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Audits of Hospital Admitted Patient Data 2005-09

This project audits hospital admitted patient data in Victorian casemix-funded public hospitals, including publicly-funded denominational hospitals and Small Rural Health Services (SRHSs), as reported by hospitals to the Victorian Admitted Episodes Dataset (VAED) for the financial years 2005-06, 2007-08 and 2008-09.

Objectives

The key objectives of the project are to:

• Assess the validity of casemix-based payments to Victorian public hospitals;
• Assess the application of the contemporary DHS Hospital Admission Policy, particularly for short stay admitted episodes;
• Support improvements in the accuracy of admitted patient data reporting.

The project will provide:

• A measure of the accuracy of the ICD-10-AM codes submitted by Victorian public hospitals, and the extent to which the codes reported are supported by the clinical documentation and allocated in accordance with contemporary reporting requirements;
• A measure of the impact of any code changes on Victorian-modified Diagnosis Related Groups (Vic-DRGs), and the impact of these changes, and/or inaccuracies in other relevant data, on hospital payments under the prevailing funding arrangements, as indicated by change in Weighted Inlier Equivalent Separations (WIES).

’Accurate’ reporting is considered to be reporting in accordance with DHS’ requirements to completely and accurately reflect the events of each admitted patient episode.

Scope

The project will audit 10,000 episodes in year one and 13,000 episodes in years two and three.  Sixty hospitals will be audited in each year of the project. 

In years two and three, sites reviewed in the previous round, where the rate of change of DRG and/or WIES exceeds rates deemed by DHS to be acceptable, may be reviewed again, with larger sample sizes designed to achieve more statistically significant results. Similarly, if this second review also delivers unacceptable results, the site may be the subject of a supplementary audit, the cost of which will be passed on to the hospital, as set out in the Standard Conditions of Funding.

Samples are randomly selected and represent approximately one per cent of each site’s annual separations, with a minimum sample size of 40 episodes, except where the sample size is increased to achieve statistically significant results in follow-up sites.

Targeted audits of particular case types, sites or data items, and additional cases may be included, depending on audit findings and ongoing data quality activities within DHS.

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Episodes for Audit

Apart from targeted reviews, audit episodes will be limited to those reported with Care Types 4 (Acute), K (Non-Designated Rehabilitation Program/Unit) or U (Unqualified Newborn), and excluding Vic-DRG R63Z Chemotherapy and Vic-DRG L61Z Renal Dialysis. Episodes for review will be drawn from throughout the relevant financial year, although consideration will be given to exempting some months immediately following the introduction of significant changes in admitted patient reporting.

Data for Audit

Data to be evaluated include ICD-10-AM diagnosis codes, ACHI procedure codes, Victorian alphabetic code prefixes, contracted procedure flags, morphology codes, and a range of administrative and demographic data items that impact on Vic-DRG grouping or WIES allocation.  The appropriateness of audited episodes will be assessed with reference to the DHS Hospital Admission Policy.

Casemix auditors may also comment on coding infrastructure including access to resources and patient record format.  Such observations will refer to objective measures/standards, or to widely accepted conventions; observations based on the auditor’s personal opinion will be acknowledged as such.

Casemix Auditors

All data reviews will be conducted by suitably qualified and experienced Health Information Managers or Clinical Coders. Casemix audits are conducted under the provisions of the Health Services Act, which sets out the role and functions of casemix auditors. Casemix auditors will carry authority from DHS to perform this role and are bound by professional ethics and practices to maintain the confidentiality of patient information and the details of their work on this project.

Review Methodology

Each episode will be reviewed by the casemix auditor ‘blind’, that is, without reference to the hospital-assigned clinical codes or values for administrative and demographic data. This will require the hospital to prepare each record for review by obscuring hospital-assigned codes and other data values, either by removing, covering or folding over the relevant page(s).

All patient documentation for the episode under review, including laboratory investigation and imaging reports, including those held electronically, will need to be accessible to the casemix auditor.

Casemix auditors will apply all relevant Australian Coding Standards (ACSs), Victorian Additions to the Australian Coding Standards, 10-AM Commandments provided in the National Centre for Classification in Health (NCCH) publication Coding Matters, and the Victorian ICD Coding Committee’s Query Database

Administrative and demographic data will be assigned by casemix auditors in accordance with data and code definitions and reporting requirements set out in the relevant edition of the VAED Manual, including updates issued from time to time by DHS.

Casemix auditors will seek agreement with relevant hospital representative(s) for those cases where the auditor-assigned data grouped to a different Vic-DRG to hospital-assigned data. Hospital staff will be given an opportunity to review these cases without the auditor present. When agreement cannot be reached, HMA will have a second auditor review the case, usually requiring de-identified episode documentation to be copied and sent off-site. The second auditor’s values will be provided to the hospital, for further discussion. Casemix auditors will outline other findings as part of the debrief process at the end of the audit but have been asked not to discuss these in detail due to time constraints.

Reporting

A written report will be produced for each site and will be posted (password protected) on the DHS website. The hospital will be notified when the report is available. Hospitals will be expected to address issues identified by auditors, and will be asked by DHS to describe action to be taken in this regard.

A final report will be produced for each year of the overall project, in which each site’s results will be summarised, broad findings described, and comments and recommendations made. The final report for each round will be made available to all Victorian public hospitals via password.

Contacts for queries

Queries regarding this audit of hospital admitted patient data should be directed to Jennie Shepheard at the Department of Human Services by email (jennie.shepheard@dhs.vic.gov.au) or phone (9096 0484) (Monday to Wednesday only).

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