4. In which ways is the initiative creative and innovative?
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2014/2015
Activity Action Plan Comments on progress Success measure Start date Completion
date Responsible person
Case management authorization.
Address late disclosure or reluctant to disclose if on medical aid.
Incorrect classification of patients by administration clerks.
Incorrect ICDI10 coding
Stale accounts leading to rejections
Ensure that admission clerks probe questions for patients to disclose if on medical aid.
Training and development of staff, in-service training of Administration clerks and on orientation of new staff.
Monitor pending cases for classification ,train ,mentor
Mentor staff on ICD 10 coding
Emphasize accountability on inappropriate coding
Assist as Mentor for hospitals coming for benchmarking
Attend regular operational meetings with Medikredit on operational issues
initiate and contributes to case management processes to Improve skill performance in ICD 10 coding
Formulates protocols to protect patients from financial risks and cost being imposed on them
-Administration clerks to probe questions.
-Orientation of new staff led to steady rise authorizations on admission.
Improved skill performance in classification ,monitor and auditing files and teach
ICD 10 coding in-service
Lectures done and ongoing
-Staff uphold ,adhere and are compliant to the principles of ICD 10 codes uphold to reduce rejections
-Operational processes are in place where Claims /Invoices are extracted weekly by Medikredit incorrect ICD10 codes or item codes are identified corrected prior being sent to Funder.
.
Reduced frequency of rejected claims
Reduced number of non-disclosures
Increase in Revenue
Reduced frequency of stale claims
Reduced rejected claims
based on ICD 10 code
by 99.99%
Reduce write-offs of hospital debts
Developed a reputation of reduced rejected claims
Protocols are in place to address shortcomings of financial risks and prevent patients from unnecessary cost being imposed on the patients.
01/01/2014
01/01/2014 01/03/2015
01/03/2015
M.Makwela
Ward clerks /staff/case managers
MMakwela
Case manager
Clinical efficiency and management,
Communication and advocacy. Clinical efficiency management systems ensure patients receive timely, adequate, safe, quality health care
Record keeping of update progress report There is evidence of adequate Case Management record keeping.
Updates and feedback from funders.
Case managers receive appropriate formal training and in-service updates in efficiency management topics
-A process is in place to manage financial risks for payment of care and to protect patients from unnecessary costs.
Positive member feedback /from the funders
-Satisfied customers / Funders and employees
-Evidence of course attended by case manager to reduce claim rejections
-Reduce frequency stale accounts
-Increase in revenue
- Increase in Revenue
-Reduced
claims rejections
-No stale accounts or claims. 01/01/2014 01/03/2015
M.Makwela
Clinical efficiency and management,
Communication and advocacy. Clinical efficiency management systems ensure patients receive timely, adequate, safe, quality health care
Record keeping of update progress report There is evidence of adequate Case Management record keeping.
Updates and feedback from funders.
Case managers receive appropriate formal training and in-service updates in efficiency management topics
-Protocol in place to protect patients from unnecessary cost
Positive member feedback /from the funders
-Satisfied customers / Funders and employees
-Evidence of course attended by case manager to reduce claim rejections
-Reduce frequency stale accounts
-Increase in revenue
- Increase in Revenue
-Reduced
claims rejections
-No stale accounts or claims. 01/01/2014 01/03/2015
M.Makwela
Client /patients satisfaction
-Ensure that patients’ service is efficiency and professional.
-Regular updates and reporting to Executive Management/Fund.
-Advocate, communicate and facilitate processes to achieve positive outcomes for the patients and healthcare team. -Continuously review case management processes, work flow with a view to improve existing process
Identify Gaps in the usage of charge sheet, billing and schedule training and development for staff to close in skill gap
-Positive member feedback/
communication
-Positive outcome in meeting program
Patient excellent outcome 01/01/2014 01/03/2015
M.Makwela
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5. Who implemented the initiative and what is the size of the population affected by this initiative?
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The project was initiated by the Department of Revenue and Budget Administration originated in partnership with
Case Management Society of America which is an international, non-profit organization established in 1990, affiliates to Case Management in South Africa which was launched in 2009, aspires to become nationally recognized as the representative body of Case Managers in South Africa. The provided us with Standards of case management Practice and Process Steps
The Department of Health with Department of Revenue and Budget Administration introduced case management in the Public Sector.
At Tembisa hospital Case Manager Margaret Makwela contributed to the design of Charge sheet, Update progress report and
Daily processes, workflow processes as it differs much with private sector. Central Office staff management Benchmarked with Tembisa Hospital.
Mrs. Zambelis Irene Facilitator for Government Case Managers contributed to the training of case managers on health risk management and policies relating to Medical Scheme Act 138 of 1999
Case Management Association in South Africa contributed to the training of case managers too Carol Garner the Director of MSO.
Staff paid for the training and passed awarded certificate in short course of case management
Implementation was carried out by individual hospitals in Gauteng Province same as Tembisa Tertiary hospital
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6. How was the strategy implemented and what resources were mobilized?
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Executive Management together with Human Resources offered a spacious office and bought the following:
Computer with CPU AND KEY BOARD
Fax, Copier, Scanner and printer connected to our main server and Gauteng Province ICT main frame,
BAS-Basic Accounting System .These connections make our work user friendly
Tembisa Financial Department had laid down infra structure long time ago to fit the organization namely:
Billing department, Tracing, Budget and Revenue .So, and Case Management unit came in as a new unique department but not that big enough to accommodate three people. Registered Nurse, Enrolled and Administration clerk
At present post have been advertised for the unit case management unit to run the department efficiently staff is needed
The project was funded by the Financial Department /Revenue and Budget Administration from Central Office under the Department of Health
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7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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Benchmarking:
Central, Provincial and District hospitals, Benchmarked with Tembisa Tertiary hospital have acquired case management principles, standards and thus enhanced the skills, efficiency, coordination and communication skills in the Public sector
These are the names of Gauteng Province that Benchmarked with Tembisa
Chris Hani Baragwanath Hospital were assessed by National core standards and obtained 98% after benchmarking
George Mkhari Academic hospital
Natalspruit hospital
Charlotte Maxeke Johannesburg hospital
Pholosong hospital
Bertha Qhowa hospital
Leratong hospital
Odi hospital
Brits hospital
Cross border hospital from Limpopo Province that is St.Ritas hospital
The above mentioned hospital have since reported to be doing well
• Community Empowerment minimized recurrence readmissions of chronically ill patients
Our case managers will locate resources in the community and may point other organizations that will be able to provide key services once patients are discharged home or might want to visit.
Advantages:
• Adjust to living as independently and safety as possible
• Attain maximum functional independence
• Reduce cyclical patterns of short-term readmission to acute facility
Evidence: A transfer to the most appropriate health care setting/provider
• Perception and staff attitude modified
• Provide an on-going in-service training on UPFS,CHARGE SHEET,ICD10 CODE and health education:
• reduced rejected claims based on ICD 10 coding by 99.99%
• reduced incorrect capturing of pertinent date
• Reduced stale accounts
• Increase generation of revenue
• Increase generation of revenue
Target set for Tembisa Tertiary Hospital for 2013/2014- R18, 000,000
Revenue collected prior the end of March 2014 financial year: R19, 200,000
Over collected by R1, 200,000 which was beyond our expectation
• Tembisa Hospital was nominated as the best hospital efficient in implementation of case management and National Core Standards
• Performance and Case management quality excellent implementation :
Obtained 85.71% in 2013 for efficiency and excellent customer care
Obtained 100% in 2014 for efficiency and excellent customer care
We worked tirelessly in order to achieve the desired goals for Tembisa Hospital without any doubt
• Compliments letters from Case Management Association in South Africa
• Central Office Head of Department-acknowledgement letter
• United States of America (Case Management Association of America
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8. What were the most successful outputs and why was the initiative effective?
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• Marketing strategy :Strategy Implementation-Pull and Push Strategy as a long term
• UPFS training. ICD 10 Coding.
• Investing in ongoing training and development for patient excellent outcome
• Mentoring and one –on-one interview
• Knowledge and experience and application of policies, laws, standards, protocols and Memo circulars needed in order to manage the department. for e.g.: Constitution of South Africa Chapter2(Bill of rights),Minimum Information Security Standard, Medscheme Act 133 of 1998,National Health Act 61 of 2003, Nursing Act 2005(Act no. 33 of 2005),R2598,R387,R373,Code of conduct of Public servants.
• Monitor and give Health education on compliance to treatment reduced many complications and minimized hospital re-admissions
• Evaluate the outcome of Quality Assurance Committee meetings
• Monitor the accurate auditing of records, problems identified note that quality improvement plan is written and recorded
daily stats, weekly and monthly statistics gaps identified are closed almost immediately
• Monitor if ward rounds are being taken daily to identify gaps and patients needs to address non-disclosure
• Private Public Partnership –Medikredit/GEMS consulted for in-service lecture for Tembisa Administration clerks /Case Managers to enhance the skill on capturing of pertinent data
• Attend seminars, workshops and conferences to enhance the skill in case management
• Participate in monthly Quality Assurance Committee meetings to identify service delivery gaps
• Auditing of records problems identified write quality improvement plan
• Community work based project should be on-going
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9. What were the main obstacles encountered and how were they overcome?
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Computer literacy:
The majorities on nursing staff are not computer literate and a need for training by Information and Technology expertise needed to close in gap. Outcome staff were trained on computer and mastered the skill in typing and spelling
• Shortage of resources for example: individual computers in each department for nursing staff and ward clerk-more computer have been motivated for the 2015/2016 financial budget
• Overcrowding and non traceable of foreigners
Tembisa community has grown up to Midrand/ Diepsloot. Daily consultations at Out-patient =2000 and average admissions per day 700.The community and foreigners sabotage the referral system and patients cannot be turned back to the clinics once inside the hospital.
• Community Empowerment -Reduced average length of hospital stay of chronically ill patients from 27.8 days to 10 days(HIV/AIDS/TB) thus saved cost per patient
Budget and Administration from Central Office have now introduced new technology to identify all patients coming to hospitals .These system is able to identify even foreigner since it linked to Home Affairs Data Base.
• Perception and staff attitude were the main obstacle due to resistant to change but now are modified through ongoing training on the Six National Priorities modified-improving values and attitude of staff managers and patients
• Non-disclosure:
Value for money-Members enrolled on medical aid are reluctant to produce their cards since they claim public sector wards are not being clean, food not appetizing and no linen. Community need to provide blankets for their loved ones in hospital.
• Less frequent admissions of chronically ill patients to hospital.
• Measuring effectiveness based on changes in awareness after campaigning for PMB and Case Management and Community Empowerment showed positive impact:
• Case management project created a competitive edge amongst staff to enter into different awards competitions to improve quality performance.
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