The Mihalik Blog

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. 

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…

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. 

Joint Commission Update Part III

This is the final installment of Michael Alcenius’ Joint Commission Update.  I’ll be back next week. 

Gary

I walked away with from the Joint Commission Hospital Executive Briefings in

Garden Grove, California with an appreciation of the significant restructuring of the emergency management standards in the Environment of Care chapter.  Most of the modifications are based on lessons learned from disasters that have impacted health care since 2001 (e.g., 9/11; Katrina).  The new standards, effective January 1, 2008, emphasize a scalable approach to managing response and organizational self-sustainability for at least 96 hours.

As a foundation, it is important to understand three definitions relative to events that impact an organization’s ability to provide care:

·        Emergency

o       Infrastructure remains intact

o       Able to support care/services

o       No deaths directly related to the event

·        Disaster

o       Infrastructure damaged

o       Able to support care/services

o       Few deaths directly related to the event

·        Catastrophe

o       Infrastructure damaged

o       Not able to support care/services

o       Many deaths possible

In addition, the new structure addresses six important areas of emergency management

·        Communication

·        Resources and assets

·        Safety and Security

·        Staff roles and responsibilities

·        Utility management

·        Clinical and support activities

A synopsis of the revised standards follows.   

EC.4.11 Planning

·        Hazard Vulnerability Analysis (HVA)

·        For each emergency identified in HVA, define:

o       Mitigation activities

o       Preparedness activities

o       Response strategies

o       Recovery strategies

·        Document assets and resources needed during emergencies

·        Objectives, scope, performance, effectiveness of planning is evaluated at least annually

EC.4.12 Written Plan

·        Emergency Operations Plan (EOP)

o       Establishes incident command structure

o       Identifies staff reporting structure

o       Identifies organizational capabilities

o       Establishes response efforts when organization cannot be supported by community for at least 96 hours

o       Identifies alternate sites of care for evacuation if necessary

EC.4.13 Communications

·        Plan for ongoing communication

·        Communication with other organizations in area

·        Communications with patients and third parties such as FBI, Health Department

EC.4.14 Strategies for Managing Resources/Assets

·        Plan for obtaining supplies at onset of emergency

·        Plan for replenishing

·        Managing staff resources

·        Managing staff and family support needs

·        Sharing of resources with other organizations

·        Evacuation

·        Transporting patient and resources during evacuation

·        Transporting patient information

EC.4.15 Strategies for Managing Safety and Security

·        Controlling egress and exit

·        Controlling movement within facility

·        Controlling traffic

EC.4.16 Staff Roles and Responsibilities

·        Define roles

·        Train staff for roles

·        Communication to LIPs about role

·        Identification of care providers and other personnel

EC.4.17 Managing Utilities

·        Identify alternative means for providing

o       Electricity

o       Water

o       Fuel

o       Ventilation/Heat

o       Medical gas/vacuum

EC.4.18 Managing Clinical and Support Activities

·        Personal hygiene and sanitation

·        Mental health

·        Mortuary services

·        Documenting and tracking clinical information

EC.4.20 Exercising the Plan

·        Define scope of exercises

o       Number and types – twice annually in response to actual emergency or planned exercise, one must include influx of actual or simulated patients

o       At least one escalated to evaluate performance when community cannot support

o       At least one community-wide exercise/year if organization has a role in community structure

o       Realistic addressing emergencies identified in HVA

o       Monitor performance and identify opportunities for improvement

o       Monitor the six crucial areas

§         Communication

§         Resources

§         Safety and Security

§         Staff roles and responsibilities

§         Utility systems

§         Clinical and support activities

·        Critique

o       Multidisciplinary process

o     EOP modified in response

Information Exchange

Last week I taught two NCQA education programs.  One on Physician and Hospital Quality and the other on Quality Plus Challenges and Solutions. 

The participants in these programs were similar to what I have experienced in NCQA programs over the last couple of years.  They were looking for answers. 

When I first started teaching NCQA programs ten years ago, the interest was largely in understanding what was required.  It seems that, now, understanding what is required is only a transit point for getting some concrete advice on how to implement systems and processes that are compliant with the standards. 

This need is one which is rarely satisfied at an NCQA conference.  But, honestly, I don’t think it’s NCQA’s role (nor their strong suit) to tell organizations how to meet the intent of the standards.  This is a distinction that I learned many years ago as Associate Director in the Joint Commission’s Department of Standards.  When doing standards interpretation, the goal was to help organizations understand what the standard meant and what it required but not specifically how to meet it. 

Clearly there’s a gray zone between these areas.  With rare exceptions, the people who work in standard-setting organizations are not really involved in health care delivery or health care management any longer—even if they once were.  Systems change.  Software evolves.  The folks who work for NCQA, the Joint Commission, and other standard-setting organizations apply their clinical and managerial experience at a meta level.  This creates an understandable tension with individuals who work for organizations trying to comply with the standards—a micro level, so to speak. 

Which brings me back to what I was thinking when I started writing this column.  At both programs, some really good advice on how to meet the intent of the standards came from the audience. 

Would harnessing that experience and making it available be of interest? 

This blog, or an extension of it, could be turned into a moderated forum where individuals could post questions and get advice from others in the field who have faced similar challenges.  Along the way I would add my perspective on the questions asked and the advice given.  Perhaps this format would span the divide between understanding the standards and knowing what to do to meet them.

I look forward to your thoughts on this topic.  If you think it’s a good idea, or a bad idea, or if you have any thoughts at all, please click on the “Comments” button at the bottom of this page and let me know.  If there’s an interest in doing this I’ll do my best to put the systems in place to meet the need.