Office of Continuing Medical Education

Founded 1824

Department of Psychiatry Performance Improvement CME (PI-CME): Physician Self Assessment of Clinical Documentation

Jefferson Medical College Jefferson College of Graduate Studies Jefferson College of Health Professions Jefferson University Physicians

Purpose: To develop a CME performance improvement project to improve the Department of Psychiatry’s documentation of key clinical elements crucial to treatment and management decisions relating to patient care. Since documentation of these elements is necessary for continuity of care and improved patient outcomes, the Department seeks to determine a base level of performance, and to identify and address any emergent issues found. Objectives: As a result of participating in this performance improvement project, the participant should be able to: Assess his/her compliance rate for accurate charting of key clinical elements, including initial evaluation and diagnoses, current medications, initial and follow-up treatment plans, and up-todate progress notes. Identify individual reasons for improper or inadequate charting. Review current protocols and / or clinical guidelines relating to charting requirements and recommendations. Reflect on practice behaviors (both individual and systems based) that might be employed to improve charting if required. Adjust current behaviors to address documentation concerns that may be found as a result of the audit. Re-assess practice outcomes after six months to determine if charting behavior has improved.

General Information CME Process: The AMA has only recently approved the award of Category 1 credit for practice based learning such as that incorporated in this performance improvement CME activity, and it works a bit differently than traditional CME activities. A Performance Improvement CME activity consists of three distinct stages, each of which is valued at 5 Category 1 AMA PRA credits. Stage A is designed to help you review your performance in an area of practice that might benefit from closer assessment. In this stage, you will be presented a report listing 25 patients and asked to select 10 for a documentation audit. A chart audit tool, developed in conjunction with the Department, will be provided and should be completed for each of the 10 charts you select. Data from these tools will be collected into a database and analyzed. In addition to the chart audit, Stage A includes a reflective worksheet to help you define specific areas for improvement addressed through an educational activity. You will be asked to specify what aspects of your practice you want to change, and how you plan to implement that change. Completion of an evaluation of this stage is also required. (September – November 2006) Stage B consists of your work investigating and implementing evidence-based changes in your practice using materials either provided by or approved by the JUP Clinical Care Committee and Office of CME. The form of this stage will be determined by the outcomes of Stage A. Key to this stage is the implementation of a planned change over time. Stage B is expected to last 3 to 6 months. For CME documentation of this stage, you will be asked to submit information on your work in this stage, and to again reflect on your experience during this time. (January – February 2007) M:\CME\Performance Improvement CME\psych spring 06\Psychiatry CME Instructions.DOC Page 1 of 2 www.Jefferson.edu

1020 Locust Street, Suite M-5, Philadelphia, PA 19107 • 215-955-6992 • Fax: 215-923-3212 • http://jeffline.tju.edu/jeffcme

Stage C is when we assess the effectiveness of the change you implemented in Stage B and compare your practice-based results after experiencing Stage B to your results from Stage A. For CME documentation of this stage, you will work through a set of questions designed to guide you through an assessment exercise:: rating your success at implementing change, describing what actions taken in Stage B were the most effective in helping achieve change, identifying barriers that impeded change for you, etc. (April – June 2007) As volunteers in this pilot project for performance improvement CME at Jefferson, we will also be asking you for feedback on the process to help us design an effective and time efficient way to provide CME credit for practice based learning projects. Participants who complete all three stages in sequence may claim up to 20 AMA PRA Category Credit(s)TM.

Accreditation Information Jefferson Medical College of Thomas Jefferson University is accredited by the ACCME to provide continuing medical education for physicians. Jefferson Medical College designates this educational activity for a maximum of 20 AMA PRA Category Credit(s)TM . Physicians should only claim credit commensurate with the extent of their participation in the activity. The JUP Clinical Care Committee is the designated CME Performance Improvement Oversight Committee for this project.. All members of the committee have submitted information about their potential conflicts of interest and have indicated that they have no financial arrangements or affiliations with any corporate organization offering financial support or grant monies for this CME program or with any corporate organization whose product(s) will be involved in this project. Members include: Rodney Bell, MD Theodore Christopher, MD Sidney Cohen, MD Herbert Cohn, MD Jeanne Cole, MS Eileen Craig, RN Albert Crawford, PhD, MBA Karl Doghramji, MD Neil Goldfarb, BA

James Harrop, MD Megan Hartman, MS Jeanette Koran, BSN, RN Thomas Klein, MD David Maguire, M.D. John Melvin, MD David Nash, MD David B. Nash, MD, MBA

Laurence Needleman, MD Jeffrey Riggio, MD Joanne Rosenthal, BSN, JD Joseph Spiegel, MD Erol Veznedaroglu, MD

Jefferson Medical College endorses the Standards of the Accreditation Council for Continuing Medical Education and the Guidelines for Commercial Support. Every effort has been made to encourage faculty to disclose any commercial relationships or personal benefit with commercial companies whose products are discussed in the educational presentation. Disclosure of a relationship is not intended to suggest or condone bias in any presentations, but is made to provide participants with information that might be of potential importance to their evaluation of a presentation. There will be no discussion of investigative or off-label use of products. Questions? For data and protocol related questions, please contact Jeannette Koran, BSN, RN, Quality Review Nurse in the Department of Health Policy at 5-9549. For questions relating to the CME aspects of this project please contact Dr. Seltzer or Jeanne Cole from the CME Office.

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7/06/2006

QUALITY IMPROVEMENT STUDY PROTOCOL PHYSICIAN SELF-ASSESSMENT OF CLINICAL DOCUMENTATION DEPARTMENT OF PSYCHIATRY THOMAS JEFFERSON UNIVERSITY

BACKGROUND According to the American Medical Association (AMA), “Performance Improvement (PI) activities describe structured, long-term processes by which a physician or group of physicians can learn about specific performance measures, retrospectively assess their practice, apply these measures prospectively over a useful interval, and reevaluate their performance.” PI activities may address any facet (structure, process or outcome) of a physician’s practice with direct implications for patient care. Performance data, therefore, validate and modify each physician’s practice skills. To achieve this goal of measuring and improving performance, the Department of Psychiatry and Human Behavior will conduct systematic performance measurement and improvement initiatives throughout the department’s faculty practice. Physicians will conduct their own chart reviews. Each participating physician will assess his or her patients’ medical records for documentation of key clinical elements crucial to treatment and management decisions. Essential clinical elements include the initial evaluation report, which includes the diagnoses, current medications, initial and follow-up treatment plans, and progress notes. Other secondary elements will also be collected to assess degree of standardization of care. This exercise will allow physicians to gather data about their practice and will provide them the opportunity to develop and implement practice action plans to improve the continuity and coordination of care delivered to their patients. CME credits will be earned at the same time. The Jefferson University Physician (JUP) Clinical Care Committee (CCC) and Office of Continuing Medical Education (OCME) are collaborating with the Department of Psychiatry and Human Behavior to implement and assess the effectiveness and applicability of this approach in fostering performance measurement and improvement activities in an academic group practice setting. SPECIFIC AIMS There are several aims of this project. One is to assess the physician and practice group’s ability to evaluate the continuity and coordination of care delivered to their patients through the examination of data generated from a retrospective chart review, 1

identification and implementation of performance improvement initiatives, and a follow up measurement of effectiveness. Participating physicians will assess their patients’ medical records for documentation of key clinical elements crucial to coordinating continuity of care in treatment management decisions. Additionally, the JUP CCC, in collaboration with the Department of Psychiatry and Human Behavior, will assess the effectiveness and applicability of this approach in fostering performance measurement and improvement activities in an academic group practice setting. Finally, we will survey the physician’s satisfaction with the process of critical self-evaluation and their perceptions of how this initiative may change knowledge and practice behavior. A project working group composed of CCC staff and representatives of the Department of Psychiatry and Human Behavior will be convened to oversee and conduct the project’s development and implementation. METHODS Design A retrospective chart review of cases during the measurement period of January 1st 2005 to December 31st 2005 will be conducted for baseline data collection. Based on the results of the data analysis, one or more performance improvement interventions will be developed and implemented, either on the individual or the practice level, if required. A subsequent retrospective chart review of new cases in late 2006 will be conducted to measure the impact of performance improvement interventions, as needed. Participating faculty members will be asked to provide evaluations at each stage of the process. Study Population All of the practicing faculty (18) in the Department of Psychiatry and Human Behavior plan to participate in this study. The study sampling frame for the charts to be reviewed will consist of all patients aged 18 years and over as of the beginning of the measurement period who have had at least 2 outpatient visits with the same physician in this time frame. Samples of 25 outpatient charts per physician will be randomly selected using data from the IDX billing system. From these respective sample lists, each physician will select 10 charts. If a practitioner has less than 25 outpatient charts that meet the criteria, all of the charts that meet the criteria will be included on the list from which the practitioner will chose the 10 to review. The following groups of patients will be excluded from this study: 1) Employees or students of Thomas Jefferson University Hospital or Thomas Jefferson University, and 2) High profile or VIP patients, as determined by the practicing physician. Sample Size Estimates Ideally, if all of the practicing faculty (18) in the Department of Psychiatry and Human Behavior participate in the study and review 10 charts, the sample size would include 180 charts for both the initial and follow-up review.

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Baseline Data Collection Patient demographics will be extracted from administrative claims data maintained in the IDX system. A chart review abstraction tool based on the Documentation Guidelines for Evaluation and Management Services 1 and the National Committee for Quality Assurance (NCQA) Guideline,s will be developed to collect data. The draft of the chart review tool will be presented to the Department of Psychiatry and Human Behavior’s PI Committee for review and additional suggestions. The recommended changes will be incorporated in the final chart review tool. A computerized database in Microsoft Access will be developed that will include a data entry form to permit input of chart review data. Study participants will use the chart abstraction tool to assess the documentation in their patient charts. Data Management and Analysis As noted above, the chart review will be implemented through a Microsoft Access database. The database will be password-protected so that only specific project staff can access it. The database will be converted for analysis using SAS Release 9.1 software. Adherence to documentation standards will be evaluated on the practice level for all participating faculty members as well as on the individual practitioner level. Specific statistical tests for analysis will be based on the data that is collected. Limitations The information gathered via medical records and medical claims may have some deficiencies due to incomplete forms and missing data. Due to the sensitive nature of the data, high profile patients and patients who are employees or students at Jefferson will be excluded from this study. These patients may represent a majority for some physicians: by excluding these patients, the end result may not be a true representation of their current practice. Follow-Up Data Collection At the time of review of baseline data a detailed plan for follow-up data collection will be developed including determination of which interventions, if any, are needed. The initial plan is to implement interventions and conduct a follow-up assessment. The follow-up sample will be drawn using an approach identical to that used for baseline data collection. The follow-up assessment phase is critical, because the ability to track progress over time is integral to the concept of continuous quality improvement in patient care. Dissemination Plan An end-of-year report will be prepared summarizing the project’s activities and findings. It will be presented to the Department of Psychiatry and Human Behavior’s Performance Improvement Committee and the JUP faculty meeting, the JUP CCC, and the OCME. It is hoped that this project will demonstrate good performance and measurable 1

As per Thomas Jefferson University Compliance Administration Policy No. 107.04 Documentation Standards for Teaching Physicians and Non-Physician Practitioners. Last review date: 07/06/2005.

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improvement as a result of the intervention. It is also hoped that the processes (measures and interventions) developed in this project can be easily adapted or applied among JUP physicians in other departments.

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Chart Audit Tool Physician Self-assessment of Clinical Documentation Department of Psychiatry Thomas Jefferson University 7/14/2006

DEMOGRAPHIC 1. Initials: _____________________________ 2. Gender: __ Male___ Female___ 3. Race/Ethnicity: ____Caucasian/White____ African American/Black____ Asian ____Hispanic____ Native American____ Multiracial____ Other ____Unknown 4. Marital Status: ____ Married____ Single ____ Separated ____ Divorced____ Widowed____ Unknown 5. Insurance: ___Medicare___ Medicaid___ Commercial ___ No Insurance ___ Other 6. Physician’s name: ______________________________ PATIENT’S ELIGIBILITY FOR STUDY ENTRY __Yes __No Confirmation of Eligibility If you checked “No,” please indicate reason below: Record Exclusion: ___ Confidential or VIP Patient ___ TJUH Student ___ TJUH/TJU Employee ___ Other (specify in space provided):_______________________________________________ AVAILABILITY OF COMPLETED FORMS 1. ___ Yes ___ No Registration 2. ___ Yes ___ No Copy of Insurance Cards 3. ___ Yes ___ No HIPAA 4. ___ Yes ___ No Release of Information 5. ___ Yes ___ No Initial Evaluation 6. ___ Yes ___ No Progress Notes 7. ___ Yes ___ No Medication Sheet CONTENT 1. Demographics a. ___Yes ___ No Address b. ___Yes ___ No Employer c. ___Yes ___ No Home Telephone Number d. ___Yes ___ No ___ N/A Work Telephone Number 2. Current Medication Documentation a. ___ Yes ___ No ___ N/A (Patient is not on medications) If Patient has been Prescribed Medications: b. ___ Yes ___ No ___ N/A Medication Allergy Status Documented

c. ___ Yes ___ No ___ N/A Adverse Reaction Documented if Medication Allergy Exists 3. ___ Yes ___ No Problem list 4. Initial Visit a. ___ Yes ___ No Chief Complaint b. ___ Yes ___ No Relevant History

c. ___ Yes ___ No Exam Findings i. ___Yes ___ No Description of Patient’s Judgment and Insight ii. ___Yes ___ No Brief Assessment of Mental Status Including: a. ___Yes ___ No Orientation to Time, Place and Person b. ___Yes ___ No Recent and Remote Memory c. ___Yes ___ No Mood and Affect (eg, Depression, Anxiety, Agitation) d. ___ Yes ___ No Prior Diagnostic/Lab Tests e. ___ Yes ___ No Assessment f. ___ Yes ___ No Clinical Impression/Initial Diagnosis g. ___ Yes ___ No Physical Exam Performed 5. ___ Yes ___ No Follow-up Treatment Plan or Plan of Care 6. Progress notes a. ___ Yes ___ No Documentation of Patient Response to Treatment Plan b. ___ Yes ___ No Documentation of Patient Progress c. ___ Yes ___ No Unresolved Problems from Previous Office Visit Addressed d. ___ Yes ___ No Planned Follow-up Care e. ___ Yes ___ No Exam Findings: iii. ___Yes ___ No Description of Patient’s Judgment and Insight iv. ___Yes ___ No Brief Assessment of Mental Status Including: d. ___Yes ___ No Orientation to Time, Place and Person e. ___Yes ___ No Recent and Remote Memory f. ___Yes ___ No Mood and Affect (eg, Depression, Anxiety, Agitation) FINANCIAL 1. Does each encounter have a note?............................. ___ Yes ___ No 2. Does each visit note have an encounter form?.......... ___ Yes ___ No OPTIONAL FORMS 1. ___ Yes ___ No No Show Cancellation Policy 2. ___ Yes ___ No Laboratory Results 3. ___ Yes ___ No Copies of Prescriptions and/or Prescription Log/List

Jefferson CME Performance Improvement – Physician Self-Assessment of Clinical Documentation

Last name: ___________________________ Last 4 digits of SSN: ___________________ (required for credit)

Prior to completing the chart reviews:. Compared to my institutional peers I would have predicted my performance on this measure to be Compared to national / authoritative guidelines I would have predicted my performance on this measure to be:

Much higher

Higher

Same as

Lower

Much lower

O

O

O

O

O

O

O

O

O

O

Please Print or Type: Last Name

First Name

MI

Title (Dr., Ms., Mr.)

Personal Title (II, Jr.)

Degree

Department

Specialty

Mailing Address City

State

Zip

Telephone

Fax

E-Mail

Year of graduation from Medical School

Degree:

Status:

MD/DO

Other

O

O

Full-Time Faculty O

Academic Rank:

Years in Practice:

% time in clinical practice

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Voluntary Faculty O

GENDER

Male

Female

O

O

Trainee

Community Physician

Other

O

O

O

Professor

Associate Professor

Assistant Professor

Instructor

None

O

O

O

O

O

0-5

6 - 10

11 - 15

> 15

O

O

O

O

75%

O

O

O

O

Jefferson CME Performance Improvement – Physician Self-Assessment of Clinical Documentation

Last name: ___________________________ Last 4 digits of SSN: ___________________ (required for credit)

Board Certified?

YES

NO

O

O

Year Certified: What year will you be RE-certified?

Very High

High

Moderate

Low

Very Low

O

O

O

O

O

I would rate my overall performance on this measure as

O

O

O

O

O

I believe my need for improvement in this area is

O

O

O

O

O

My commitment to improvement in this area is

O

O

O

O

O

The value of this chart review as a practice-based performance improvement exercise is

O

O

O

O

O

This process helped me understand my practice patterns

O

O

O

O

O

After completing the chart reviews I would rate the accuracy of my predicted self-assessment as

Upon reflection and additional case review, I believe the reason(s) for performance variance in this area may be assigned to the following categories Very High

High

Moderate

Low

Very Low

O

O

O

O

O

O

O

O

O

O

Systems barrier (identify) (ie, practice system, insurance system, etc)

O

O

O

O

O

Payment issue (for example, not a reimbursable procedure)

O

O

O

O

O

O

O

O

O

O

Staffing issue

O

O

O

O

O

Other (specify)

O

O

O

O

O

Knowledge barrier (for example: new protocol, new technology, new/recent information, changed guidelines) Performance barrier (for example not enough time to prepare, too many patients for given time frame, Specify: what keeps me from performing to standard?)

Inadequate training

Please comment on performance variance in the space below:

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Jefferson CME Performance Improvement – Physician Self-Assessment of Clinical Documentation

Last name: ___________________________ Last 4 digits of SSN: ___________________ (required for credit)

Based on this review, I have identified the need for practice improvement in one of the following areas * (check the PRIMARY area that applies) Patient Care Medical Knowledge O O O

Interpersonal/Communications Skills

O

Professionalism

O

Systems-based practice

O

None

O

Other

O

*The American Board of Medical Specialties (ABMS) has identified these as important to maintenance of certification for physicians in practice.

I would identify my attitude toward a need to change as Pre-contemplation (not considering any change) O

O

Preparation (decided change is needed, and will experiment with small changes )

O

O

O

Maintenance (successfully implemented identified change for over 6 months; is now incorporated into practice)

Contemplation (ambivalent about changing; reflecting on barriers and benefits of making a change) Action (identified a change to make and already implemented) Other (specify)

O

I have reviewed the data provided and completed the Stage A task for this project.

Credits* Claimed for Stage A

YES

NO

O

O

1

2

3

4

5

O

O

O

O

O

*Please note that the AMA no longer calculates credits based on hours spent. Please claim credits based on the extent of your involvement in completing this portion of the activity.

Don’t forget to ATTACH YOUR STAGE A WORKSHEET. Return all forms to: Office of CME, Jefferson Alumni Hall / M5 Fax 215 923 3212

Please also complete page 4.

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Jefferson CME Performance Improvement – Physician Self-Assessment of Clinical Documentation

Last name: ___________________________ Last 4 digits of SSN: ___________________ (required for credit)

As a participant in this pilot project, we would appreciate your responses to the following questions. Your responses are not required to obtain your CME credits; however, your feedback will assist us in designing effective and user-friendly processes for Performance Improvement CME projects. 1hr

2 hr

3 hr

4hr

>4 hr

What amount of time was required for your review of practice data, relevant charts, and completion of the worksheet?

O

O

O

O

O

What amount of time was required for completion of the CME documentation (this form)?

O

O

O

O

O

The American Board of Medical Specialties (ABMS) has mandated recertification to include “evidence of performance in practice” and emphasizes periodic self-assessment and practice-based learning and improvement through a Maintenance of Certification process. Please respond to the following questions Very High

High

Moderate

Low

Very Low

Your current knowledge about your Board’s Maintenance of Certification (MOC) requirements

O

O

O

O

O

Extent to which you found this portion of the CME Performance Improvement activity educationally worthwhile (i.e., did you learn something important about your practice?)

O

O

O

O

O

Extent to which you would consider this portion of the activity as “CME”

O

O

O

O

O

Appropriateness for this portion of the activity to carry up to 5 Category 1 CME credits

O

O

O

O

O

Please rate

Your comments and suggestions about this project are important to us. Please use the space provided or contact the Office of CME to discuss your feedback.

Return this form to: Office of CME, Jefferson Alumni Hall / M5 (fax 215 923 3212)

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