Data Quality Management Control (DQMC) Program DQMC Program Review List for FY 2010 and FY 2011

DQMC Program Review List Agenda History of DQMC Program Purpose of Review List DQMC Review List Overview New/changed Questions for FY10 Questions? Unclassified

DQMC Program History Memo dated November 2000 and signed by Acting Assistant Secretary of Defense Jarrett Clinton established DQMC Program for the MHS. The directing memo was sent to the three services Assistant Secretaries, with copies furnished the three services Surgeon Generals. Established the various components of the program, (DQ Manager, DQ Assurance Teams, Review List, CDR’s monthly DQ Statement, Internal/External Audits). Unclassified

DQMC Program History DQMC Program Objectives To improve the overall quality of financial and clinical workload data. Command oversight to improve submission of complete, accurate, and timely data. Assure uniformity and standardization of information across the MHS. Unclassified

Purpose DQMC Review List Assists MTF Commander in establishing and maintaining an effective DQMC Program. Completed Review List is reported monthly to Executive Committee and MTF Commander. Review List kept on file for 5 years. The Review List is an internal management control tool that contains the details behind the Monthly DQ Statement. Unclassified

DQMC Review List – Section Overview A. Organizational Factors Leadership commitment and support are critical to assure the appropriate environment for data quality B. Data Input Controls in this category are designed to ensure data are entered into the application in an accurate, complete, and timely manner C. Data Output Data Output controls are used to ensure the accurate and timely distribution of outputs D. Security These controls should provide assurances that computers and the data they contain are properly protected against theft, loss, unauthorized access, and natural disaster E. System Design, Development and Education and Training Intended to ensure that systems meet user needs, are developed economically, are thoroughly documented and tested, and contain appropriate internal controls

New/Changed Questions on Review List for FY10 Section B.1. Addresses whether or not MTFs have written procedures for the processing of data. Also, added Essentris to systems list. Section B.2. Addresses current software version in use at MTFs. Added Essentris to systems list and categorized DMHRS-I & MEPRS/EAS as N/A. Section B.3. Addresses system updates and associated software loading activities. Now identifies software availability date to the MTF and subsequent MTF software load date. Unclassified

New/Changed Questions on Review List for FY10 Section B.4. Changed wording from “rejected records” to “rejected data” and also added Essentris as a system to be monitored. Section B.5. - Removed question about closing every clinic every day. This was question 1a on the DQ Statement, which has been removed. Section C.1.C. Addresses the review of MEWACS website. Removed the words “current version”. Section C.1.4 Three questions added to this section. Unclassified

New/Changed Questions on Review List for FY10 C.1.4.d “For DMHRSi have the “DoD Batch and Timecard Status Report” and “HR Data Issues affecting EAS” reports been run and the results presented to the Commanding Officer for review?” C.1.4.e “For DMHRSi what is the percentage of submitted timecards by the suspense date? This is question 3c of the DQ Statement. (Formula, Number of timecards submitted on time / total number of timecards for an MTF).” C.1.4.f “For DMHRSi what is the percentage of timecards approved by the suspense date? This is question 3d of the DQ Statement. (Formula, Number of timecards approved on time/ total number of timecards for an MTF).” * Questions contained in C.1.4.e. & f. above have been added to DQ Statement, questions 3c & d (will not be colored coded for FY10). Unclassified

New/Changed Questions on Review List for FY10 Section C.2. Addresses the use of CHCS software used to identity potential duplicate patients. Have changed wording of “reporting month” to “data month”. Section C.2.a. Changed wording to reflect that this question is only for those MTFs that are CHCS/AHLTA host sites. This is question 10a of the DQ Statement. Section C.2.e. This is an added question which requires the CHCS/AHLTA host site to list the DMIS IDs of the MTF’s they are reporting on. Unclassified

New/Changed Questions on Review List for FY10 Section C.5.c. Addresses percentage of DRG codes that were correct. A calculation formula has been added (number of correct MS-DRGs /total number of MS-DRGs). Section C.8.a. Addresses workload comparisons. The new calculation formula is, (Number of SADR encounters(count encounters only) /number of WWR visits). When doing the calculation for this metric if the result is greater than 100%, then the percentage greater than 100% will be subtracted from 100% (i.e. 103% compliance would actually be 97% compliance). This is question 8a of the DQ Statement. Unclassified

New/Changed Questions on Review List for FY10 Section E.1. Addresses whether or not system POCs have been appointed in writing for various operating systems. Added Essentris to list of systems. Section E.2. Addresses whether or not personnel responsible for entry of data have been trained and educated on system. Added Essentris to list of systems. Section E.3. Addresses using the System Change Request process. Added Essentris to list of systems. Section E.4. Addresses using the System Incident Report process. Added Essentris to list of systems. Unclassified

New/Changed Questions on Review List for FY10 Section E.5. Addresses written maintenance standard operating procedures. Added Essentris to systems list and categorized DMHRS-I & MEPRS/EAS as N/A (centrally managed). Section E.6. Addresses contingency plans to restore operations. Added Essentris to list of systems. Section E.7. Addresses unresolved trouble tickets. Added Essentris to list of systems. Unclassified

New/Changed Questions on Review List for FY11 Section A.7. Questions about training for DQ Managers and Data Quality Assurance Team Members, within their respective area of responsibility Section B.5. Question on end-of-day processing. Changed wording from reporting month to data month. Section C.1.c. Addressed outliers/variance in MEWACS and whether or not explanations have been provided in the comments section for flagged data anomalies. Unclassified

New/Changed Questions on Review List for FY11 Section C.1.e. For DMHRS-I the goal of timecards submitted by suspense date changed to 100% Section C.1.f. For DHMRS-I the goal of timecards approved by suspense date changed to 100%. Section C.3.e Added new question on the daily transmission of patient appointment files (DOWDR – Daily Outpatient Workload Detail Report) Unclassified

New/Changed Questions on Review List for FY11 Section C.6.a. Have added the word “adequate” to the question about “documentation of encounter selected to be audited available.” Section C.8. Questions on the collection of DD Form 2569, Other Health Insurance, have been consolidated for Inpatients, Outpatients and APVs into one section. Section C.8 Question on DD Form 2569 has changed from “30 on-hand records” to read “Non-Active Duty medical records”. This means the denominator for these questions will be a minimum of 30. Unclassified

New/Changed Questions on Review List for FY11 Section E.4.i. The compliance requirement has increased for the question on the number of outpatient encounters documented in AHLTA . Goal Increased from 80% to 95% . Section E.5. Question on Standard Operating Procedures for system software and hardware maintenance. Detail has been added on who is responsible for reporting (e.g. host site only, centrally managed, all). Section E.8. New question added to Review List only addresses Managed Care activities. “For the data month, how many patients, enrolled to the MTF, were referred to the network for care?” Unclassified

DQMC Program Review List Questions? Unclassified