Quality Report Card - Outpatient Colonoscopy Measures as of April 2018

Outpatient Colonoscopy Measures

(April 2018 reporting is based on discharges from April 2016 to March 2017)

More recent data is also available reporting discharges from April 2017 - March 2018


<<back to Quality Report Card home page

Facility has implemented Provation which provides a template for required documentation
by physicians. New software implemented in January 2018 to make it easier for physicians to document
appropriate follow up interval. Education to all
providers performing colonoscopy cases (GI providers and surgeons) regarding the CMS guidelines were implemented. Monthly results are
reviewed and re-education provided as needed. We are working
with physicians to ensure the appropriate documentation is present in the medical record. Completed education of staff and physicians regarding CMS requirements. All
fallouts are addressed as soon as abstraction of information is complete. An 'Opportunity for Improvement' letter is used for one-on-one
communication with physicians/offices/patients to find the missing data and correct the documentation in the chart. Compliance data is
posted quarterly and year-to-year comparison data is posted as well and mailed to physicians when a kudos is indicated. Provation software rolled out Dec 2017 to improve electronic
documentation practices.  Physician re-education of CMS guidelines recently completed. Working with physicians
to ensure complete documention.

Completed education of staff and physicians regarding CMS requirements. All fallouts are addressed as soon
as abstraction of information is complete.