The Mihalik Blog

Making Quality Happen

I just got back from a brief jaunt to the East Coast where I gave a presentation on HEDIS and Quality Improvement and then facilitated a small group session to identify interventions to improve performance.  All in all, this is a fairly typical role for me.

What struck me for some reason this time around, was how much more often I used to facilitate quality improvement processes than I do now.  I’m not sure what caused the change but I’m more convinced than ever that quality improvement efforts at health plans and health care facilities would improve significantly with good facilitation.  Honestly, I think that the health care field isn’t paying enough attention to good technique when it comes to the tools and techniques of QI. 

As part of my talk, I described brainstorming techniques, much as I did in a previous blog.  Despite the “just in time” training, and knowing that I was sitting in the back watching, the groups were not able to implement what they had just been taught.  Brainstorming sounds simple but learning to do it well is like learning many other skills.  It takes practice, modeling, and mentoring. 

The group members quickly fell into the all-too-common pattern of having long, discussions about their thoughts of what would improve performance.  When I was asked to help facilitate, I took a moment to refocus the group on the task and then went back to the book.  The book on structured brainstorming, that is. 

I had everyone take 5 minutes to write down his/her ideas for possible interventions to improve performance.  We spent the next 25 minutes transcribing everyone’s ideas onto the flip chart.  On a number of occasions, had I not “facilitated” the process, the group would have fallen back into the old habit of discussing ideas. 

In the course of 30 minutes the group had generated over two dozen credible interventions to improve outcomes for a specific high-risk patient group.  In the thirty minutes before I began facilitating, they hadn’t generated any. 

Clearly the ideas were there—they just needed to be set free.  Good facilitation was the key. 

Although it might sound self-serving, I truly encourage you to think about involving The Mihalik Group in deployment of your quality improvement program.  When you need to understand the causes of key outcomes or develop interventions to improve performance (like maybe your HEDIS rates), our facilitation skills may be just what you need. 

Give me a call or send me an email and we can discuss how The Mihalik Group can help. 

Performance Measurement

I’ve been doing quite a number of speaking engagements over the past few months.  Many of them have been on HEDIS.  Most of these are for health plan audiences or for practitioners who are in health plan networks.  One upcoming HEDIS is for hospital staff.  One I did recently for the St. Louis Professionals for Health Care Quality included quality professionals from health plans and hospitals. 

I’ve been questioned about why hospital staff would want to learn about HEDIS.  While it’s true the HEDIS doesn’t have the impact on hospitals that it has on health plans (for which HEDIS results are a major component of NCQA’s health plan accreditation process), HEDIS is a good model.

First off, HEDIS works.  Its standardized measurement process is implemented across the country, allowing reliable comparisons to be made on outcomes between health plans.  Doing something similar for hospitals was the Joint Commission’s dream for the Indicator Measurement System back in the early 1990s.  Unfortunately they failed to even come close to the goal, in the process missing a historic opportunity to implement a modernized version of Ernest Codman’s End Results System.  I believe it also stalled the process of furthering the quality agenda for hospitals.  But I digress…

Increasingly, HEDIS serves as the basis for health plans constructing practitioner-level performance measures.  While these are not (yet) reportable to NCQA, their frequency has prompted NCQA to issues specifications for practitioner-level HEDIS as a way of improving reliability.

Even though practitioner-level HEDIS is not reportable to NCQA, NCQA is putting a major investment of resources into developing practitioner level performance measures.  The latest effort to be unveiled is a set of measures for HIV/AIDS.  These measures, which can be implemented at the practitioner or system level, look more like HEDIS measures than the ones in NCQA’s Practitioner Recognition Programs—perhaps signaling a new trend. 

Whether a health care organization needs to implement HEDIS measures or not, it is clear that one can learn quite a bit from NCQA’s success in implementing national outcome measurement processes for diverse audiences. 

Since our inception, The Mihalik Group has assisted health care organizations develop and implement performance measurement initiatives and improve performance. 

Satisfaction Surveys

For a while, member surveys had become no-brainers.  CAHPS is required for health plans and ECHO was used by an increasing number of managed behavioral health care organizations. 

ECHO was retired, and is now so out of date that it has fallen out of use.  CAHPS is still around, and required, to be sure, but the requirements to survey members in disease management programs and complex case management have, once again, opened the field beyond CAHPS. 

I’m seeing more poorly constructed surveys, inadequate analysis, and questionable methodologies now that “free-form” surveys are common once again.

Research has shown that using rating scales, such as 1 to 10, rather than a series of descriptions, such as very satisfied, slightly satisfied, slightly unsatisfied, etc. is more easily transferable to surveys in languages other than English.  I also believe that numeric rating scales remove a source of confounding information since the survey respondent’s assessment of satisfaction isn’t filtered through the words chosen by the folks who wrote the survey.  Numbers are numbers, and if there are 10 steps between the best and the worst, someone can identify his or her level of satisfaction without thinking about whether a word such as “somewhat satisfied” captures the experience.

Some survey vendors merely report results.  Others provide varying degrees of quantitative analysis.  When comparing vendors, be sure you know what level of analysis will be provided.  In all instances, you will need to do the qualitative analysis.

Be sure the methodology will pass muster.  How was the sample size selected?  What is the sampling process?  How is the instrument administered?  What mechanisms are used to improve response rate?

The Mihalik Group has been developing and conducting member and practitioner satisfaction surveys for nearly a decade.  We have off-the-shelf surveys—both member and practitioner—which can be customized with additional questions if you’d like.  We can also develop a fully individualized survey to meet your needs.

 

One of the advantages of having us do your survey is that you can be assured that it’ll meet NCQA standards!

NCQA Speak (#1 of a Series): It’s not delegation

Let’s face it, any group of professionals ultimately develops its on lingo that can seem cryptic or confusing to outsiders.  NCQA is no exception.  This is the first in an occasional series of articles on NCQA “language” with the goal of making communications more understandable.

Is it delegation or not?

In general, any time an NCQA-accredited organization has another organization do something on its behalf that it would otherwise need to do itself to be in compliance with the NCQA standards, the organization has delegated the activity. 

Sometimes, in seeming violation of this rule, you’ll hear an NCQA staff member or surveyor say something isn’t delegation, when the “something” clearly meets the definition above.  For example, having an organization conduct performance measurement for a standard that requires measurement (like access or availability) or having a nurse-staffing organization conduct practitioner site visits. 

So, is the definition wrong or are they really delegation?

They’re really delegation.  What we sometimes mean when we say “it’s not delegation” is “it’s delegation, but NCQA does not review (and therefore does not require that the organization perform) delegation oversight.”  Granted, it’s a confusing twist of phrase but it’s a lot easier to say “it’s not delegation” than “it’s delegation but NCQA does not require delegation oversight.”

The next time you hear someone say “it’s not delegation” I suggest you determine if that’s really the case or if the process fits the definition of delegation and if it’s just that NCQA does not require oversight of the delegation.  If you do this, you’re less likely to take an exception and treat it like the rule.  Unless NCQA grants an exception, all delegation requires oversight of the delegate’s performance. 

Hot Off The (Proverbial) Press

I was all set to write an entry on the unintended consequences of NCQA’s changes to standard CR 6 but that got scooped by a recent decision. 

Here’s the issue.  CR 6, Practitioner Office Site Quality, was changed for standards year 2008 eliminating the requirement to conduct site visits for all PCPs, OB/GYNs and high volume behavioral health practitioners.  In its place is a requirement to conduct site visits for practitioner offices about which the organization receives a complaint related to:

§         Physical Accessibility

§         Physical Appearance

§         Adequacy of Waiting and Examining Room Space

§         Availability of Appointments

§         Adequacy of Treatment Record Keeping

The process, as described in the 2008 standards, required a full-scope site visit for any single member complaint related to any of the five categories listed above.  There is no provision for an organization to validate the complaint before conducting the site visit. 

The intention was to reduce the burden that site visits place on organizations by focusing on sites where there is a reason to suspect an issue.  The unintended consequence is that, for many organizations, the number of site visits would increase exponentially due to member complaints about availability of appointments—many of them not valid. 

Good News!!!

NCQA has decided to NO LONGER REQUIRE A SITE VISIT in response to complaints about Availability of Appointments and Adequacy of Treatment Record Keeping.  This will significantly relieve organizations from an otherwise almost unmanageable site visit burden. 

NCQA still has not addressed the issue of multiple complaints being received in a short period of time about the same practitioner site.  As the standard is currently written, each would trigger a full-scope site visit.  The benefit of conducting serial site visits in a short period of time is questionable. 

The lack of a process for the organization to validate a complaint before conducting a site visit is also of concern. 

I’ll keep you posted on additional changes.