1. Please mute yourselves, on phone or computer. Thank you.

2. Performance Improvement Project (PIP) Clinic: Indicators and Outcomes
June 19, 2015
Amy McCurry Schwartz, Esq., MHSA
EQRO Consultant
Behavioral Health Concepts, Inc.

3. Performance Improvement Projects
The purpose of PIPs
To assess and improve processes, and thereby outcomes, of care.
42 CFR (d) defines PIPs as having a “focus on clinical and non- clinical areas.”

4. Performance Improvement Projects
Clinical PIPs Might Target
Prevention and care of acute and chronic conditions
High-volume services
High-risk procedures
Special health care needs

5. Clinical PIPs
While enrollee satisfaction is an important outcome of care in clinical areas, improvement in satisfaction should not be the only measured outcome of a clinical project.
Some improvement in health or functional status should be addressed.
CMS Protocol 3: Validating Performance Improvement Projects (PIPs), September 2012

6. Performance Improvement Projects
Non-Clinical PIPs Might Target
Coordination of Care
Appeals, Grievances Process
Access or Authorization
Member Services

7. Non-Clinical PIPs
For projects in non-clinical areas, the use of health or functional status measures is preferred…when addressing access or availability status.
Enrollee satisfaction alone may be sufficient for some non-clinical projects.
CMS Protocol 3: Validating Performance Improvement Projects (PIPs), September 2012

8. Questions

9. Select the Study Indicator(s)
A study indicator is:
A measurable characteristic, quality, trait, or attribute of a particular individual, object, or situation being studied.

10. Study Indicators
Indicators may be quantitative or qualitative and continuous or discrete.
Discrete or categorical indicators have a limited number of possible categories
An individual has/has not received a flu shot in the last 12 months.

11. Study Indicators
Continuous indicators have unlimited possible values within the limits of the indicator range
Age
Blood Pressure
Temperature
Data collected on a continuous indicator such as blood pressure can be used for a discrete indicator (e.g. a consumer’s blood pressure is/is not below a specific level)

12. Study Indicators Criteria
Each PIP should have one or more measured indicators to track performance and improvement over a specific period of time. All measured indicators should be:
Objective; and
Clearly defined; and
Based on current clinical knowledge or health services research; and
Enrollee outcomes (e.g. health or functional status, enrollee satisfaction); or a valid indicator of these outcomes.

13. Study Indicators
The number and complexity of indicators (measures) may vary depending on:
The Study Question(s);
The complexity of existing practice guidelines for a clinical condition; and
Availability of data and resources to gather data

14. Study Indicators Potential Sources of Supporting Information
Clinical and non-clinical practice guidelines
guidelines
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Administrative Data
Claims data
Enrollment files
Medical Records

15. Developing Appropriate Indicators
Examples of measures currently existing within the public health community or managed care industry include:
NCQA Healthcare Effectiveness Data Information Set (HEDIS)
Measures developed by CMS and AHRQ (Pediatric or Adult Core Measures)

16. Questions

17. Example of HEDIS Indicators
Timeliness of Prenatal Care example
Number of women with a live birth who had a prenatal visit within 42 days of enrollment/notification of pregnancy
Data sources: claims data and/or medical records (hybrid review)
This is the HEDIS measure.
Number of women with a live birth who had two prenatal visits throughout their pregnancy
Data sources: hybrid
This is in addition to the HEDIS measure.
Number of women with a live birth who had three prenatal visits throughout their pregnancy

18. Developing Study Indicators
The MHP may also develop measures based on current clinical practice guidelines or health services research.
When developing your own measures, the MHP must document the basis for adoption. Consider the following questions:
Did the study use objective, clearly defined, measureable, time- specific indicators?
Do the measures capture changes in health status, functional status, or enrollee satisfaction?

19. Developing Study Indicators
Do the measures have any of the following key characteristics:
Related to identified health care guidelines relevant to the study question?
An important aspect of care or operations that made a difference to the MHP’s consumers
Data available through administrative, medical records or another readily accessible source
Limitations on the ability to collect the data skew the results
Require explicit or implicit criteria
If relevant, a strategy to ensure inter-rater reliability

20. Example of Study Indicators
If goal is: More participation in treatment
Indicator – “On follow up visit, clinician reported the consumer was engaged in treatment and willing to work towards treatment goals.”
If goal is: More ability to recall what client was to accomplish before the next visit
Indicator – “Consumer was able to accomplish 1 or more next steps in their treatment plan by their return visit”.
If goal is: Consumer satisfaction
Indicator – “Pre and post satisfaction testing”

21. Outcomes
Outcomes
Changes in patient health, functional status, or satisfaction resulting from the PIP.
Clinical PIPs
Measures should include a change in health status or functional status or a process of care proxy.
Standardized performance measures addressing outcomes may be limited because health outcomes are influenced by factors outside of the organization’s control, such as poverty, genetics, and environment. For these reasons, quality measures do not always need to be outcome measures.

22. Outcomes
Process measures, while acceptable, must offer strong clinical evidence that the process being measured is meaningfully associated with outcomes
This determination should be based on published guidelines, including citations from randomized clinical trials, case control studies, or cohort studies.

23. Outcomes
The PIP should demonstrate a consensus among relevant practitioners with expertise in the defined area who attest to the importance of a given process.
It is important that MHPs note within their PIP any potential external threats to validity which could affect the results of the outcome measures.

24. Questions