Administrative Processes and Billing
in the Healthcare for Criminal
Offenders in the Netherlands
Enabling the rehabilitation of criminal offenders through mandatory, government-provided mental healthcare in an efficient and affordable way2 This scientific research project explains the methods conducted at The Beagle Armada. This project is the final assignment of the Master Medical Informatics, a two-year academic programme which is given at the Academic Medical Center (AMC), the medical faculty of the University of Amsterdam (UvA). Student: Manon Plokker BSc. SRP Mentor: dr. T. Oosterbaan SRP Tutor: dr. F.J. Wiesman Teaching Period January 2018 – July 2018
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Preface
This thesis describes the administrative processes and billing in the healthcare for criminal offenders in the Netherlands. The thesis is a part of the Master Medical Informatics and was performed at The Beagle Armada, also known as TBA advies. The aim was to get an overview for the causes of errors in the billing of healthcare products of criminal offenders. I promised myself I would not fall into clichés when writing the preface of my thesis, but I can honestly say that there is a sense of finality now that it is done. I knew next to nothing about the subject of healthcare administration and forensic healthcare when I started my thesis and learning about healthcare administration and forensic care has been a journey full of challenges that I enjoyed very much. I want to thank everyone at TBA advies and specifically Teun Oosterbaan, for allowing me to research this subject with a freedom a student could only wish for and for providing me with knowledge and contacts whenever it was necessary. I have enjoyed working with you on this subject and I have learned a lot from you. Furthermore, I want to thank Floris Wiesman for all the constructive criticism and the willingness to take on a subject that was initially beyond either of our expertise or comfort zone. A special thanks for the clinics and their employees for their participation in this thesis. Lastly, I want to thank my family, friends and my boyfriend who supported me with patience and feedback through the writing of this thesis.4
Summary
In the Dutch justice system, criminal offenders can receive mental healthcare as part of their sentence. The ministry of Safety and Justice have contracted roughly 130 mental healthcare institutions to provide mental healthcare, which they reimburse on a monthly or yearly basis. Currently 25% of the bills that are sent to the ministry are rejected because they contain faulty information. The goal of this thesis is to gain insight into the administrative processes, what factors lead to errors and what factors can help prevent errors. To achieve this, interviews were conducted with healthcare administrators and professionals who perform tasks that concern the administrative information of a client. Through an analysis of interviews, UML activity diagrams have been created to capture the administrative processes that have to be performed in order to bill a healthcare product. Furthermore, a literature study was done to find a framework which could help categorise the types of errors that were made leading up to the rejection of the billed services. The framework by M. Leaver et al. was then used to identify human factors that played a role in the occurrence of errors. Then potential facilitators were identified that could help reduce the possibility of errors. Lastly the UML-activity diagrams were discussed in a focus group, in order to validate them. The resulting five UML-activity diagrams were validated by the focus group and are an accurate representation of administrative tasks that are performed in FPA clinics. An analysis of the errors that were made in the administrative processes showed that seven human factors and twenty-two associated elements played a role in the administrative processes. The most mentioned human factors were teamwork between partners, individual errors in the form of slips and lapses and the interaction between human and computer due to error prone systems. Facilitators that helped to prevent errors were a good collaboration between staff members in a mental healthcare facility, the vigilance of the administrators and the availability of good contacts within all chain partners.5
Samenvatting
In het Nederlandse rechtssysteem kunnen mensen zorg opgelegd krijgen als onderdeel van hun veroordeling. Het ministerie van Veiligheid en Justitie heeft hiertoe ongeveer 130 zorginstellingen gecontracteerd, die ze afhankelijk van het product, per maand of per jaar vergoeden. Op dit moment wordt gemiddeld 25% van de rekeningen die naar het ministerie worden gestuurd door zorginstellingen afgekeurd. Het doel van deze scriptie is om inzicht te krijgen in de administratieve processen omtrent de forensische zorg, welke factoren er leiden tot fouten en welke factoren helpen om fouten te voorkomen. In deze scriptie zijn interviews uitgevoerd met enkele zorgprofessionals en zorgadministrators die administratieve informatie van cliënten verwerken. Op basis van deze interviews zijn UML-activiteitdiagrammen van de administratieve processen gemaakt die nodig zijn om een zorgproduct in rekening te brengen. Daarna is een literatuurstudie gedaan naar de classificatie van fouten. De resulterende classificatie methode van M. Leaver et al. is daarna toegepast op de fouten die plaats vonden in het administratieve proces. Vervolgens zijn de factoren die helpen bij het voorkomen van fouten geïdentificeerd. Als laatste zijn de UML-activiteitdiagrammen gevalideerd door middel van een focusgroep. De vijf UML-activiteitdiagrammen zijn gevalideerd door de focus groep als een nauwkeurige weergave van de administratieve taken van een FPA-kliniek. De meest genoemde factoren die leiden tot fouten waren samenwerking tussen organisaties, individuele fouten en de interactie tussen mens en computer. De factoren die hielpen bij het voorkomen van fouten waren onder andere een goede samenwerking tussen werknemers binnen de zorginstelling, administratieve medewerkers die “bovenop” het proces zaten en goede contacten hebben met ketenpartners.6 Preface 3 Summary 4 Samenvatting 5 Chapter 1. An overview of the thesis 8 1.1 Forensic Care 8 1.2 The Goal of the Thesis 9 1.3 Research Question 10 1.4 Chapter Organization 10 Chapter 2. Selecting Suitable Data Sources 12 2.1 Selecting Suitable Data Sources 12 2.2 Demographics 13 Chapter 3. Identifying Administrative Tasks in the Forensic Care 14 3.1 Introduction 14 3.2 Methods 14 3.3 Results 15 Forensic care: Placing clients 15 Forensic care: Treatment 18 Forensic care: Billing services to the department of Justice 22 Forensic care: Changing a placement request 25 Forensic care: Correcting previously rejected billed services 26 Forensic care: The exceptions 29 3.4 Conclusion & Discussion 29 Chapter 4. Human Factors in Billing Healthcare Products 30 4.1 Methods 30 Literature 30 Model 30 4.2 Results 30 Literature search 30 Analysis 32 4.3 Conclusion and Discussion 34 Chapter 5. The Bottlenecks in the Forensic Healthcare Administration 36 5.1 Method 36 5.2 Results 36 Human factors in incidents: Placement 36 Human factors in incidents: Treatment 40 Human Factors in incidents: Billing services 45
7 Human factors in incidents: New indication 48 Human factors in incidents: Correcting billed services. 51 5.3 Conclusion and Discussion 54 Chapter 6 Facilitating Factors in the Prevention of Errors 56 6.1 Method 56 6.2 Results 56 Treatment 56 Billing 57 Correct billing 59 General facilitators 59 6.3 Conclusion and Discussion 61 Chapter 7. The Validation of the Forensic Care Administration Processes 62 7.1 Methods 62 7.2 Results 62 7.3 Conclusion and Discussion 63 Chapter 8 Discussion, Conclusion and Recommendations 64 8.1 Conclusion 64 8.2 Discussion 65 8.3 Future research 66 8.4 Recommendations 67 Recommendations for policy makers and the ministry of Justice and Security 67 Recommendations for healthcare institutions 67 References 68 Appendix A. Lexicon 70 Appendix 2. Interview guides 72
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Chapter 1.
An overview of the thesis
1.1 Forensic Care
In the Dutch justice system, the court can assign mental healthcare as part of a sentence, or condition of a parole, this mental healthcare is called forensic care. This thesis will explore the bottlenecks in the administration with regards to clients and billing forensic healthcare. When a person is in prison, or under the supervision of a probation officer, the persons supervisor can request mental healthcare at a select number of clinics. The mental healthcare that is offered is called “forensic care”. The department of justice is responsible for the placement, execution and payment of forensic care. The department of justice contracts clinics to provide this care for them and pays the bills the clinics send them. The annual budget for the healthcare of people under supervision of the justice system is 750 million euros, of which an estimated 500-550 million is spent on the mental healthcare. (1)(2) The forensic care consists of several care products. There are several different intensity levels (Dutch: zorgzwaarte) and different levels of security at which a client can be treated. The maximum-security state supervised offenders (Dutch: TBS) go to a forensic psychiatric centre (FPC). The high security state-supervised offenders go to a forensic psychiatric clinic (FPK). Offenders that do not fall under the state supervision and have a lower level of security can be admitted or receive ambulatory treatment at an forensic psychiatric ward (FPA). (3)(4) Furthermore, the administration, treatment and registration that surrounds mental healthcare in the Netherlands is subject to strict guidelines. In 2018 the standard product of care is a DBBC (Diagnosis treatment security combination), a ZZP (Care intensity package) or an EP (extramural product). The administrative load that accompanies the registration and billing of these treatments is high and requires healthcare professionals and administrators to enter a large amount of details manually into systems.Forensic care in societal context
Forensic care is given to lower the chance of offenders committing another crime. By treating the underlying conditions that led to the crime, such as addiction and mental illness, the chance of an offender using violence is reduced.(5) The judge receives an advice concerning the mental health of a defendant and can order a specified or unspecified time of treatment under varying conditions.(6) Annually there are several examples of cases where forensic care would be necessary; one such case is the case of Malek F. who stabbed three people in the Hague in May 2018. The family of Malek F. later sued a mental healthcare institution where he was a client before the incident, because they believed errors were made in his treatment. (7) However forensic care also makes national headlines through different incidents, such as the case of Anne Faber. She went missing in 2017 and her body was found a couple of days after she went missing. The suspect for her abduction, rape and murder was Michael P., who was on unsupervised leave from his treatment facility after being sentenced for several crimes in 2010. Although incidents like the case of Anne Faber are rare, they cause a large upheaval in the Dutch society. (8)
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Forensic care in the context of healthcare
The mental healthcare offered in the forensic care is not different from the care offered to clients who are admitted on voluntary basis; however, the treatment of forensic clients will last until the end of their sentence, after which they can voluntarily continue treatment. The lower security forensic care (non-state-supervised) have non-forensic alternatives funded through different bodies of government: For long-term care and admittance there is the bill of long-term care (WLZ) and there are living arrangements for people who cannot live independently funded by the bill societal support (WMO). (9)(10) The payment of the forensic healthcare resembles the payment structure of WLZ and those of insured healthcare. A professional must arrange a care indication or placement request and send it to the appropriate financer. The client is subsequently treated, and his or her care is billed to the appropriate instances. This bill is sent in accordance to the standards created by Vektis, which is subsequently checked and payed. The billing of healthcare insurers with the Vektis standards is similar for hospitals and mental healthcare. In April of 2018, the Dutch cabinet announced that it wanted to reduce the amount of fraud in healthcare billing through a letter to the House of Representatives (Dutch: Tweede kamer).(11) While the exact scope of the problem concerning fraudulent billing is unclear, a total of 45.4 billion euros were billed in 2017. Zorgverzekeraars Nederland (ZN) reported that 3.6 billion euros were denied because of errors, which amounts to 8% of the total amount that was claimed.(12) To the contrary, the ministry of Justice and Security reported that the rate of erroneous bills in the forensic care was 25%. While there is speculation as to what causes this, no definitive cause has been identified yet.(2)
Forensic care in international context.
The Netherlands is not the only country that offers treatment for mental illness for people who pose a risk to society; such care is also offered e.g. in the United Kingdom, Australia and Sweden. The specialised mental care deals with both the mental illness as well as the risk reduction and could also deal with the mental health issues that can arise through imprisonment.
1.2 The Goal of the Thesis
The Dutch ministry of Justice and Security is responsible for the provision and payment of healthcare for people who fall under its supervision and provision of forensic care. Currently 25% of the billed services are rejected according to the ministry of Justice and Security. A service is billed after the completion, which can take up to 365 days in the case of a DBBC. Considering that the treatment can include housing and the time a healthcare professional spends with the client, a healthcare product can easily amount to 100,000 euros or more. (2) If a bill is rejected, it has to be corrected by the healthcare institution and subsequently rechecked by the systems of the ministry of Justice and Security. The correction can take from a few minutes up to several hours and even days, depending on how quickly the error is identified and how easy it is to correct. Meanwhile, the healthcare provider will not receive the payment until the bill is found to be accurate and complete, which can cause cash flow problems for the healthcare institutions.(6)
10 On the 19th of June 2018 the Safety and Justice minister sent a letter to the House of Representatives, informing them on the results of several researches that looked into the forensic care. (11) The reports stated that there was a high work pressure in forensic clinics, due to the administrative burden, financial pressures and a shortage in suitable personnel. These pressures put the safety of the personnel that works with the forensic client under pressure. Currently a healthcare professional spends 16 hours in a 36-hour workweek on administration, which is more than he or she spends on direct contact with a client.(13) The minister proposed several solutions, one of which is the reduction of the administrative burden by 25% by 2020. At that time, there were no concrete measures as to how this administrative burden should be reduced. Goal The objective of this research is to make a process information framework which allows healthcare providers to gain insight into administrative tasks surrounding the forensic care chain, so they can better address issues that can arise in this chain. It can also be used to gain more insight into the processes that take place in the clinic. Furthermore, it aims to provide tools to identify processes in healthcare institutions that attribute substantially to the amount of rejected bills and tools to improve the approval rate of bills. It will focus on the perspective of healthcare institution and will therefore not concern laws and regulations because these are not within a clinics sphere of influence. The scope of this research is limited to administrative tasks are related to the billing of a healthcare and excludes tasks that are not related to the billing of a healthcare product; e.g: building an appropriate medical history and medication history is important to the treatment of a client, but not necessary to bill a healthcare product.
1.3 Research Question
Research question What administrative and billing tasks are causes for errors and drivers for improvement in the administrative and billing information processed by healthcare institutions. Sub questions: • RQ1 What and how is administrative information processed in the forensic care? • RQ2 What are causes for billing conflicts? • RQ3 Where in the Forensic care chain can billing errors occur? • RQ4 What mechanisms are used by healthcare institutions to reduce the number of errors?
1.4 Chapter Organization
The research done in this thesis will make use of interviews in every research question. Therefore, the selection of participants, the interview guides and the resulting interviewees are discussed in Chapter 2, prior to the chapters that will make use of the interviews. The interviews will be used in Chapters 3 to 6, to answer RQ1 through RQ4; each Chapter will contain a separate analysis with regards to interviews. Chapter 3 describes the creation of a process framework for the administrative tasks that have to take place in a healthcare-institution in order to receive payment for a care product (RQ1). In Chapter 4 a literature search is conducted on the subject of human factors. The results of the literature search are then used to identify human factors that play a part in the administrative tasks that lead to the rejection of bills (RQ2). Subsequently Chapter 5 details the location of human factors in the process framework (RQ3). Chapter 6 will detail finding facilitators that help the clinics prevent the occurrence of billing errors (RQ4). For chapter 7 a focus group was conducted to validate the process diagrams that were created in Chapter 3 and to explore the opinion of experts on the human factors, facilitators and incident locations that were identified in chapters 4 through 6. Chapter 8 describes the general conclusions of this thesis. Lastly, it should11 be mentioned that while this thesis is in English, the subject is largely exclusive to the Netherlands and all the interviews were conducted in Dutch. As such, sometimes a translation of a Dutch term is not always entirely accurate. To cover any meaning that would get lost in translation a lexicon was added Appendix A. Lexicon.
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Chapter 2.
Selecting Suitable Data Sources
This chapter will describe the data collection for this thesis. It starts with the selection criteria for potential clinics and the professionals within the clinics. Subsequently the conduction of the interviews and the interview guides are discussed. The analysis of these interviews will be discussed in the Chapters 3 through 6.2.1 Selecting Suitable Data Sources
To select mental-healthcare institutions that are suitable for the research, the whole scope of the forensic healthcare landscape must be considered, before the scope of the research is narrowed.
The forensic care landscape
There are several types of forensic care that come in different care products and security levels. The different levels of intensity and security are offered in different clinics, each with a specific spectrum of care: FPC, FPK and FPA. The treatment for TBS clients can be given in an FPC or FPK for the highest and high security level clients respectively. The number of clients enrolled in TBS is limited and the rules and regulations concerning these clients are very strict. Besides care for TBS, these clinics often also provide specialised treatment for lower security levels or even non-forensic clients as a side-business. An FPA offers a wide range of care, catering to clients who can have both ambulatory as well as clinical care. They can get referrals from prisons, as a part of scaling down care for clients from an FPC or FPK, or directly from the judge. Their care products can come in the form of DBBCs, ZZPs and EPs which are offered to a variety of treatment options. Subsequently there are smaller contractors, often offering only care for a small portion of clients, often ambulatory or housing. They usually have one area of specialisation, such as care for people with mental disabilities. Scope The choice was made to contact healthcare institutes that provided both clinical and ambulatory care but do not provide TBS. TBS was excluded because it is offered by a very small range of clinics. TBS care is subject to guidelines and regulations that exceed the regulations for other forensic care. Investigating only ambulatory or only clinical clients would dismiss a large financial component of the forensic care, or a large portion of the client list respectively. A further selection was made regarding the finances of an institution. There are several large organisations who provide forensic care; the assumption was made that these organisations have their administration in order due to sufficient manpower. A further assumption was made that clinics that were small did not have the manpower to treat a variety of clients. Therefore, it was decided to only include mid-sized clinics with an annual overturn between one and ten million in the year 2016 or 2017. The required response rate was 2 clinics, with four participating staff members per clinic. This would allow for at least eight interviews. This minimal response was chosen because it was necessary to have at least information on an administrative process from two clinics. However, it was not expected that there would be large differences in the administrative processes. Time constraints on
13 the part of the participants did not allow for an extensive exploration of in-depth administrative processes in this study. With these selections, three random clinics were contacted through telephone and email. They were asked to participate in this research, which investigated the administration in the forensic care, which would consist of 4 interviews. One additional clinic was contacted through the contacts of TBA advies, which agreed to participate. Of the three random clinics that were contacted, one clinic declined to participate on grounds that they did not have sufficient time, one clinic failed to respond to the invitation and one clinic agreed to participate in the research. Interviews The staff that was interviewed per clinic were divided into four separate professions: healthcare administrator, financial administrator, healthcare professional and a manager. These professions were chosen because they all had different perspectives on various aspects of the administrative tasks that must be done. While some other professionals might have given a slightly different insights into the administrative tasks, these functions would have enough knowledge of the other functions to shine light on the general administrative tasks. An interview guide was made for each profession that was interviewed. The interview guides contained a question pertaining what client information they encountered and how they processed it. Furthermore, interviewees were asked if they had a work process and what kind of difficulties they encountered during this process. The full interview guides can be found in Appendix 2. The interviews were planned and executed by one researcher and one participant at the time, and they were recorded with a smartphone. Afterwards the interviews were transcribed verbatim by the same researcher that conducted the interviews.
2.2 Demographics
In both locations the healthcare administrator involved in placing was also involved in the controlling of care products before they are billed. In one clinic the healthcare administrator dealt exclusively with clinical cases, whereas in the other clinic the healthcare administrator dealt with both ambulatory as clinical cases. The financial administrators in both clinics were involved in the whole billing process, as well as the correction of billed services. They were also knowledgeable about the billing of mental healthcare services to healthcare insurers and to cities. The healthcare professionals were a psychiatrist and a clinical psychologist. They were involved from admission to dismissal and the process in-between. They were also both knowledgeable about some management and financial details of their organisation. The managers differed slightly per organisation. One was also an admission coordinator, involved in deciding whether they should admit a client.
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Chapter 3.
Identifying Administrative Tasks in the Forensic Care
The goal of this Chapter is to explore what administrative tasks are performed in the forensic care that takes place in a healthcare institution (RQ1). To achieve this process models will be made in UML style. The Chapter describes the technique that was used to create an information model, and the assumptions and choices that were made regarding the abstraction. Subsequently the resulting diagrams are depicted and split up into several large processes; the admission of a client into care, the treatment and the billing. It concludes with some exceptional information processes.3.1 Introduction
Currently there is no publicly available visualization of the administrative process in the forensic care in the UML-language. The rules and regulations for DBBCs are written down, in part in the manual for forensic care and in part in the regulations for the DBC published by the NZa.(6) To avoid overlap, the “handboek forensische zorg” refers to the DBC regulations of the NZa.(14) Organisations are expected to be familiar will all rules and regulations concerning the treatment of forensic clients and to keep up to date with any changes that are made by the NZa or the ministry of Justice and Security. A model of the administrative tasks could be useful to determine the impact of changes in rules and regulations on the administrative load.3.2 Methods
The interviews were analysed to identify components of the administrative process. The administrative process was considered to be everything that was related to the administration that was necessary to compile a billable service product that would be paid by the department of justice. Subsequently diagrams were drawn up on A5 paper where the processes that were previously identified would be sketched. These sketches were divided into at least 3 different process flows: placement, treatment and billing. This division was made beforehand because this is considered a standard flow for forensic care from start to finish. Any other process flows or exception flows that would fit the previously described definition of a process will be included to give a complete process overview. Lastly the sketches on A5 paper were transformed into UML-diagrams. Sketch by sketch, the information was entered in the program LucidCharts1. The resulting UML-diagrams were subsequently discussed with another researcher and improved where necessary. The UML-diagram notation conforms with the UML-activity diagram extension for activity diagrams that depict user interaction with a system, as described by Eriksson et al.. (15) It has a regular UML-activity diagram with swim lane notation with some additional lanes, which signify systems that are sometimes interacted with during an activity. The interaction with a system within an activity is shown by a dashed-arrow towards the lane of the system. 1. https://www.lucidchart.com/15
3.3 Results
Figure 1. An overview of the forensic healthcare, as seen from the healthcare providers perspective, in an UML-activity diagram. Figure 1 shows an abstract birds eye view of the forensic healthcare. It starts with the assignment of a person to forensic care, as part of a conviction. Subsequently the person will be referred to and placed under the care of a healthcare institution by the appropriate organisation. The treatment will then take place for as long as the sentence or judge determines. The treatment that is provided to these offenders will be billed to the Dutch government.Forensic care: Placing clients
Figure 2 shows the activity diagram for the placement of clients in healthcare institutes. It usually starts after an assignment for a type of forensic care has been ordered by a judge or by a probation officer. After the conviction and need for forensic care, a referral agency, usually a probation officer or the Nederlands Instituut voor Forensische Psychiatrie en Psychologie (NIFP), must enter a request for placement into the Informatiesysteem Forensische Zorg (IFZO). The placement request form can differ per type of sentence and care. Subsequently the placement request is sent to a healthcare institute. Upon the receival of a placement request, the healthcare administrator in the institute enters the data (e.g. identifying number, request number) in their electronic client record (ECR). This client is manually entered as a do-not-bill case, to signify this client is not undergoing any care yet. The admission coordinator, sometimes in conjunction with a specialised clinician, decides whether to accept a client. The acceptance of a client depends on the bed occupancy, the correctness of the request and the description of the client, including if his or her behaviour would be suitable with the clients that are currently being treated at the facility. However, the department of justice has the power to force an institution to take a client, unless they legitimate reason to decline, such as the personal involvement of a staff member, or someone they know, in the crime. The choice whether to accept the client has to be communicated to the organisation that entered the request into the system. The acceptance of a request for a clinical admission or a request for housing will be followed up by sending additional information through a secure-cloud called “Postbus.nl”. This additional information can contain information such as a pro-justitia-report and the verdict. After the acceptance of a client the placement request will become a provisional placement letter.
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Figure 2. UML-activity diagram depicting the administrative activities that are required to admit a client into care.
18 Usually, when the verdict is final and there is space in the clinic, the admission date will be planned by the admission coordinator and healthcare coordinator. For Clinical care and housing the admission date is communicated to the relevant referral agency and the client. In the case of ambulatory care sometimes only the client is informed of the admission-date. Since clients that will be admitted mostly come from prison or another mental healthcare institute, special transport will have to be arranged from e.g. prison or a TBS-clinic. While usually the verdict is final, clients can be admitted on a pre-planned placement, or can be admitted while they can still appeal their sentence. Subsequently the client will be admitted or come for his or her first appointment, at which the treatment of the client starts. The healthcare administration will then send a confirmation of placement to the referral agency, which will have to enter the definitive date of placement in IFZO. The definitive placement date can be entered at any point that the request is still valid, it is however common practice to enter it within a couple of days. When the placement date is entered into the system, the provisional placement letter is changed to a definitive placement letter.
Forensic care: Treatment
Figure 3 describes the activities that take place during the treatment of an ambulant or a clinical client for a DBBC, ZZP and EP service. It starts with the planning of a client’s appointment. During the first appointment or admission the treatment plan is discussed with the client. The description of the treatment is usually generic and allows for personalisation as the treatment progresses. After an admission there is a preliminary risk assessment that takes place as soon as possible, to assess if any privileges should be revoked or any special caution should be used when dealing with a new client. An example of a privilege and special caution would be a client undergoing treatment for stalking, who should not have (unsupervised) access to the Internet. During the first period of the further treatment of this client, an extensive risk assessment is done to get a clear picture of the risk and dangers he or she might pose to others or themselves. During the treatment the time that a healthcare professional spends on a client must be recorded per minute. The time that is spent by a healthcare professional is divided into two types: direct time is the time that is spent with a client, whereas indirect time is time that is spent on e.g. administration or consulting colleagues about a client. Direct time in the system is registered in the system in the form of appointments with reporting on the details. An appointment can be made by either healthcare administrators or healthcare professionals, whereas only the healthcare professional can add the report on the appointment. The indirect time could be registered separately by the healthcare professional; however, one could also use a multiplier in conjunction with the direct time. Furthermore, during the treatment, additional administrative information must be gathered on a client. These could be internal or external quality indicators or general information on a client such as the client’s level of education. Healthcare professionals and administrators both enter these into the system, however the administrators cannot always access the necessary information or the client to fill in a form, therefore some information has to be entered by the healthcare professionals. At some point during the treatment, an evaluation of the treatment is necessary. The decision to evaluate can be prompted by several factors. Time and “taking the next step” are common drivers to evaluate the treatment. This evaluation is followed by a choice, often made by a healthcare professional and a head of treatment (Dutch: hoofdbehandelaar). This choice can lead to the continuance of a treatment as it stands, the ending of a forensic care treatment or offering a less
19 intensive type of care (downscaling). When offering a less intensive treatment, two things can be done: Either scale down the intensity level (zorgzwaarte), but continue with the same treatment or to change the treatment and or housing so much that a new placement request is necessary; in this case the appropriate referral agencies must be contacted through the “renewed placement request” pathway, shown in Figure 5. If the forensic care tract ends for a client, it is because the care in the sentence has been carried out in full. At the end of the forensic care tract a final meeting takes place, in which an evaluation on the forensic care tract takes place, and the continuance of treatment under a regular care regime is offered. A client can choose to accept or decline such an offer of his own volition, but the clinic has to offer a suitable continuation of care outside the forensic tract. At the end of the treatment the care product that was offered is closed by the healthcare administration, so it can subsequently be billed.
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Figure 3. UML-Activity diagram depicting the administrative tasks that are performed during the treatment of a client.
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Forensic care: Billing services to the department of Justice
Figure 4 shows the activities that take place in order to bill a service, such as a DBBC, to the department of Justice. It starts when a service is ready to be billed, for ZZPs and EPs this is once a month and for DBBCs this is once every 365 days. A financial administrator will retrieve a list of billable services from the electronic client record, possibly through another system which is linked to the electronic client record. The list is subsequently sent to one or more healthcare administrators to check the services. This check is usually done according to a predefined check list, which contains e.g. like SKN-number and placement letter number. After the check by healthcare administrative tasks the two different clinics deviated from each other. One institute only billed the services that passed all the checks; if a service was not correct in any way it would be corrected and put in a separate excel file until the corrections were made and then billed. The other institute that was interviewed checked the services, tried to correct those which did not pass the checks, but would still bill a service if the corrections had not been completed yet. (services which were hard to check if they were accurate and complete were also sent to the department of justice) They chose to bill the services regardless because their own administrative system would then follow the client, reducing the risk of losing track of a client in their systems. Then the services that would be billed were packed into the correct upload format by the administrative system. This file is then uploaded to VeCoZo. VeCoZo is a digital switch board, which provides safe communication between healthcare insurers and healthcare providers. VeCoZo executes the technical checks and a few checks on content. The content that is check is for example related to the format and validity of the billed service itself; e.g. if the date is within a valid range. If an error is identified by VeCoZo the process terminates here, returning an error to the healthcare institute. If it passes the checks in VeCoZo it is then forwarded to FCS (Facturatie Controle Systeem). FCS does technical and content checks on the billed services that come through VeCoZo. The technical checks partially overlap with the checks done by VeCoZo. Subsequently it checks the content of the services per client and accepts or refuses per client. If any client’s service is refused, a message will be sent with an accompanying error code as determined by the Vektis standard. After FCS has finished checking all the billed services, it sends the response for the healthcare institute to VeCoZo, which then reports back to the healthcare institute. It furthermore sends a response to Leonardo, the financial administration system used by the ministry of Justice and Security, which after its own financial checks subsequently pays the bills.
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24 Fi gu re 4 . U M L-ac tiv ity d iag ra m d ep ict s t he ad m in ist ra tiv e t as ks th at ar e pe rfo rm ed in or de r t o b ill a he alt hc are
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Forensic care: Changing a placement request
Figure 5 shows how a placement request can be changed through two different drivers. It starts with either a judge giving a new verdict, in which the forensic care has to be changed or terminated; or the client has progressed to a point in his or her treatment where the placement request needs to specify another form of care in order for the treatment to progress. Subsequent to a change in the sentence the probation officer has to enter the changes into a new placement request in IFZO, whereas if the change comes at the request of a healthcare facility, he or she has to decide to grant such a request first and then enter the new placement request in IFZO. After a change has been made to a care request in IFZO, the healthcare institute will be notified of the change. The healthcare administrator will then adapt the entry in the electronic client record accordingly and notify healthcare professionals of the relevant details. Figure 5. UML-activity diagram depicting the administrative actions that are performed in order to change a placement request.
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Forensic care: Correcting previously rejected billed services
Figure 6 shows how refused billed services are handled by healthcare providers. It starts with the feedback on the billed services, brought to healthcare facilities through VeCoZo. The feedback consists of Vektis error codes, which give a general description. These error codes can be cross-referenced with a list of common errors with a detailed explanation published by the department of justice. If this error code is not on this list, a manual, detailed check must be done into the client to see why the error occurred. In extreme cases, contact can be made with the department of justice to identify the cause of the error. When the error is located there are two different types of error; an error that can be corrected by the healthcare administrators, or an error they cannot correct without any help. This can include the adaptation of a placement request by the referral agencies. If an error cannot be corrected by the healthcare administrators, the correction has to be made with communication with either the DIZ (department of individual affairs) or DJI (Dienst Justitiele inrichtingen). The nature of these errors can differ widely; two examples are a treatment path that does not conform to the standards the system requires, or the placement request must be changed after the conclusion of a care product.
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Figure 6. UML-activity diagram depicting the administrative tasks that are performed in the correction of billing process.
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Forensic care: The exceptions
Emergency placement In the case of an emergency placement, the conventional placement path is abandoned. Institutes are contacted directly if they want to admit a client as soon as possible. The care-coordinator then, often in conjunction with a head of treatment decides to accept or refuse the client. If they accept a client, the proper placement request is often filed after the client is already placed. To ensure the proper placement request will come through, deals are often confirmed by email. Scaling up treatment Treatment can be a rocky path for clients, while the treatment intensity and level of care is supposed to scale down during the treatment, client can relapse or become distressed. This could lead to a client needing an (re)admission. While it is possible to immediately admit someone if a judge has included the possible use of the time-out rule. The time-out rule allows a person to temporarily be placed back to the original treatment intensity once, for a maximum of 7 weeks. However, if a judge has not made such provisions during sentencing, a new placement request has to be made or a client has to be admitted under regular, non-forensic, care rules. Revoked sentence It is possible that clients that are placed before they have exhausted all their appeals, or that clients have a length of treatment that has to be evaluated by a judge. If the sentence determines that the treatment should have ended previously, or the updated sentence does not reach the healthcare institute in time, it is possible that the treatment time surpasses the ordered length; if the treatment time surpasses the length of the sentence, the treatment is not funded by the department of Justice but must instead be paid through private healthcare insurance means.
3.4 Conclusion & Discussion
The UML diagrams above show an accurate representation of the administrative tasks that take place in an institute when providing forensic care. It shows the tasks related to the placement of a client, the treatment of a client and the billing of a care product. In addition to the UML-diagrams depicting the work process, some exception flows have been included: acquiring a new placement request and the correction of a rejected billed service is shown. The UML-diagrams are at an abstract level, depicting high-level administrative tasks. The advantage of the high-level depiction is that the activity diagrams are not likely to change if there are changes in rules and regulations. However, the UML-diagram is still detailed enough to assess who is involved and what activities are necessary to bill a healthcare product. The UML-activity diagram can also be used to assess what activities are likely to be affected with changes in rules and regulations. When modelling a process both the accuracy and the applicability are of concern. The UML-diagrams depict both ambulatory and clinical care cases; therefore, one could assume that if it was accurate it would be applicable to any clinic who offered either form of care. The accuracy of this model will be addressed in Chapter 7 with a validation. The abstract level of the UML-diagrams does limit the scope to which it can be used. The first limitation is that the UML-diagram cannot be directly used to form a work process for a specific type of forensic client because they are not detailed enough. The UML-diagram does not contain the specific administrative information and tasks that are required by regulations or laws. Therefore, it cannot be used as a manual. Secondly it cannot be used to analyse a work process to find detailed errors, only missing activities.
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Chapter 4.
Human Factors in Billing Healthcare Products
“To err is human” is a common saying in both the English and the Dutch language. The rate of rejected bills is far lower for regular healthcare than it is for forensic healthcare (8% vs 25%), while the billing of healthcare products works through similar mechanisms. The ministry can keep track of the type of errors that are made, but no research has been done into the factors that contribute to the occurrence of an error at an healthcare institute.(2)(12) The objective for this Chapter is to assess the human factors that play a role in the occurrence of errors in the healthcare products that are billed to the department of justice. (RQ2) It starts with a literature search into human factors that play a role in registration to identify existing frameworks. After a framework is chosen, the interviews are analysed with that framework, to find human factors that play a role in erroneous billed healthcare products.4.1 Methods
Literature
The literature search was a scoping search. The first step of the literature analysis was constructing a search query. The query consisted of terms that related to billing or finance and errors or rejection and to factors or risks and to framework or evaluation. The search terms had to occur in the title or the abstract of the article. The literature search was conducted in Web of science. Subsequently the identified literature was analysed and selected based on title and abstract. Subsequently the selected articles are reviewed based on full text. Lastly, all suitable articles were evaluated to determine which framework fitted best.Model
The chosen framework was then used to analyse the interviews. The identification and the classification of these interviews would be done according to the guidelines that were specified in the selected framework. The classification of the interviews was done by three different researchers. Each interview was classified by at least two researchers. After the classification of the interviews the researchers compared their results, any disagreements between the researchers was resolved between the researchers through debate.4.2 Results
Literature search
The literature search yielded 2322 publications, of those 6 duplicates were removed. After a selection based on abstract and title, 2280 titles were excluded. After a selection based on full text, one publication remained. It was the only publication that contained a framework suitable for the analysis of an interview. The selection process of the literature search is described in Figure 7 below.31 Figure 7. The selection process of literature. After the identification of one relevant paper, the references of the article were used to identify two more frameworks that could be used as a framework to analyse the interviews. All the frameworks were designed for the analysis of incidents, which was found to be suitable because the errors in the billed healthcare products could be regarded as an incident that had occurred. The framework created by Itoh et al. describes the incident reporting in healthcare, with the aim to understand the nature of errors and the ability to track their occurrence over time.(16) It sets up several dimensions, including an outline of the event, the type of error, the contextual conditions and the outcome of the recovery. However, the framework is extensive and its scope is too broad for this research. Whereas some categories may apply, the scope of this thesis is limited to the administrative actions around a healthcare product, most of which are not performed by medical professionals and with little medical relevance. Helmreich explored the sources of threat and types of error observed in aviation and surgery.(17) Types of errors seen in aviation were violations of regulations, procedural errors, communication errors, a lack of proficiency and decision-making. The different types of errors can help aviators manage the errors more efficiently e.g. reducing the lack of proficiency by new training. In the case of medical errors Helmreich categorises behaviour that leads to risk as communication, leadership, interpersonal relations and preparation, planning and vigilance. He further uses the threat and error
32 model, a research project from the University of Texas, in which is differentiated between latent and immediate threats, as well as the error management when an error occurs. This model could potentially be used to categorise the incidents occurring in the administration of the forensic care, however the categories used are broad and like the research of Iho et al. specialised for the treatment of patients. The article that resulted from the literature search was a framework created by M. Leaver et al. The framework was created for the analysis of incidents in the financial market. Incidents such as faulty transactions can be examined and classified with this framework, that offers insight into individual, organisational and computer aspects. Due to the similarities between administrative and financial tasks and the transactions, such as accurately entering data into a system the framework was considered a good fit. Furthermore the framework covered not only organisational and individual aspects but also the interaction between humans and computers. (18)
Analysis
The framework of M. Leaver et al. is shown in Table 1, consists of main categories, subdivided into associated elements. Each associated element comes with a short description and examples of situations are available research paper by M. Leaver. One or more of these associated elements can contribute to the occurrence of an incident. Furthermore Table 1 shows the occurrence of associated elements in an incident in no, one or two clinics. Table 1. Shows the human factor table that was used by M. Leaver and T.W. Reader and the occurrence of the associated elements per healthcare institute. The green rows represent factors that were identified, whereas the grey rows represent factors that were not identified.Category Associated Elements Occurrence in clinic A or clinic B Situation
awareness Attention (distraction, lack of concentration, divided or overly focused attention) A+B Gathering information (poorly organized information, not enough gathering of information) - Interpretation of information (miscomprehension, assumptions based on previous experience) B Anticipation (i.e., thinking ahead, judging how a situation will develop) B Other A+B Teamwork Role and responsibilities (e.g. unclear segregation of roles) B Communication and exchanging of information between team members B Shared understanding for goals and tasks B Coordination of shared activities B Solving conflicts (e.g., between team members and teams) - Knowledge sharing between teams - Other - Decision making Defining the problem -
33 Cue recognition (e.g., finding and recognizing the cues to the decision) A+B Seeking advice on a decision B Noise and distraction (e.g., that reduce the capacity to take a decision) - Bias and heuristics (e.g. overoptimism, overconfidence) - Other A Leadership Authority and assertiveness (e.g., taking command of a situation) - Listening - Prioritization of goals (e.g., team/organizational) B Managing workloads and resources - Monitoring activity and performance of team members - Maintain standards and ensuring procedures are followed A+B Other B
Slip/Lapse "Fat fingers" A+B
Procedural (not following a protocol or following a protocol incorrectly) A+B Routinized task (e.g., a loss of concentration) A+B Forgetfulness (forgetting information or how to perform an activity) - Memory - Distraction - Other A Human-computer interface Use of the tools (e.g., spreadsheets) - Training on the tool A+B System did not detect the error A+B Design of the software and application A+B Maintenance and testing of the tool - Other A The associated elements do not only account for human factors on an individual level, but also cover team work, organisational aspects and covers human computer interaction. The categories as determined by M. Leaver are all human factors that can lead to incidents within an organisation, e.g. the teamwork between colleagues or different departments; the forensic care chain however, an incident can occur anywhere in the chain, or in the cooperation between two or more partners in the chain. Therefore, some of the teamwork and one leadership associated element were copied into new categories named “Chain-Teamwork” and “Chain-Leadership”, as shown in Table 2. Furthermore, the detection of an unresolved conflict between two members of the forensic care chain associated element was added under chain-teamwork.
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Table 2. Shows the categories and associated elements that were added by the researchers, as well as the number of institutes in which the associated element was mentioned
Category Associated Elements Occurrence in clinic A or clinic B Chain - Teamwork Role and responsibilities (e.g. unclear segregation of roles) B Communication and exchanging of information between team members A+B Shared understanding for goals and tasks A Coordination of shared activities A+B Solving conflicts (e.g., between team members and teams) A Knowledge sharing between teams A Detecting an (unresolved) conflict between chainmembers A Chain -
Leadership Prioritization of goals (e.g., team/organizational) A
4.3 Conclusion and Discussion
A framework was identified and adapted to identify the errors that take place in the forensic care chain. It can identify factors concerning organisation, IT, teamwork and individual errors. At least three human factors were identified per category and most human factors were found in interviews at both locations. The framework was previously validated for use in financial trading incidents but was not yet validated for use in the financial administration of the healthcare sector. However, considering that the human factors were not specifically tailored to the industry, it was assumed that they could offer a suitable fit. The fact that all the categories were used suggests that this assumption was accurate. For the factors that were identified that did not fit inside the scope of a single organisation, the human factors that were scoped to a single organisation were extended to fit in a chain organisation. To ensure that the model would be used right, each interview was analysed by two separate researchers. The researchers had no previous experience with human factors, which might have resulted into some human factors being overlooked. This possibility cannot be excluded, however many incidents were mentioned by more than one clinic and sometimes mentioned more than once in an interview. The repetition of many incidents, as well as the analysis of two researchers per interview makes it unlikely that many human factors have been missed, especially the factors that play a role in the more common incidents. The addition of the new categories “chain teamwork” and “chain leadership” regarding cooperation in a healthcare chain was due to problems arising in this cooperation. Similar problems in cooperation between healthcare institutions can be seen in transitional care. Loos et al. has investigated the barriers to transitional care in Germany when transitioning from mental healthcare for children and adolescents to adult mental healthcare.(19) The paper states that healthcare professionals from either clinic show a lack of interest in cooperation and collaboration. Similarly, Lee et al. researched the transfer of care for patients suffering from a congenital heart disease and the barriers that exist for a good continuity of care.(20) The paper concludes that a close collaboration between different healthcare professionals is essential to the success. Due to the
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voluntary basis of the treatment, it is difficult to compare the situation to forensic healthcare because the patients also play a large factor.
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Chapter 5.
The Bottlenecks in the Forensic Healthcare Administration
The goal of this Chapter is to determine in which parts of the forensic care administration bottlenecks, with regards to administrative errors, occur (RQ3). The incidents and the accompanying human factors framework will be placed in the UML-activity diagrams, allowing bottlenecks in the healthcare administration and registration to be identified. Previously in Chapter 3 an information model was created that made an abstract representation of the administrative tasks that take place in the forensic care. The framework that was developed is used to allocate the incidents to administrative tasks. In Chapter 4 incidents that lead to errors in the registration of healthcare products were identified; subsequently the human factors that played a role in the incidents were categorised.5.1 Method
Firstly, all human factors that were identified in Chapter 4 were entered in an excel sheet. Subsequently the first error that was identified in an interview was assigned a location with a number in an UML-diagram. The subsequent errors in the interviews were also allocated a location and a number based on the order of occurrence in the UML-diagram. In the case that a new location was found which took place earlier in the process depicted in the UML-diagram, the new location was numbered as 1, and the numbers of subsequent locations were renumbered in order of occurrence. The human factors that were related to an error were subsequently registered per location per UML-diagram.5.2 Results
The results described below describe an UML-activity diagram that has been labelled. For each location the most important or frequently mentioned incident or human factors are explained in the description. A complete list of all the human factors can be found in the corresponding tables.Human factors in incidents: Placement
Figure 8 depicts an UML-activity diagram that is nearly identical to Figure 2, the only difference is that Figure 8 also shows labels in the diagram. The labels represent activities or choices that have been identified to lead to incidents that result in the refusal of billed services. The human factors that have been identified to have an impact on the occurrence of these incidents are shown in Table 3 below. The number in Table 3 corresponds with the location in Figure 8. Figure 8, Location 1 Figure 8, location 1 is the entering a placement request into IFZO by the referral agency. A commonly mentioned problem is that a referral agency does not complete the application in the correct fashion or make a typo in filing the placement request. Human factors playing a role in such situations are related to the human computer interface and the chain teamwork category.
37 Figure 8, Location 2 Location 2 in Figure 8 concerns the entry of a placement request in an electronic client record by a healthcare administrator. Examples of an incident here would be making a typo while copying the data from the placement request pdf into their own electronic client record. Such an incident would be largely due to Slip/Lapse, is also partially caused by the message format that IFZO uses to notify healthcare institutes, which makes it impossible to directly import. Another incident that could come forth from the human computer interface category is the inability to enter the “left-over” treatment time for clients that transfer from other clinics in some healthcare administration systems and electronic client records. Figure 8, Location 3 The 3rd location in Figure 8 concerns the decision to accept a client into the clinic. The incident is caused by clinics accepting clients before there is a correct placement request in IFZO, accepting an incorrect instead. While the placement requests can be corrected in hindsight, after the acceptance of a client, the pressure is less for a referral agency to correct the request. Figure 8, Location 4 The 4th and final location in Figure 8 is the entry of a definitive placement date for the placement request. An incident that can occur here is that a referral agency enters the wrong date or enters free text, such an incident would relate to slip/lapse human factor, or a situation awareness.
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Figure 8. UML-activity diagram depicting the processes that take place in order to admit a client to care. The notations with numbers indicate locations of incidents.
40 Table 3. Shows the main human factor categories and their associated elements that were found at a particular location in the placement process. Location Human factors 1 Chain - Leadership - Prioritization of goals (e.g., team/organizational) Chain - Teamwork - Communication and exchanging of information between team members Chain - Teamwork - Shared understanding of goals and tasks Human computer interface - Design of the software and application Human computer interface - System did not detect error Human computer interface - Training on a tool Leadership - Monitoring activity and performance of team members Situation awareness - Attention Slip/Lapse - Procedural Slip/Lapse - Routinized task Teamwork - Shared understanding for goals and tasks 2 Human computer interface - Design of the software and application Human computer interface - System did not detect error Situation awareness - Attention Slip/Lapse - Fat fingers Slip/Lapse - Other Slip/Lapse - Procedural Slip/Lapse - Routinized task 3 Situation awareness - Other Slip/Lapse - Other Slip/Lapse - Procedural 4 Situation awareness - Anticipation Situation awareness - Other Slip/Lapse – Procedural
Human factors in incidents: Treatment
Figure 9 shows an UML-activity diagram that is very similar to the diagram shown in Figure 3, however Figure 9 includes labelled activities and choice nodes. The labelled activities and nodes are places where incidents take place according to the identification of human factors described in Chapter 3 Table 5 shows what human factors and associated elements were found in the locations marked in Figure 9.
41 Figure 9, Location 1 The first location of Figure 9 is the first appointment of an ambulatory client or the admission of a clinical client. Decision-making is a human factor that is involved in a particular situation that can cause problems in billing services later on. Sometimes healthcare professionals admit clients before there is a placement request; while this would not be a problem for an emergency placement, if the placement request never comes through the care will not be funded by the department of justice. Furthermore sometimes, ill-fitting clients that have been admitted, are transferred back to the institute where they came from before a head of treatment got to see them. Figure 9, Location 2 The treatment of clients is labelled as 2 in Figure 9. Here human computer interface and situation awareness play a role in cases where head of treatment does not put enough time into a case or does not enter the diagnosis into the system. The system does not alert them to this in one clinic, while in the other it is easy to ignore the warnings concerning this. Both systems alert the healthcare administrator to these errors when a service is being validated. Figure 9, Location 3 Location 3 in Figure 9 concerns the registration of treatment time. The most common situation in which incidents occur here is due to healthcare professionals still wanting to add treatment time after a service has already been closed and sometimes billed to the department of justice. While this does not directly contribute to the 25% refusal of billed services; it does add to the administrative burden created by correcting already billed services. Figure 9, Location 4 The 4th label in the activity diagram shows the registration of administrative details, including quality indicators by healthcare administrators and healthcare professionals. A common incident in this category is vital administrative data not being entered into the system, therefore violating the rules, such as the DBC-spelregels, for a product. Figure 9, Location 5 The final label for Figure 9 is label five, which concerns the evaluation of a client’s treatment. The incidents that occur here are the continuance of treatment for longer than was allowed by the sentencing.
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Figure 9. UML-activity diagram depicting the administrative tasks that are performed during the treatment of a client. The numbers indicate the location of incidents.
44 Table 4. Shows the main human factor categories and their associated elements that were found at a particular location in the treatment process. Location Human factors 1 Decision making - Cue recognition Decision making - Other Decision making - Seeking advice on a decision Leadership - Managing workloads and resources Slip/Lapse - Procedural Teamwork - Communication and exchanging information between team members Teamwork - Role and responsibilites 2 Human computer interface - Design of the software and application Human computer interface - System did not detect error Leadership - Managing workloads and resources Leadership - Prioritization of goals Situation awareness - Anticipation Situation awareness - Other Slip/Lapse - Procedural Teamwork - Shared understanding for goals and tasks 3 Human computer interface - Design of the software and application Human computer interface - System did not detect error Human computer interface - Training on a tool Leadership - Other Situation awareness - Anticipation Slip/Lapse - Procedural Teamwork - Communication and exchanging information between team members 4 Human computer interface - Design of the software and application Human computer interface - System did not detect error Human computer interface - Training on a tool Leadership - Other Situation awareness - Anticipation Situation awareness - Attention Slip/Lapse - Fat fingers Slip/Lapse - Procedural Slip/Lapse - Routinized task Teamwork - Communication and exchanging information between team members Teamwork - Other Teamwork - Shared understanding for goals and tasks 5 Situation awareness - Attention Slip/Lapse - Fat fingers Teamwork - Communication and exchanging information between team members
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Human Factors in incidents: Billing services
The UML-activity diagram shown in Figure 10 shows the same process as Figure 4; However, Figure 10 also shows the location of incidents with labels. The incidents that take place at these labels have been identified in Chapter 3 and cause a billed service to be refused due to an error. Figure 10, Location 1 The first label in Figure 10 concerns the checking of billable services. The list with care products that are time-wise ready to be billed is being checked by healthcare administrators. In the process of checking these care products, the healthcare administrators can still slip up, because the care product can only be partially validated by a system. Data that is not subject to a system check, must be checked manually, which leaves room for slips and lapses. Figure 10, Location 2 Label two in Figure 10 concerns the uploading of bills to VeCoZo. The sequence in which the bills are uploaded is of vital importance. The credit billing must be sent before the debit billing, otherwise this will result in an error. The human factors found for this incident related to human computer interface and slips and lapses. Table 5. Shows the human factors involved in the incidents that take place during the billing of care products to the department of justice. Location Billing 1 Human computer interface - Design of the software and application Human computer interface - System did not detect error Situation awareness - Attention Slip/Lapse - Fat fingers Slip/Lapse - Procedural Slip/Lapse - Routinized task 2 Human computer interface - Other Human computer interface - System did not detect error Situation awareness - Attention Slip/Lapse - Procedural
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Figure 10. This UML-activity diagram shows the activities that take place during the billing service. The labels in this diagram signify activities where incidents that lead to billing errors take place.
