The Mihalik Blog

Summer’s Almost Here…

I know you haven’t heard from me in a while.  I’ve been swept up in a whirlwind of activity—preparing presentations, teaching seminars, getting organizations ready for survey.  I hope to get a chance to enjoy a bit more of the vegetables coming out of the garden this year than I did last year but so far the summer is shaping in a way that indicates that I’ll be on the road quite a bit.

 

A few upcoming trips include teaching programs for NCQA. 

 

On June 24^th I’ll be co-teaching an all day seminar on Data Analysis.  The focus of my sessions will be on how to use key tools and techniques of quality improvement.  For those of you who’ve read my blog, you know that I feel like the basics of QI don’t get used often enough by organizations in the health care industry.  I’m excited about trying to kindle interest in just how powerful these tools can be.

 

On June 25^th I’ll be presenting a half-day seminar, with another presenter, on Behavioral Health HEDIS.  We’ll discuss the challenges facing organizations trying to improve BH HEDIS measures, highlight some of the upcoming changes to the measures, and describe interventions that organizations have used to successfully improve BH HEDIS scores.

 

Both programs will be held at the new NCQA headquarters in Washington, DC and there’s still time to register.  I hope to see you and one or both of these programs.

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. 

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. 

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. 

NCQA Clearinghouse

A while back, I discussed using this blog as a forum for discussing NCQA-related compliance issues.  I got some positive responses, both here and directly from some client organizations. 

Let’s see if we can get this started.

My suggestion is that you use the comment feature at the bottom of this post to submit topics or questions that you’d like to see discussed.  I’ll use the suggestions to create topic threads, solicit feedback through the comment feature, and moderate the posts. 

This could be a really good way to pool collective expertise regarding how to meet some of the challenges of complying with NCQA accreditation standards. 

So, send in your NCQA-related questions, concerns and comments, please…

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.