The Mihalik Blog

Increasing the Spread #2

Just a few days ago I discussed changes to NCQA’s scoring algorithm that will reduce the average survey score.  Before that, I blogged on the demise of QIAs and the increasing importance of HEDIS that will, presumably, have the same outcome. 

By now, you all know about the technology-heavy 2007 NCQA Accreditation Standards and the effect these are having on compliance with standards, and thus survey outcomes—especially the ones for Complex Case Management, Physician and Hospital Directories, and Member Connections.

Well, get this:  HEDIS regional adjustments are going away!  Yep, not only is HEDIS playing an ever-important role in determining accreditation outcomes for MCOs, but the game is getting tougher. 

Starting with the 2011 standards (Breathe!) NCQA’s Board has approved an end to adjusting a Health Plan’s HEDIS results.  By 2011, HEDIS could account for about 50% of the accreditation outcome so this will have a major impact.

Those few extra points that have historically been added to HEDIS results can result in a significant change in a Plan’s percentile ranking.  The thresholds aren’t as daunting when actual results get a boost.  With the boost gone—and the move to more and more administrative data collection—a Health Plan’s Quality Improvement Process needs to be top-notch to garner top scores. 

In previous columns, I described what I see as a declining interest in quality improvement in health care.  I also mentioned a few pointers on how to revitalize a QI program.  With the recent, current, and future changes to the NCQA accreditation process, having a world-class QI program is more critical than ever. 

Long before The Mihalik Group began providing consulting services related to accreditation preparation, we taught educational programs on quality improvement theory and practice and designed and implemented state-of-the-art quality improvement programs.  Contact us and let us help you design a process that will produce world-class performance.

Increasing the Spread

If you’re an investor, spread can be a good thing.  If you’re an organization accredited by NCQA increasing the spread can be to your disadvantage depending where you are in the spread. 

As I’ve noted before, MCO and MBHO survey results tend to cluster in a relatively narrow range.  This clustering makes survey outcomes and accreditation status less valuable in differentiating between organizations based on this presumed indicator of quality.

NCQA has embarked on a number of strategies to increase the spread.  Some of the new accreditation standards introduced for 2007 that rely heavily on technology—and that require implementation of fairly complex technological solutions for full compliance—are part of this strategy.  The compliance challenges created for some organizations by these standards will increase the spread in survey outcomes. 

A new strategy, for 2008, changes the model for the scoring algorithm.  Many scoring elements require compliance with a number of factors.  A score of 100% is often awarded for meeting less than all factors, say 5 or 6 out of 6.  Beginning with the 2008 standards year, the plan for achieving 100% is for an organization to be in compliance with all the factors. 

There’s no doubt, that scoring has gotten tougher over the past couple of years.  This new change is just one more step in the process. 

If you need help achieving 100%, contact us.  We have a great track record at helping organizations achieve high scores.  Just take a look at this, and this, and this.  After all, if you’re devoting resources to accreditation, why not get an outstanding outcome.  That’s what will differentiate you from the competition.

RIP: QIA 2008

Quality Improvement Activities (QIAs) are dead—or at least they will be—beginning with NCQA’s 2008 Standards for Managed Care Organizations.  Nothing big will be taking their place, either.  HEDIS results will continue their relentless march to account for more and more of a health plan’s accreditation status.  (Kind of reminds me of Dr. Who and the Pescatons, when, as the Pescatons were invading and overtaking Earth they repeated the refrain  “The great march of life goes on!”)

Quality Improvement Activities, those written-up summaries of an MCO’s efforts to improve a clinical or service measure, have been less common for health plans seeking NCQA accreditation since the advent of “Earned Credit.”  Earned Credit allowed a health plan to get credit for an improvement, clinical or service, based on changes over time in an appropriate HEDIS or CAHPS measure.  With the retiring of QI 12 (Clinical Quality Improvements) and QI 13 (Service Quality Improvements), MCOs will no longer get credit for improving poor HEDIS results. 

Having an effective system to improve clinical and service performance is more critical than ever.  Nearly 40% of an MCO’s accreditation outcome will be based on how well it performs on HEDIS and CAHPS in relation to other health plans—and this percentage will creep up over time as additional measures are added.  The 2008 standards year is just around the corner.  The window is closing on being able to implement interventions to improve performance that will translate into improved HEDIS and CAHPS results measured in early 2008. 

For Managed Behavioral Healthcare Organizations QIAs are not dead.  It isn’t practical to implement a similar system for MBHOs since there are not enough relevant HEDIS measures, and the behavioral health measures that exist are way to difficult to improve; not to mention the data-source problems that most MBHOs have.

It wasn’t too long ago that I was focusing on NCQA changes for 2007.  That seems like old history by now.  Look for upcoming columns to discuss other big changes for 2008.

Thoughts On the New Approach to Joint Commission Survey

Today’s column is written by our senior Joint Commission consultant Mike Troncone, based on his experience with the new Joint Commission survey preparation.

I enjoyed the “old” approach to survey preparation.  About a year before a Joint Commission survey was expected, the organizations that I was involved with would begin preparations by doing a gap analysis and taking necessary corrective action so that a twelve-month track record of compliance could be demonstrated at the time of survey.  Flow charts and presentations were prepared so that we could “Wow!” the surveyors.  The hot topics and areas that were being emphasized were reviewed with all staff and our responses were carefully orchestrated.  Senior Leadership supported those efforts and was prepared to put the Joint Commission on their radar screens for a few months every three years to ensure a successful survey.

By now, almost every organization surveyed by the Joint Commission has been through some form of the new survey process and knows that the emphasis has changed considerably.  To successfully maintain accreditation, we need to operate by the book (the Accreditation Manual, that is), keep a careful inventory of identified areas in need improvement, and monitor corrective actions on an ongoing basis.  Continuous Survey Readiness is the key to sleeping well at night with the new process.

The big difference is to “be prepared,” not to prepare.  For this shift to occur, Senior Leadership must support a cultural shift.  This is a gradual process that will take some time.  Without an agreed upon direction and clear processes for achieving the shift, it is doomed to fail.  The survey coordinator will find her or himself in solitary chaos as the coordinator struggles to complete the annual PPR and be prepared for the unexpected arrival of the surveyors.

Leadership buy-in through a Continuous Survey Readiness plan, whether developed within the organization or with the help of the experts, will provide a blueprint for success.  The plan should define the role of each area of the organization in maintaining compliance with the standards and incorporate a succinct process for keeping the senior leaders informed of areas that require attention.

The standards can be viewed as guidelines for providing good care that can be implemented in a way that also makes good business sense in day-to-day operations.  Of course, this must be demonstrated before most leaders will commit organizational resources to the change.  The survey coordinator needs to develop the evidence necessary to support the shift and to define a process for achieving the shift efficiently and economically.

Give QI A Chance

In my last column I mentioned that managed care organizations seem to have lost interest in trying out some real, honest-to-gosh QI tools and techniques.  I thought I would use this column to suggest that you try out some QI tools and techniques generate ideas and establish priorities. 

I suggest picking an performance measure that is important but that seems to be stuck.  Don’t pick something big, like the equivalent of trying to solve world hunger.  Pick something focused, like trying to improve a specific HEIDS rate.  And keep it focused, don’t include a series of related HEDIS rates.  Just pick one.

Next, figure out which stakeholders are INVOLVED INTIMATELY in the process.  They may be your staff (in fact, no doubt some of them will be) but could also include practitioners, hospitals, health plan members, and maybe vendor staff.  Give this some thought.  The ideas generated will be a function of the participants.  You want a truly representative group of knowledgeable people.  Avoid having a lot of managerial staff involved.  And avoid stacking the deck with lots of folks from the same narrow slice of the organization. 

Bring the group together.  Ten to 15 people is probably a reasonable number.  Silence cell phones (seriously!).  Set the stage by telling the group what you want them to do.  It might be something like: “We’re here to generate ideas about how to improve our rate of optimal practitioner contacts for members with depression.”  Assure them that all ideas are welcome and that they shouldn’t hesitate to suggest anything that they think has a chance of working.

Next, give everyone five minutes to write IN SILENCE (yes, I really mean in silence) ALL their ideas about how to improve the optimal practitioner contact rate.  (Of course, if that’s not the task you’ve chosen, then give them five minutes to write down their ideas about the correct task). 

When everyone is done—there’s no need to hurry them along since this isn’t a time-limited exam.  Identify a scribe to write down all the ideas of the group.  The room should remain SILENT (yes, really) except for each person taking a turn reading one, just one, idea from his/her list.  If he/she starts to justify the idea or do anything except read it in a way that can be TRANSCRIBED (yes, I really mean JUST transcribed.  NOT edited.  NOT paraphrased.  NOT commented-on) stop him/her and ask him/her to just speak the idea using the words that the scribe should write down.

Similarly, if the scribe does anything other than transcribe, stop him/her and ask him to write down what the speaker is saying. 

Continue going around the room having each person read one idea at a time.  Continue round, and round, and round the room till everyone has read every idea.  Don’t allow folks to shy away from this responsibility unless you’re really sure that they’ve read every one of the ideas the wrote down.

Throughout all of this KEEP EVERYONE FROM TALKING—and most especially keep them from engaging the speaker in any discussion of his/her idea.  One of the factors that frequently inhibits creativity is the fear that one will have to justify one’s suggestions.  There is absolutely no need to explain one’s rationale for suggesting something.  All ideas are good ideas and, when you’re trying to come up with a lot of them, you don’t really need to know why they were suggested.

If you chose a representative group of stakeholders and followed the instructions above, you should have 3 dozen or more ideas.  At least some of them should be things you haven’t heard before. 

Now, if I were there with you, the next step would be to learn how to do nominal group technique to establish priorities among all the ideas—again without any real discussion.  But that lesson will need to wait for another column.

If you haven’t done this before, and you do it well, it can be a revelation.  In an hour you can go from no idea of what to do to improve something, to having a short list of really creative ideas with minimal discussion. 

You might have noticed a certain emphasis on form and technique in my instructions.  That’s because the success of this process depends on technique.  Without the discipline, silence, and lack of commentary you’d have little more than a regular meeting—and you already know what ideas that will generate.

Quality Improvement in Health Care

I started working in health care administration in the late 80’s.  I ran a teaching service at a university hospital for a year and liked it so much that I took a position as the medical director of a hospital—then the medical director of a really big hospital in the public sector.  That’s when I got serious about learning about the Joint Commission.  Of course, the fact that the hospital underwent a state regulatory survey during my first month, a Medicare survey during my second month, and a Joint Commission survey during my third month helped kindle my interest just a bit. 

A little more than a year later, I became a Joint Commission surveyor (in the days when surveyors could still have full-time jobs and do a handful of surveys a year).  This began to pique my interest in quality improvement.  Shortly thereafter, I and two other physicians from the public sector made an ambitious attempt to implement an honest-to-gosh quality improvement program in our public sector facilities (think Deming, Crosby, and Juran).  We were encouraged by articles about how the US Military, a government bureaucracy much larger than ours, had had some significant successes doing the same. 

My education in quality improvement began in earnest. 

In the early 90’s I became Associate Director in the Department of Standards at the Joint Commission.  This was just when the Joint Commission was making a big shift from accreditation “silos” to cross-functional integration and quality improvement.  I began teaching education programs on quality improvement.  My favorite ones were the weekend long programs (Friday evening, all day Saturday, and half-a-day on Sunday) where I and another faculty member taught quality improvement skills-building workshops for physicians.  My co-presenters were all hospital-based physicians with impressive experience in quality improvement from whom I learned a tremendous amount. 

Interestingly, I learned even more about quality improvement when studying for my MBA.  (Crazy me, I did this while working full-time at the Joint Commission, part time as a managed care medical director, and Saturdays in clinical practice.)  But I digress.  Learning about statistical process control (the true underpinnings of quality improvement if you ask me) from the perspective of a manufacturing industry or for inventory control suddenly made some of the concepts that didn’t quite fit in a health care context make sense.

I began adding information about the differences in quality improvement for service-based industries as opposed to product-based industries to my seminars. 

A little while later I left the Joint Commission, became a full-time managed care medical director, and joined the NCQA orbit.  I was given free-reign to develop a quality improvement program for the managed care company.  It was an incredible experience building it from the ground up: identifying data sources, developing data bases, figuring out the best graphic displays for performance data, implementing cross-functional teams (yes, really, teams—not just committees) each responsible for understanding and improving a single, important organizational process. 

I kept teaching educational programs.  I did more and more health care consulting work.  I continued to survey for NCQA and I helped develop NCQA’s behavioral health standards. 

After an incredibly successful and heady run as a managed care medical director, with my consulting business tugging at me, I made a career shift into full-time consulting.  In the early years, a number of managed care organizations were interested in learning about quality improvement and applying the principles, tools and techniques to their operations. 

Over the last five years or so, I’ve seen a declining interest in quality improvement.  Maybe it’s a lack of knowledge about what QI can really do, but it seems like folks just want the answer.  I’m frequently asked by clients and seminar attendees what changes to implement to improve performance. 

It’s not that easy.  To improve performance you need to understand the causes of current performance.  To do that, you need to apply quality improvement tools and techniques.

Personally, I’d like to see a renewed interest in QI.  If used well, I think we’d begin to see improvements in member and practitioner satisfaction, improvements in health status, and improved job satisfaction for managed care employees. 

Even if it’s only a couple of hours a month, engaging staff and outside stakeholders in a “real” quality improvement endeavor provides a jolt of creativity and out-of-the-box thinking that boosts morale as it boosts performance.

Stay tuned for some pointers on how to do this.

Delegation and the MCO Standards

NCQA’s standards for delegation have been fairly constant for a number of years.  This makes compliance activities a bit easier.  Even with consistent standards though, organizations need to be vigilant about maintaining compliance.  The standards may be constant but organizations change—and these changes may lead to non-compliance.

Pharmaceutical management is one area to watch carefully.  Over the past year, I have worked with a handful of organizations that have a "Swiss cheese" (OK, Emmenthaler, for you foodies) approach to delegation of pharmaceutical management.  Maybe it’s just that I’ve had a skewed perspective but, until recently, my experience had been that MCOs either delegated the bulk of pharmaceutical management to a PBM or maintained the functionality in house.  My recent experience is that delegation is becoming more selective.

Point-of-dispensing communication of potential drug-drug interactions is a case in point.

NCQA’s position is that delegation exists if the surveyed organization gives another entity (the vendor) authority to carry out a task that the surveyed organization is required to perform under the standards.  What this means is that a PBM can perform lots of tasks for an MCO that do not constitute delegation; things like claims payment, rebate processing, contracting with a network of pharmacies, and so forth.  None of these issues would be addressed during an NCQA survey.

Point-of-dispensing communication is different.  NCQA has standards making the MCO responsible for these activities.  UM 13C.1 requires the MCO “adopt or create” a system for identifying, at the time of dispensing, potential drug-drug interactions and assigning the interactions to severity levels.  UM 13C.2 requires evidence that the system is implemented at the point of dispensing, in real time, when a potential interaction meets a defined severity threshold. 

Few MCOs create their own system.  Most adopt a system created by another organization.  Adopting another organization’s system is delegation and, even if this is the only activity delegated to a PBM, all of UM 15 applies. 

UM 13C is worth 0.1 points.  If an organization did not implement point-of-dispensing communication of potential drug-drug interactions, it would loose 0.05 points as indicated by the scoring algorithm.  On the other hand, UM 15 (the “delegation” standard) is worth 1.87 points.  In essence, delegating UM 13C.1 and 13C.2 increases their value by a factor of 37!  This is not a low-stakes game. 

If you delegate point-of-dispensing communications be sure that you’re in full compliance with the delegation requirements.  In particular, check to see that your vendor is required to supply reports that relate to point-of-dispensing communication, that you actually receive them, and that there is evidence that the reports are reviewed.  It’s all too easy to overlook such a report when negotiating reporting requirements with a PBM.