Remote Area Aboriginal Health Services (RAAHS) quality checking in QST 111-22180000

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

The quality checking process:

• helps Team Leaders and Quality Checkers to identify process improvements
• makes sure consistency in quality checking

PBS quality portfolio holder is responsible for:

• National implementation of PBS quality practices
• analysis of national quality reports to identify learning needs or process improvement opportunities
• escalation of national quality issues to the program area and/or Health Service Delivery Division, Quality Operations & Technical Support

Managers must make sure:

• quality checks are done as specified in the sampling plan
• quality assurance is performed as per Remote Area Aboriginal Health Services (RAAHS)
• Quality Checkers complete the process for quality checker accreditation
• Quality Checkers hold appropriate skill tags in the Quality and Support Tool, by sending an email to Quality Operations & Technical Support
• timely error feedback is discussed with Service Officer as a part of coaching conversation to support any learning and development opportunities
• analysis of errors, i.e. if errors occur due to factors such as limited training, understanding the business rules, environmental or system based issues
• positive quality checking outcomes are acknowledged with the Service Officer
• lodgement of quality checking outcome disputes
• analysis of data to identify learning needs or process improvement opportunities
• escalation of serious quality issues

The Resources page contains links to the Quality Checking Feedback Policy and Privacy Incident Portal.

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
• examine source documents to make sure data entered into the PBS Claims Processing System and RAAHS Journal is accurate
• complete root cause analysis and identify systemic issues
• report and escalate trends or concerns to their 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 providing feedback
• adhere to program business rules

Quality checking of own work

Quality Checkers must not quality check their own work. If their work is selected it must be given to another accredited checker to complete.

Quality Team is responsible for:

• providing support for quality checking in the Quality and Support Tool (QST)
• providing relevant reports as required
• arranging QST training for Quality Checkers
• supporting the business with flexible and fit for purpose quality approaches

Staff members performing quality checks must:

• have knowledge of relevant policies and procedures and know where to find them
• maintain a high standard of personal correctness, for the work they check
• have an understanding of the quality checking procedure
• meet accreditation standards annually

Quality checking accreditation must be renewed annually.

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

Pre-checks

Pre-checks apply:

• to new starters
• when new processes are introduced

New starters have 100% of their work reviewed and corrected until deemed proficient. PBS Remote Area Aboriginal Health Services (RAAHS) claims are not finalised in the system, until this check is completed.

Pre-checks are completed within 1 business day of processing. Checks are made against completed work held in the:

• Processing and National Demand Allocation (PaNDA) tool
• PBS Claims Processing System
• AHS Journal

Any errors made in pre-checks must be recorded as errors and are captured in the Quality and Support Tool. Results are used to support ongoing training.

Program checks

Programme/post-checking randomly selects work completed the previous business day in Processing and National Demand Allocation (PaNDA). The results are given to management and external stakeholders as needed. Program checks are completed against source documentation in:

• PaNDA
• PBS Claims Processing System
• AHS Journal database

Program checks are completed daily so errors can be corrected before the payment journal is generated.

The results of program checks are captured in the Quality and Support Tool and are included in quality reports.

Targeted checks

Targeted checks apply:

• in response to business triggers or when there is a consistent/long term quality issue identified
• to Aim for Accuracy process (Check the Checker) which is completed every 12 months. This is to confirm the accuracy of quality checking results. The process involves rechecking a representative sample of previously checked work to decide if quality checking procedures have been followed correctly.

Pre-checks

Staff who are new to this work are considered proficient when they have processed a minimum of 40 claims 100% correct.

As a guide, checks should be completed over several days; up to a maximum of 10 claims per day:

• Day 1 - 100% of their work
• Day 2 - 70% of their work
• Day 3 - 50% of their work
• Day 4 to 8 - 20% of their work
• Day 8 onwards - 20% of their daily work is checked until 40 claims are processed 100% correct

If errors are detected at any stage, staff remain on that day’s percentage rate until no errors are detected.

A Quality Checker may deem a person proficient sooner, if there is enough evidence they can process this work correctly. The Learning and Development Team must agree with this determination.

Program checks

• 5% of the monthly total of Remote Area Aboriginal Health Services claims are randomly selected for quality control
• For large claims the Quality Checker checks for 30 mins (starting at the end of the claim). This gives a representative sample of the claim’s quality
• A large claim may have been actioned by a number of operators. The Quality Checker must check PaNDA comments to see where each operator started and finished processing
• The outcome of the quality check is provided to the operator who finalised the claim and based on their work only. Any errors by earlier operators is provided to them as feedback only

Targeted checks

Team Leaders are to send an email request to Quality Operations & Technical Support. Include:

• staff member's details
• the reason
• length of time needed for the check

Time frames

Pre-checks: quality checks are expected to be completed within one business day of work completion

Program checks: where possible, quality checks are completed within one business day after being allocated in the Quality and Support Tool

Payment checks: quality checks are completed immediately before a payment journal is generated, before the journal is sent to the delegate and the Finance Accounting Branch for payment

Resources

Quality Checkers must have access to the following to undertake quality checks:

• Skill tags on the Quality and Support Tool
• Quality and Support Tool
• RAAHS policies and business rules on Operational Blueprint
• PBS Claims Processing System
• Schedule of Pharmaceutical Benefits
• Processing and National Demand Allocation (PaNDA)
• FileNet
• Team share drive for the AHS Journal database, and the AHS error spreadsheet

Pre quality checks are manually assigned as part of the learning program. This is in line with the Remote Area Aboriginal Health Services (RAAHS) sampling plan quota. Records of these checks are maintained in the Quality and Support Tool (QST).

Program quality checks are completed using the QST. QST randomly selects work completed in PaNDA in line with the RAAHS sampling plan quota.

The AHS error spreadsheet is located on the team share drive. This is used to record journal payment errors in comparison to the Claims Summary Statement totals.

Critical and non-critical errors

Error codes are categorised as critical and non-critical.

A critical error is when there is a potential risk to:

• a customer's:
• privacy
• eligibility
• payments
• application assessment being finalised
• record
• the agency's reputation

A non-critical error is when it does not meet the above criteria. Generally, this relates to administrative errors.

Only critical errors are used to calculate the health status of the program.

Quality Checkers record the results of all checks in the Quality and Support Tool as the checks are completed. Results are captured in the monthly reporting data, if actioned within four calendar days of the end of the month.

A system generated email is sent in real time to the Service Officer and their Team Leader advising them of the quality check outcome. Individual results are captured in QST.

Quality checking feedback is emailed to the Service Officer and their Team Leader. It includes details about the:

• check
• the result (including any errors identified)
• quality checking dispute process

Managing feedback

Managers should review and analyse error feedback to decide the appropriate action. This includes:

• reviewing individual feedback during coaching sessions
• determining underlying causes
• implementing individual learning support actions
• notifying the line manager of quality concerns or issues
• escalating systemic issues by sending an email to the PBS quality portfolio holder
• notifying senior management of serious errors which place the agency’s reputation at immediate risk
• reporting all privacy breaches using the Privacy Incident Portal

During coaching sessions staff can contribute to a collective understanding of why the errors happened. Staff can help identify underlying causes. This can include:

• weaknesses in the process
• gaps in business rules
• system faults/limitations, or
• environmental issues

If the outcome of quality checking is disputed, managers can email Quality Operations & Technical Support to have this reviewed.

Managers also acknowledge staff’s commitment to quality, when their work is error free.

Critical errors – Quality Checkers must correct critical errors as they are found.

Non-critical errors – Quality Checkers provide instruction in the feedback email. Service Officers correct non-critical errors.

Quality Checkers should consult subject matter experts for procedural or policy related queries. If the query remains unresolved it can be escalated to the manager. If needed, managers can email escalated queries to the Pharmaceutical Benefits Branch.

Queries relating to quality arrangements should be escalated to the PBS quality portfolio holder.

Enquiries about the quality checking process or issues with checking results that cannot be resolved on site, should be directed to Quality Operations & Technical Support by email.

Quality checking procedures are reviewed and updated by the business and program in consultation with Quality Operations & Technical Support. The review makes sure error codes are current and approved policy changes are included.

Any changes that need immediate action will be advised and updated accordingly. Any changes not critical to quality will be included in the review of the procedures.