / Total of Encounters

Auto-Populated by the NAVMISSA eDQ
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Commanders Statement AHLTA Utilization
Note that the vertical axis on the historical
charts is adjusted to better display trends
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Commanders Statement AHLTA Utilization
One Navy MTF utilized the incorrect methodology
to report their AHLTA utilization (i.e. AHLTA
Utilization cannot be greater than 100, etc.).
NMSC and NAVMISSA Tiger Team On-Site
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Commanders Statement Duplicate Patients

• Methodology
• A standard CHCS report is provided to Host sites
  and is used to provide the raw data for this
  metric.
• Only sites that are a CHCS Host report this
  metric (others report N/A).
• This metric is not graded (red/yellow/green) on
  the TMA report.
• 10a - of Potential Duplicate Encounters

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Commanders Statement Duplicate Patients
Note that the vertical axis on the historical
charts is adjusted to better display trends
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Commanders Statement Commanders Signature

• Methodology
• The Commander or Officer in Charge signs the
  Commanders Statement indicating that it has been
  reviewed and acknowledged.
• This cannot be signed By Direction. If the
  CO/OIC is away, the Acting may sign.
• This metric should always be Yes.

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Thank You!
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DQMC Process Flow and Deadlines
Reporting Timeframe Issues
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MTFs DQMCP execution, Review List, Commanders
Statement, CO briefs, and communication of issues
to regional representatives.
Navy DQMCP Roles and Responsibilities
BUMED Program management, oversight, policy and
strategies.
REGIONS Regional consolidation of Commanders
Statements, DQMCP coordination, issue resolution,
audits and training.
NMSC Systems execution, website maintenance /
development, and DQMCP support.