Aged Care payments quality checking in QST 111-21031647

The Aged Care payments quality checking process aligns Services Australia's Enterprise Quality Framework and the 7 quality principles.

See Resources for a link to the Enterprise Quality Framework.

The Aged Care payments quality checking process will:

• ensure the quality of work types not checked within the quality online (QOL) assurance program
• support consistent and correct activity outcomes
• provide managers and checkers the tools to identify strengths and weaknesses in the aged care claim process, highlighting opportunities for continuous business improvement, using effective quality checking processes
• ensure quality checks are completed in a consistent manner

The following work types are not covered by this procedure:

• eACCRs/NASF
• adjustments
• bank details
• opt in
• hardship
• held events
• quarterly review
• unapproved
• Email enquiries

The 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, Performance & Technical Support team
• reviewing and updating relevant Operational Blueprint files and training materials
• reviewing suggestions and working collaboratively with the Quality, Performance & Technical Support 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 make sure:

• Quality Checkers complete the process for Quality Checker accreditation for Health Service Delivery Division
• Quality Checkers hold appropriate skill tags in the Quality and Support Tool by sending an email to Quality, Performance & Technical Support team
• error feedback is discussed with 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 of:
• limited training
• limited 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 serious error which places the agency’s reputation at immediate risk
• they escalate systemic issues
• they lodge quality checking outcomes disputes

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 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 giving feedback
• examine system information/source documents to make sure Aged Care payment claims processes are in line with business rules, policies and procedures
• make sure they do not check their own work. If a quality checker’s own 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 needed
• arrange QST training for Quality Checkers
• 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 for Aged Care Payments
• meet accreditation standards annually

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. Any errors made in pre-check must be recorded as errors.

Claim tolerance approval criteria

Before approving a claim, Quality Checkers must check the following tolerances:

• Difference is less than 10% between the Total entitlement of the service’s current and the previous claim month
• Total entitlement in the current claim is between 1 cent and $5,000,000
• Total of the retrospective adjustments in the current claim, excluding manual adjustments, is less than 10% of the total entitlement
• Current claim does not contain multiple retrospective adjustments
• Current claim is neither the first or last claim. For example, the service has opened or is closing

There have been no viability supplement changes

If the claim does not meet any of the tolerances, Quality Checkers must investigate and remediate errors before the claim can be finalised and approved again.

Programme/post-checks

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

Targeted checks

Targeted checks apply to:

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

Pre-checks

Staff have 100% of their work checked until they become proficient. As a guide, new starters are considered proficient as per the training and consolidation plan from the Learning and Development team.

Programme/post-checks

2% of Aged Care Payments work types are randomly selected for quality checking.

Targeted Checks

To arrange a targeted check(s), Team Leaders send an email request to the Quality, Performance & Technical Support team 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 length of time required for the targeted check
• details about how often a targeted check report is required. For example, weekly

Source documents

Aged Care Payments work are randomly selected for quality checking in the QST from work types allocated through the PaNDA tool. PaNDA provides the source documents.

Quality checking is done on the source documents below (where applicable):

• scanned application forms such as the scanned Application for the Oxygen or Enteral Feeding Supplement form (AC011)
• supporting documentation, for example:
• accreditation certificate for a practice relocation
• certificate from a doctor, and
• copies of tax invoices as proof of evidence when claiming the higher oxygen or enteral feeding supplement
• faxes
• letters

Timeframes

Quality checks are undertaken daily on a random sample of work.

• Pre-checks - quality checks are normally done within 1-2 business day of the work being completed
• Programme checks - where possible, quality checks are completed within 4 calendar days of being allocated in the QST

All quality checks for the month must be actioned within 3 calendar days of the following month. After this time, remaining work is abandoned.

Resources

Quality checkers must have access to the following to do quality checks:

• program specific processing systems
• PaNDA
• Quality and Support Tool (QST)
• skill tags added on the Quality and Support Tool
• relevant internet and intranet sites, for example, Operational Blueprint

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

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 impact the above criteria. Generally, this relates to administrative errors.

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

Each time a quality check is completed, the Quality Checker records the outcome in the Quality and Support Tool (QST).

An email is sent in real time to the Service Officer and their Team Leader advising them of the outcome.

Individual results are captured in QST.

Feedback is emailed to the Service Officer and their Team Leader. It gives details about the:

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

Method for managing and storing feedback

Feedback is recorded/stored in the Quality & Support Tool. Discussion notes about the feedback should be detailed in coaching sessions.

Correcting Errors

If errors have been identified, action must be taken to correct the error. An email will be sent to the Service Officer and their Team Leader following the completion of the quality check. Any errors will include feedback with details of the error and directing staff member to appropriate resources to correct.

In the case that the Service Officer is absent, on extended leave or a time sensitive situation arises the Team Leader will need to follow up any remedial action.

The Team Leader is responsible for ensuring that corrections have been undertaken for errors identified.

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

Non-critical errors - Quality Checkers provide instruction in the feedback email. Service Officer’s correct non-critical errors.

Quality Checkers must consult their Tier 1 technical support - Local Peer Support (LPS) for questions about Aged Care Payments.

Enquires about quality checking process or issues with checking results that cannot be resolved on site should be emailed to the Quality, Performance & Technical Support team.

Quality checking procedures are reviewed and updated by the business and program in consultation with Quality, Performance & Technical Support team. 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 incorporated in the review of the procedures.