Training/Education for the Targeted Investments Program

Participant Guidance on Self-audits

A number of Year 3 Core Component Milestones (Milestone Measurement Period 2) require participants to perform a ‘Self-audit’. Self-auditing involves attesting to a percentage target based on the TI participating practice/organization’s own review of a random sample of records.

Random Sampling:

The following steps outline how TI participants should conduct a random sample.

AHCCCS prefers that participants use Excel or a more powerful statistical software program, if available, to create a random sample in the following manner:

  1. Query the electronic health record to create a list of all medical record numbers [MRN] that meet the denominator criteria listed in the Milestone for the most recent 12-month period. For example, some Milestones require practices to conduct a random sample of patients who received behavioral health services while other Milestones require a random sample of patients listed in the high-risk registry.

  2. Sort the list randomly. This random sort can be performed using Excel or a more powerful statistical software program. One possible way of sorting a list through Excel is explained in the following online tutorial: How to Create a Random Sample in Excel (in 3 minutes!)

  3. Review at least the first 20 records selected to determine what percentage of the sample was compliant. A participant may choose to review more than 20 records, but is still required to meet the compliance threshold (e.g., 85%, 70%) for the specific Milestone. Worksheets for all areas of concentration have been created to calculate the percentage target (see below).

  4. If a TI participant does not have access to Excel or a more powerful statistical software program, the participant should divide the total number of records identified in Step 1 by 20 (or more, if the practice chooses to assess compliance based on a larger sample size, as mentioned in Step 3). Then use the result to choose the records in a sequence. For example, if a TI participant identified 100 records in Step 1, it would divide by 20 to get 5. The practice would then choose the 5th, 10th, 15th, 20th, etc. records to pull the sample of records which it should review.

  5. If the sample size for a specific Milestone has fewer than 20 records identified in Step 1, then the TI participant should review all the records and no random sample should be drawn. The percentage target specified in the respective milestone applies.

  6. When attesting to a percentage target, participants must also attest to having created a random sample of records for review.

Percentage target Calculator:

MS excel worksheets have been designed to assist the participants with calculating a percentage target for all the Milestones that require self-audits across all six Areas of Concentration.

Click on your area of concentration to use the worksheet

  1. TI Year 3 Self Audit Worksheet: Adult BH
  2. TI Year 3 Self Audit Worksheet: Adult PCP
  3. TI Year 3 Self Audit Worksheet: Hospital
  4. TI Year 3 Self Audit Worksheet: Justice
  5. TI Year 3 Self Audit Worksheet: Peds BH
  6. TI Year 3 Self Audit Worksheet: Peds PCP

Important note: the numerator and denominator must be uploaded into the TI Year 3 Attestation portal to complete your attestation.

Instructions to use TI Year 3 Self- audit worksheet