Transcript Victorian Statewide Audit Program: Methodology, Results

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Victorian Statewide Audit Program:
Methodology, Results and Significance for
Activity Based Funding
Jennie Shepheard
Victorian Department of Health
Presentation outline
• Background to the Victorian audit program
• Development of the program
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Key principles
Methodology
• Results
• Lessons learnt and reinforced
• Implications for HIM profession in an activity based
environment
• Other data audits
Background to coding audits in Victoria
Casemix Funding Model for acute inpatient care
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Introduced in 1993
Replaced ‘historic budgets’ funding model
Casemix funding = a method of allocating funds
Provides equity, transparency and accountability
• Financial risk is shared between the purchaser and
the provider (the Department and the hospital)
– Funds are allocated on the basis of:
• An agreed service at an agreed price
Background cont…
Auditor General:
• Requires that the casemix system is audited
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Accountability
Transparency
Objectives of the audit program
• Assess the validity of casemix based payments to Victorian
public hospitals
• Assess the application of the Department’s admission policy
• Support improvements in the accuracy of admitted patient
data reporting.
Development of the program: name change
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Originally known as coding audits
Later changed to ‘patient admitted episode audits’
Patient Admitted Episode Audits
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DRGs use items other than clinical codes
– Admission weight
– LOS etc
Reflects complexity of the casemix system that uses;
– DRGs
– Copayments
– Outlier payments
Methodology
• Pre-audit survey
• Random Selection
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Hospital and cases for audit
• Blind recoding
• Discussion between auditor and hospital
representative/clinical coder
• Dispute resolution
• Management debrief
• Re-audit plan
Methodology cont …
• Ensure auditor capability
• Electronic data collection method
• Reports for each hospital
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Details of all changes to data items (incl DRG and WIES)
Details of all codes assigned by both hospital and auditor
Recommendations
• Statewide report
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Quantitative results
– Confidence intervals
Qualitative results
Recommendations
Principles of audits
• Ethical conduct (professionalism)
• Fair presentation (report truthfully and accurately)
• Due professional care (diligent; good judgement)
• Independence (impartiality)
• Evidence based approach (rational method;
reproducible)
International Standard ISO 19011:2002 Guidelines for quality and/or
environmental management systems auditing
Audit results
1993/94 – 1998/99
• DRG changes ranged from 13.50% to 11.70%
• WIES changes ranged from 1.80% 0.80%
1999/2000 – 2008/09
• DRG changes ranged from 10.20% to 8.43%
• WIES changes ranged from 0.94% to -1.23%
Secondary outcomes
• Information about code assignment
– Development of coding standards
– Development of DRGs
– Education requirements
• Infrastructure issues
– Workforce
– IT systems
– Management of coding services
Lessons learnt: Auditors
Auditor skill paramount
• It is not enough to be a good coder
• Must also be a good auditor
All the auditing principles apply to auditors.
• Ethical conduct
• Fair presentation
• Due professional care
• Independence
• Evidence based approach
Lessons learnt: Clinical Coders
• Clinical Coders need a voice
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Must not feel intimidated
Must have confidence in their work
Must be able to articulate their understanding of
standards etc
Must be willing to ask questions
Must be willing to learn
Must be willing to change
Lessons learnt: Department of Health
• Audits are very expensive
• Hospitals not all the same
• Support for auditors and for clinical coders
• Department management of the audit process
Lessons learnt: Hospitals
• Audits are part of business as usual
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Need to accommodate them in staffing
arrangements
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Need internal audit programs to manage the risk
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Need to engage strategically with recommendations
National Reforms
• Activity Based Funding
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Will require audit program
This will be problematic
– Workforce issues will impact
– Need to look at smart ways to audit
– Consider desktop analysis and
targeted audits
– Consider expanding the use of PICQ
and similar products
– Consider compulsory internal auditing
and reporting
Expansion of auditing program
• Elective Surgery
• Emergency Department
• Spot audits
Conclusion
• Audits are:
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An integral part of the management of high quality coded
data
Demand a highly skilled workforce
Are highly resource intensive
Essential to an activity based funding model
Serve to create high quality data