WELCOME to the PIP Technical Assistance Training for Florida HMOs/PSNs We will begin shortly. Please...

WELCOMEto the PIP Technical Assistance Training for Florida HMOs/PSNs

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Performance Improvement Projects (PIPs)

Technical Assistancefor Florida Medicaid

HMO/PSNs

August 22, 2007

Christi Melendez, RNPIP Review Team Project Leader

Presentation Outline

Purpose Review of PIP Activities II, IV, V, VI,VII,VIII

and IX Review PIP submission process for the 2007-

2008 validation cycle Questions and Answers

PURPOSE

To provide technical assistance with examples for Activities receiving an overall score of Partially Met or Not Met for the 2006-2007 validation cycle.

PIP submission process for the 2007-2008 validation cycle.

Activity Two: The Study Question

HSAG Evaluation Criteria

The study question stated the problem to be studied in simple terms.

Was answerable.

*In general, the question should illustrate the point of: Does doing X result in Y?

Activity Two: Study Question

Examples: Do targeted interventions increase the rate

of annual retinal (dilated) eye exams for members with diabetes mellitus?

Can interventions with members and providers increase blood lead testing rates?

Do targeted interventions improve coordination of care between XYZ health plan and ABC mental health providers for members with ADHD?

Activity Four: The Study Population

HSAG Evaluation Criteria Was accurately and completely defined. Included requirements for length of a

members enrollment in the Health Plan. Captured all members to whom the study

question applies. Included ICD-9 codes and procedure codes

(if applicable).

Activity Four: The Study Population

Example: 100 percent of the eligible plan members are included in

this study. The eligible population is defined as Medicaid members ages 18-75 years of age as of December 31st of the measurement year. Continuous enrollment for the entire measurement year was applied. No more than one gap in enrollment of up to 45 days during the measurement year was allowed.

Codes: V72.0, CPT code 92287, 67028, 67038-67040

Activity Five: Sampling Techniques

HSAG Evaluation Criteria The true or estimated frequency of

occurrence was provided and considered in the sampling technique.

Sample size was specified. Confidence level was specified. Acceptable margin of error was specified.

Activity Five: Sampling Techniques

HSAG Evaluation Criteria (cont.)

The sampling technique ensured a representative sample of the eligible population.

Sampling techniques were in accordance with generally accepted principles of research design and statistical analysis. Valid sampling techniques should be used for all study indicators, which can be replicated by using the reported sampling parameters.

Study Implementation Phase

E. Activity 5: Use sound sampling methods. If sampling is to be used to select consumers of the study, proper sampling techniques are necessary to provide valid and reliable information on the quality of care provided. The true prevalence or incidence rate for the event in the population may not be known the first time a topic is studied.

Measure Sample Error and Confidence Level

Sample Size

Population Method for

Determining Size (describe)

Sampling Method (describe)

Diabetic Retinal Exams: Baseline 7/1/03-6/30/04

Confidence level 95%. Margin of error +/-5%

411 10,000 On-line sample size generator.

Simple Random Sampling

First Remeasurement: 7/1/04-6/30/05



Second Remeasurement 7/1/05-6/30-06



Activity Five: Sampling TechniqueEXAMPLE

E. Activity 5: Use sound sampling methods. If sampling is to be used to select consumers of the study, proper sampling techniques are necessary to provide valid and reliable information on the quality of care provided. The true prevalence or incidence rate for the event in the population may not be known the first time a topic is studied.

Measure Sample Error and Confidence Level

Sample Size

Population Method for

Determining Size (describe)

Sampling Method (describe)

Retinal Eye Exam: Baseline 1/1/05-12/31/05

No sampling: Entire population

used

First Remeasurement: 1/1/06-12/31/06

Second Remeasurement 1/1/07-12/31/07

Activity Six: Data Collection

HSAG Evaluation Criteria Data elements collected were clearly

identified. The data sources were clearly identified. A systematic method for data collection was

outlined in the PIP documentation. The timeline included both starting and

ending dates for all measurement periods.


For Manual Data Collection: The relevant education, experience, and

training of all manual data collection staff were described in the PIP text.

The manual data collection tool was included with the PIP submission.

A discussion of the interrater reliability process was in the PIP text.



Written instructions for the manual data collection tool was clearly and succinctly written and included in the PIP documentation.

A brief statement about the purpose of the study (overview) was included in the written instructions for the manual data collection tool.


For Administrative Data Collection: Documentation included a systematic

process of the steps used to collect data. This can be defined in narrative format or with algorithms/ flow charts.

The estimated degree of administrative data completeness was included along with an explanation of how the percentage of completeness was calculated.

Activity Six: Data Collection Data Sources [ ] Hybrid (medical/treatment records and administrative)

[ x ] Medical/Treatment Record Abstraction Record Type [ x ] Outpatient [ ] Inpatient [ ] Other ____________________________ Other Requirements [ x ] Data collection tool attached [ x ] Data collection instructions attached [ x ] Summary of data collection training attached [ x ] IRR process and results attached

[ ] Other data

.

Description of data collection staff (include training, experience and qualifications):

3 RNs with BSN degrees with 5 years of clinical and quality improvement experience will perform medical record abstraction. All 3 RNs have attended 8 hours of training on how to perform data abstraction and use of manual data collection tool.

[ x ] Administrative Data

Data Source [ x ] Programmed pull from claims/encounters [ ] Complaint/appeal [ ] Pharmacy data [ ] Telephone service data /call center data [ ] Appointment/access data [ ] Delegated entity/vendor data ____________________________ [ ] Other _______________________

Other Requirements [ ] Data completeness assessment attached [ ] Coding verification process attached

[ ] Survey Data

Fielding Method [ ] Personal interview [ ] Mail [ ] Phone with CATI script [ ] Phone with IVR [ ] Internet [ ] Other ____________________________

Other Requirements [ ] Number of waves _____________________________ [ ] Response rate _____________________________ [ ] Incentives used _____________________________

Activity Six: Data CollectionF. Activity 6b: Determine the data collection cycle. Determine the data analysis cycle. [ ] Once a year [ ] Twice a year [ ] Once a season [ x] Once a quarter [ ] Once a month [ ] Once a week [ ] Once a day [ ] Continuous [ ] Other (list and describe):

[ ] Once a year [ ] Once a season [ x] Once a quarter [ ] Once a month [ ] Continuous [ ] Other (list and describe):

F. Activity 6c. Data analysis plan and other pertinent methodological features. Complete only if needed.

Estimated percentage degree of administrative data completeness: __90__ percent.

The explanation of how the estimated degree of administrative completeness was calculated should be entered here.

Example of Analysis plan:

The study will be a non-randomized time series design. Measurement will be made in the baseline period and at one year intervals. A chi-square analysis will be performed to assess significance of any observed change and reported at the 95% confidence interval.

Activity Seven: Improvement Strategies

HSAG Evaluation Criteria A completed causal/barrier analysis

explanation of how the intervention(s) were related to causes/barriers identified through data analysis and quality improvement processes was included in the PIP documentation.

System interventions that will have a permanent effect on the outcomes of the PIP were documented in the text.



If repeat measures did not yield statistically significant improvements, there should be an explanation of how problem solving and data analysis was performed to identify possible causes.

If quality improvement interventions were successful, it should be documented that the interventions were standardized and the interventions were monitored.

How to perform a Causal/Barrier Analysis

Determine why an event or condition occurs?

1. What’s the problem?– Define what the problem is and why it’s a concern.

2. Determine the significance of the problem.– Look at data and see how the problem impacts your

members and/or health plan.

3. Identify the causes/barriers?– Conduct analysis of chart review data; surveys; focus

groups.– Brainstorming at quality improvement committee

meeting.– Literature review.

4. Develop/implement interventions based on barriers identified.

Causal/Barrier Analysis Methods and Tools

Methods: Quality improvement committee

Develop an internal task force

Tools: Fishbone

Process mapping

Barrier/intervention table


Example: Fishbone Diagram

Barrier/Intervention TableEXAMPLE

Interventions Taken for Improvement as a Result of Analysis. List chronologically the interventions that have had the most impact on improving the measure. Describe only the interventions and provide quantitative details whenever possible (e.g., “hired 4 customer service reps” as opposed to “hired customer service reps”). Do not include intervention planning activities.

Date Implemented Check if Ongoing

Interventions Barriers that Interventions Address

September 2004 X Member education (newsletter/article) regarding the importance of getting an annual retinal eye exam.

Members are not having an annual retinal eye exam.

October 2004 X Provider education( on-site training) regarding importance of members having an annual retinal eye exam.

Members are not having an annual retinal eye exam.

HSAG Evaluation CriteriaThe data analysis: Was conducted according to the data analysis plan in the study design. Allowed for generalization of the results to the study population if a sample was selected. Identified factors that threaten internal or external validity of findings (change in

demographic population, acquiring another health plan’s members, change in the IS system, change in health plan staff).

Activity Eight: Data Analysis and Interpretation of Study Results


Included an interpretation of findings Was presented in a way that provides accurate, clear, and easily understood information. Identified initial measurement and remeasurement of study indicators. Identified statistical differences between initial measurement and remeasurement.




Identified factors that affect the ability to compare initial measurement with remeasurement (changes to the methodology, change in

time periods, seasonality, or a change in vendors).

Included the extent to which the study was successful.


Example: Baseline Interpretation

A baseline rate of 14.1 percent of members received a retinal eye exam for the baseline time period of 7/1/03-6/30/04.


Example: Remeasurement 1

The baseline rate of members receiving a retinal eye

exam at 14.1 percent increased to 21.7 percent in the first remeasurement (7/1/04 -6/30/05). This represents a statistically significant (p = 0.00167) increase.


Example: Remeasurement 2

The first remeasurement rate increased from 21.7 percent to 27.6 percent in the second remeasurement (7/1/05 – 6/30/06). This increase was not a statistically significant increase (p = 0.0699).


Overall Analysis:The rate of retinal exams increased each year with statistically significant results in the first remeasurement with no decline in performance.

The study has been successful in increasing the rate of retinal exams and will be continued until the 75% baseline goal is met.

Activity Nine: Assessing For Real Improvement

HSAG Evaluation Criteria The use of the same methodology for

baseline and remeasurements was documented.

If there was a change in methodology, the issue was discussed in the PIP text that justified the needed changes.

Documentation was included how intervention(s) were successful in affecting system wide processes or health care outcomes.


HSAG Evaluation Criteria (cont.) The improvement in performance as a result

of the intervention(s) was documented in the text of the PIP.

The PIP documentation included calculations and reported on the degree to which the intervention(s) were statistically significant.

The table in Activity IX was completely filled out for each measurement period. The actual p values were documented and whether or not the value was statistically significant.


Quantifiable Measure No. 1: Diabetic Retinal Exams

Time Period Measurement

Covers

Baseline Project

Indicator Measurement

Numerator Denominator Rate or Results

Industry Benchmark

Statistical Test and Significance*

Test statistic and p-value

7/1/03 – 6/30/04 Baseline: 62 440 14.1% 38.7% N/A 7/1/04 – 6/30/05 Remeasurement 1 136 627 21.7% 40.3% Chi-square = 9.88 P = 0.00167

Statistically Significant increase 7/1/05 – 6/30/06 Remeasurement 2 227 822 27.6% 39.2% Chi-square = 3.28 P = 0.0699

Not Statistically Significant increase. Remeasurement 3 Remeasurement 4 Remeasurement 5

Example: Completed Table

New PIP submissions

New PIPs were not submitted for the 2006-2007 validation cycle.

For new PIP submissions, it is important to contact HSAG to obtain the most current updated PIP Summary Form.

How to Submit Continuing PIPs

On-going PIPs (submitted to HSAG for the 2006-2007 validation cycle).

Highlight, bold, or add text in a different color, and date any new information that is added to the existing PIP Summary Form.

Strikethrough and date any information that no longer applies to the PIP study.

Ensure all Partially Met and Not Met evaluation elements from the previous validation cycle have been addressed in the documentation.

Resources Frequently asked questions (FAQs) and PIP

information - myfloridaeqro.com NCQA Quality Profiles -

http://www.qualityprofiles.org/index.asp Institute for Healthcare Improvement – www.ihi.org Center for Healthcare Strategies – www.chcs.org Health Care Quality Improvement Studies in

Managed Care Settings – A Guide for State Medicaid Agencies www.ncqa.org/publications

National Guideline Clearinghouse – www.guidelines.gov

Agency for Healthcare Research and Quality – www.ahrq.gov

http://www.qualityprofiles.org/index.asp

http://www.ihi.org/

http://www.chcs.org/

http://www.ncqa.org/publications

http://www.guidelines.gov/

Deliverables

September 7th: HMO/PSNs notified electronically of

submission date with instructions

October 5th: Submit PIP studies to HSAG

* HSAG will be validating two PIPs per HMO/PSN; one clinical and one nonclinical. If the collaborative PIP is clinical, the other PIP chosen for validation will be nonclinical.

PIP Tips

1. Complete the demographic page before submission.2. 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. Go to myfloridaeqro.com for FAQ or contact Cheryl Neel at [email protected] to answer any questions.

mailto:[email protected]

HSAG Contacts

For questions contact: Cheryl Neel

– [email protected]– 602.745.6201

Denise Driscoll– [email protected]– 602.745.6260



Questions and Answers

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