External Breast Prostheses Reimbursement Program (EBPRP) quality checking in QST 111-22050000

The EBPRP quality checking process aligns the Enterprise Quality Framework and the 7 quality principles.

The quality checking process:

• helps Team Leaders and Quality Checkers identify process improvements
• ensures consistency in quality checking

Service Delivery Support team is responsible for:

• analysing national quality reports to identify learning needs or process improvement opportunities
• escalating national quality issues to the relevant program or policy area and/or to the Quality and Skill Tags team
• reviewing and updating relevant Operational Blueprint files and training materials
• reviewing suggestions, and collaborating with the Quality and Skill Tags team to improve Operational Blueprint quality checking process and resources
• identifying strategic and operational risks or issues that impact customer outcomes

Managers/Team Leaders must ensure:

• Quality Checkers complete the process for Quality Checker accreditation
• Quality Checkers have the right skill tags in the Quality and Support Tool. Send an email to Quality and Skill Tags to get more information
• error feedback is discussed with the Service Officer as part of the coaching conversation. This supports any learning and development needs
• they analyse any errors. For example, did the errors occur because there is limited training, understanding of the business rules, environmental or system based issues
• positive quality checking results are discussed with the Service Officer
• they analyse data to identify learning needs or process improvement opportunities
• quality checks are done as specified in the sampling plan
• they notify senior management of a serious error which places the agency's reputation at immediate risk
• they escalate systemic issues
• lodgement of quality checking outcomes disputes
• they escalate serious quality issues, such as reporting all privacy breaches using the Privacy Incident Notification form on the Report a privacy incident intranet page. See the Resources page of PBS Authorities quality checking in QST

Quality Checkers must:

• carry out quality checks as outlined in the sampling plan
• update and maintain technical knowledge, procedures and policies
• maintain a correctness standard for personal accuracy
• complete root cause analysis and identify systemic issues
• report and escalate trends or concerns to the Team Leader
• give constructive and non-judgemental feedback. Include reference materials such as Operational Blueprint
• explain the impact of errors and action to be taken to correct the error (where applicable) when giving feedback
• examine system information/source documents to make sure EBPRP claims are actioned in line with EBPRP business rules, policies and procedures
• complete Quality Checker accreditation
• consult subject matter experts for procedural or policy related queries
• report results of quality checks in the QST
• make sure they do not check their own work. If a quality checker’s work is selected, it must be passed to another accredited checker to check

Quality Team must:

• provide support for quality checking in the QST
• provide relevant reports as required
• support the business with flexible and fit for purpose quality approaches

To be accredited, Quality Checkers must:

• have knowledge of relevant policies and procedures
• maintain a high correctness standard in the program they are checking
• have an understanding of the quality checking procedure
• meet accreditation standards

See Quality Checker accreditation for Health Service Delivery Division for more information.

Pre-checks

Pre-checks will be applied to new starters and when there are new processes for the Program. Staff will have their work 100% reviewed and corrected until deemed proficient. These results are not included in accuracy of processing results.

Letters

Letters are to be checked for the correct customer and scenario before being sent to the claimant. See Preparing, quality and peer to peer checking of Medicare external mail and Processing claims for External Breast Prostheses Reimbursement Program (EBPRP) for more information.

Program/Post-checks

Program/Post-checking randomly selects work completed the previous business day in PaNDA. The results are provided to Program Management and external stakeholders as needed.

Targeted checks

Targeted checks for EBPRP are completed for:

• staff when there is a substantial new process or an identified quality issue
• Aim for Accuracy process (Check the Checker) every 12 months. This confirms the accuracy of quality checking results. The process involves rechecking a sample of checked work to decide if quality checking procedures have been followed correctly

New starters will have:

• Pre-checks: 100%`of their work checked until they reach the program accuracy Key Performance Indicators (KPI), with at least 30 activities checked
• Letters checked for the correct customer and scenario before sending to the claimant. For more information, see:
• Preparing, quality and peer to peer checking of Medicare external mail, and
• Processing claims for External Breast Prostheses Reimbursement Program (EBPRP)
• Program/Post-checks completed daily on a statistically valid sample of incentive transactions. The results are used to report on the health of the program. All discretionary claims are to be checked, and always sent to the Program Management team for assessment approval or rejection
• Targeted checks - to arrange a targeted check(s), Team Leaders send an email request to Quality and Skill Tags with the:
• percentage of work type to be checked. For example, 100%
• staff member's name and logon details
• Quality Checker's name and logon details
• reason and the length of time required for the targeted check
• details of how often a targeted check report is required, for example, weekly

Source documents

EBPRP transactions are randomly selected for quality checking in the QST from work types allocated through PaNDA. Source documents are obtained from PaNDA.

Quality checking is performed on the EBPRP claim form, letters and receipts (if applicable).

Note: if a notation has been made, this becomes part of the source (supporting) documentation that is subject to quality checking. This will be in the form of notations in PaNDA.

Timeframes

• Pre checks: quality checks are expected to be completed within one business day of work completion
• Program/Post checks
• If possible, quality checks are completed within 4 calendar days of being allocated in the QST. High-risk work is prioritised for daily action
• At the end of the month, any program checks not completed are automatically abandoned after 4 calendar days

Resources

Quality checkers must have access to PaNDA, QST and program specific processing systems.

Quality checks

Enquiries about the sample of work being checked can be emailed directly to the EBPRP Processing team.

Quality checking

Checkers must consult their subject matter experts, in the first instance, when clarification is sought for any issues encountered while quality checking this work.

Enquiries about quality checking process or issues with submitted checking results that cannot be resolved on site should be emailed to Quality and Skill Tags.

An error is information processed or keyed that does not match the documents supplied, or the supporting documents uploaded on the systems.

Critical and non-critical errors

The error codes are categorised as.

• a critical error when there is a potential risk to:
• a customer's, privacy, eligibility, payments, record or application assessment being finalised
• the agency's reputation
• a non-critical error when it does not impact the above criteria. Generally, this relates to administrative errors

Note: only critical errors are used to calculate the accuracy of processing results.

The Resources page lists error codes.

Each time they complete a quality check, the Quality Checker records the outcome in QST. An email is sent to the Service Officer and their Team Leader advising the QC outcome. Individual results are captured in QST.

The QC feedback email includes details about the check and the result, including any errors identified.

Feedback on errors must:

• be direct and to the point, non-judgemental and constructive
• describe the error, and what was incorrect
• explain the impact the error has, for example to the recipient/claimant, Services Australia
• explain the action to be taken to correct the error (where applicable)
• include any relevant reference material that supports the action, such as an Operational Blueprint file
• provide the opportunity for development and not be used for punitive purposes

Method for managing and storing feedback

Record feedback in QST.

Detail discussion notes about the feedback in coaching sessions.

Error analysis is conducted by the:

• Team Leader or Local Peer Support (LPS) as required for local issues
• Program Management Support for analysis of the program

If errors have been identified, the original processing Service Officer (where required), must take action to correct them.

When corrections cannot be made by the original processing Service Officer, the Team Leader is responsible for ensuring an escalation process is in place for corrections.

If the error requires a file fix, the Quality Checker must send the request for the file fix. See Processing claims for EBPRP.

Quality checking procedures are regularly reviewed and updated by the Program in consultation with Learning Development and Quality. The review ensures the error codes are current and applicable and that approved changes to Program Management business policies are included.

Issues with the Quality Checking Procedure are recorded and escalated to Quality Management via email.