2016 Value Reporting Measures and Services
- 1. To contact the RAF Physician Concierge, please call (540) 741-7566
- 2. RAF facilities have achieved accreditation by the American College of Radiology (ACR) in areas including: Clinical Correlation MRI Safety Questionnaire PMs Professional Requirements/CMEs Report Review Mammography Machine Ultrasound (Breast, OB, GYN, General, Vascular) Breast MR MRI CT (Centers of Excellence included) RAF radiologists have earned a top 100 ranking in Radiology Business Journal, based on criteria including: Procedure volume Radiologist and employee FTEs Number of imaging centers Number of hospitals served Radiologic Associates of Fredericksburg is committed to providing services of the highest value to our community by focusing on three core components: Compliance, Satisfaction, and Quality RAF physicians attend an annual physician coding in-service 100% of technologists complete radiation safety training at the time of hire 100% of providers and staff complete annual HIPAA Privacy and Security training RAF has a dedicated compliance committee that assesses compliance metrics including coding accuracy, medical necessity, and regulatory and statutory conformance RAF physicians regularly meet with other specialists to develop programs that increase the quality of clinical services. Order Facilitator successfully indexed 43,080 faxes at Medical Imaging of Fredericksburg, LLC locations, closing the loop on referring physician communication from orders to results. RAF Physicians are evaluated through a Physician Workplace Relationship survey, which is designed to assess employee perception of physician workplace relationships. Of 31 RAF Physicians, 26% scored above a 95% rating, and 45% scored above 90%. The median score for all RAF Physicians was 89%. Compliance Satisfaction Quality RAF physicians actively participate in community and healthcare conferences regularly, to include: TAVR VHVI Primordial General, Breast, and Thoracic Cancer Conferences Regional Cancer Conference
- 3. Compliance Compliance Committee Audit Review Satisfaction Quarterly Diagnostic Audits of Coded Procedures: 100% of coded procedures were above the 92% accuracy threshold in 2016. Employee Satisfaction Referring Physician Satisfaction RAF actively reaches out to referring physicians to gain valuable feedback on ways to better serve referring physicians and patients. In addition to sending regular surveys to referring physicians, RAF physicians also make frequent visits to referring physician offices, with a total of 32 visits in 2016. = meets or exceeds national benchmark and/or internal goals 100% RAF employee satisfaction ranked at 100% for corporate administration, and 97% for executives, based on an 83% participation rate in the annual survey. 97% Corporate Administration Executives Patient Satisfaction On average, 2016 Patient Satisfaction Scores were reported in the 96th percentile for MIF, LLC (via Press Ganey) and at 98 percent for VIVA. 96% 98% MIF, LLC VIVA The 2016 goal for MIF, LLC and VIVA was 94%. Radiologic Associates of Fredericksburg continuously evaluates performance through specific Compliance, Satisfaction, and Quality Measures Medical Imaging of Fredericksburg employee satisfaction had a power item score of 4.21 out of 5.00, achieving Tier 1. This score was based on data compiled through Press Ganey. 4.21 out of 5.00 RAF MIF MWH Medical Staff Survey Radiology services achieved high performance scores in the 2016 Press Ganey Medical Staff Survey at Mary Washington Hospital. 4 4.1 4.2 4.3 4.4 4.5 Accuracy of Results Performance of Services Timeliness of Obtaining… RAF National Average Medical Imaging of Fredericksburg ranked among the top five of all MWHC departments. MIF & VIVA
- 4. Quality Adequate Biopsy Samples Biopsies Fax/Confirm RAF Radiologists have documented notifications to ordering providers for critical or significant findings. 5,010 fax/confirm notifications using information technology platforms were completed in 2016. Hospital Compare Percentage of patients who came to the ED with stroke symptoms who received brain scan results within 45 minutes of arrival. Outpatient CT scans of the chest that were "combination" (double) scans. Outpatient CT scans of the abdomen that were "combination" (double) scans. Outpatients with brain CT scans who got a sinus CT scan at the same time. National Average Mary Washington Hospital Stafford Hospital 68% 75% * Data collected from Hospital Compare (CMS) * = No Data Available QRUR (Quality Resource Use Reports) 80% 90% 100% Q1 2016 - 92% Q2 2016 - 97% Q3 2016 - 98% Q4 2016 - 99% Average- 96.5% QRUR are generated using PQRS measures and CMS calculated quality and cost measures. This is used to determine quality of care delivered during a performance period compared to peers. Scores result in a negative, neutral, or positive adjustment to Medicare Part B FFS payments. RAF reviews QRUR reports annually to identify opportunities to improve quality and cost of care. RAF QRUR scores are equal or better than specialty peer categories. RAF has achieved its goal of performing above the national benchmark. Turnaround Time Nuclear Cardiac Turnaround Time: 1 hour 1 minute SH ED Report Turnaround Time: 7 minutes 34 seconds MWH ED Report Turnaround Time: 22 minutes 36 seconds Stroke Turnaround Time (Head CT): 99.35% of patient studies were read in </=45 minutes MIF, MILH, MINS Average Report Turnaround Time: 7 hours 15 minutes 2.1% 0% 0% 8.4% 0.4% 1.1% 2.9% 1.9% * Biopsy Complication Rate Q4 2016 Image Guided Biopsies Success Rate: 97.7% Complication Rate: 1.2% Thoracic Biopsies Success Rate: 97.3% Complication Rate: 4% All within SIR and ACR practice parameters = meets or exceeds national benchmark and/or internal goals Benchmark: >90% VIVA Mary Washington Healthcare