CDC Module 1

What are the three basic situations where coding occurs?

• Diagnosis

• Procedures

• Productivity

In regards to coding, not tracking services could cause…

• Misdiagnosis

• Clinic not getting credit for productivity

What coding process is used for diagnosis?

• International Classification of Diseases 10th Revision (ICD-10) codes

What are the ICD-10 prefixes?

• F-prefix (e.g. F33.0 MDD, Recurrent, Mild)

  • Pt meets diagnostic criteria

• Z-prefix, T-prefix, or R-prefix

  • Pt either did not meet diagnostic criteria or they meet non-diagnostic conditions

What coding process is used for procedures?

• Current Procedural Terminology (CPT) Codes

What are some actions that CPT codes describe?

• Initial eval

• Short/long-term psychotherapy

• Individual/group psychotherapy services

• CDE

• Starting medications or making phone calls (t-cons)

Why is CPT coding strict?

• Involves how much a pt will pay for a service

What are PLA codes?

• Alpha-numeric CPT codes used for lab testing

What coding process is used for productivity?

• Therapists = Procedure Codes

• Physicians and PNPs who are adding MM to their psychotherapy must add a pre-defined E+M code to their psychotherapy codes

Who officially reviews coded data?

• Personnel in the MTF and Major Command (MAJCOM)

According to DHA, how is the term peer review defined?

• Any assessment of the quality of medical care carried out by a healthcare provider

For peer review, how often are all active records reviewed?

• On a semiannual basis to ensure that all admin tasks have been appropriately accomplished

What percentage of all cases must be peer reviewed each month?

• At least 5%

Due to the sensitive nature of information, peer reviews are done…

• Internally by exchanging client records among providers

For peer review, what does quality documentation and accurate descriptions of services provided accomplish?

• Enhances pt care

• Ensures continuity of care

Which two AF publications provide guidance for peer reviews?

• AFI 44-172, MH

• DAFI 44-119, Medical Quality

Peer review is a tool to identify and correct (through education and/or remediation) concerns in care/documentation that…

• Do not meet standard of care

• Could expose providers to medicolegal liability

• Cause harm to a pt before they become problematic

For peer review, providing feedback for improvement does NOT translate to…

• Loss of privilege

• Prevent renewal of privileges in a facility

What is the result of peer review?

• Improves pt care through…

  • Communication

  • Education

  • Health system improvement

What is the importance of peer review?

• Preventing harm

• Increase the reliability of safe and high-quality clinical outcomes

What are the 3 electronic peer review forms?

• AF Peer Review Worksheet for BH Providers and Paraprofessionals

• FA Strength-based Therapy (FAST) 

• FA Maltreatment

What are the 4 roles of the clinical supervisor?

• Teacher

• Coach

• Consultant

• Mentor/Role Model

For clinical supervisors, describe the teacher role.

• Identify learning needs

• Promote self-awareness

• Transmit knowledge for practical use and professional growth

For clinical supervisors, describe the coach role.

• Provide morale building

• Asses strengths and needs

• Suggest clinical approaches

• Prevent burnout

For clinical supervisors, describe the consultant role.

• Review cases

• Monitor performance

• Provide alternate case conceptualizations

• Ensure professional gatekeeping

For clinical supervisors, describe the mentor/role model role.

• Facilitate professional development

• Train next generation of supervisors 

What are the 4 models of clinical supervision?

• Competency based

• Treatment based

• Developmental

• Integrated

Describe competency based models?

• Focus on skills and learning needs of supervisee

• Goals are SMART

What are the key strategies of competency based models?

• Modeling role reversal, role playing, and practice

• Using demonstrations

• Using various supervisory functions (e.g. teaching, consulting, counseling)

Describe treatment based supervision models.

• Train to a theoretical approach, incorporating EBPs like…

  • Motivational interviewing

  • CBT

  • Psycho-dynamic psychotherapy

Describe developmental models of clinical supervision.

• Recognize that counselors go through different stages of development, which can be affected by changes in…

  • Assignment

  • Setting

  • Population served

What is the purpose of clinical supervision?

• Improved client care and job performance

What is the purpose of administrative supervision?

• Ensure compliance with agency and regulatory body

What is the purpose of counseling?

• Personal growth

• Behavior changes

• Better self-understanding

What is the outcome of clinical supervision?

• Enhanced proficiency

What is the time-frame for clinical and administrative supervision?

• Short-term and ongoing

What is the agenda for clinical supervision?

• Based on agency mission and counselor needs

What is the agenda for administrative supervision?

• Based on agency needs

What is the basic process for clinical supervision?

• Teaching/learning specific skills

• Evaluating job performance

• Negotiating learning objectives

What are the six stages in the continuum of cultural competency?

• Cultural Destructiveness

• Cultural Incapacity

• Cultural Blindness

• Cultural Openness (Sensitivity)

• Cultural Competence

• Cultural Proficiency

Cultural Destructiveness

• Active discrimination

Cultural Incapacity

• Passive discrimination

Cultural Blindness

• Discrimination by ignoring culture

Cultural Openness (Sensitivity)

• Working with minority populations

Cultural Competence

• Working with complex issues and cultural nuances

Cultural Proficiency

• Commitment to excellence and proactive effort

What are the 7 principles of DHA’s RRC?

• Preoccupation with failure

• Sensitivity to operations

• Deference to expertise

• Respect for people

• Commitment to resilience

• Constancy of purpose

• Reluctance to simplify

[RRC Principles] Preoccupation with failure

• Drive zero harm by anticipating and addressing risks

[RRC Principles] Sensitivity to operations

• Be mindful of how people, processes, and systems impact outcomes

[RRC Principles] Deference to expertise

• Seek guidance from those with the most relevant knowledge and experience

[RRC Principles] Respect for people

• Foster mutual trust and respect

[RRC Principles] Commitment to resilience

• Leverage past mistakes to learn, grow, and improve processes

[RRC Principles] Constancy of purpose

• Persist through adversity towards the common goal of zero harm

[RRC Principles] Reluctancy to simplify

• Strive to understand complexities and address root causes

What are the 4 domains of change in RRC?

• Leadership commitment

• Culture of safety

• Continuous process improvement

• Patient centeredness 

What are the responsibilities of the DHA director?

• HCA of each military MTF, including:

  • Budget

  • IT

  • Management

  • Policy and procedure

  • Construction

  • Any other matters SecDef determines appropriate

What is the commander of each military MTF responsible for?

• Ensuring readiness

• Furnishing

DHA Assistant Director

• A career appointee reporting directly to the director

DHA Deputy Assistant Directors

• Responsible for…

  • Info ops

  • Financial ops

  • Healthcare ops

  • Medical affairs

• Report to assistant director

Why were MHS COEs established?

• Provide DoD with ability to speed advancement of scientific knowledge and EBPs for diagnosis/treatment of diseases/conditions that impact SMs and their families with the help of a “critical mass” of experts

What do medical centers consist of?

• Large, tertiary-care facilities that provide a full range of medical services, including ER, surgery, and specialized treatments

• Graduate and residency programs

• They may designate a medical center as a regional COE for unique and highly specialized services (including polytrauma, organ transplantation, and burn care)

Why is the SecDef important?

• Maintains military…

  • MTFs (in consultation with other military Secretaries)

  • Medical centers (with high population of SMs and beneficiaries)

  • Hospitals (where civilian facilities are unable to support the needs of SMs and beneficiaries)

  • Ambulatory care centers (where civilian facilities are able to support the needs of SMs and beneficiaries)

What do hospitals consist of?

• Inpatient/outpatient services to maintain medical readiness

• 24-hour emergency care

• Surgery

• Any other program/functions that SecDef determines appropriate

What do ambulatory care centers consist of?

• Outpatient services with limited speciality care that SecDef determines is…

  • Cost effective

  • Not available at civilian facilities in the area

• Partnerships with civilian facilities (section 706, NDAA for FY17)

What are satellite COEs?

• SecDef may establish these to provide speciality care for certain conditions like…

  • PTSD

  • TBI

  • Any others approved by SecDef

In addition to U.S.C. Title 10, what did the NDAA sign into law for FY 2008?

• A congressional mandate for the creation of COEs for PTSD and TBI within the DoD

  • This led to the establishment of DCoE, which was later reorganized to DHA’s PHCoE and TBICoE

Medical Groups

• Smaller facilities that provide primary care, outpatient services, and limited speciality care

Medical Squadrons

• Smaller units that provide medical support to specific USAF bases/installations

Clinics

• Outpatient facilities that provide primary care, preventative medicine, and limited specialty care

Which term best describes the principle(s) DHA uses to advance its practices across the MHS?

• RRC

DoD PSP Goals (Quadruple Aim)

• Patient experience

• Population health

• Lower costs (healthcare)

• Care team well-being (improving work life and well-being of team)

DoD PSP Provisioning

• Provides products, services, and support enabling frontline healthcare personnel to eliminate harm and promote a culture of safety

What are the DoD PSP’s primary functions?

• Manage patient safety (PS) events

• Support a learning organization

• Foster a culture of safety

What must all MHS direct care facilities (MTFs) do regarding PS events?

• Report all PS events to the DOD PSP through Joint Patient Safety Reporting (JPSR) system

What is a PS event?

• An incident or condition that could have resulted in, or did result, in harm to pt

What are the 4 main types of PS events?

• Adverse events

• No-harm events

• Near-miss events

• Unsafe/hazardous conditions

[PS Event] Adverse Event

• Resulted in harm to pt

• Event may occur by the omission/commission of medical care

[PS Event] No-Harm Event

• Reached pt but did not cause harm

[PS Event] Near-Miss Event

• Did not reach pt (close call, good catch)

[PS Event] Unsafe/Hazardous Condition

• Increases the probability of an adverse event

What are 2 other PS event types?

• Potentially Compensable Event (PCE)

• Intentional Unsafe Act

[PS Other Event] PCE

• Reaches patient

• Has a HRM assessment that determines possible financial loss to the federal government

• All DOD REs are PCEs

• Will be referred to PS manager to ensure capture in JPSR

[PS Other Event] Intentional Unsafe Act

• Any alleged or suspected act or omission that involves…

  • A criminal act

  • Purposefully unsafe act

  • Pt abuse

  • Substance abuse

• Matters for law enforcement, disciplinary system, or administrative investigation

What must be reported to the appropriate HRM Program for assessment? 

• Any PS event that reaches pt (adverse and no-harm events)

What is harm?

• Any physical or psychological injury or damage to the health of a person, including temporary and permanent injury

What is the Agency of Healthcare Research and Quality’s (AHRQ) Harm Scale used for?

• To assign harm to PS events recorded in JPSR, Global Trigger Tool (GTT), and Joint Centralized Credentials Quality Assurance System (JCCQAS)

Agency of Healthcare Research and Quality’s (AHRQ) Harm Scale

• A - Death

• B - Servere Harm

• C - Moderate Harm

• D - Mild Harm

• E - No Harm

• F - Unknown

[Harm Scale] A - Death

• Death at time of assessment

[Harm Scale] B - Severe Harm

• Bodily or psychological injury that interferes significantly with functional ability or quality of life

[Harm Scale] C - Moderate Harm

• Bodily or psychological injury adversely affection functional ability or quality of life

[Harm Scale] D - Mild Harm

• Bodily or psychological injury resulting in minimal symptoms or loss of function

[Harm Scale] E - No Harm

• Event reached pt, but no harm evident

Scale of Duration of Harm to Pt

• A - Permanent (1 year or greater)

• B - Temporary (less than 1 year)

• C - Unknown

DOD REs

• Any PS event resulting in death, permanent harm, or severe temporary harm

• Besides JPSR, they have additional reporting and notification requirements

Comprehensive Systematic Analysis (CSA)

• Thorough, credible, and acceptable analysis following PS event

• Seeks to identify system vulnerabilities to be eliminated or mitigated in a sustainable manner to prevent reoccurrence

• Root cause analysis (RCA) is one type of CSA

• Also can be conducted for performance improvement purposes for events that have the potential to be catastrophic

What are the 5 guidelines that support the identification of causal factors in CSAs?

• Clearly show cause and effect relationships

• Use specifics and accurate descriptions of events

• Human errors must have a preceding cause

• Violations in procedure must have a preceding cause

• Failure to act is only causal when there’s a pre-existing duty to act

Corrective Action Implementation (CAI) Plan Report

• Includes…

  • Solutions

  • Corrective actions implemented

  • Measures of effectives/sustainment of corrective actions implemented (reducing/eliminating risk of reoccurrences)

Proactive Risk Assessment (PRA)

• Process used to identify, rate, prioritize risks and/or hazards

What is a form of PRA?

• Failure Mode Effect Analysis (FMEA)

  • A systematic, proactive method for evaluating a process to identify…

    • Failures

    • Impact or failures

    • Parts of process that need change the most

Describe 3 methods PS event reports are collected through.

• Anonymous, self-reported PS events through JPSR

• Harm surveillance data using GTT methodology

• Administrative data related to pt harm collected through other programs