Performance Improvement Projects (PIPs)

1. Performance Improvement Projects (PIPs) Agency for Health Care Administration (AHCA) Tuesday, June 27, 2006 2:45 p.m. – 4:45 p.m. David Mabb, MS, CHCA Senior Director of Statistical Evaluation Cheryl L. Neel, RN, MPH, CPHQ Manager, Performance Improvement Projects

2. Presentation Outline • Overview of the PIP process • PIP Summary Form Review • MCO demographics • CMS rationale • HSAG evaluation elements • PIP Scoring Methodology • Deliverables through the end of 2006 • Questions and Answers

3. Overview of PIPs What is a PIP? • It is a quality improvement project. What is the purpose of a PIP? • To assess and improve processes, and subsequently, outcomes of care. It typically consists of a baseline, intervention period(s), and remeasurement (s).

4. Overview of PIPs (cont.) The PIP process provides an opportunity to: • Identify and measure a targeted area (clinical or nonclinical) • Analyze the results • Implement interventions for improvement

5. Overview of PIPs (cont.) Useful PIP “SIDE EFFECTS” • Develop a framework for future performance improvement projects • May improve member satisfaction • Improve HEDIS rates as a “bonus” to improving other health outcomes

6. Overview of PIPs (cont.) HSAG’s role: • Validates PIPs using CMS’ protocol, Validating Performance Improvement Projects, A protocol for use in Conducting Medicaid External Quality Review Activities, Final Protocol, Version 1.0. • PIP Validation is a desk audit evaluation • HSAG validates the study’s findings on the likely validity and reliability of the results • Provides PIP Validation Reports to AHCA and the MCOs • Identify best practices

7. PIP Summary Form Review • Health plan demographics (first page of the submission form) • Discuss the 10 PIP Activities • CMS Rationale • HSAG evaluation elements

8. Activity One: Choose the Selected Study Topic CMS Rationale • Impacts a significant portion of the members. • Reflects Medicaid enrollment in terms of demographic characteristics, prevalence of disease, and the potential consequences (risks) of the disease.

9. Activity One: Choose the Selected Study Topic CMS Rationale • Addresses the need for a specific service. • Goal should be to improve processes and outcomes of health care. • The study topic may be specified by the State Medicaid agency or on the basis of Medicaid enrollee input.

10. Activity One: Choose the Selected Study Topic HSAG Evaluation Elements • Reflects high-volume or high-risk conditions (or was selected by the State). • Is selected following collection and analysis of data (or was selected by the State). • Addresses a broad spectrum of care and services (or was selected by the State).

11. Activity One: Choose the Selected Study Topic HSAG Evaluation Elements (cont.) • Includes all Medicaid eligible populations that meet the study criteria. • Includes members with special health care needs. • Has the potential to affect member health, functional status, or satisfaction.

12. Activity One: Choose the Selected Study Topic Example Study Topics: • Cervical Cancer Screening • HbA1c testing • Flu Vaccinations • Initial Contact Data Systems • Early Periodic Screening Detection and Treatment (EPSDT) Services for Children 1–3 Years of Age • Early Entrance to Prenatal Care and Check Ups after Delivery

13. B. Activity Two: The Study Question CMS Rationale • Stating the question(s) helps maintain the focus of the PIP and sets the framework for data collection, analysis, and interpretation.

14. B. Activity Two: The Study Question HSAG Evaluation Elements • States the problem to be studied in simple terms. • Is answerable/provable. In general, the question should illustrate the point of: Does doing X result in Y? Example: Will increased planning and attention to the importance of follow-up after inpatient discharge improve the rate of members receiving follow-up services?

15. C. Activity Three: Selected Study Indicators CMS Rationale • Quantitative or qualitative characteristic. • Discrete event (member has or has not had XX). • Appropriate for the study topic. • Objective, clearly and unambiguously defined.

16. C. Activity Three: Selected Study Indicators HSAG Evaluation Elements The study indicator(s): • Is well defined, objective, and measurable. • Is based on practice guidelines, with sources identified.

17. C. Activity Three: Selected Study Indicators HSAG Evaluation Elements (cont.) The study indicator(s): • Allows for the study question/hypothesis to be answered or proven. • Measures changes (outcomes) in health or functional status, member satisfaction, or valid process alternatives.

18. C. Activity Three: Selected Study Indicators HSAG Evaluation Elements (cont.) The study indicator(s): • Has available data that can be collected on each indicator. • Is a nationally recognized measure such as HEDIS®, when appropriate. • Includes the basis on which each indicator was adopted, if internally developed. HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

19. D. Activity Four: Identified Study Population CMS Rationale • Represents the entire Medicaid eligible enrolled population. • Allows system-wide measurement. • Implements improvement efforts to which the study indicators apply.

20. D. Activity Four: Identified Study Population • HSAG Evaluation Elements • The method for identifying the eligible population: • Is accurately and completely defined. • Includes requirements for the length • of a member’s enrollment in the • managed care plan. • Captures all members to whom the • study question applies.

21. D. Activity Four: Identified Study Population Example of Study Population: All Medicaid children with at least 11 months (12 months with one 30-day gap of enrollment) of continuous enrollment in the health plan, who were born on or between January 1, 2001, and December 31, 2003.

22. E. Activity Five: Valid Sampling Techniques • CMS Rationale • Sample size impacts the level of statistical • confidence in the study. • -Statistical confidence is a numerical statement • of the probable degree of certainty or • accuracy of an estimate. • Reflects improvement efforts to which the study • indicators apply. • Reflects the entire population or a sample of that • population.

23. E. Activity Five: Valid Sampling Techniques • HSAG Evaluation Elements • Consider and specify the true or • estimated frequency of occurrence (or • the number of eligible members in the • population). • Identify the sample size (or use the • entire population). • Specify the confidence interval to be • used (or use the entire population).

24. E. Activity Five: Valid Sampling Techniques • HSAG Evaluation Elements (cont.) • Specify the acceptable margin of error • (or use the entire population). • Ensure a representative sample of the • eligible population. • Ensure that the sampling techniques • are in accordance with generally • accepted principles of research design • and statistical analysis.

25. F. Activity Six: Data Collection Procedures, Data Collection Cycle, and Data Analysis • CMS Rationale • Automated data collection • Manual data collection • Inter-rater reliability • Frequency of collection and analysis • cycle

26. F. Activity Six: Data Collection Procedures, Data Collection Cycle, and Data Analysis • HSAG Evaluation Elements • The data collection techniques: • Provide clearly defined data elements • to be collected. • Clearly specify sources of data. • Provide for a clearly defined and • systematic process for collecting data • that includes how baseline and • remeasurement data will be collected.

27. F. Activity Six: Data Collection Procedures, Data Collection Cycle, and Data Analysis • HSAG Evaluation Elements (cont.) • The data collection techniques • Provide for a timeline for the collection • of baseline and remeasurement data. • Provide for qualified staff and • personnel to collect manual data.

28. F. Activity Six: Data Collection Procedures, Data Collection Cycle, and Data Analysis • HSAG Evaluation Elements (cont.) • The manual data collection tool: • Ensures consistent and accurate • collection of data according to • indicator specifications. • Supports inter-rater reliability. • Has clear and concise written • instructions for completion.

29. F. Activity Six: Data Collection Procedures, Data Collection Cycle, and Data Analysis • HSAG Evaluation Elements (cont.) • An overview of the study in the written • manual data collection tool instructions. • Automated data collection algorithms • that show steps in the production of • indicators. • An estimated degree of automated • data completeness (important if using • the administrative method).

30. F. Activity Six: Data Collection Procedures, Data Collection Cycle, and Data Analysis • Other Considerations: • Determine time period of data to be abstracted (i.e.) • – From birth to end of study period • – Only EPSDT services provided • during study period • – All visits or EPSDT visits only? • – Calendar or Fiscal Year?

31. F. Activity Six: Data Collection Procedures, Data Collection Cycle, and Data Analysis • Other Considerations (cont.): • Administrative method or hybrid • method • Design and test data collection tool • Electronic or hard copy tools? • Enter data into database on laptop • Keypunch data from hard copy

32. F. Activity Six: Data Collection Procedures, Data Collection Cycle, and Data Analysis • Other Considerations (cont.): • Design tool instructions • Clearly defines study indicators • Attempts to cover a variety of medical • record scenarios • Supports reliability

33. F. Activity Six: Data Collection Procedures, Data Collection Cycle, and Data Analysis • Other Considerations (cont.): • Design tool instructions • Clearly defines study indicators • Attempts to cover a variety of medical • record scenarios • Supports reliability

34. F. Activity Six: Data Collection Procedures, Data Collection Cycle, and Data Analysis • Other Considerations (cont.): • On-site vs. mail-in data collection? • Allow 10 to 12 weeks for medical • record retrieval and abstraction. • Health plans should conduct and • document ongoing monitoring of • abstractors. HSAG recommends 5% • per abstractor using “rater to standard” • method.

35. Impact of Missing Medical Records on Results The Case of the Missing Records MR MR

36. Comparison Between Immunization Results With and Without Missing Records Included HEDIS Combined Rate DTP,OPV, MMR, HIB, & HBV With Missing MRs Without Missing MRs 90% Goal

37. F. Activity Six: Data Collection Procedures, Data Collection Cycle, and Data Analysis • Other Considerations (cont.): • Create an Analysis Plan • Determine the statistics to be reported • Report rates for indicators along with • significance • Example: Lead screening rates may be reported at 24 months of age, and then also for children by 35 months of age.

38. F. Activity Six: Data Collection Procedures, Data Collection Cycle, and Data Analysis • Other Considerations (cont.): • Examine indicators by categories such • as age and gender, and overall • Analyze necessary referrals • Example: Children with elevated blood lead levels require additional follow-up.

39. G. Activity Seven: Improvement Strategies • CMS Rationale • An intervention designed to change • behavior at all levels of the care • delivery system, including the • members. • Changing performance, according to • predefined quality indicators. • Appropriate interventions. • Likelihood of effecting measurable • change.

40. G. Activity Seven: Improvement Strategies • HSAG Evaluation Elements • Planned/implemented strategies for improvement are: • Related to causes/barriers identified through data • analysis and Quality Improvement (QI) processes. • System changes that are likely to induce • permanent change. • Revised if original interventions are not • successful. • Standardized and monitored if interventions are • successful.

41. G. Activity Seven: Improvement Strategies • HSAG Evaluation Elements (cont.) • Planned/implemented strategies for improvement are: • May be at the health plan, provider, or • member level • Should be realistic, feasible, and • clearly defined • Need a reasonable amount of time to • be effective

42. G. Activity Seven: Improvement Strategies • Examples of EPSDT Improvement Strategies: • Sharing member-level results with providers • Mailing out reminder postcards to members • and providers • Developing an intervention tool kit that • contains clinical guidelines, tracking forms, • wall charts, and other provider office tools

43. H. Activity Eight: Data Analysis and Interpretation of Study Results • CMS Rationale • Initiated using statistical analysis • techniques. • Included an interpretation of the • extent to which the study was • successful.

44. H. Activity Eight: Data Analysis and Interpretation of Study Results • HSAG Evaluation Elements • The data analysis: • Is conducted according to the data • analysis plan in the study design. • Allows for generalization of the results • to the study population if a sample • was selected. • Identifies factors that threaten internal • or external validity of findings. • Includes an interpretation of findings.

45. H. Activity Eight: Data Analysis and Interpretation of Study Results • HSAG Evaluation Elements (cont.) • The data analysis: • Is presented in a way that provides accurate, • clear, and easily understood information. • Identifies initial measurement and • remeasurement of study indicators. • Identifies statistical differences between initial • measurement and remeasurement. • Identifies factors that affect the ability to compare • initial measurement with remeasurement. • Includes the extent to which the study was • successful.

46. I. Activity Nine: Study Results and Summary Improvement • CMS Rationale • Probability that improvement is true • improvement. • Included an interpretation of the extent to • which any changes in performance is • statistically significant.

47. I. Activity Nine: Study Results and Summary Improvement HSAG Evaluation Elements • The remeasurement methodology is the same as the baseline methodology. • There is documented improvement in processes or outcomes of care. • The improvement appears to be the result of intervention(s). • There is statistical evidence that observed improvement is true improvement.

48. J. Activity Ten: Sustained Improvement CMS Rationale • Change results from modifications in the processes of health care delivery. • If real change has occurred, the project should be able to achieve sustained improvement.

49. J. Activity Ten: Sustained Improvement • HSAG Evaluation Elements • Repeated measurements over comparable time • periods demonstrate sustained improvement, or • that a decline in improvement is not statistically • significant.

50. PIP Scoring Methodology HSAG Evaluation Tool • 13 Critical Elements • 53 Evaluation Elements (including the Critical Elements)