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.