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 plan- specific 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 data- based PIPs), the MCO should state that sampling was not used

Activity VI: Define 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: 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 completed- consider 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