PA Trauma Systems Foundation March 2017 : C1

REGISTRY ROUNDUP: Volume 22 Issue 4 PAGE 1 REGISTRY ROUNDUP Volume 24 Issue 1 | March 2017 Registry’s Increased Focus on Quality Many of you may have noticed an increase in the number of records returned for correction, particularly diagnosis related corrections. Believe it or not, this volume of corrections has always existed; however, the Foundation did not have the staff or the processes to efficiently address all the corrections. This has changed for two primary reasons. First, the Foundation created a new position to support the central site registry. This new position is called the Trauma Registry Auditor and it was filled by Gabrielle Wenger in May 2016. The focus of this position is to support the integrity, ongoing data quality and accuracy of the PTOS through educational support and quality improvement initiatives. This focus on quality leads me to the next reason for the increase in corrections. The second reason for the increase in corrections is a philosophy change at the central site registry. For years, almost two decades, the registry staff has focused primarily on processing the data, supporting site survey and maintaining the PTOS and its associated software. All of these responsibilities still continue and do so in an increasingly more efficient manner. However, the registry staff is now developing a philosophy less focused on standard maintenance of the PTOS to a more proactive, concurrent quality improvement focus. We are considering it “performance improvement for the registry.” We are now beginning to change processes internally to allow us to create a PI loop for the registry involving all of the central site registry staff. So what does this mean to you, besides an increase in corrections? It does not mean you will be adversely affected. Nothing we are doing regarding data quality improvement will in anyway be used as part of the accreditation process or review. It does means that you will see more education throughout the year, targeted PI initiatives, and perhaps increased proactive discussions around the quality of data at your registry. We will be using the data we have in the PTOS as well as input from the trauma centers to help identify PI opportunities in regards to the data. Make no mistake, thanks to the meticulous efforts of the trauma registrars at all of the trauma centers, the PTOS contains some of the highest quality data in the nation. Through the changes we are currently undertaking, we at the central site are increasing our efforts to support you in these quality efforts and are working to take the PTOS to an even higher level of quality and consistency. Thank you for your support and patience! New Educational Visit Process On July 28, 2016 the PTSF board of directors approved changes to the Trauma Registry Educational Visits policy (TR-106). These changes will become effective January 1, 2017. The on-site registry educational visit will continue

Registry Roundup

Registry’s Increased Focus on Quality

Many of you may have noticed an increase in the number of records returned for correction, particularly diagnosis related corrections. Believe it or not, this volume of corrections has always existed; however, the Foundation did not have the staff or the processes to efficiently address all the corrections. This has changed for two primary reasons.

First, the Foundation created a new position to support the central site registry. This new position is called the Trauma Registry Auditor and it was filled by Gabrielle Wenger in May 2016. The focus of this position is to support the integrity, ongoing data quality and accuracy of the PTOS through educational support and quality improvement initiatives. This focus on quality leads me to the next reason for the increase in corrections.

The second reason for the increase in corrections is a philosophy change at the central site registry. For years, almost two decades, the registry staff has focused primarily on processing the data, supporting site survey and maintaining the PTOS and its associated software. All of these responsibilities still continue and do so in an increasingly more efficient manner. However, the registry staff is now developing a philosophy less focused on standard maintenance of the PTOS to a more proactive, concurrent quality improvement focus. We are considering it “performance improvement for the registry.” We are now beginning to change processes internally to allow us to create a PI loop for the registry involving all of the central site registry staff.

So what does this mean to you, besides an increase in corrections? It does not mean you will be adversely affected. Nothing we are doing regarding data quality improvement will in anyway be used as part of the accreditation process or review. It does means that you will see more education throughout the year, targeted PI initiatives, and perhaps increased proactive discussions around the quality of data at your registry. We will be using the data we have in the PTOS as well as input from the trauma centers to help identify PI opportunities in regards to the data.

Make no mistake, thanks to the meticulous efforts of the trauma registrars at all of the trauma centers, the PTOS contains some of the highest quality data in the nation. Through the changes we are currently undertaking, we at the central site are increasing our efforts to support you in these quality efforts and are working to take the PTOS to an even higher level of quality and consistency. Thank you for your support and patience!

New Educational Visit Process

On July 28, 2016 the PTSF board of directors approved changes to the Trauma Registry Educational Visits policy (TR-106). These changes will become effective January 1, 2017. The on-site registry educational visit will continue to provide continuing education to the trauma registry staff, suggestions/ideas for improving the trauma center’s registry, as well as assuring consistent and accurate data abstraction to the PTOS across the Commonwealth of Pennsylvania. The approved changes to TR-106 were first recommended by the Educational Visit Enhancement Work group and the Trauma Registry Committee.

Changes for accredited trauma centers include:

• Frequency of visits decreased to once every five years

• Ten records will now be selected by PTSF staff for review

• The types of cases that are selected by PTSF for review will have a common theme each year (i.e. penetrating trauma cases, isolated head injury cases, burn cases)

• A chart navigator will be available on the day of the visit

Registry educational visits for pursuing centers and newly accredited trauma centers will experience little change.

Policy TR-106 can be reviewed in its entirety at http://www.ptsf.org/index.php/resources.

Links for 2017 ICD-10-CM/ PCS Coding Updates

The 2017 ICD-10-CM/PCS files on the CMS website contain information on the ICD-10-CM/PCS updates for FY 2017. These 2017 ICD-10-CM/PCS codes are to be used for admissions occurring from January 1, 2017 through December 31, 2017.

2017 ICD-10-CM links can be found at https://www.cms.gov/Medicare/Coding/ICD10/2017-ICD-10-CM-and-GEMs.html.

2017 ICD-10-PCS links can be found at https://www.cms.gov/Medicare/Coding/ICD10/2017-ICD-10-PCS-and-GEMs.html.

AHIMA Code-Check™

Looking for a source to send your ICD-10 coding questions to? Try AHIMA’s Code-Check™! AHIMA’s Code- Check™ is made up of credentialed, experienced coders to assist you. Their experience spans multiple settings such as inpatient, ambulatory care, and physician coding, and provides a unique ability to ask an ICD-10-CM, ICD 10-PCS, CPT, or HCPCS question.

Code-Check™ provides:

• Expert interpretation and guidance on necessary pathways for accurate code assignment

• Nomenclature and terminology relationships vital to correct coding paths

• Professional coding staff knowledgeable in ICD-9 and ICD-10 code sets

• Solutions with cited sources

• Guidelines for when to query for necessary documentation

• Quarterly reporting options for organizations to target employee training needs

For further information, visit http://www.ahima.org/codecheck.

New Educational Requirements

Effective October 1, 2016 the trauma registrar must have evidence of continuing education related to the trauma registry. Eight (8) hours of continuing education per year is required for Adult Level 1, 2 and 3 centers and Pediatric Level 1 and 2 centers. Four (4) hours of continuing education per year is required for Level 4 centers. This requirement can be fulfilled by attendance at PTSF registry conferences, internal, external and/or online opportunities.

Within one year of hire trauma registrars must also complete a basic registry course and the AAAM Injury Scaling Course. The PTSF Basic Registry Course, the ATS Trauma Registrar Course or other equivalent course will satisfy the basic registry course requirement. Previous completion of the PTSF Intermediate or Advanced Registrar Course also fulfills this requirement.

Registrars in the role prior to October 1, 2016 must have these requirements completed by October 2017. Basic registrar course participation and/or AAAM Injury Scaling Course participation will count towards continuing education hours for the year they are completed.

PTSF Learning Management Software (LMS)

The PTSF is in the process of migrating all previously recorded webinars and future educational offerings to a new, improved learning management software (LMS) system. Please see “Educational Opportunities” below to access PTSF’s first LMS webinar, “The ED Response Tab.” The PTSF staff will provide formal directions on how to access ALL of the previously recorded and new webinars in our new LMS system in the near future.

Certified Specialist in Trauma Registries (CSTR) Exam

Would you like to have formal recognition of your trauma registry knowledge? The CSTR exam is once again being offered by the American Trauma Society (ATS)! Information regarding the certification itself, eligibility, fees, and how to register can be found on the ATS website at http://www.amtrauma.org/?page=CSTR.

Remote Educational Visits

The PTSF still has a desire to remotely access trauma centers’ electronic medical records in order to conduct inter-rater reliability reviews remotely! Please contact Lyndsey at ldiehl@ptsf.org if your center would be interested in a remote educational visit in 2017.

ICD-10 Questions

ICD-10-CM/PCS arrived on January 1, 2016 for PA trauma registrars! The PTSF has received many questions and we anticipate many more questions to come! In order to best address each question, the PTSF has put into place an ICD-10 specific e-mail account and an ICD-10 Q&A document. Please send all ICD-10 related questions to ICD10Questions@ptsf.org. PTSF staff will review these questions and post responses within the ICD-10 Q&A document. To access the ICD-10 Q&A go to www.ptsf.org. Click on ‘Resources.’ Click on ‘+’ next to Trauma Registry. Scroll down until you see “ICD-10 Q&A” and click to download.

Don’t Wait!

Do you have a question for PTSF staff ? Do you have recommendations for changes? Don’t wait! Contact PTSF staff ! There is no need to hold any questions or changes until the end of the year. The sooner you bring an issue to our attention, the sooner we can address it.

• Nathan McWilliams, Director of Technology/Trauma Registry – nathan@ptsf.org

• Stephanie Radzevick, Trauma Data Analyst – sradzevick@ptsf.org

• Lyndsey Diehl, Trauma Data Quality Specialist – ldiehl@ptsf.org

• Gabrielle Wenger, Trauma Registry Auditor – gwenger@ptsf.org

Read the full article at http://digital.graphcompubs.com/article/Registry+Roundup/2741101/393519/article.html.

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