The Mihalik Blog

Cultural Competency in Health Care

 

Recently I've done a number of presentations on cultural competency.  While it's a topic that I've been interested in for a long time (it's a main reason that I have a graduate degree in Anthropology) my interest has been rekindled lately with the work I'm doing in the Middle East. 

 

The population of the United States is expected to change significantly.  The US Census bureau projects that by 2050, only 50% of the population will identify themselves as white, compared to 69% in 2000.  The Census Bureau also projects that by 2050, the HIspanic/Latino population of the United States will increase to 132.8 million, representing 30% of the population.

 

The countries surrounding the Arabian Gulf have some of the most multicultural societies in the world.  In the UAE for example, somewhere between 80% and 95% of the population is estimated to be foreign depending on which report, which Emirate, and what time period is being considered. 

 

Clearly cultural competency is an issue in many parts of the world. 

 

In upcoming blogs I will delve into the topic of cultural competency more.  For now, I'd like to close with a definition of cultural competency promulgated by the Office of Minority Health of the US Department of Health and Human Services (adapted from Cross, 1989):

Cultural and linguistic competence is a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations.

 

Culture’ refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups.

 

Competence implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities.

 

I've been away

I'm sure you've noticed that I haven't posted in quite a while.  Sorry about that.  Let me explain.

Shortly after my last post I headed off to Dubai.  This was October 2009.  The upshot of the October trip, and the November trip, and the early January trip was that I found myself working in the United Arab Emirates beginning mid January 2010. 

And a fascinating project it was...and still is!

The Mihalik Consultancy, based in Dubai, has a contract to evaluate the health care facilities operated by the Federal Government of the UAE.  Following the evaluations, some of which were conducted in the first half of this year, we will be working with health care facility staff and the UAE Federal Government to develop and implement an action plan to improve the quality of health care services. 

A few news stories that were published shortly after the contract was signed can be found here, and here, and here.

Survey Prep: Highlight and Annotate

Even if you’ve mastered the first five components of survey preparation (understanding the specific requirements of the standard; understanding the required evidence of compliance; using support text to tell the story; submitting the right evidence; and submitting the right amount of evidence) you’re not done till you make it clear to the surveyors what portions of the evidence are relevant.

Sometimes a surveyor needs to review the entire document.  This is often the case with policies and procedures on appeals used as evidence for the various elements of UM 8.  Even so, highlighting and annotating are critically important.  Since the surveyor needs to find evidence of compliance with each and every factor for each element—and since appeals P&Ps tend to be long and complicated—you should show the surveyor where evidence of compliance with each factor is addressed. 

I believe the best all-around way to show surveyors what to read, and to what elements and factors the section relates, is with a combination of highlighting and text boxes. 

The most intuitive way to do this is to highlight a section of text in a specific color then use the same color in an adjacent text box that indicates the specific element(s) and factor(s) addressed by the highlighted text. 

For most documents, a single color works fine but if there are lots of small sections of relevant text and they tend to be close together (as is often the case for appeals P&Ps), using a series of colors, matching text highlighting color to text box color, makes it very easy for the surveyors to pick out the relevant portions. 

Connecting arrows from a text box to a section of highlighted text can sometimes create problems if the arrow covers text that a surveyor needs to read.  It can also make a document messy to read if there are lots of such references. 

I dislike “in line” references that affect the formatting or pagination of the document.  By in line references, I’m referring to insertion of text, usually in a contrasting color, right in the body of the document that indicates the standard, factor, and element being addressed by that section of text.  Text boxes placed in the margins do not affect formatting or pagination. 

A well-prepared ISS submission will dramatically improve everyone’s stress levels.  The surveyors will be able to find what they need to give you credit and if they can’t find it, the part that’s missing is likely to be circumscribed and easy for you to resolve.  The corollary is that your stress level will go down as well as you won’t be faced with needing to find and highlight multiple documents across multiple standards and create additional support text on 72 hours’ notice.

Survey Prep: Evidence of Compliance

While the support text is key to help the surveyors understand HOW you comply with a requirement, it’s the evidence of compliance itself that will get you actual credit for meeting the standard. 

Once you’re clear on what data sources are required you are in a position to select the evidence and to determine the right amount of evidence. 

This is one area where more is definitely not better.  To do this right you really need to understand what the standard is about.  If you do not you will not be able to reliably supply the correct evidence of compliance or the correct amount of evidence. 

For most standards you need to show that you have been in compliance with the requirements throughout the look-back period.  For renewal surveys this typically means two year’s worth of evidence. 

Let’s look at UM 10B as an example of how to proceed. 

This element addresses a health plan’s written process for technology evaluation.  The data source is “Documented Process” and the look-back period for renewal surveys is two years.  The most common documented process used as evidence for this element is a policy and procedure, or set of related and well-integrated policies and procedures, on technology evaluation.  Any evidence other than a documented process will just be noise for the surveyors.  Reports and materials are meaningless for scoring this element.

How many documented processes do you need to attach? 

However many documented processes cover the look-back period.  For an organization undergoing a renewal survey that has not changed its technology assessment P&P in the two years prior to the survey date, only one P&P will be needed. 

One of the most frustrating experiences a surveyor can have is for an organization to load up the ISS with every document that might be relevant to an element.  I once received 100 documents for Continuity and Coordination between Medical and Behavioral Healthcare!!!  I’ve had similar experiences with other standards and other organizations.  And I can assure you that I am not alone among surveyors. 

The right amount of evidence is critically important.  The Standards and Guidelines describe scope and meaning of the standard (the explanation), what evidence is required (the data source), and the amount of evidence (the look back period).  What you need to do is determine precisely what, and how much, evidence is needed to demonstrate that your organization is in compliance with the standard. 

If you don’t do that, you are likely to get lots of questions from the surveyors.  

Upcoming NCQA Education Programs

This is just a quick note to let everyone know that I will be serving as faculty for two upcoming NCQA education programs: 

The first is Update on Health Plan Accreditation: Documentation and Strategies from the Surveyors Perspective in Washington, DC on October 16, 2009. 

The second is Introduction to NCQA Accreditation for Health Plans and MBHOs in Washington, DC on November 18-19, 2009

I hope to see you at one of the programs!

Survey Prep: Telling Your Story

I’ll be the first to admit it—different surveyors approach surveying in different ways.  I lunge for the support text before reviewing documents.  Other surveyors only read the support text if they can’t find what they need from trolling through all the documents linked to an element.  In either case, the support text plays a critical role:  it tells the surveyor how your organization complies with the element. 

 

I could review a hundred documents for an element (trust me, it’s happened!) and still not get a full picture of the organization’s processes.  The support text should paint a picture, clearly and briefly describing HOW the organization meets the intent of the element.  That way when the surveyor reviews the documents, he/she has a framework for interpreting them.   

 

Remember, though, that support text does not count as one of the four identified data sources (documented process, materials, reports, and records or files).  That means that you cannot plunk a process description that sounds like it should be a policy and procedure in the support text box and have the surveyor accept it as a documented process.  Support text is meant to guide the surveyor to understand the evidence.  It is not evidence in and of itself.  Said another way, support text is unofficial—helpful—but unofficial whereas a documented process should have been officially approved by the organization. 

 

Despite my preference for support text, there are several instances where it’s not needed.

 

File review standards don’t need evidence of any sort—nor do they need support text.

 

Standards which are completely scored based on a documented process don’t usually need support text if the documented process is clear.  Look at CR 1B, for example.  There are four factors, each quite clearly described, that need to be addressed in policies and procedures.  Assuming each of these is well described in the policies and procedures that are linked to this element, support text won’t be very helpful. 

 

Support text should add something to the surveyor’s understanding.  It doesn’t really help the surveyor to use the support text box to state that the organization is in compliance with the element without saying HOW the organization is in compliance. 

 

The support text box is NOT a good place to tell the surveyor which pages of which documents to read.  Annotating documents to make it easy for surveyors to find what they need will be covered in the last blog of this series. 

 

As a surveyor, I make few assumptions.  If the combination of the support text and evidence doesn’t clearly demonstrate that an organization is in compliance with the element, I’ll ask for clarification.  With only 72 hours allowed for turn-around on such questions, an organization that gets 30 or 40 questions of clarification from the survey team will likely have a harrowing three days. 

 

Next time I’ll talk about evidence of compliance. 

Survey Prep: Correcting the Course

In my last post I lamented the deteriorating state of preparation for NCQA accreditation surveys.  I also discussed the first of six steps for good survey preparation: understanding the specific requirements of the standard. 

In this post, I’ll talk about the next step:  understanding the required evidence of compliance.

Identifying the required evidence of compliance can be challenging.  Start off by reviewing the “Data source” section of the specific NCQA element. There are four data sources:

1.   Documented process.

2.   Materials.

3.   Reports.

4.   Records or files.

Definitions of each data source can be found in the glossary of the standards and guidelines. 

But here’s the tricky part…the “Data source” section will list all the data sources applicable to the element but it won’t tell you which of the data sources are applicable to which factors and if you need all, some, or one of the data sources.  Reading the “Explanation” section will provide some answers to these questions.  Just don’t expect the answers to be crystal clear.  [I understand that NCQA is working on this issue but it wasn’t corrected in the recently released 2010 standards.]

Let’s look at QI 7B: Access to Case Management.  The element reads as follows: 

The organization has multiple avenues for members to be considered for case management services, including:

1.   Health information line referral, if applicable

2.   DM program referral

3.   Discharge planner referral

4.   UM referral, if applicable

5.   Member self-referral

6.   Practitioner referral.    

The data sources are listed as documented process, reports, and materials.

The explanation helps a bit.  It says:  “NCQA reviews the organization’s documented process and either materials or reports for evidence that the complex case management staff receives or has the ability to receive referrals from various sources [emphasis added].”  From this you can safely assume that the documented process needs to describe how referrals to case management are accepted from each of the listed avenues. 

If you read further, the explanation states:  “The organization must demonstrate that it provides a means for member self-referral or practitioner referral by communicating the availability of programs and contact information (e.g., telephone numbers) to members and practitioners. The organization may communicate this information using printed materials or on its Web site.”  This makes it clear that materials, as defined by NCQA, are the required data sources for factors 5 and 6. 

With no other guidance in the explanation about which data sources apply to which factors, one is left to conclude that either reports or materials are acceptable data sources for factors 1-4.  In preparing the evidence of compliance with this element, then, you would need to include a documented process (or processes) that address all six factors, materials for factors 5 and 6, and either materials or reports for factors 1 through 4. 

Next time we’ll talk about step three: using support text to tell the story. 

Survey Preparation is Heading South

Over the past year or so I’ve noticed (as have many other NCQA surveyors) that the quality of survey preparation has diminished.  The reason for this trend is unclear but it is unmistakable. 

 

Good survey preparation should make it easy for the surveyors to assess compliance.  I don’t mean to say that it should be easy for the surveyors just to be easy.  It should be easy so that you get the best possible score.  If a surveyor cannot see evidence of compliance, the score will suffer. 

 

Organizations have a limited number of opportunities to demonstrate compliance.  If you don’t “take your best shot” at demonstrating compliance at the initial submission, you’ll waste one of these few opportunities for providing evidence of compliance as you struggle to pull together evidence that should have been submitted initially with the Interactive Survey System (ISS).

 

Good survey preparation involves several steps:

1. Understand the specific requirements of the standard.
2. Understand the required evidence of compliance.
3. Use support text to tell the story.
4. Submit the right evidence.
5. Submit the right amount of evidence.
6. Highlight and annotate relevant portions of documents.

 

To understand the requirements of the standard, you need to study the manual—especially the “Explanation” section.  For example, Health Plan standard UM 7A states:  “The organization notifies practitioners about…[t]he organization’s policy for making an appropriate practitioner reviewer available to discuss any UM denial decision [emphasis added].”  However, the Explanation says:  “This element applies only to UM medical necessity denial decisions, including pharmaceutical denials.”  The language of the standard would lead you to believe that all denials are covered but the explanation indicates that only medical necessity denial decisions are covered. 

 

In this example, you also need to know NCQA’s definition of a medical necessity denial since it is very specific and different from definitions commonly is use in the field.  For this, you need to review the Glossary. 

 

Remember that NCQA changes and clarifies standards on an ongoing basis.  In addition to reviewing the manual, you need to review the “Questions, Clarifications and Policy Changes” document that comes out periodically.  You also need to review the FAQs.  If you are using the Survey Tool section of the ISS, the revisions described in the Questions, Clarifications and Policy Changes document will be integrated into the text as of the effective date.  This is not true for FAQs!  Even if you are using the ISS, you need to check the FAQs on a regular basis.  [Please note that the ISS has a PDF version of the manual in addition to the Survey Tool.  The PDF file is NOT updated with the Questions, Clarifications and Policy Changes, just the Survey Tool.]

 

In subsequent entries I’ll discuss the other components of survey preparation. 

Summer Vacation?

I know it’s been a long time since I’ve posted an entry.  I bet some of you are wondering if I took a summer vacation.  No, but I wish!

 

I’ve had writer’s block—sort of.

 

I know blog entries aren’t long and shouldn’t be too difficult to write but, honestly, I couldn’t come up with a topic that I thought merited an entry. 

 

Sure, I could come up with something to write nearly every day but I know that many of you rely on this blog to post meaningful information.  I don’t want to change the character of the blog.  I want it to be a place that you can go to for honest, up-to-date, cutting-edge information on accreditation.

 

I have a topic planned for my next blog entry based on a few recent experiences.  It would be really helpful to me if you would take the time to send me your thoughts on topics you’d like me to cover. 

 

The best way to do that is to use the comments section of this site.  That way everyone will see, and be able to weigh-in on, your suggestion.  However, if you’re more comfortable, you can send me an email. 

 

I’ll be back in the saddle with regular posts in the next few days. 

Highlights of NCQA 2009 Standards Changes

NCQA’s 2009 standards went into effect July 1, 2009.  There were to many changes between 2008 and 2009.  The notable ones are described in this entry.  In my last blog I discussed the changes to the 2010 standards that were put into effect in 2009 because they represented a significant lessening of some burdensome requirements.  The changes I’m discussing here are the ones that were planned for 2009. 

These changes are all described in the 2009 standards but you won’t have to wade through hundreds of pages to find them. 

 

QI 3C, Provider Contracts, can now be scored “not applicable” if no new provider (remember providers are facilities or programs; practitioners are people) contracts have been executed since the last survey. 

 

QI 7E, the Initial Assessment file review for Complex Case Management, now explicitly allows the initial assessment to be conducted over multiple sessions by different members of the team.  Neither of these is really new, but the fact that the possibility is clearly described is a big help. 

 

UM 13C continues to require that most health plans jump through all the delegation hoops even though the process to provide point of dispensing communication of potential drug-drug interactions is systematized and requires no independent thought once the parameters are agreed upon by the health plan.  Almost without exception, these systems use one of two national data bases of drug information.  In any case, the change for 2009 is that if a health plan contracts with another entity to provide the functionality but not the content, delegation does not apply.  If the vendor actually communicates with the dispensing provider or compiles the data, delegation applies.  While this change may be helpful to some very, very large health plans it is unlikely to be of much benefit to the majority.   

 

For credentialing, CR 1A added additional clarification of when dental practitioners need to be credentialed.  CR 3B added the Federation Credentialing Verification Service as a recognized source for verification of closed residency programs. 

 

MEM 7A has been clarified to indicate that other electronic messaging technologies, not just email, meet the intent of the requirement.  These other technologies are more secure. 

 

MEM 8A, Identifying Members (for wellness activities), requires the use of more than one wellness category. 

NCQA has also made changes to the Medicare Advantage deeming module and to New Health Plan Accreditation.  I will discuss these changes in a future blog. 

 

As always, we’re here to help you negotiate NCQA accreditation requirements.