Quality Assurance System

Transcription

1 Quality Assurance System Saskatchewan Workers Compensation Board Gary Gehring & Ernie Hinck For CES 2006 Conference, P.E.I.

2 Presentation Overview Reason for QA initiative Getting Started Growing pains The QA/QC System Examples Questions

3 Our Incentive 1. Committee of Review recommendation The Board implement a system to monitor and measure all adjudication in the administration of the Act, regulations and Board policy. The Board implement a comprehensive training program for Client Service Representatives and other employees involved in primary adjudication.

4 First Steps Program Evaluation -requirements to meet C of R -short term :Paper template completion with standalone database. Manual and labour intensive quick response. -long term Integrated reviews as part of the claims system -recommendations for integration into a Quality control program

5 Quality Assurance Templates (first one) Initial adjudication: up to 4 weeks In the course of employment at time of injury Yes No Specific injury Yes No If No, Non specific onset of condition recorded Y N Cause and effect determined Y N Decision Documented- MCD Yes No MCD required Y N Policy application appropriate Yes No Policy to be applied: Decision/Policy application communicated LCA Yes No Worker Pamphlet included Yes No Forwarded by 4 weeks to Case Management Team Yes No Reason for delay if No: No Client Contact 1 Claim Acceptance Unexplained 2 No Recovery and RTW Plan 3 Diagnostic Delay 8 Specialist Delay 9 Surgery Wait List 10 Physical Rehab Program Delayed 12 Physical Rehab Program Discontinued 13 Physical Rehab Program Interrupted 14 Medical Condition Other than Injury 15 Medical Condition Worsened 16 Medical Condition Not Adjudicated 17 Expansion of Medical Conditions 18 Interrupted Treatment 19 Ongoing Unexplained Symptoms 20

6 Discussions on Content Error versus Operational Problem Type of review, targeted vs random Why are we doing this? Just for the sake of reporting? For Who? Our customers, Our Board, Our Government Leads to how much detail required vs effort How will feedback be acted on, not just reporting findings for the sake of reporting.

7 Where we are Now An online system using Lotus Notes QC reviewers complete at their desk QA reviewers complete at their desk Central database for ease of reporting Initial system functioning fairly well.

8 QA/QC System

9 Import Function

10 Data collection CM

11 CM data report

12 Claims Entitlement Data

13 Claims Entitlement

14 Review number

15 Claims Entitlemet Review

16 Review Type

17 Policy/Act Identification

18 Benefit Entitlement

19 Case Management 1

20 Case Management 2

21 Quality Assurance Review

22 Problem Type

23 Problem Item

24 Completed Claims Entitlement

25 Action Record

26 Action item

27 Policy/Act Setup

28 Claims Entitlement Reporting 1

29 Claims Entitlement Reporting 2

30 Qualitative Feedback Reporting Jan 2006 QA feedback CEB Claim Num ber Claim O w ner_prev Problem Type P ro b le m W ith QAComments CEB10 Adjudication Com m unication no lca, no paym ent info, pay s e t u p in c o rre c tly. CEB10 Adjudication Com m unication no LCA or paym ent explanation. CEB03 O perational Docum entation over 4 wks to obtain E1 info CEC Claim Num ber Claim O w ner_prev Problem Type P ro b le m W ith QAComments CEC09 Tim e loss issue needs to be re s o lv e d s till. CEC07 Adjudication Docum entation history required, m iscom m unication to em ployer and worker re acceptance. CEC01 G ood developm ent and ongoing m anagem ent but exceeded tim eline for transfer to CM. If reopened s/b to CM. Positive findings: Claim Num ber Claim O w ner_prev CEB08 CEB12 CEB09 QAComments Initial setup well developed and tim ely transfered. good com m unication, tim ely Supervisor review noted, claim correctly decided and paid.

31 Case Management Reporting

32 Case Management Reporting CM Claim Num ber Claim O w ner Problem Type P ro b le m W ith QAComments CMD65 O perational Decision The claim is currently accurate based on correct handling following a fourth assessm ent that confirm ed early determ ination of fitness for work at a sedentary level. The case has been plagued with incorrect decision m aking and lengthy delays of m ore than CMD46 Adjudication Decision Historical inform ation fails to confirm a head injury. O nce transferred to case m anagem ent, the use of an im m ediate neuropsych assessm ent was an effective plan, however the im plem entation of the assessm ent recom m endations becam e m ired in unnecessary(to CMD43 O perational Docum entation RRW S does not record the logical action steps to define extend of responsibility. CMD34 Adjudication Docum entation M ultiple significant problem s. No RRW S. Failed to develop and docum ent extent of prior injury and nature of chronic hip problem s as required by Policy and Procedures for Section 50 application that is the stated intent of the RRP. The required worker, CMD31 O perational Com m unication inconsistent work and lack of follow through or follow up are contributing to extending the disablem ent and duration off work in a case situation where there are m inim al clinical findings with significant pain focused behaviours. Experience shows that if

33 CORPORATE CUSTOMER SERVICE EXPECTATIONS REPORTING METHOD Customer Service surveys Whenever possible, calls will be answered, i.e. ringing phones are not to be ignored. Client can be informed you will call them back as you are in the middle of something. At time of initial referral, 100% of clients are contacted by Case Manager/Case Management Support to advise of the referral and who the Case Manager is. All calls are to be returned within 24 hours. (Assuming following day is a work day). - Customer Service surveys Ninety percent of clients report receiving service congruent with corporate values (Dignity, Fair, Open, Honest, Professional). Written correspondence acknowledged within ten working days. Up fronts to be dealt with within 20 minutes of notification. Month-End Performance reports 75% of claims paid within 14 days of date of loss or less. Ninety-five percent of Recovery and Return to Work plans are to be on file 4 weeks from date of loss pending referral times, if applicable, or within 2 weeks of referral. One hundred percent of Recovery & Return to Work plans are updated at 12 weeks, 6 months and one year from date of loss on applicable files. Ninety-five percent of injured workers return to work or to Earnings Replacement, as per the initial plan. (Under Review) Eighty percent of out of pocket expenses are reimbursed on the same day or before requested, for open claims. An individual vocational plan will be on file at a maximum of five months from date of referral. Note: Currently under review.?? -Ninety-five percent of injured workers are accurately paid every two weeks from time of first cheque.

34 CORPORATE CUSTOMER SERVICE EXPECTATIONS, continued Q/A Reviews/Performance Reviews Where there is a change in the RRP, the Case Manager will contact the client, by telephone or face to face, and follow up in writing. Minimum of one face-to-face meeting on each claim that requires referral to Voc Services. Could be combined CM and Voc. All negative decisions will be discussed with the client, by telephone or face to face, and will be followed up in writing. All negative decisions and controversial positive decisions will be documented in memorandum MCD. Voc Services staff will contact 100% of referrals by the phone within 48 hours of the referral. Face to face visits with clients by Voc Services Specialists will occur within 20 working days of referral. Note: Currently under review.

35 Vocational Services 1

36 Vocational Services 2

37 Example: Review 247 p1

38 247 2

39 247 3

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42 247 6

43 403 1

44 403 2

45 403 3

46 403 4

47 403 5

48 403 6

49 Monitoring for Results Recommendations for corrections What happened? Isolated or repeated Research cause Develop a plan Submit corrective action Make sure the fix worked

50 mexpp1

51 scclp1

52 Questions???????