Transcript Overview of 2004-2005 External Quality Review (EQR) Activities

Performance Improvement
Project (PIP) Reviews
Presenter:
Christi Melendez, RN, CPHQ
Associate Director, PIP Review Team
Activity I: Choose the Study Topic
The study topic should:
 Be selected following collection and analysis of data- if
the MCO is a new plan and has no historical or planspecific data, the documentation in Activity I should
reflect this. The MCO should provide its effective
enrollment date and the rationale for not having data.
 Have the potential to affect member health, outcomes of
care, functional status, or satisfaction. The MCO should
be documenting the link between the study topic and
outcomes of care.
Activity II: State the Study Question
The study question should:
 State the problem to be studied in simple terms and
be in the recommended X/Y format
“ Does doing X result in Y?”
Activity III: Identify the Study Population
The study population should:
 Be accurately and completely defined and capture all
members to whom the study question applies
 Include all applicable codes that identify members
for the population (denominator)
Activity IV: Select the Study Indicator
The study indicator(s) should:
 Be well-defined, objective, and measures changes in health
or functional status, consumer satisfaction, or valid process
alternatives
 Allow for the study question to be answered (the study
question and study indicator should be in alignment)
 Include the title of the study indicator(s) in the gray shaded
box
 Include remeasurement goals. The goals should be
documented as percentages
Activity V: Use Valid Sampling Techniques
 If sampling was used (most HEDIS-based PIPs), the
MCO should complete the table in Activity V
 If sampling was not used (most administrative databased PIPs), the MCO should state that sampling was
not used
Activity VI: Define Data Collection
Data Collection
 The step-by-step process that leads to the production
of the study indicator(s) rates should be documented
 The MCO should include a copy of the manual data
collection tool, if applicable
 When surveys are used to collect data, the MCO
should include a copy of the survey, CATI script if
applicable, and cover letter that accompanies the
survey
 The data analysis plan should be documented (how
rates are calculated, how rates will be compared to the
goal, and what statistical test will be used
Activity VII: Analyze Data and
Interpret Study Results
Data Analysis
 The MCOs should complete the data table for all PIPs that
have progressed to the point of reporting data
 For HEDIS-based PIPs, the rates reported in the PIP should
match the MCOs rates reported to AHCA
 The rates in the data table should be reported accurately
(numerator divided by the denominator)
 The measurement periods documented in Activity VII
should match those documented in Activity IV
Activity VIII:
Implementing Interventions and
Improvement Strategies
Improvement strategies should:
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Be related to causes/barriers identified through data
analysis and quality improvement processes- the MCOs
should be describing what quality improvement tools were
used to identify barriers
Be revised if there was a decline in performance
The MCOs should be documenting the process used to
evaluate the effectiveness of its interventions
The interventions should align with the barriers and
directly impact the study indicator(s)
Disparity PIP TIPs
 Disparity PIPs must have two study indicators
 The MCO must have identified a statistically significant
difference between two entities (i.e., race/ethnicities, age
groups) for there to be a true disparity. This information
should be documented in Activity I
 The focus of the PIP should be to increase the rates for the
two study indicators and to eliminate the disparity
 The study question should be structured to reflect an increase
in both rates and eliminate the disparity
Tips for Retiring PIPs
 Before a PIP can be considered for retirement, the
PIP should include at least baseline and two
remeasurement periods of data
 The study indicator(s) have achieved statistically
significant improvement over the baseline and
sustained the improvement
 If a PIP has been in progress for greater than five
years and all ten activities have been completedconsider the PIP for retirement. If rates are
suboptimal, the MCO can continue its efforts for
improvement internally
General PIP Tips
 For HEDIS-based PIPs, the MCOs should provide
the HEDIS technical specifications annually
 Data collection tools and surveys should be submitted
on an annual basis
 Verify that the survey question listed in the PIP
matches the question in the survey
 Review submitted Fishbone and/or cause and effect
diagrams annually to ensure that they have been
updated
 Use the Interactive Data Submission System (IDSS)
document to verify reported HEDIS rates
Questions and Answers