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Health Care Compliance Association6500 Barrie Road, Suite 250, Minneapolis, MN 55435888-580-8373 | www.hcca-info.org
Identifying and Analyzing Compliance Issues
John Falcetano, CHC-F, CCEP, CHRC, CIA
University Health Systems of Eastern Carolina
(252) 347-3919 [email protected]
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Compliance Issue Analysis
• Put the right team on the field
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Compliance Issue Analysis
• The Message
• The Leaders
• The Plan
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Compliance Issue Analysis
• Determine the Span or Range of the Analysis
• Understand the Issue (s)
– Event (s)
– Documentation
– Question
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Compliance Issue Analysis
• Assess the documentation
– Medical Records
– Policies and Procedures
– Existing Data
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Compliance Issue Analysis
• Contributing Factors
Brainstorm
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Compliance Issue Analysis
• Identify
– Reason (s)
– Source (s)
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Compliance Issue Analysis
� Process Variation
� Common
� Special
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Compliance Issue Analysis
• It’s not what you say but how you say it that helps get to the bottom of things.
– Listen
– Don’t jump to conclusions
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Compliance Issue Analysis
• The Big Picture
– Other Department Involvement
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Compliance Issue Analysis
• Organizational Culture
– Risk assessment
– Structure
• Leadership
• Accountability
• Communication
The
Boss
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Compliance Issue Analysis
�Review and Analyze the Problem List
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Compliance Issue Analysis
• Determine Weak Links in the Process
– Flaw in the system
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Compliance Issue Analysis
• Information
– Availability
– Collection
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Compliance Issue Analysis
• Review progress
• System focus
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Tools
1. Flowchart
2. Cause and Effect (Fishbone) Diagram
3. Check Sheet
4. Pareto Chart
5. Literature Search
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Flowchart
� A picture that shows all the steps in a process.
� A flow chart is a way to show a complex task or process by easy to understand symbols.
When to Use
�To identify problems
�Compares actual and ideal steps in order to identify variation
�Promotes understanding of the process
�Can differentiate between value-added steps and cost-added steps
� Identifies where measurement can be taken
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Flowchart Construction
� Draw actual steps of
the Compliance
Process
� Draw ideal steps
� Compare the two and
note variation
� Use consistent
symbols
START
PROCESS STEP
DECISION
DOCUMENT
END
FLOW CHART SYMBOLS
OVAL - Beginning of the process
Rectangle - Step in the process
Diamond - Decision step in the process
Connector for steps if more than one page
Document indicated forms or documentation required in the process
Oval - End of the process
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Evaluate the Sub-Process
Entry Points
Computer
Knowledge
Staff
Education
Sub-
processes
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Cause and Effect Diagram (Fishbone)
� A diagram that represents effects of all the possible causes of a problem
When to Use
� To identify the possible causes so you can cure the cause not the symptom
� Organizes possible causes of variation
� Identifies categories and subcategories of "causes"
� Provides guidance for data collection
� Identifies relation to positive and negative effects
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Cause and Effect Diagram Construction
� Generate a list of possible causes and effects by
brainstorming.
� Construct a diagram with causes on the left and effects
on the right.
� For each cause ask, "Why?"
� Interpret by identifying repeated causes and then
determine relative frequency.
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Cause and Effect Diagram Structure
� Many different structures:
� 4 Ms of Cause and Effect Diagram
�Manpower
�Methods
�Material
�Machines
� 4 Ps of Cause and Effect Diagram
�People
�Procedures
�Policies
�Plant
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Cause and Effect Diagram
ManpowerMethods
Materials Machinery
Wrong Payer
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Check Sheet
� Tool used to determine how often things occur. “Fact
Finder”
When to Use
� To gather data based on sample observations so that
patterns can be detected. Use the tool when you want to
count symptoms of a problem.
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Check Sheet Construction
� How to Construct
� Determine symptoms to observe
� Decide on period for observation
� Design a user friendly form
� Collect data honestly and consistently
� Wrong Payer
�II�Computer mapping error to wrong payer.
�IIIIII�Patient provided wrong payer information.
�IIIIIIIIIIIIIIIIIIIIIIIII�Staff did not ask for payer information.
FREQUENCYREASON
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Pareto Chart
� Vertical bar graph that is used to identify which and in
what order to solve problems
When to Use
� Use to show relative importance
� Work on the tallest bar first
� Use the 80 - 20 rule (80% of cost comes from 20% of
efforts)
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Construct Pareto Chart
� Select problem by brainstorming.
� Decide to use a check sheet or existing data.
� Select standard of measurement.
� Select time period.
� Gather data and begin to compare.
� List categories from the left to the right in order of
decreasing frequency.
� Above each category draw a bar or rectangle to identify
the amount of cost or frequency.
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25
6
2
0
5
10
15
20
25
30
Wrong Payer Cause
Staff
Patient
Computer Mapping
Pareto Chart
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Compliance Issue Analysis
� Reduction of risk
�Reduce or mitigate risk - Implement internal controls to reduce the probability of an issue from
occurring.
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Compliance Issue Analysis
• Organizational Impact
• Action Plan Implementation
• Monitoring Process
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Listen to the Data
• Bar, Run, Control Chart (s)
Errors
Claims
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Statistical Process Control
• Run charts
– Dynamic display of performance
• Performance plotted on the “Y” axis
• Time plotted on the “X” axis
• Use the median as the centerline
– Help distinguish between “signals” and “noise”
– Identify most special causes
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Statistical Process Control
• Interpreting a run chart—
– Determine the number of data runs in the chart
– Determine the number of useful observations
– Look for shifts in the process and trends
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Statistical Process Control
Fi g u re 1 : R u n C h a r t f o r P e rf o r m a n c e M e a s u re 1 2 3 .4
0 .0 0
5 .0 0
1 0 .0 0
1 5 .0 0
2 0 .0 0
2 5 .0 0
3 0 .0 0
3 5 .0 0
4 0 .0 0
4 5 .0 0
5 0 .0 0
M o n th / Y e a r
R a t e F a c ilit y M e d ia n
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Statistical Process Control
• Control charts
– Variety of charts available
– More complex in construction
– More precise than run charts identifying special
cause variation
– Signal unstable performance, NOT poor quality!
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Statistical Process Control
• Elements of a control chart—
– Performance plotted on “Y” axis
– Time plotted on “X” axis
– UCL—Upper Control Limit
– LCL—Lower Control Limit
– CL—Process Average (centerline)
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Statistical Process Control
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QUESTIONS