Auditors are Human Too

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Auditors are Human Too

• A Personal Insight Into the Value of a Good,
  Green Pen
• Kim Eland, Senior Clinical Auditor
• ACC, Risk Assurance

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General Housekeeping

• Garlic, religious icons and wooden steaks do not
  affect us.
• If required, auditors can be successfully
  subdued by waving green pens and post-it notes at
  them.

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History of Practice Audits

• Developed in collaboration with NZMA
• Pilot 2005 11 selected practices
• Team Senior Internal Auditor (CA) Senior
  Clinical Auditor
• 84 Practice Audit visits to date
• 44 Regulations (11 Cornerstone Accredited), 9
  Accident Medical, 13 Rural, 18 Follow-up
• Second team began 2006 looking at other
  provider types (physiotherapists / osteopaths /
  vocational rehabilitation)

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Our Obligation

• To engage providers so that injured people in NZ
  can receive the most appropriate treatment /
  rehabilitation services available to restore
  their health to the maximum extent practicable.
• To obtain assurance that all services purchased
  or subsidised for our clients are necessary,
  appropriate, provided only on the number of
  occasions required, at an appropriate time and
  place and are delivered by appropriately
  qualified treatment providers (Schedule 1, Part
  1, S.2(1), IPRC Act 2001).

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What Does an Audit Assess?

• Compliance with a Contract / Regulations
• Validation of service provision
• That payments are valid and correct
• Adequacy of the Control Environment
• Adequacy of clinical notes
• That clinical management of ACC clients is
  necessary and appropriate

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Softer Objectives of Audit

• To encourage the adoption of best practice in
  relation to record keeping and clinical practices
• To improve the relationship between providers and
  ACC
• To encourage a partnership approach towards
  rehabilitating the patient / client

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It is NOT our aim to

• Recoup cash
• Investigate fraud
• Cause disruption to the practice
• Name, blame or shame individuals
• Report doctors to their professional bodies
• Cause anxiety ( yes, I know we do)

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A quick reminder

HUMAN
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Process

• Random sample of claims issued to randomly
  selected practice (usually 35 files)
• Team onsite for two days review / interview
• External (objective) GP peer review comment
  obtained on documentation / clinical management
• Internal and external reports issued
• Opportunity for practice and ACC to comment on
  any findings

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What is Measured?

• Documentation standards
• Diagnosis, date of injury, assessment,
  management, follow-up, progress outcomes,
  legibility, key identifiers
• Billings
• Notes exist match billings, relate to covered
  injury, consultation levels procedure codes,
  combined multiple billings
• Clinical management
• Appropriate, necessary of quality required
• Appropriate completion of ACC45 forms
• Accident, injury, work details, authorisation

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Documentation

• Clinical notes should reflect key components of a
  consultation
• Subjective findings (S)
• Objective findings (O)
• Provisional diagnosis (Dx)
• Immediate management / follow-up plan (P)
• They should be comprehensive enough to stand up
  to medical, legal audit scrutiny and keep
  colleagues well informed when sharing the care of
  patients.

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Not just an ACC expectation!

• Records must be legible and should contain all
  information that is relevant to the patients
  carepatient records are essential to guide
  future management, and invaluable in the uncommon
  occasions when the outcome is unsatisfactory
  (MCNZ, The Maintenance and Retention of Patient
  Records)
• It is a tool for management, for communicating
  with other doctors and health professionals, and
  has become the primary tool for continuity of
  care in many practices (Coles Medical Practice
  in New Zealand 2007)

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Common Findings
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Assessment

• Head Injuries - / - findings, distance fallen
• Multiple injuries (i.e. Motor Vehicle Accidents)
  speed travelled, direction of impact
• Wounds type, general underlying condition
• Back injuries previous injury or condition,
  distance fallen, Cauda Equina symptoms?
• Needs to include history, mechanism, pre-existing
  factors, etc.

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Diagnosis

• Vague / non-specific hurt back / sore knee
  / cut hand, etc.
• Not clearly defined / distinguished from other
  existing conditions / injuries
• Lack of DOI can further cloud matters
• If diagnosis is not clear ? investigations
  ordered?
• A clear provisional diagnosis will justify the
  type and duration of subsequent management. A
  vague diagnosis may not.

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Management / Follow-Up

• Head Injury (HI)
• Fractures
• Wounds
• Sutures
• Antibiotics
• Notes could suggest under / over-servicing,
  where management may have been entirely
  appropriate. Clinical rationale for any chosen
  management pathway should be evident in the
  records

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Case Studies

• KOd in rugby tackle. Friend states was
  unconscious a few minutes and been v sleepy
  since. Seems out of it. Vomited x 2 on way
  here. Pt has no recollection of events before or
  after and feels out of it. Seems confused.
  Reassured and advised TCB prn. HI sheet given.
• Infant (22/12) fell out of car. Large haematoma
  R forehead. Abrasions R cheek. Not concussed.
  Watch state of consciousness.

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Case Studies

• 78yr old Fell backwards off ladder on concrete.
  Feels tight in chest. Difficulty breathing or
  moving. O2 sat 92. O/E tracheal shift to L. R
  air entry breath sounds. Transfer AE in
  own car. (x-ray showed sizeable pneumothorax
  with mediastinal displacement)
• Burn L forearm secondary hot steam from car.
  7cms full thickness burn. Tender around it.
  Mildly infected.

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Case Studies

• 4 days post injury Cut fingers while cooking.
  Wound almost healed. Today he gave coin to
  homeless guy worried he may get infected. Wound
  clean and almost healed. Reassured. Px Aug 500mg
  with Potassium Claviculanate 125mg 1 tab, tds,
  7/7.
• Bee sting itchy, not tender. Mother wants Abs.
  Px Aug 180mg 7/7.
• Inflamed, old wound. Some cellulitis. Looks
  infected.

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Outcomes / Progress

• X-ray, other results not mentioned and not
  scanned - Phoned pt with results
• Wound healing changing dressing type why?
• Effectiveness of treatment physiotherapy,
  steroid injections, acupuncture, analgesia, etc.
• 50 physiotherapy sessions for minor sprain
• Re-assessments to compare current status with
  previous baseline observations pain levels,
  range of movement, etc.

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Date of Injury

• Helps other providers and ACC identify correct
  claim to bill against (especially where multiple
  claims for same site)
• Helps establish causation between accident
  injury
• Helps establish appropriateness of treatment,
  investigations, referrals which will vary
  depending on whether injury is acute or chronic
• Can add DOI to automated ACC heading

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ACC Versus Health

• A visit or consultation must be an assessment
  in person (face to face) and a necessary and
  appropriate service performed or treatment
  provided by a provider for an injury or condition
  covered by ACC (Pg 17 2007 ACC Treatment
  Provider Handbook)
• If a patient seeks treatment for an old injury,
  the treatment provider is responsible for
  establishing a clear and significant causative
  link between the original covered injury and the
  presenting conditionThe presence of a similar
  clinical presentation does not necessarily
  constitute a causative link (Pg 73 2007 ACC
  Treatment Provider Handbook)
• ACCXXXXX. Ankle sprain. 01/04/05. Wants to
  discuss oral contraception

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Where Green Pen Becomes Red!

• No notes rare, usually offsite visits
• Nurse writing for GP
• Billing telephone calls / receipt of clinical
  notes, etc. as a consultation
• Patient or provider not identified in notes /
  multiple GPs or nurses using same provider number
• Notes do not relate to a covered injury
• Headings as notes
• ACC45 Injury Heading / ACC18 / Prescription

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ACC45 Expectations

• Page 38 of the ACC Treatment Provider handbook
  states
• Your clinical records can be required, along
  with the information you provide on documents
  such as the ACC45 Injury Claim form, to provide
  ACC with the necessary clinical evidence to
  determine whether an injury meets the legislative
  requirements
• The ACC45 does not, in itself, constitute a full
  consultation record and is rarely passed between
  providers

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ACC18 Expectations

• Certification must be firmly grounded in your
  clinical assessment, following examination, and
  should be in line with the relevant Treatment
  Profile
• Verification of face to face examination, which
  does not include telephone or third party reports
• Verification that the client is entitled to
  ongoing time off work / alert ACC of need for
  extra input
• ARC18 - shovelling coal

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Prescriptions

• Rx Diclax Sr 75mg Tab - 1 sos bd after food
• Consider the difference
• repeat meds Metoprolol 47.5 daily 3/12 or
• Repeat meds, well, 130/80, pulse reg 64/min,
  Metoprolol 47.5mg daily 3/12, buying Cartia
• (Coles Medical Practice in new Zealand)

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Another reminder

• BARELY HUMAN
• HUMAN (honest)

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Common Findings

• Memo-style notes
• More common in smaller practices, where locums
  are not used or where there is a familiar patient
  base
• I know what I did at the time
• Im the only one who needs to read them
• Well it may not be written , but I would
  normally
• However

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What if?

• You were hit by a bus (or dodgem car) tomorrow?
• Previous unsuccessful management could be
  repeated
• Rehabilitation could be delayed
• Sometimes GPs cant decipher their own notes at a
  later date

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Published in NZGP, 1998

• When I encounter sketchy consultation notes,
  not only does it become difficult to confirm the
  facts of a case but it tends to throw suspicion
  on any supplemental information provided. In the
  end, whatever is remembered at a later date, the
  written record is the most significant witness of
  your actions. It is important for your sake, as
  well as your patients, that this is clear and
  complete
• (For the Record, Health Disability
  Commissioner)

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Common Findings cont

• There is no direct relationship between the
  standard of documentation and how busy the
  practice may be
• Locum notes are often excellent they know
  theyre writing for the benefit of another reader
  
• Some of the busiest AMs have presented the best
  notes
• Is time / caseload really an excuse for poor
  documentation?

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Common Findings cont

• Consistency of documentation becomes harder in
  larger practices staff retention issues
• Local GPs working to a roster lack of ownership
  / simply fulfilling an obligation
• Handwritten notes are dying out, but electronic
  notes are not without problems
• Keyboard dyslexia
• More likely to use automatic entries that are no
  longer relevant 3 year old shoulder sprain?
• System will not pick up incomplete notes only
  missing ones

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Common Findings (ACC45)

• Incomplete accident / injury details
• Assists ACC in identifying nature of injury /
  causation to accident / whether case management
  is required / and to tailor injury prevention
  strategies to those activities identified as
  causing accidents
• Inaccurate employment / ability to work details
• Can delay cover, if unable to contact employer to
  clarify details / can delay initial payments to
  client / can result in claim being streamed into
  incorrect fund code
• No signed patient declaration / authorisation
• The client, parent/guardian or authorised
  representative filling out the form must sign the
  ACC45 (Pg 57, 2007 ACC Treatment Provider
  Handbook)

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Common Provider Issues

• ACC do not always accept GPs clinical judgement
• Management of clinically suspected fractures
• Foreign bodies not accepted unless injury
  deliberately caused on removal!
• Actual injury may be more complex than injury
  code may imply ? management may differ from ACC
  expectations / inadequate coding system
• When acute becomes chronic what is covered?
• Lower limb wounds in elderly / multiple back
  injuries and osteoarthritis / chronic pain
  syndrome or depression following back / head
  injury, etc.

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Ultimately

• If it is written it can be justified!!!

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Key Messages

• Use our findings as a diagnostic tool for your
  own peer review and continue regular self /
  collegiate peer review where possible
• Adapt consultation screens to include prompts /
  headings
• Take time to speak to the auditors onsite, to
  raise issues for clarification and to give
  feedback on findings and processes
• Tell us how we can make our reports more useful
  to you

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But Most of All

• This is NOT fraud
• This is NOT punitive
• This is NOT about claiming back money
• This IS about
• Working in partnership
• Improving our businesses taking pride in what
  we do
• THE PATIENT

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P.S. We age like humans too.

• But we figure the stress is worth it!