Performance Improvement Projects Technical Assistance

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Performance Improvement Projects Technical
Assistance PIP 101Monday, June 18, 2007130
p.m. 300 p.m.

• David Mabb, MS, CHCA
• Sr. Director of Statistical Evaluation

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Presentation Outline

• Balance Budget Act (BBA) 1997
• Who is HSAG?
• Overview of the PIP process
• PIP Summary Form Review
• MCO demographics
• CMS rationale
• HSAG evaluation elements
• PIP Scoring Methodology
• HSAG Contact Information
• Questions and Answers

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Balanced Budget Act (BBA) of 1997

• The BBA requires states with Medicaid managed
  care programs to implement certain standards and
  business practices pertaining to
• Enrollee Rights and Responsibilities
• Quality Assessment and Performance Improvement
• Grievance and Appeals System

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Who is HSAG?

• We are an External Quality Review Organization.
• To date, we have validated over 300 PIP studies.
• We validate Managed Care Organization and
  Behavioral Health Organization PIPs.

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Overview of PIPs

• What is the purpose of a PIP?
• To assess and improve processes, and
  subsequently, outcomes of care. It typically
  consists of a baseline, intervention period(s),
  and remeasurement (s).
• What is a PIP?
• It is a quality improvement project.

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Primary Objective of a PIP

• Measurement of performance using objective
  quality indicators.
• Implementation of system interventions to achieve
  improvement in quality.
• Evaluation of the effectiveness of the
  interventions.
• Planning and initiation of activities for
  increasing or sustaining improvement.

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PIP Validation

• Ensures that
• PIPs are designed, implemented, and reported in a
  methodologically sound manner.
• Real improvement in the quality of care can be
  achieved.
• Documentation is compliant with CMS protocols for
  conducting PIPs.
• Stakeholders can have confidence in the reported
  improvements.

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Overview of PIPs (cont.)

• The PIP process provides an opportunity to
• Identify and measure a targeted area (clinical or
  nonclinical)
• Analyze the results
• Implement interventions for improvement

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Overview of PIPs (cont.)

• HSAGs role
• Validates PIPs using CMS protocol, Validating
  Performance Improvement Projects, A protocol for
  use in Conducting Medicaid External Quality
  Review Activities, Final Protocol, Version 1.0.
• PIP Validation is a desk audit evaluation
• HSAG validates the studys findings on the likely
  validity and reliability of the results
• Provides PIP Validation Reports to AHCA and the
  MCOs
• Identify best practices

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PIP Review Process

• The PIP team includes clinicians and
  statisticians.
• PIP review team members assigned to the PIP study
  reads it in its entirety.
• Each PIP study has one clinician and one
  statistician assigned to reading the study. They
  read the study independently.
• If discrepancies, the PIP reviewers meets to
  reconcile any scoring differences.

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PIP Review Process (cont.)

• Once scored, the PIP Validation Reports are sent
  to AHCA.
• The MCOs have an opportunity to comment on any
  miscalculations or errors noted in the PIP
  Validation Report.
• The final PIP Validation Reports are then
  released to the MCOs.

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PIP Summary Form Review

• Health plan demographics (first page of the
  submission form)
• Discuss the 10 PIP Activities
• CMS Rationale
• HSAG evaluation elements

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Activity One Choose the Selected Study Topic

• CMS Rationale
• Impacts a significant portion of the members.
• Reflects Medicaid enrollment in terms of
  demographic characteristics, prevalence of
  disease, and the potential consequences (risks)
  of the disease.

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Activity One Choose the Selected Study Topic

• CMS Rationale
• Addresses the need for a specific service.
• Goal should be to improve processes and outcomes
  of health care.
• The study topic may be specified by the State
  Medicaid agency or on the basis of Medicaid
  enrollee input.

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Activity One Choose the Selected Study Topic

• HSAG Evaluation Elements
• Reflects high-volume or high-risk conditions (or
  was selected by the State).
• Is selected following collection and analysis of
  data (or was selected by the State).
• Addresses a broad spectrum of care and services
  (or was selected by the State).

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Activity One Choose the Selected Study Topic

• HSAG Evaluation Elements (cont.)
• Includes all Medicaid eligible populations that
  meet the study criteria.
• Includes members with special health care needs.
• Has the potential to affect member health,
  functional status, or satisfaction.

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Activity One Choose the Selected Study Topic

• Example Study Topics
• Cervical Cancer Screening
• HbA1c testing
• Flu Vaccinations
• Timeliness of Case Management
• Discharge Planning
• Readmission to Inpatient Psychiatric Care within
  30, 90, and 120 days

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B. Activity Two The Study Question

• CMS Rationale
• Stating the question(s) helps maintain the focus
  of the PIP and sets the framework for data
  collection, analysis, and interpretation.

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B. Activity Two The Study Question

• HSAG Evaluation Elements
• States the problem to be studied in simple terms.
• Is answerable.
• In general, the question should illustrate the
  point of Does doing X result in Y?
• Example Will increased planning and attention
  to the importance of follow-up after inpatient
  discharge improve the rate of members receiving
  follow-up services?

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C. Activity Three Selected Study Indicators

• CMS Rationale
• Quantitative or qualitative characteristic.
• Discrete event (member has or has not had XX).
• Appropriate for the study topic.
• Objective, clearly and unambiguously defined.

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C. Activity Three Selected Study Indicators

• HSAG Evaluation Elements
• The study indicator(s)
• Is well defined, objective, and measurable.
• Is based on practice guidelines, with sources
  identified.

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C. Activity Three Selected Study Indicators

• HSAG Evaluation Elements (cont.)
• The study indicator(s)
• Allows for the study question to be answered.
• Measures changes (outcomes) in health or
  functional status, member satisfaction, or valid
  process alternatives.

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C. Activity Three Selected Study Indicators

• HSAG Evaluation Elements (cont.)
• The study indicator(s)
• Has available data that can be collected on each
  indicator.
• Is a nationally recognized measure such as
  HEDIS, when appropriate.
• Includes the basis on which each indicator was
  adopted, if internally developed.
• HEDIS is a registered trademark of the National
  Committee for Quality Assurance (NCQA).

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D. Activity Four Identified Study Population

• CMS Rationale
• Represents the entire Medicaid eligible enrolled
  population.
• Allows systemwide measurement.
• Implements improvement efforts to which the study
  indicators apply.

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D. Activity Four Identified Study Population

• HSAG Evaluation Elements
• The method for identifying the eligible
  population
• Is accurately and completely defined.
• Includes requirements for the length
• of a members enrollment in the
• managed care plan.
• Captures all members to whom the
• study question applies.

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D. Activity Four Identified Study Population
Example of Study Population All Medicaid
children with at least 11 months (12 months with
one 30-day gap of enrollment) of continuous
enrollment in the health plan, who were born on
or between January 1, 2001, and December 31,
2003.
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E. Activity Five Valid Sampling Techniques

• CMS Rationale
• Sample size impacts the level of statistical
• confidence in the study.
• -Statistical confidence is a numerical statement
  
• of the probable degree of certainty
  or
• accuracy of an estimate.
• Reflects improvement efforts to which the study
  
• indicators apply.
• Reflects the entire population or a sample of
  that
• population.

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E. Activity Five Valid Sampling Techniques

• HSAG Evaluation Elements
• Consider and specify the true or
• estimated frequency of occurrence
• Identify the sample size
• Specify the confidence level to be
• used

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E. Activity Five Valid Sampling Techniques

• HSAG Evaluation Elements (cont.)
• Specify the acceptable margin of error.
• Ensure a representative sample of the
• eligible population.
• Ensure that the sampling techniques
• are in accordance with generally
• accepted principles of research design
• and statistical analysis.

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F. Activity Six Data Collection Procedures,
Data Collection Cycle, and Data Analysis

• CMS Rationale
• Administrative data collection.
• Manual data collection.
• Inter-rater reliability.
• Frequency of collection and analysis
• cycle.

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F. Activity Six Data Collection Procedures,
Data Collection Cycle, and Data Analysis

• HSAG Evaluation Elements
• The data collection techniques
• Provide clearly defined data elements
• to be collected.
• Clearly specify sources of data.
• Provide for a clearly defined and
• systematic process for collecting data
• that includes how baseline and
• remeasurement data will be collected.

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F. Activity Six Data Collection Procedures,
Data Collection Cycle, and Data Analysis

• HSAG Evaluation Elements (cont.)
• The data collection techniques
• Provide for a timeline for the collection
• of baseline and remeasurement data.
• Provide for qualified staff and
• personnel to collect manual data.

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F. Activity Six Data Collection Procedures,
Data Collection Cycle, and Data Analysis

• HSAG Evaluation Elements (cont.)
• The manual data collection tool
• Ensures consistent and accurate
• collection of data according to
• indicator specifications.
• Supports inter-rater reliability.
• Has clear and concise written
• instructions for completion.

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F. Activity Six Data Collection Procedures,
Data Collection Cycle, and Data Analysis

• HSAG Evaluation Elements (cont.)
• An overview of the study in the written
• manual data collection tool instructions.
• Administrative data collection algorithms
• that show steps in the production of
• indicators.
• An estimated degree of automated
• data completeness (important if using
• the administrative method).

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G. Activity Seven Improvement Strategies

• CMS Rationale
• An intervention designed to change
• behavior at all levels of the care
• delivery system, including the
• members.
• Changing performance, according to
• predefined quality indicators.
• Appropriate interventions.
• Likelihood of effecting measurable
• change.

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G. Activity Seven Improvement Strategies

• HSAG Evaluation Elements
• Planned/implemented strategies for improvement
  are
• Related to causes/barriers identified through
  data
• analysis and Quality Improvement (QI)
  processes.
• System changes that are likely to induce
• permanent change.
• Revised if original interventions are not
• successful.
• Standardized and monitored if interventions are
  
• successful.

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G. Activity Seven Improvement Strategies

• HSAG Evaluation Elements (cont.)
• Planned/implemented strategies for improvement
• May be at the health plan, provider, or
• member level
• Should be realistic, feasible, and
• clearly defined
• Need a reasonable amount of time to
• be effective

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H. Activity Eight Data Analysis and
Interpretation of Study Results

• CMS Rationale
• Initiated using statistical analysis
• techniques.
• Included an interpretation of the
• extent to which the study was
• successful.

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H. Activity Eight Data Analysis and
Interpretation of Study Results

• HSAG Evaluation Elements
• The data analysis
• Is conducted according to the data
• analysis plan in the study design.
• Allows for generalization of the results
• to the study population if a sample
• was selected.
• Identifies factors that threaten internal
• or external validity of findings.
• Includes an interpretation of findings.

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H. Activity Eight Data Analysis and
Interpretation of Study Results

• HSAG Evaluation Elements (cont.)
• The data analysis
• Is presented in a way that provides accurate,
• clear, and easily understood information.
• Identifies initial measurement and
• remeasurement of study indicators.
• Identifies statistical differences between
  initial
• measurement and remeasurement.
• Identifies factors that affect the ability to
  compare
• initial measurement with remeasurement.
• Includes the extent to which the study was
• successful.

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I. Activity Nine Study Results and Summary
Improvement

• CMS Rationale
• Probability that improvement is true
• improvement.
• Included an interpretation of the extent to
• which any changes in performance is
• statistically significant.

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I. Activity Nine Study Results and Summary
Improvement

• HSAG Evaluation Elements
• The remeasurement methodology is the same as the
  baseline methodology.
• There is documented improvement in processes or
  outcomes of care.
• The improvement appears to be the result of
  intervention(s).
• There is statistical evidence that observed
  improvement is true improvement.

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J. Activity Ten Sustained Improvement

• CMS Rationale
• Change results from modifications in the
  processes of health care delivery.
• If real change has occurred, the project should
  be able to achieve sustained improvement.

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J. Activity Ten Sustained Improvement

• HSAG Evaluation Elements
• Repeated measurements over comparable time
• periods demonstrate sustained improvement, or
• that a decline in improvement is not
  statistically
• significant.

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PIP Scoring Methodology

• HSAG Evaluation Tool
• 13 Critical Elements
• 53 Evaluation Elements (including the Critical
  Elements)

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PIP Scoring Methodology

• Overall PIP Score
• Percentage Score for all Evaluation Elements
• Calculated by dividing the total Met (includes
  critical
• elements) by the sum of the total Met,
  Partially Met, and Not Met.
• Percentage Score for Critical Elements
• Calculated by dividing the total critical
  elements Met by the sum of the critical elements
  Met, Partially Met, and Not Met.
• Validation Status Met, Partially Met, Not Met

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PIP Scoring Methodology

• Met
• (1) All critical elements were Met, and
• 80100 of all elements were Met
• across all activities.

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PIP Scoring Methodology

• Partially Met
• All critical elements were Met, and 60 to 79
  of all elements were Met across all activities
• or
• (2) One or more critical element(s) were
  Partially Met.

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PIP Scoring Methodology

• Not Met
• All critical elements were Met and lt60 of all
  elements were Met across all activities
• or
• One or more critical element(s) were Not Met.

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PIP Scoring Methodology

• Not Applicable (NA)
• NA elements (including critical elements) were
  removed from all scoring.
• Not Assessed
• Not Assessed elements (including critical
  elements) were removed from all scoring.

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PIP Scoring Methodology

• Example 1
• Met 43, Partially Met 2, Not Met 0, NA 8,
  and all critical elements were Met.
• The MCO receives an overall Met status,
  indicating the PIP is valid.
• The score for the MCO is calculated as 43/45
  95.6 percent.

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PIP Tips

• Complete the demographic page before submission.
• Notify HSAG when the PIP documents are uploaded
• to the secure ftp site and state the number of
  documents
• uploaded.
• 3. Label ALL attachments and reference them
• in the body of the PIP study.
• 4. HSAG does not require personal health
• information to be submitted. Submit only
  aggregate
• results.
• 5. Document, document, and document!!
• 6. Look for the CMS Protocols on
  myfloridaeqro.com. If you
• have additional questions, contact HSAG.

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HSAG Contacts

• For questions contact
• Cheryl Neel
• cneel_at_hsag.com
• 602.745.6201
• Denise Driscoll
• ddriscoll_at_hsag.com
• 602.745.6260

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Questions and Answers