Archive for the ‘Surveys’ Category

OBQM/Chart Audits and the New Survey Protocols: Tweaking and Streamlining Process for Real Improvement

Tuesday, October 25th, 2011

From Outcome-Based Quality Improvement (OBQI) refresher training to Total Quality Management Agency Programs, the home health agency of today needs to define the level of programs needed to operationally and financially drive  success. The home health agency needs OASIS stop, logic, and congruence edits to prompt clinicians and flag incongruence between M questions. But, that is just the start. The OASIS integrated assessment sets the stage for the plan of care created. From the plan comes the visits and they must support that plan and drive to expected outcomes.

Perhaps your firm would benefit from a third party quality clinical chart audit. Your Professional Advisory Committee, Board of Directors, and you may well see the merit of an independent view of clinical processes and care. Noting strengths and determining opportunities for improvement before a survey makes sense. Are you spending too much time and money internally for chart reviews? What does happen after those reviews? Do you educate personnel? How do you know if that education was successful?

Clinical chart audits can assist you to remedy issues, provide education and training, and improve efficiencies. Clinical audits can assist to streamline processes, determine areas of risk, and assist to improve the bottom line.  Clinical audits can assist to identify quality customer service and improve patient care.

“Identifying ways that an outcome-based corporate culture fully extends to both internal and external customers is the responsibility of leadership. Developing and using simple tools can aid in the process. Once systems are implemented, maintaining a true commitment to TQM becomes a powerful challenge. But, to the persevering leader, the rewards of quality customer service can go hand in hand with a positive bottom line” (Carmichael, 2005)*

The new survey protocols mandate an outcome–oriented survey process, therefore, know that the surveyor will continue evaluating, per CMS, “the quality of care and services furnished by the agency as measured by indicators of medical, nursing, and rehabilitative care.” In addition, the new process will emphasize the clinical record of assessment and care, agency personnel interviews, and home visits. The new regulations provide clear guidance for expanding the survey, if needed.

Besides Process and Chart reviews, agencies should routinely use the Surveyor Worksheets to review agency data filed with the state, look at diagnoses and expected outcomes, monitor potentially avoidable event outcomes, and be certain there is adequate documentation for case mix indicators.

An evaluation of Level 1 indicators (see Select Data University April, 2011 article on New Survey Protocols, Survey Protocol Worksheets) includes standards under skilled nursing and therapies. If the agency is in compliance with Level 1 standards and no additional issues or concerns are identified, the survey is completed. If the expected outcomes are not met for one or more Level 1 standards, then the survey expands to become a partially extended survey.

At the very minimum, compliance with Level 2 standards is evaluated if deficiencies were identified with Level 1 standards. This is the partially extended survey. Be aware that surveyors may review additional non Level 1 or 2 standards under the same conditions during the partially extended survey at their discretion. (State Operations Manual, SOM, Appendix B). In an extended survey, all conditions will be reviewed. Appendix B and Survey Protocols provide specific recommendations for: citing condition-level deficiencies, extending the survey, and related conditions for further survey.

Now, more than ever, a thorough assessment must drive discipline specific care plans that drive the overall POC with every visit skilled and enhancing the process toward expected outcomes. Clinical record reviews, clinical interviews, and home visits drive the survey process. Documentation is essential. Good documentation starts with a thorough assessment. That assessment should be specific. Does your assessment tool set the stage for success? Is it detailed enough to gather data to allow the highest level of coding specificity? Does it cue the clinician with requests for detail to support a case mix diagnosis that may be assigned?

It is simple in the guidelines; a good POC starts with a solid clinically integrated OASIS assessment. That assessment drives the discipline specific care plan and those plans contribute to the overall POC. That POC has diagnoses present that require substantiation in the clinical record and the expertise of master coders. That very record supports the diagnoses sequences chosen. The visits can stand alone as to skill but reflect that they are a part of an individualized skilled plan of care.

Documentation takes time and thought. Clinicians are busy and require assistance and support. Consider a third party coding entity. Also consider an OASIS data collection service that was created by clinicians.  The system should be reflective of what you expect and of what your clinicians need.

The new survey protocols are data driven. Agency leaders need real data daily, weekly, monthly to monitor clinical performance and patient care outcomes.

The Surveyors have the data when they arrive. Do you?

*Carmichael, S (2005). Total quality management and outcomes based quality improvement: revisiting the basics. In Home Health Care Management and Practice (17)(2),119-124

RACs, MACs, Z-Pics:The Auditors are Unleashed

Saturday, October 15th, 2011

What are your agency case mix averages by admission: clinician: diagnosis?

Do you know your top five diagnostic patient profiles?

How do you set visit frequencies? Formula-based or what seems right?

Are you making visits that have no impact on patient outcomes?

Are you auditing for homebound status?

Are you auditing documentation for medical necessity?

What is your cost per visit by discipline?

What is your recertification percentage?

Do you know your supply utilization per patient?

Do supply usage have adequate supportive documentation?

Do you know what coding, operational, or billing edits you are routinely triggering?

How are you applying the data collected to your business processes?

The RACs, MACs, MICs, and Z-PICs are now in place. The auditors are expected to perform. They have been chosen based upon performance.

Algorithms and Matrices are in place using Predictive Analytics.

Per Wikipedia, predictive analytics “encompasses a variety of statistical techniques from modeling, data mining and game theory that analyze current and historical facts to make predictions about future events”.

CMS is using predictive models to identify patterns found in transactional data gathered to identify risks and potential future behaviors.  They are looking at diagnoses in relation to visit frequencies and recertifications. They are looking at HIPPS scores compared to visit frequencies and durations. They are looking at predictive models that capture relationships among many factors to allow assessment of risk or potential associated with a particular set of assessment/care frequency/payments expected. In other words, what are the guiding decision-making factors for agency transactions? This is one reason why there needs to be rhyme and reason for visit frequency and patient diagnoses and care needed.

Predictive analytics look at past performance to assess how likely an agency is to exhibit a specific behavior in the future. That behavior is then compared to other agencies’ behavior in order to calculate risk, then encompasses models that seek out subtle data patterns that  answer questions about that agency’s overall  performance. These analytics quickly become fraud detection models.

The MACs are using predictive models to perform calculations during live transactions to evaluate the risk or opportunity of a given agency transaction, in order to guide a decision. Individual agency modeling systems can simulate likely human behavior or reaction to specific situations.  The new term for animating data specifically linked to an individual in a simulated environment is avatar analytics. Hopefully, CMS is not there yet but gaming experts ARE employed by CMS.

The government is serious about attacking fraudulent behavior. The danger that exists is that some agencies not intending to commit fraud, but who are not auditing their data submitted, may be triggering alerts. Home Health Agencies can no longer afford to provide care without auditing the assessment, the care predicted, and the care provided.

The RACs have also identified that insufficient documentation for medical necessity will be one of the first area of focus for their audits. But, no agency should believe that only therapy documentation will be scrutinized. Skilled nursing with observation and assessment O/A continues to be high on the list for visit and episode denials.

What happens if compliance measures are not employed? Targeted Medical Reviews (TMRs)/(ADRs) Additional Documentation Requests will rise. There will be claim denials and Medicare audits.

CMS has Unleashed the Auditors

Annually, CMS receives 1.2 billion claims. That breaks down to 4.3 million claims per work day, 574,000 claims per hour, and 9,579 claims per minute. Fraud and abuse are on the rise and the pressure is on.

CMS has unleashed the age of the auditor with the advent of the RACs, MACs, CERTs, MICs, Z-PICs, and now, the HEAT.

RACs- The contingency motivated Recovery Audit Contractors (retrospectively focused). The RAC Demonstration Project of 2005-2007 recovered over $1.3 billion, mostly due to medically unnecessary services (45%), incorrect coding (35%), and insufficient documentation (10%). With four RAC approved firms covering specific geographic regions, these auditors are expected to continue their positive recovery program. The RAC demonstration project yielded a cost of only 22 cents for every $1.00 recovered. They are now in place and ready to go at measure. Certain RACs have been held back until all MACs were in place. That is now completed.

MACs – Medicare Administrative Contractors have been transitioning in and replacing the Regional Home Health Intermediaries (RHHIs). There are 15 MACs with 4 focusing only on DME claims. Though providers fear the RACs, they are well aware of the power of the MAC. This auditing body can impose “severe administrative action” such as up to 100% prepayment review, payment suspension, and use of statistical sampling for over payment estimation of claims (current and prospective focus). MACs have power and Congress is encouraging them to use it.

CERTS – (Comprehensive Error Rate Testing) To better calculate the performance of the FIs and MACs, as well as to look at the reasons for their errors, CMS decided to look at a number of additional rates. The additional rates include

—   provider compliance error (how well providers prepared claims for submission)

—   paid claims error rates (measures how accurately FIs and MACs make coverage, coding, and other claims payment decisions). CERTs randomly select a sample of about 100,000 claims each reporting period.

—  CERTs review the claims for proper Medicare coverage, coding, and billing rules, and if not in compliance, they assign an overall error rate.

CERTs also identify if providers received overpayment letters or notices of adjustments to be made for claims that were overpaid and underpaid. CERTs are considered the Quality Improvement specialists who track and trend the performance of fiscal intermediaries and Medicare Administrative Contractors.

Z-PICs – Zone Program Integrity Contractors will perform Medicare Program integrity functions for CMS. They will interact with each MAC to handle fraud and abuse issues within their jurisdictions. ZPICs are seen to consolidate the work of present CMS Program Safeguard Contractors (PSCs) and Medicare Drug Integrity Contractors (MEDICs) and are divided into 7 zones.

The Z-PICs act with the Department of Justice and FBI and act as the investigators when fraud is very strongly thought to have been found. The Z-PICs have the power to suspend claims for up to a year and the agency has no appeal recourse during that time.  That power can cripple or financially devastate an agency.

HEAT –This auditing body is considered the more aggressive investigator of essentially DME and Home Health.  There has been expansion of DOJ/CMS/HHS Inspector General Medical Strike forces to Baton Rouge, Brooklyn, Detroit, Houston, LA, Miami-Dade, and Tampa Bay and as recently as September, 2011, they have struck, arresting 91.

The HEAT is the technologically oriented auditing body using state of the art analytics to expand the CMS Medicaid provider audit program. This program leadership has meetings with top anti-fraud leaders in Congress/Law enforcement/Private sector.

CMS states that their mission includes, “providing additional resources to our civil enforcement efforts under the False Claims Act to increase dollars recovered; data sharing, including access to real time data; detect patterns of fraud through technology; strengthening partnerships among Federal agencies between public and the private sectors.”

Clearly, with all of the auditing bodies, CMS is making a bold statement; fraud and abuse will not be tolerated.. Unfortunately, in this kind of environment, innocent casualties can occur. Agencies need to take action now.

Can Audits be Prevented?

Maybe not, but exposure for paybacks can be limited by enacting solid compliance measures.

Prepare now. Be aware of what other providers have faced with auditors.

Be certain a clinical documentation chart audit is available for all disciplines for clinical records.

The following items should be included in every clinical note:

Homebound status: Identify what taxing effort was exerted if a patient left the house since the last clinical visit. Be certain all assistive devices are listed and/or the caregivers needed, the purpose for leaving the home, and if this was expected and/or a part of the careplan.

Identify what skilled the visit. If teaching was conducted, was it initial teaching, reinforcement teaching, or was it re-teaching? Identify in objective terminology measureable progress towards goals; ie for the psych nurse, what evidence toward cognitive structural behavior was identified? For physical therapy, how many feet were walked since the last visit and where does this relate to the plan? For the SN, did the patient identify at least two key side effects for their medications? Does the patient know what their medication is for and what it is expected to do for them? Do they know how to safely take their medications?

Compare the Visits to the POC: Compare the visit note to the plan of care that is developed by the clinician based upon the assessment. Have physician orders or notification for changes in condition. Note all change of condition clearly.

SN should be reviewing the body systems noting VS and pain assessments.

When Teaching: Note if the teaching is New, Reinforced Teaching, or Reteaching of the same subject to, perhaps, another caregiver. Note the caregivers willingness and capacity to learn and carry out the learning skills. Note the patient and caregiver’s learning in percentage; ie 70% or 80%.

Interdisciplinary communication: Comments to the physical therapist or the home health aide or other disciplines should be clearly noted. The visits should show the progress of the care in relation to the plan of care.

Specificity of wounds, skin conditions, falls risk, depression, and the focus of care are necessary. Auditors look for detail; for reasons that support skill. No skill can mean denial of visit payment.

For Diabetics Receiving Insulin

Be certain homebound status is clearly and adequately documented.

Skilled Visits must have skill identified such as specific instructions.

Return demonstration responses by the patient or caregiver should be documented. Note the patient or caregiver’s ability to follow their diet. Give examples to support diet and meal planning learning.

Caregiver willingness and availability should be specifically noted on each visit.

More Strategies

Review all claims against known edits prior to submission.

Have a system that prevents claims from being submitted without a signed physician order.

Counsel and hold clinicians accountable for accurate, complete, and concise documentation that matches the planned care expectation.

Clinicians must now be aware that surveyors are looking at their assessments, discipline specific plan of care, the overall plan of care, the visit documentation outlining care provided and patient response, and the outcomes at the episode conclusion. The diagnoses listed in M1020/M1022 must be compliant with ICD-9 coding guidelines, be unresolved, must read as the table of contents for the clinical record, and must be supported by the clinical documentation.

RAC auditors use clinicians and coders on their team to provide more specific auditing. Ask your clinicians: could their visits withstand that kind of auditing review?

Establish peer review sessions at your agency. Proud clinicians want their peers to think highly of them. Peer Review audits can be an excellent defense against an audit, not only because they can be enlightening to clinicians as to what is expected, but because they can be a motivation for excellence.

Missed and PRN Visits

Tuesday, June 28th, 2011

With the advent of the new Surveyor guidelines that went into effect May 1, 2011, the focus is data collection and outcome achievement moving away from the prior focus on process. Outcome achievement starts with a great assessment, careplan, and visit strategy that means adherence to physician frequency orders. What happens if the clinician misses a visit?

Missed Visit
In home health care under the CMS guidelines, a missed visit occurs when a scheduled RN, LVN/LPN, HHA, PT, PTA, OT, OTA, S/LP, or MSS does not keep an appointment with a patient.  Examples:  1) Because of an ice storm, a PT does not visit the patient as planned.  2) The RN wound care specialist does not visit the patient as she is detained with another patient.

If calls to the agency to apprize them of the situation and a call to the patient results in the rescheduling of the visit to maintain the physician-ordered frequency, then there is no missed visit.  The agency must communicate with the patient to ensure that his or her needs are met and there is no jeopardy.

Though the physician must be notified, there is no need to get an order.  The agency can notify the physician by phone, fax, e-mail, or mail. 

If no rescheduling within the physician prescribed frequency can be accomplished, then a call to the physician to apprize him/her of the missed visit is necessary and, in this case, a new order may be necessary.

Make certain documentation reflects the missed visit and is a part of the clinical record.

The Interpretive Guidelines for the Conditions of Participation, §484.18, discuss notification of the physician when a visit is missed.

PRN visit
A PRN visit is an additional visit or visits, ordered by the physician, that can be made when the  specifics of the identified care are warranted.

It must include a specified number of visits during a designated time (usually a certification period) and a specific reason or a delineated description of signs and symptoms necessitating the visit.  The reason for the visit must be anticipated and the frequency predicted based upon the assessment of the situation.  Reasons for a PRN visit might include the need to change a catheter, manage an IV, or reassess vitals if a B/P exceeds specific parameters.  Other situations might include a description of signs and symptoms that are linked to the patient’s specific medical condition, such as specific fluctuations in blood glucose readings. PRN orders can apply to any discipline if they are written specifically. Examples of complete, valid orders include:

2 wk 6 + 2 PRNs when blood sugar is over 280 then 1 w3 + 2 PRN visits when BS over 280 .

PRN visits can be denied if the order was found invalid/ lacking in specificity. Both the services and the number of PRN visits to be permitted for each type of service must be clearly identified as well as predictable.  CMS state that “Open-ended, unqualified PRN visits do not constitute physician orders since neither their nature nor their frequency is specified”.

CAHABA states,

PRN Orders

Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 7 §30.2.2)

  • PRN orders are acceptable only when the orders are qualified for a specific potential need of the beneficiary and quantified to a specific number of visits to meet this need.
  • When a PRN visit is made, the date and reason for the visit should be explained in the medical record.
  • When an extra visit is billed and the plan of care contains open ended and/or unqualified PRN orders, an additional physician order must be obtained for the visit. If the agency does not have a signed interim order for the visit, the visit will be denied as in excess of orders.

Example 1: A beneficiary with a Foley catheter requires monthly catheter changes. The physician orders “Two (2) PRN visits per month for problems with the Foley catheter including blockage and/or leakage around the catheter.”  Visits are allowed because the physician specifically quantified the number of visits and qualified the visits to a specific need.

Example 2: A beneficiary with a Foley catheter requires monthly catheter changes. The physician orders include “PRN visits.” In this instance, since the orders are not quantified as to the number of visits or qualified as to a specific potential need of the beneficiary, no PRN visits are allowed.


Well written PRN orders and clear concise documentation supports patient need  The orders are acceptable (per CAHABA), if audited, when they are qualified for a specific potential need of the patient with a quantified  number of visits to meet this need. Make certain the physician is made aware of  PRN visit use, where appropriate. Also, be certain to inform the physician of trends in use of PRN visits which begin to identify a clear need for order frequency  modification.

Part 4: Record Reviews/Home Visits/Analysis/Assigning Citations

Thursday, April 28th, 2011

As stated in Parts 1-2 of this series, CMS has released the new survey protocols, including new guidance as to what HHA surveyors will be expecting from HHA. It is believed the new protocols will provide more survey consistency. According to CMS, the revised survey process incorporated in the protocols is “data-driven, patient outcome-oriented and less structure and process-oriented.” This guidance is effective May 1, 2011.

The protocols focus on the 34 highest-priority standards that closely relate to care quality. During the CMS April 6, 2011 training for surveyors, Pat Sevast (a nurse consultant with the CMS Survey and Certification group) stated that just one finding related to the standards could merit a citation which is a significant move from the present behavior that is seeking non compliant trends at an agency; ie, one of five records or 20% of records reviewed yielded a specific ongoing trend.

With the new survey protocols, a surveyor could cite an agency if just one patient file reflected a patient care issue or a lack of one omitted supervisory visit.  Industry leaders expect an increasing number of condition-level citations. The new protocols allow for one standard level citation to trigger a partial extended survey. If that would occur, the agency would be evaluated against the level 2 standards thus increasing their risk for serious citations.

The training for surveyors included Ms Sevast noting that CMS expects surveyors to cite at a condition level the patient rights’ conditions of participation (CoP) if an agency is out of compliance with two of the highest-priority standards and one level 2 violation. That would trigger an automatic extended survey necessitating review of all CoPs.

So what should an agency do?

Agencies should review the new survey protocols and become familiar with the Home Health “G” Tags and Abbreviated Identifiers, HHA Survey Investigation Worksheets and Calendar, and HHA Survey Investigation Worksheets as well as the Revised Home Health Survey Protocols of February 11, 2011 and the advanced copy of Appendix B- Guidance to Surveyors.

Parts 1-3 of the Select Data article regarding Survey Protocols published in the March 30, 2011 ezine looked at the types of surveys, level 1 and 2 citations, surveyor prep for the survey as well as the new entrance interviews, and the entrance information with specific information gathering techniques.

This segment, part 4, looks at the clinical records and home visits.

The number of records reviewed is still determined by the unduplicated census of the prior year as well as the number of records and home visits necessary to assess compliance with the CoPs.  There is an increase in required home visits by the surveyor as the focus is essentially patient care oriented.

Home visits to patients should include those receiving high-tech care, home health aide services  as well as patients triggering “at risk” of Level 1 and Level 2 potentially avoidable events. Some of the areas the surveyor will be looking at:

  • storage of records,
  • the most recent plan of care and its specificity as to orders and goals,
  • when the patient was visited in relation to the physician’s order,
  • completeness of the comprehensive assessment,
  • evidence of “major decline or improvement,”
  • how coordination of services are met,
  • any evidence of the patient/caregiver contributing,
  • care provisions not in compliance with the law,
  • case conferences, informal conferences and telephone calls,
  • patient specificity of the plans and visits,
  • evidence of patients denied or not offered services,
  • patients hospitalized,
  • patients with LUPAs,
  • reconciliation of care provided to orders given by the physician,
  • inter-related factors of patients with co-morbidities and the care received,
  • therapy visits made at ordered frequency,
  • evidence that PTAs, COTAs, and LVN/LPNs were supervised appropriately,
  • evidence home health aide visits were made every two weeks,
  • if an RN or PT ever observed the aide’s provision of care,
  • evidence the aide careplan was specific to the patient,
  • evidence of consistent documentation of VS, insulin injections, B/P, pain frequency/ severity/interventions,
  • how corrections are made in the record,
  • evidence of discharge summaries in discharge records,
  • evidence of consistent assessment of patient status and progress over the visits.

The home visit and interviews.

Home visit probes will focus on “compliance related to patient rights, accepted professional standards of practice, coordination of care, and comprehensive assessment of patients, plan of care, services provided, and clinical records.” Though not all inclusive, consider the surveyor will be looking at:

  • any instances of personnel providing care that may not be in accordance with laws, regulations, state practice acts, accepted professional standards, or agency policies and procedures,
  • communication by providers with patients/caregivers,
  • evidence that care is delivered by accepted professional standards,
  • evidence that care providers follow CDC guidelines,
  • evidence the aide follows the plan as identified by written instructions,
  • evidence that “medications in the home are the same as those listed on plan of care, interim orders, and clinical record notes,”
  • and asking the clinical personnel “about instances of patient care noted in home visits or record reviews that deviated from the physician orders, accepted professional standards or agency policy.”

The surveyor will interview the patient caregiver to validate that care documented in the plan is the care that is provided, will ascertain if needs are being met by the agency, identify if caregivers are satisfied with the care, that medications presently taken are what have been prescribed (and will compare it to physician orders found in the clinical record), that there is participation by the patient/caregiver in the planning of care, and if they understand the process for handling a complaint. These are minimum areas of review and the agency should be aware that the surveyor may ask when visits occurred, did the clinician and care provider wash their hands, and did they bring their own towels? The surveyor may ask to see all medications taken, including OTC meds and engage the patient/caregiver in discussing when and how they take the meds.

It is important that agencies review processes that are in place to be certain that appropriate agency personnel understand policy and those procedures that support that policy. There needs to be consistency of statements when speaking with the surveyors, who will now have a greater number of interviews scheduled then documented.

The information analysis

This process requires surveyors to review the information gathered during the survey and exercise judgments about the effect of care upon patient outcomes, the degree of severity of any behaviors not fully in compliance, the frequency of the non compliance, and how the services were impacted.

Standard and Condition Level Deficiencies

Data Tags (G-Tags) are assigned to the standards in the interpretive guidelines. If a data tag is assigned to a condition it becomes a condition level data tag. If assigned to a standard level deficiency it is cited at a standard level tag.

If a Level 1 standard-level deficiency is identified, “the surveyor is required to move to a partial extended survey and the surveyor examines, at a minimum, the Level 2 standards under the same condition and any other standards the surveyor chooses to examine.” A review of all Level 2 standards that relate to a deficiency at  Level 1 standards is the minimum requirement.

Any condition level deficiency “requires a move to an extended survey which includes a review of all CoPs and the policies and procedures that resulted in the substandard care.” Substandard care is defined by CMS as “one or more CoPs out of compliance.”


The new survey process is data-driven and begins with the surveyor’s pre-survey preparation. The surveyor will be focusing on patient care and outcomes derived. The Appendix B of the State Operations Manual has been revised and all are encouraged to read about the new survey process. The definition of a standard survey has been revised to increase the survey’s focus on those standards most related to patient care. Surveyor worksheets are available online at the CMS worksite and provide insight as to the depth and path of the survey. CMS has established a special mailbox for questions related to the new survey protocols Appendix B Guidance to Surveyors: Home Health Agencies of the State Operations Manual offers, in addition to the surveyor process, a full listing of the G-Tags and the interpretive guidelines allowing the agency to see the basis for the interview questions.

This survey process is believed to offer more consistency and focus. The new process complements the patient/outcome focus of OASIS and the drive for improved outcomes and quality patient care.  The surveyors training has been completed. It would be interesting to hear from agencies that experience the new process. Arm yourself with information. Let the new process begin!

Educational Video: New Survey Protocols

Wednesday, April 20th, 2011

CMS New Survey Protocols Clinical Compliance

Surveyors will, more in depthly, prepare for surveys, using OASIS data. They will review any complaints, previous survey data, and reports generated from the OASIS data. Available OASIS reports can be generated for specific time periods, as requested, from the OASIS Coordinator’s office. These reports include case-mix, potentially avoidable events, risk adjusted outcomes based quality improvement (OBQI) or process measure reports.

More Videos

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