Annual Reports

10th SOW Annual Report of QIO Case Review Information
United States Virgin Islands
Virgin Islands Medical Institute, Inc.

I. Total # of Reviews – Provide the total number of reviews the QIO performed in CRIS by the associated review type.

Review Type	# of Reviews	Percent of Reviews (%)
Coding Validation (120 - HWDRG)	0	0.00%
Coding Validation (All Other Selection Reasons)	0	0.00%
Quality of Care Review (101 through 104 -Beneficiary Complaint)	3	7.69%
Quality of Care Review (All Other Selection Reasons)	8	20.51%
Utilization (158 - FI/MAC Referral for Readmission Review)	0	0.00%
Utilization (All Other Selection Reasons)	5	12.82%
Notice of Non-coverage (105 through 108 - Admission and Preadmission)	0	0.00%
Notice of Non-coverage (118 - BIPA)	15	38.46%
Notice of Non-coverage (117 - Grijalva)	0	0.00%
Notice of Non-coverage (121 through 124 -Weichardt)	4	10.26%
Notice of Non-coverage (111-Request for QIO Concurrence)	1	2.56%
EMTALA 5 Day	0	0.00%
EMTALA 60 Day	0	0.00%
Total	39

 

II. Top 10 Principal Medical Diagnoses – Provide the top 10 principal medical diagnoses for inpatient claims billed for Medicare beneficiaries.

Top 10 Medical Diagnoses	# of Beneficiaries	Percent of Beneficiaries (%)
1. 486 - PNEUMONIA, ORGANISM NOS	97	18.98%
2. 43491 - CRBL ART OCL NOS W INFRC	87	17.03%
3. 4280 - CHF NOS	83	16.24%
4. 5990 - URIN TRACT INFECTION NOS	49	9.59%
5. 25080 - DMII OTH NT ST UNCNTRLD	41	8.02%
6. 41401 - CRNRY ATHRSCL NATVE VSSL	37	7.24%
7. 71516 - LOC PRIM OSTEOART-L/LEG	34	6.65%
8. 27651 - DEHYDRATION	30	5.87%
9. 0389 - SEPTICEMIA NOS	27	5.28%
10. 2859 - ANEMIA NOS	26	5.09%
Total	429	100.00%

 

III. Provider Reviews Geographics – Provide the count and percent by Rural vs. Urban geographical locations for Health Service Providers (HSPs) associated with a completed QIO review.

Geographical Area	# of Providers	Percent of Providers (%)
Rural	6	100.00%
Urban	0	0.00%
Unknown	0	0.00%
Total	6	100.00%

 

IV. Provider Reviews Settings – Provide the count and percent by Setting for Health Service Providers (HSPs) associated with a completed QIO review.

Setting	# of Providers	Percent of Providers (%)
0 - Acute Care Unit of an Inpatient Facility	2	33.33%
1 - Distinct Psychiatric Facility	0	0.00%
2 - Distinct Rehabilitation Facility	0	0.00%
3 - Distinct Skilled Nursing Facility	0	0.00%
5 - Clinic	0	0.00%
6 - Distinct Dialysis Center Facility	0	0.00%
7 - Dialysis Center Unit of Inpatient Facility	0	0.00%
8 - Independent Based RHC	0	0.00%
9 - Provider Based RHC	0	0.00%
C - Free Standing Ambulatory Surgery Center	0	0.00%
G - End Stage Renal Disease Unit	0	0.00%
H - Home Health Agency	1	16.67%
N - Critical Access Hospital	0	0.00%
O - Setting does not fit into any other existing setting code	0	0.00%
Q - Long Term Care Facility	0	0.00%
R - Hospice	3	50.00%
S - Psychiatric Unit of an Inpatient Facility	0	0.00%
T - Rehabilitation Unit of an Inpatient Facility	0	0.00%
U - Swing Bed Hospital Designation for Short-Term, Long-Term Care, and Rehabilitation Hospitals	0	0.00%
Y - Federally Qualified Health Centers	0	0.00%
Z - Swing Bed Designation for Critical Access Hospitals	0	0.00%
Other	0	0.00%
Total	6	100.00%

 

A. Quality of Care Concerns Confirmed – Provide the number of concerns by Quality of Care PRAF Category Code and the number that were confirmed at highest level of review, for completed quality of care reviews.

 

B. Serious Reportable Events on Quality of Care Reviews - Provide the number of Quality Improvement Activities (QIAs) initiated (initial activity date within the reporting period) for all quality of care reviews with confirmed concerns. Indicate the number and percent of those QIAs that are associated with quality of care concerns you deemed to fall into the category of “Serious Reportable Events”.

 

C. Confirmed Quality of Care Concerns with Associated Interventions – Provide the number of Initial Quality Improvement Activities initiated, by Activity Type, for reviews with one or more confirmed Quality of Care concerns. Provide the percent of total activities that each comprises.

Initial Quality Improvement Activity	# of Interventions (QIAs) with this Initial Quality Improvement Activity	Percent of Interventions (QIAs) with this Initial Quality Improvement Activity
1 - Send educational/alternative approach letter	0	0.00%
2 - Perform intensified review	0	0.00%
3 - Require continuing education	1	16.67%
4 - Request/review policy/procedure	0	0.00%
5 - Request development of QIP	1	16.67%
6 - Accept provider-initiated QIP	0	0.00%
7 - Conduct informal meeting or teleconference	0	0.00%
8 - Refer to licensing board	0	0.00%
9 - Initiate sanction activity	4	66.67%
10 - Other	0	0.00%
Total	6	100.00%

 

D. Discharge/Service Termination – Provide discharge location of beneficiaries linked to discharge/service termination reviews for Selection Reasons 111 (Request for QIO Concurrence) and 121 – 124 (Weichardt Selection Reasons). Note: Data represents discharge/service termination reviews from 8/1/2011 – 4/30/2012, 8/1/2012 – 4/30/2013 and 8/1/2013 – 2/28/2014 for the first, second and third annual reports respectively. A shortened data timeframe is necessary to allow for maturity of claims data which is the source of “Discharge Status” for these cases.

Discharge Status	# of Beneficiaries	Percent of Beneficiaries (%)
01 - Discharged to home or self care (routine discharge)	1	50.00%
02 - Discharged/transferred to another short-term general hospital for inpatient care	0	0.00%
03 - Discharged/transferred to skilled nursing facility (SNF)	0	0.00%
04 - Discharged/transferred to intermediate care facility (ICF)	0	0.00%
05 - Discharged/transferred to another type of institution (including distinct parts)	0	0.00%
06 - Discharged/transferred to home under care of organized home health service organization	1	50.00%
07 - Left against medical advice or discontinued care	0	0.00%
09 – Admitted as an inpatient to this hospital	0	0.00%
20 – Expired (or did not recover – Christian Science patient)	0	0.00%
21 – Discharged/transferred to court/law enforcement	0	0.00%
30 – Still a patient	0	0.00%
40 - Expired at home (Hospice claims only)	0	0.00%
41 - Expired in a medical facility (e.g. hospital, SNF, ICF or free standing Hospice)	0	0.00%
42 - Expired – place unknown (Hospice claims only)	0	0.00%
43 - Discharged/transferred to a Federal hospital	0	0.00%
50 - Hospice - home	0	0.00%
51 - Hospice - medical facility	0	0.00%
61 - Discharged/transferred within this institution to a hospital-based Medicare approved swing bed	0	0.00%
62 - Discharged/transferred to an inpatient rehabilitation facility including distinct part units of a hospital	0	0.00%
63 - Discharged/transferred to a long term care hospital	0	0.00%
64 - Discharged/transferred to a nursing facility certified under Medicaid but not under Medicare	0	0.00%
65 - Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital	0	0.00%
66 - Discharged/transferred to a Critical Access Hospital	0	0.00%
70 - Discharged/transferred to another type of health care institution not defined elsewhere in code list	0	0.00%
Other	0	0.00%
Total	2	100.00%

 

E. Beneficiary Demographics – Provide the number of beneficiaries for whom a case review activity was started, by demographic category, and the percent of beneficiaries each category represents.

Demographics	# of Beneficiaries	Percent of Beneficiaries (%)
Sex/Gender
Female	15	51.72%
Male	14	48.28%
Unknown	0	0.00%
Total	29	100.00%
Race
Asian	0	0.00%
Black	24	82.76%
Hispanic	0	0.00%
North American Native	0	0.00%
Other	2	6.90%
Unknown	0	0.00%
White	3	10.34%
Total	15	100.00%

 

F. Quality of Care Reviews and Concerns by Intervention Type - Using a QIA started within the reporting period for the current year’s report, please provide a short description as to the type of intervention(s)/QIA(s) employed, per C.6 Technical Assistance requirements in the Contract, for three diverse or different quality categories (C1-99). Intervention/QIA types may include, but are not limited to: Educational or Alternative Approach to Care letter; Continuing Education; Assistance in Developing Policy & Procedure; Modification to Existing Policy & Procedure; Formal Quality Improvement Plan and/or Corrective Action Plan. Note: If the QIO does not have three diverse or different quality categories, please indicate such on the report.

Description 1 – Type of Intervention for Quality Category C <1-99>
Quality Category: C02 – Apparently did not make appropriate diagnosis and or assessments

During the review process, some discrepancies were found in the nurses’ visit notes and assessment scales and physician evaluation and treatment notes. These inconsistencies resulted in documentation/a medical record that did not support the discharge. A QII was requested of the provider. A root cause analysis identified the following issues:

As part of the QII, all IDT members were required to complete continuing education on anthropomorphic measurements and function scales to promote consistent and reliable assessments among care professionals.

 

Description 2 – Type of Intervention for Quality Category C <1-99>
Quality Category: C11- Apparently did not demonstrate that the patient was ready for discharge

Discrepancies were identified in physician documentation regarding patient suitability for discharge and in nursing documentation. There was no evidence in the medical record that these differing opinions and assessments regarding discharge readiness was ever resolved or even discussed in IDT meetings; the discussions at IDT meetings were inefficient and did not focus on key aspects of patient discharge suitability.

The QII included policy and procedure change that specified that all reported/documented measurable decline of a patient over 30-45 days will be reviewed at IDT to determine accuracy and validity of applied scales. This will allow for consensus about patient physical/clinical status that will result in a unified discharge or continued treatment plan.

 

Description 3 – Type of Intervention for Quality Category C <1-99>
Quality Category: C15 - Apparently did not effectively coordinate across disciplines

Inconsistent attendance of the medical director or physician to IDT meetings was identified. The discussions were not chaired by a physician and the communication between the physician and the other IDT members was poor. The provider failed to plan an appropriate discharge due toinefficient communication between the medical director, physician and other IDT members even when opposing discharge readiness assessment existed.

As part of the QII policy and procedure changes that include mandatory review of the physician’s face to face encounter with the patient in the IDT meetings as well as participation of the physician in these meetings. The face to face encounter discussion will occur at IDT meetings prior to finalization of the discharge plan.

Using one example from the previously identified intervention(s)/QIA(s), describe how the intervention/QIA was determined, along with any identified “Best Practices” for the resolution of the identified quality concern.

 

Example from Description <1, 2 or 3>: How Interventions Determined/Best Practices
Description #1

The decision to pursue a QII was based on identification of similar inconsistency in documentation in previous cases with the provider. The QII interventions were guided by a root cause analysis. This analysis demonstrated lack of physician participation and lack of comprehensive discussion and review of the record in IDT meetings as factors contributing to provider failure in detecting and correcting documentation mismatches. One of the best practices included in the QII was development and incorporation of a checklist process to ensure that IDT meetings included review of all relevant areas prior to making discharge determinations.

G. Evidence Used in Decision-Making - Drawing upon your QIO’s case review practices, please describe the one or two most common types of evidence/standards of care criteria used to support Review Analysts’ assessments and Peer Reviewers’ decisions for Medical Necessity/Utilization Review and Appeals. Provide a brief statement of rationale for how the specific evidence/standards of care were chosen. The types of evidence/standards of care may include, but are not limited to, Local Coverage Determinations (LCD), Medicare Conditions Coverage, Medicare Conditions of Participation and National Coverage Determinations (NCD).

For QoC, describe the one or two most common types of evidence/standards of care criteria used to support Review Analysts’ assessments and Peer Reviewers’ decisions for the specific list of diagnostic categories provided in the table.
Note: The list is from other 10^th SoW initiatives in which QIOs are involved. If there are any categories for which you did not conduct a QoC review during the reporting period, denote that in the table.

Review Type	Diagnostic Categories	Evidence/ Standards of Care Used	Rationale for Evidence/Standard of Care Selected
Quality of Care	Pneumonia	No QoC during this period	No QoC during this period
	Heart Failure	No QoC during this period	No QoC during this period
	Acute Myocardial Infarction	No QoC during this period	No QoC during this period
	Pressure Ulcers	NPUAP Guidelines	Relevance to case under review. Expert status in the field.
	Urinary Tract Infection	No QoC during this period	No QoC during this period
	Sepsis	No QoC during this period	No QoC during this period
	Adverse Drug Events	-Therapeutic Monitoring of Vancomycin in Adult Patients: A Consensus Review of the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the Society of Infectious Disease Pharmacists, 2009.   Up-to-date, “Vancomycin Dosing and Serum Concentration Monitoring in Adults”, 201   - Kin Solez (Edmonton), Roy Axelsen (Brisbane), Hallgrimur Benediktsson (Calgary), James F. Burdick(Baltimore)..: International standardization of criteria for the histologic diagnosis of renal allograft rejection: The Banif working classification of kidney transplant pathology. Kidney International, Col. 44 (1993)	Vancomycin was dosed and monitored inappropriately with no trough level drawn for extended period. Therefore, reviewers’ decisions must have been guided by expert recommendations regarding standards for drug dosing and monitoring.           A patient with known renal transplant presented to the ED with fever and was inappropriately dosed with NSAIDs and subsequently developed signs of transplant failure. Therefore, selected standards must have included some discussion of the pathophysiology related to NSAIDs in patients with renal transplant.
	Falls	Standards: State Operations Manual: Survey Protocol, Regulations and Interpretive Guidelines for Hospitals; 42 Code of Federal Regulations 482.23; 42 Code of Federal Regulations 482.13(e)10; 42 Code of Federal Regulations 482.13(c)2; Preventing Falls in Acute Care: “Evidence Based Geriatric Nursing Protocols “, 2008..	The patient did not receive the appropriate level of care during a psychiatric hospitalization which led to multiple falls that were inappropriately documented, reported and should have been preventable. Selected standards were used to demonstrate best practices in falls prevention and hospital requirements for ensuring a safe environment
	Patient Trauma	No QoC during this period	No QoC during this period
	Surgical complications	No QoC during this period	No QoC during this period
Medical Necessity/Utilization Review		McKesson (Interqual)	One of two recognized MN or UR software programs available to the QIO at the time of review. The second program has recently become available and the QIO will utilize as needed going forward.
Appeals		Local Coverage Determination (LCD's) Guielines   Medicare Conditions of Participation   Medicare Claims Processing Manual   Medicare Benefit Policy Manual   Chapter   Palliative Perfomance Scale   Functinoal Assessment Scale   Karnofsky Score Performance Status	Guidelines used for Hospice admission and contuinued stay. Commonly utilized standards/regulations.

 

Please provide three brief examples/case studies where case review was linked to another Aim of the QIO contract, for example, readmissions, pressure ulcers, adverse drug events, etc. Identify the evidence based criteria used to support review decisions on those cases and what influenced the selection of that criteria. Documentation should be two paragraphs or less per example/case study.

 

Example/Case Study 1

Linkage to C. 7.3 Reducing Adverse Drug Events (ADE’s)

In this case, a nephrotoxic antibiotic was dosed inappropriately in a patient with chronic renal insufficiency. After an initial supra-therapeutic drug level, follow up monitoring did not occur until 13 days later when a consultant evaluated the patient for significant worsening of renal status. The physician failed to follow generally accepted standards of care; therefore, the review decision relied heavily on published standards of care regarding use of this drug as well material that included discussion of proven nephrotoxic potential of this drug at supra-therapeutic levels. Additionally, the provider failed to follow best practice as determined by national and local standards of care by implementing pharmaceutical monitoring systems designed to reduce these types of error;

 

Example/Case Study 2

Linkage to C. 7.3 Reducing Adverse Drug Events (ADE’s)

In this case, a medication with nephrotoxic potential was administered to a patient with known history of renal transplantation. Therefore, selected standards of care needed to document the evidence for this nephrotoxicity and recommendation for alternate drug.

 

Example/Case Study 3

Linkage to C. 7.3 Reducing Adverse Drug Events (ADE’s)and C7.2 Healthcare Associated Conditions – Falls

In this case a patient was admitted for psychosis and was treated with multiple anti-psychotic and sedative medications with drug changes occurring almost daily without giving the drug an appropriate trial period to reach therapeutic doses. Additionally, despite use of multiple sedatives and subsequent documentation of unsteadiness, no actions to prevent falls were taken. The selected standards included current scientific understanding of pharmacodynamics and implications for appropriate drug dosing to achieve therapeutic levels. Best practices for falls risk assessment and prevention also guided reviewers’ decisions.

 

H. Effectiveness of QIAs - Please provide an analysis of how the findings in tables B, C and F can be used to support the effectiveness of QIAs conducted as part of the BFCC Aim. The QIO should provide a narrative analysis on the information provided and recommendations for how the information could be used to make a positive impact on the work done in other 10SOW Aims.

Narrative Analysis:

The QII and corrective action plans (CAP) initiated for confirmed concerns included an educational component certified by the AMA or other relevant professional body. In these instances effectiveness of the improvement plan was measured by involved clinicians receiving a satisfactory score on associated testing components.

QIIs and CAPs that require the provider to implement policies and procedures that promote proper assessment of discharge planning and discharge readiness impact the C8 AIM by reducing avoidable admissions and readmissions. The effectiveness of these QIIs and CAPs also is measured by increasing rates of QIO concurrence with the provider when discharge appeals occur as well as by decreasing rates of inconsistent documentation in abstracted records and records reviewed during appeals.

Similarly, QIIs developed to decrease inappropriate use of nephrotoxic drugs directly relate to and impact C7.3 Reducing ADEs. By requiring the provider to implement a system of checks and balances by having enhanced pharmacy oversight of high risk drugs, patients are protected from drug errors. Effectiveness can be measured on a systems level by measuring facility rate of ADEs pre and post intervention since the expectation is that this type of change/approach impacts safe use of multiple classes of drugs – not just the one involved in the case. Additionally, effectiveness is also assessed by trending rates of provider adherence to the new policy and procedure when the involved drug is used.