The Mihalik Blog

Auto-Credit Woes

Using an NCQA accredited or certified vendor can lock in scores of 100% for many elements.  This is great news for organizations looking to improve their accreditation outcomes. 

In order for the auto-credit to apply, however, the delegation agreement must clearly describe which elements are delegated and the vendor’s accreditation or certification must cover the specific elements.   

For the former requirement, I suggest that the delegation agreement describe which elements are delegated using language that is as close to the wording of the NCQA standards as possible.  In addition, the accreditation manuals contain appendices that contain information on delegation.  These appendices include language that should be included in the delegation agreements for the auto-credit to apply.

For the second requirement, it is important to look at the specific standards and elements under which the organization was accredited or certified to know if you will be able to get auto-credit.  Disease management is one of the areas where the Managed Care Organization (MCO) and Health Plan Accreditation (HPA) standards have diverged from the Disease Management Accreditation/Certification standards.  Unless a disease management vendor was surveyed under standards that match those in the 2007 MCO or 2008 HPA standards, you won’t get auto-credit for all of the disease management elements.

If you delegate elements to an organization that are not covered under that organization’s NCQA accreditation or certification, remember that you are not relieved of oversight for those elements.  For example, you will now need to conduct a pre-delegation audit and an annual evaluation for the elements not covered under the organization’s NCQA accreditation or certification. 

Demonstrating Web Functionality During a Survey

A number of standards in the Member Connections and Members’ Rights and Responsibilities categories of NCQA’s Health Plan Accreditation program require web-based functionality.  Demonstrating this functionality is a requirement of the survey process.

Unless access to your site is explicitly prohibited, most of the elements that require web-based functionality must be tested by the surveyors.  This means that you need to give the surveyors IDs and passwords, if required, to access and use the site.  Don’t forget to embed a hyperlink to the website in the ISS as well.

Not all of your web-based functions may be password protected.  Often, physician and hospital directories are available on a health plan’s public site.  Other functions, like changing a PCP or requesting a new ID card, are typically on a secure site accessible by ID and password only. 

If you cannot give surveyors access to your site to test the web-based functionality you should be prepared to demonstrate why access is not possible.  If surveyors cannot test the site itself, you should provide screen shots of the whole process accompanied by a step-by-step explanation of how the process works and what the screen shots demonstrate. 

Integrating Member Information

It’s been way too long since my last post.  A combination of writer’s block and lots of deadlines conspired to prevent blog entries.  I apologize to those of you who’ve been periodically looking here for new information. 

I write the entries myself—unless the entry notes that it’s been written by someone else—and sometimes I just can’t keep up with my editorial calendar. 

Anyhow, enough of that.

Integrating member information is an element in the Disease Management Standard for NCQA’s Health Plan Accreditation program.  Questions have arisen about just what NCQA expects for such integration, given that the areas involved are ones that are frequently delegated. 

Just to recap, QI 8I, Integrating Member Information, requires that the health plan integrate information between a health information line, a disease management program, a case management program, and a utilization management program to facilitate access to member health information for continuity of care. 

Even when one or more of these functions are delegated, NCQA expects the integration of member information to occur.  This integration can be quite a challenge without delegation!

What you need to think about is whether the current systems and processes will allow staff performing each of these different functions to have access to member information when needed.  Consider for example:

·        If a member in the asthma disease management program called the health information line to get advice on what to do for a bee sting that seemed to be getting worse, would the staff at the health information line know that the member had asthma and was in the asthma disease management program?

·        If a member in a complex case management program were hospitalized, would the complex case management staff know of the hospitalization?  How long would it take for them to find out?

I could go on, but you get the idea.  Come up with a series of scenarios for how members could utilize the services provided by each of the four components mentioned above, and see if your current systems and processes would allow staff to have access information about the member’s involvement with the other program(s). 

Despite the fact that NCQA does not typically look at documentation prepared by delegates, except for the file review standards, this may be an element where delegate-prepared reports will be needed to demonstrate that the integration is, in fact, happening. 

Root Cause Analysis

Requests from hospitals for assistance in facilitating root cause analyses of sentinel events are up this year.  This appears to be related to the Joint Commission’s more intensive focus on this area.

Although the process for completing a root cause analysis remains rather opaque in most instances, the final products are remarkably similar.  They usually bear a strong resemblance to the framework promulgated by the Joint Commission or to a conceptually similar format required by regulation. 

If a particular format is not required by regulation, I think some modifications of the Joint Commission’s suggested form can make the document much more user-friendly. 

Those of you who know me know that I’m usually more inclined to use a concise narrative style rather than a series of checkboxes when trying to describe something.  So, the Joint Commission’s boxes for “Root Cause?”, “Ask ‘Why?’”, and “Take Action?” don’t do much for me.  I’d rather analyze each issue until the root causes are identified at which point they can be simply listed as a bulleted list at the end of the narrative that concisely sums up the analysis of that specific issue.  Doing this eliminates the need for the first two boxes since the group continues to “Ask Why” until they’ve reached a “Root Cause.”  A major benefit of this is that each topic can be fully developed in a single place on the report rather than scattered around a lengthy form like installments in a Victorian novel. 

When the analysis is complete, each root cause can be copied into a table where planned interventions and measures of effectiveness can be listed, along with other critical information like responsible person and due dates.  If a root cause is not going to be acted upon, the same table can be used to explain why.  The third check box is now gone.  In its place is a clear description of the interventions for each root cause or the reasons for not intervening. 

I think these modifications of the reporting template (along with a few others) make the results—and the reasons for the results—much more understandable.  Of even more significance, though, is the process that I recommend to develop an understanding of the event. 

Knowing that in the end I’ll need to correlate the results with the minimum required scope of a root cause analysis, based on the type of event, I simply forget about the need to do this throughout the bulk of the analysis.  I believe that trying to make a group think in narrowly defined categories hinders, rather than helps, analysis.  With a good facilitator, the group can conduct a thorough analysis using a few standard tools and techniques of quality improvement, such as brainstorming, nominal group technique, and a prioritization matrix.  Afterwards, each of the root causes can be associated with one or more components of the required scope such as staffing levels or supervision of staff.  With good facilitation you’ll likely find that you’ve touched on all the required processes or else decided that a particular process was not relevant. 

A solidly conducted root cause analysis can be an effective component of an organization’s quality improvement strategy.  If you’re facing one of these events and want some assistance we’re here to help.

CR 6 Gets a Much Needed Facelift

As noted in a prior blog, NCQA tried to make CR 6 more relevant for health plans, and in the process increased the workload tremendously.  There has been a series of revisions to CR 6 with the latest being released on January 22, 2008.  [Click here and then click “Clarifications” under 1.22.08 on the NCQA website.]

With the recent change, NCQA will allow organizations to establish “reasonable thresholds” for conducting a site visit based on complaints received.  Previously, each complaint about physical accessibility, physical appearance, and adequacy of waiting and examining room space triggered a full scope site visit.  This no longer is the case!

Establishing reasonable thresholds for the number of complaints received before an office site visit is required is a challenge.  The threshold cannot be so high that so few site visits are conducted that the intent of the standard is not met.  Neither should it be so low that resources are utilized without reasonable indication of cause.

A method to differentiate complaints that considers frequency, pattern, and severity should be established.  All complaints related to physical accessibility, physical appearance, and adequacy of waiting and examining room space need to be tracked by practice site.  I also recommend tracking by practitioner. 

I suggest logging each complaint in a database as received and analyzing trends every month by looking back at the most recent six months’ worth of complaint data. 

You will probably want to set several different types of thresholds based on number, pattern, and severity of complaints.  For example, your thresholds might look like these, any one of which would trigger a site visit:

§         X number of total complaints, regardless of category, within the past six months.

§         Y number of complaints in any single category in the past six months.

§         Z number of complaints about particular issues closely related to patient safety or quality of care within the past six months. 

In my model, “X” would be a bigger number than “Y” and “Y” would be a bigger number than “Z.”  In some instances, depending on the complaint, Z might equal 1.  You’ll need to spend some time thinking through what numbers to use, and what types of complaints should trigger a site visit based on a single occurrence, if any.

I suggest using a rolling six month analysis.  That is, when looking at complaint patterns every month, look at the most recent six months, rather than arbitrarily dividing the year into time periods.  If a flurry of complaints is received divided between the end of one time period and the beginning of another, the threshold might not be triggered for either time period, even though the total number of complaints in a short period of time exceeds the established number.  A rolling time period is more sensitive to changes and also more timely.  In addition, it will serve to spread out any required site visits throughout the year rather than clustering them in the same months.

Once triggered, the office site visit needs to be conducted with 60 calendar days and actions implemented to improve the site.  The effectiveness of actions taken must be evaluated at least every six months until the site meets thresholds.  A follow-up site visit is required if the complaint threshold is triggered subsequent to correcting deficiencies.  The date of each site visit along with monitoring actions should be tracked on the spreadsheet.  This is helpful because the process could potentially be repeated multiple times for the same practitioner. 

eHorizons

This is the era of the “e” as in eMail, eBanking, eCommerce.  You name it and someone has probably put an “e” in front of it.

We’ve done the same.  Some of you may know of The Mihalik Group’s eGlobe—the electronic version of our newsletter.  It used to be that our eGlobe was just a PDF of our paper Globe.  It was a convenient delivery format but not easy to read.  The new eGlobe comes as a series of short introductions to each article with a hyperlink to the full text on line.  There’s no need to scroll through an unwieldy PDF to find the second part of an article.  If you haven’t done so already, I encourage you to sign up for our eGlobe. 

If you’re reading this, you obviously know about my Blog.  But if you’re one of those people who hasn’t mastered RSS feeds, we have a monthly eNews feature that’s custom made for you.  RSS feeds are intended to keep you updated on changes to web pages (such as blogs) but they’re not really easy to use.  And you still need to remember to DO something to get the information from the RSS feed.  Our eNews, delivered directly to your eMail inbox, contains links to recent blog posts and other topics of interest.  I find that I don’t remember to regularly check websites and blogs of interest to me—even though I want to.  We thought that delivering a reminder with hyperlinks each month was a good solution. 

If you sign up for the eGlobe you will automatically be included as a subscriber to The Mihalik Group’s eNews feature.

 

If you have any suggestions for improving our offerings—or if there are topics you’d like to see us write about in the Globe or in the blog—just let me know.  You can reach me here.

Managed Care Speaker Bureau

Forest Laboratories has launched a Managed Care Speaker Bureau. 

I spent the better part of two days last week in Coral Gables, Florida at the speaker training meeting.  The weather was beautiful—but in comparison to Chicago in January most weather is!

Among the topics I’ll be able to speak on as part of the Forest Laboratories Managed Care Speaker Bureau are:

§         Improving HEDIS Scores in Antidepressant Medication Management

§         Depression in the Workforce: Improving Recognition and Treatment

§         Pharmacoeconomics of Depression: Managing the Economic Impact through Improved Clinical Care.

Your Forest Laboratories representative should be able to arrange a speaking engagement if any of these topics would be of interest. 

New Year’s Resolution: Planning for Improvement

Our office reopened on January 2^nd after a year-end break. 

Late December into early January is a period when not much new happens in the areas of accreditation and regulatory compliance.  That makes it a very good time to plan for the coming year.  The quality improvement calendar is a critical part of the planning process—and one that I find is often not used to its full potential. 

The problem that I typically see is a timing issue.  QI program evaluations and revised program descriptions are typically not completed until late first quarter or early second quarter.  Many health care organizations include the annual QI calendar as part of the revised program description.  Consequently, the QI committee has not explicitly planned activities for the first three or four months of the year. 

As a New Year’s Resolution, I suggest you do away with treating the QI calendar as a once-a-year task.  Quality Improvement is a dynamic process and planned activities should be modified during the year based on new information. 

Set up your QI calendar in a table format.  Each activity should occupy one row.  Set up columns for the information you want to include, such as the name of the indicator, the responsible party, the goal, etc.  End your table with a series of twelve columns, one for each month.  In each of these cells, describe what should be happening during that month for the specific activity.  Leave the cell blank if nothing should be happening.  Developing a set of abbreviations will make it easier to maintain the calendar; things like M for measure, R for report to committee, etc.

On a regular basis, as you are preparing the minutes of the most recent QI committee meeting, add enough new columns to the calendar to project a full twelve months into the future.  In the new cells, describe what should be happening during each newly added month, if you know.  For example, if a particular indicator is reported on a quarterly basis, you can project out when the next reports will be due. 

Every three to six months, make the calendar update a specific agenda item for the QI committee.  With the committee’s input, revise the calendar to customize it to the reality of what is happening. That quarterly report you added might need to be revised if there’s some sort of a delay, for example.  If you schedule one of these calendar updates for the last QI committee meetings of the year, you’ll be starting the new year with the most up to date plan possible. 

Although it is easier to word process in a word processing program, using a spreadsheet program for the calendar will enable you to print just the columns that you want to print.  So, while your spreadsheet might have two years’ worth of planned activities, you can choose to print just the next twelve, without loosing the history.

Nonna Tata

Earlier this week, on a cold and rainy evening, Melinda and I were sitting in a darkened car on a ramshackle street in Fort Worth with a bottle of wine between us.  The bottle wasn’t open, mind you, just sitting there.  As were we.

In Fort Worth on business, we planned to have dinner at a small restaurant called Nonna Tata.  The restaurant has 21 seats—quite literally.  We counted them, including the four that were piled in the corner next to our table. 

Being not much bigger than a phone booth turned on its side, the restaurant doesn’t take reservations.  There’s really no place to wait inside till one’s table is ready.  Hence for us, and I suspect several other patrons, our car became our waiting room.  We were called on the cell phone when our table was ready. 

Nonna Tata doesn’t have a beer and wine license, so when we put our name on the waiting list, we were told we could buy wine at the shop across the street.  The shop across the street turns out to be a vegan coffee shop, the Spiral Dinner, that stocks one type of red and one white wine.  Both organic.  The red was quite drinkable.

Dinner turned out to be an unexpected delight.  Our antipasto platter was well portioned for two and featured an array of superb quality Italian meats and cheeses.  The spaghetti with spinach and lemon was perfectly cooked and had just enough cream to keep it from being dry but not overly rich.  The lemon juice provided a spike of excitement to the flavor.  The salad was disappointing, but not because it wasn’t good.  It just wasn’t Italian.  The dinner salad included with each entrée, was packed with an array of fresh vegetables plus a sprinkling of canned corn kernels.  It was a great American salad but out of character with the rest of the meal.  Neither of us had room for dessert. 

We planned to go back the next evening to try a few other items on the menu but when the weather got even colder and rainier, we decided that we weren’t up for sitting in our makeshift waiting room till a table cleared out but we’re eagerly awaiting our return to Fort Worth in better weather when two outdoor tables are added to the mix. 

On to the business of accreditation…

As noted in a previous blog, NCQA came out with its clarification to CR 6B on November 19^th. 

Thinking about HIPAA

Does anyone think about HIPAA much any more?

The Privacy and the Security Rules require periodic assessments of privacy and security practices and modification of systems and processes based on the results of the assessments.

Larger organizations have teams of people who can address these issues.  It’s more challenging for smaller organizations that need to spread complex functions across a small pool of staff.  This is especially true for the security provisions—which are quite technical—but even a periodic assessment of privacy practices can be permanently relegated to the “back burner” by busy staff.  After all, there aren’t any HIPAA police, right?

Privacy and Security assessments make good business sense.  Think of all those agreements you’ve signed agreeing to comply with HIPAA.  Could you prove that you’re doing what you’ve agreed to do if asked?

I’m also seeing HIPAA issues show up in the work that I do as an expert witness for medical malpractice and other types of legal cases.  Think about what might happen if there was an alleged breach of confidentiality and you were asked to produce evidence of your compliance with HIPAA, including periodic assessments.

If you haven’t gotten your privacy and security policies and procedures completed, don’t wait!  It’s way past the deadline.  If you haven’t done your periodic assessments, make it a New Year’s Resolution to begin early in the first quarter. 

Suitable for smaller organizations, The Mihalik Group has comprehensive sets of policies and procedures—one set for privacy and one for security—should you need to jump-start your efforts.  We can even do an assessment of privacy practices and a security risk analysis.