NASI Compliance Resources: Performance Management

INTRODUCTION

It is important to understand that “Performance Management is the Keystone of the Accreditation.” The Surveyors will review your Performance Management Plan and you must be able to describe and show your compliance at the time of your onsite survey. In the CMS Quality Standards, CMS described Performance Management:

“The supplier shall implement a performance management plan that measures the outcomes of consumer services, billing practices, and adverse events. The data collection may target certain aspects of services that have a potential to cause harm or injury; occur frequently, creating a greater than expected number of adjustments, repairs, or replacement; or require significant instruction to assure safe use and benefit of items.”

CMS believes that Suppliers who develop a Performance Management Plan in compliance with the above stated Quality Standard will provide higher quality services and products to beneficiaries in a safe and cost-effective manner. Any problems that arise will be detected and rectified through new policies, procedures and/or training.

The NASI PERFORMANCE MANAGEMENT PLAN

A pharmacy/facility must pass through three distinct phases in the NASI Performance Management Plan in order to be compliant.

  • Data Collection (Compliance Guide, Phase 2 – Level 1 and Phase 2 – Level 3)
  • Performance Management Audit (Compliance Guide, Phase 2 – Level 4)
  • Corrective Action (Compliance Guide, Phase 2- Level 4)

In order to comply with the NASI Performance Management Plan it is important to understand that these policies and procedures in your Accreditation Manual must be implemented and clearly understood by the appropriate staff members. It is essential that the phases of the Performance Management Plan are implemented in the order listed above.

It is important to understand that pharmacies/facilities seeking to obtain accreditation must implement all policies and procedures in your Accreditation Manual for all DMEPOS patients prior to the onsite survey. Pharmacies/facilities seeking to maintain their accreditation must continue to implement all of these policies and procedures for all DMEPOS patients. Performance Management is a vital component to running an accredited pharmacy/facility and these policies and procedures must remain in place throughout your accreditation period.

DATA COLLECTION

Below you will see the individual Policies and Procedures (and corresponding forms/documentation) a pharmacy/facility must follow in order to begin collecting the data for the NASI Performance Management Plan.

  • Policy and Procedure: DMEPOS Medicare Beneficiary Satisfaction (Phase 2 – Level 3) – The Pharmacy shall continuously monitor all aspects of the Beneficiary/Caregiver satisfaction of DMEPOS products and/or services.
  • Patient Satisfaction Survey of DMEPOS Products and/or Services Form
  • Policy and Procedure: Beneficiary Records (Phase 2 – Level 3) – The pharmacy/facility shall maintain all necessary Patient Record in accordance to the HIPAA Regulations and any Third-Party Payor requirements.
  • All data sets in Patient Records
  • Policy and Procedure: DMEPOS Medicare Beneficiary Complaints (Phase 2 – Level 3) – The pharmacy/facility shall document Beneficiary complaints and determine whether an investigation is warranted.
  • DMEPOS Medicare Beneficiary Complaint Form
  • DMEPOS Medicare Beneficiary Complaint Investigation Outcome Form
  • DMEPOS Medicare Beneficiary Complaint Log
  • DMEPOS Medicare Beneficiary Complaint Receipt
  • Policy and Procedure: Claims Reconciliation (Phase 2 – Level 1) – The pharmacy/facility shall reconcile and correct all Third-party claims in a timely manner.
  • Claims Adjustment and Error Log
  • Policy and Procedure: Beneficiary/Caregiver Questions and Concerns (Phase 2 – Level 3) – The pharmacy/facility requires that appropriate Pharmacy personnel respond to and document Beneficiary/Caregiver questions and concerns in a timely and professional manner.
  • Patient/Caregiver Questions and Concerns Form
  • Policy and Procedure: Investigation of Incidents or Injuries(Adverse Events) (Phase 2 – Level 3) – When notified of any incident or injury to a Beneficiary in which DMEPOS product(s) may have contributed the pharmacy/facility shall conduct an investigation.
  • DMEPOS Product Investigation Report (Adverse Events)
  • Changes to the Business Practices (All Phases)
  • Changes to the Products carried by the Facility (All Phases)

Full Performance Management hinges on complete and accurate data collection. The pharmacy/facility must be consistent in using all of the aforementioned forms and logs for data collection. The better you implement data collection, the more accurate results you will receive during your audits.

PERFORMANCE MANAGEMENT AUDITS

Below you will see the individual Policies and Procedures a pharmacy/facility must follow to conduct Performance Management Audits. The pharmacy/facility will follow each Policy and Procedure to conduct each Performance Management – auditing the appropriate data collected in the above phase.

  • Policy and Procedure: Patient/Caregiver Satisfaction Audit (Phase 2 – Level 4)
  • Policy and Procedure: Patient Record Audit (Phase 2 – Level 4)
  • Policy and Procedure: Patient/Caregiver Complaint Audit (Phase 2 – Level 4)
  • Policy and Procedure: Billing and Coding Error Audit (Phase 2 – Level 4)
  • Patient/Caregiver Questions and Concerns Audit (Phase 2 – Level 4)
  • Policy and Procedure: Business Impact Review (Phase 2 – Level 4)
  • Changes to the Business Practices
  • Changes to the Products carried by the Facility

In conducting the Performance Management Phase, the pharmacy/facility will develop a Performance Management Report for each of the Performance Managements Audits listed above. This Report will document audit findings and corresponding corrective action plans on pharmacy/facility letterhead. Each Report for each Audit should be documented separately (do not document information for all Audits in one report). The Report should include:

  • The Name of the Particular Audit (example: Patient/Caregiver Satisfaction Audit)
  • Date the Audit occurred
  • Annual Data collection Period (date range spanning one year). List the Annual Date range of Data Collection. This date range would be based off of when your pharmacy/facility collected the data for the audits, which are conducted once per year. This may be based off of the calendar year, or the fiscal year. The recommended data collection period for the Annual audit is:
  • January through December
  • Description of the Audit, describing the general audit itself
  • Strengths found during the Audit with examples if possible
  • Weaknesses found during the Audit with examples if possible
  • Based on the weaknesses found, the DMEPOS Coordinator should, with the help of Management, develop a Corrective Action Plan (See the Corrective Action section Below)
  • Signature and Date of the DMEPOS Coordinator
  • Signature and Date of Management/Ownership

CORRECTIVE ACTION

At the end of the Performance Management Report, the Facility will include a Corrective Action Plan that ultimately corrects any deficiencies that were found during the Audit. The Corrective Action could include:

  • Development of new Policies and Procedures (Please provide your Accreditation Specialist with copies of the new Policies and Procedures)
  • Amending existing Policies and Procedures (Please provide your Accreditation Specialist with copies of your amended Policy and Procedure)
  • Additional Training
  • Other actions as deemed necessary

The Corrective Action Plan will address any issues found while analyzing your data during the audits. Part of your Corrective Action Plan should include your expected goals and outcomes for Performance Management during the next quarter.

PERFORMANCE MANAGEMENT REPORT EXAMPLE

Below is a Performance Management Audit Report for the Billing and Coding Error Audit to use as a point of reference and example.

Billing and Coding Error Log Audit

Year: 2009

January through December

Date Completed: January 5, 2010

Findings: After reviewing the Billing and Coding Error logs for 2009, we found 3 issues:

  • Billing for the wrong side of body
  • Billing for the same date as being released from the hospital
  • Billing for unaccredited items.

Corrective Action: The pharmacy has implemented the following Corrective Action Plan to address the three issues.

Billing for the wrong side of body – Pharmacy staff has been retrained on using the correct Modifiers for DMEPOS:

  • LT – Left
  • RT – Right

Billing for the same date as being released from the hospital – All new patients will be asked if they have been discharged today from a SNF, LTC, Hospital, or other facility. If they have the items will not be billed until the next day.

Billing for unaccredited items – The pharmacy staff have been educated on the acceptable DMEPOS items to be billing.

Review: The DMEPOS Coordinator will review the Billing and Coding Error Logs in one month to determine if the training and practices have assisted in removing the above issues. If the issues are still present an additional Corrective Action Plan will be created.

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DMEPOS Coordinators SignatureDate

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Printed Name

______

Ownership/Managements SignatureDate

______

Printed Name

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