1. All materials © 2014, National Committee for Quality Assurance The Recognition Process Getting OnBoard Part 2 During: Earn It

2. 2 Start-to-Finish (S2F) Pathway Your Roadmap to Recognition

3. 3

4. 4 3 PHASES BEFORE: LEARN IT BEFORE: LEARN IT – Am I eligible? Can I make the commitment? Why would I want to do this? DURING: EARN IT DURING: EARN IT – I am committed what do I need to do submit? What is required? AFTER: KEEP IT AFTER: KEEP IT – I made it! How do I keep my recognition? What do I do if my practice changes? How do I promote my achievement?

5. 5 “During/Earn It” Phase The Nuts & Bolts of the Recognition Process

6. 6 First NCQA Software Used During the Recognition Process Online Application Account One account per organization handles many applications, multiple sites. Used for PCMH (2011 & 2014), PCSP, CAHPS PCMH Enter primary contact, demographic practice and clinician information Sign BAA and program agreement Resource library inside One application precedes every ISS survey tool Used to initiate Multi-Site approval Used to initiate Add-Ons Safeguard your user names and passwords

7. 7 Order free Online Application Account www.ncqa.org/PublicationsProducts/RecognitionProducts.aspx Organizations use the same Online Application Account for PPC-PCMH, PCMH, PCSP, and CAHPS-PCMH

8. 8 Start-to-Finish

9. 9 What Are Multi-Site Surveys? (PCMH & PCSP) Option for organizations or medical practices with 3 or more sites that share policies and procedures and electronic systems across all of their practice sites. NCQA does not give organization-wide Recognition A specified number of corporate (shared) elements are completed once for multiple practice sites in an additional survey tool All other elements require responses at the site level Any possible multi-site should attend the “Getting on Board” training for complete details

10. 10 What are Multi-Specialty Surveys? (PSCP ONLY) Multi-Specialty organizations can be a single site or Multi-site practice Both require NCQA approval Request approval teleconference through Online Application Multi-specialty eligible practices will submit examples from 3 or more specialties, including a mental health specialty, if present for specified elements Conference call will discuss submission of individual specialty surveys versus multi-specialty surveys

11. 11 During | Earn It Start-to-Finish Step 8 Attend FREE Standards Training “The Rules of the Program” Free training each month http://www.ncqa.org/tabid/109/Default.aspx http://www.ncqa.org/tabid/109/Default.aspx PCMH & PCSP Standards (2 part program) Attend as often as you want Recorded version of PCMH 2014 (Coming Soon) Time to ask NCQA staff questions

12. 12 Transform Practice

13. 13 Transformational Prep Work Start-to-Finish Step 9 Assess practice site against Standards & Guidelines Document gap in performance and need for written documentation Write, finalize, and implement new procedures Implement EMR Build EMR data to support reporting requirements Procedures and EMR must be in place for at least 3 months before initial submission Anticipate at least 3 - 6 months prep time Procedures and EMR must be fully implemented at least 3 months before survey submission

14. 14 Now Prepare Your Submission Start-to-Finish Steps 10-13

15. 15 Software Training Start-to-Finish Step 10 Software Training – Online Application – Interactive Survey System (ISS) Tool Training is Recorded - Attend anytime! http://www.ncqa.org/Programs/Recognition/RelevanttoAllRecognition/Recogniti onTraining/PatientCenteredMedicalHomePatientCentered.aspx http://www.ncqa.org/Programs/Recognition/RelevanttoAllRecognition/Recogniti onTraining/PatientCenteredMedicalHomePatientCentered.aspx Not available as a live monthly training Demonstrates how to navigate and enter information into the software Submit any questions or technical difficulties to assigned technical analyst

16. 16 Buy ISS Survey Tools Interactive Survey System Tool http://www.ncqa.org/tabid/629/Default.aspx# pcmh Survey tool purchase is the first of 2 payments to NCQA for each practice site Pay by check or credit card at $80 per survey license Corporate and each site tool cost $80 E-mail, fax, or mail printed order form with payment

17. 17 Buy ISS Survey Tools Interactive Survey System Tool Single site tools can be ordered on-line. Multi-sites need preapproval 2 emails follow purchase acknowledging purchase and providing username, password and license number for each survey tool purchased Order with the same practice name used in application Manager and Analyst assigned after purchase

18. 18 Complete Your Online Application

19. 19 Complete Your Online Application Log in Online Application Click new or continue

20. 20 Completing your Online Application Sign the Agreements electronically Create a separate application for each site Enter your clinician data for each site Note: Punctuation and spelling matter Do NOT enter ALL CAPS Link your clinicians to each application – which clinicians are currently practicing at each site Enter the ISS license # from your e-mail order for each site – creates a link to the ISS tool Submit each site application to NCQA NCQA needs 5 business days to verify site prior to accepting ISS tool – NCQA will send you an e-mail

21. 21 Prepare and Submit ISS Tool

22. 22 NCQA Website: ISS Login Access to Survey Tool You can always access ISS from NCQA Website

23. 23 Using the Survey Tool Steps for the practice: 1.Organize supporting documentation 2.Respond to ALL factors 3.Build document library 4.Link documents to elements 5.Complete Organizational Background tabs 6.Review results

24. 24 Organize Supporting Documents Create a folder on the hard-drive for documents the practice MAY want to attach Develop a checklist of documentation already used in the practice and documents that need to be prepared Refer to standards and guidelines publication to identify that the practice is providing the expected documentation (see FAQs) No Protected Health Information Save a copy of the Record Review Workbook and Quality Measurement and Improvement Worksheet NCQA advises a maximum of three (3) documents or fewer per element (averaged – some require more, others just one) Consider putting multiple documents in one document for a single element in a logical order – tell your story

25. 25 Use a unique naming convention Use any organizing principle desired, for example: – PCMH 1 A—Name of Document.docx – PCMH 1 B—Name of Document.xlsx Avoid file names with special characters (e.g. quotation marks, question marks, commas, apostrophes, ampersands) Documents can be linked to multiple elements; no duplicates should be in the Document Library Use text boxes and highlighting to identify important sections and briefly explain the importance Manage the Documents

26. 26 Respond to All Factors Answer EVERY radio button even if the answer is No. If NA make sure to justify in Text/Notes area

27. 27 Build the Document Library Assemble documents in a PC file No Protected Health Information Assign meaningful file names Highlight and label contents to draw reviewer attention Aim for 1- 3 attachments per element Attach one document to several elements Load up to 3 documents at a time into ISS Tool Library and rename Link documents to relevant elements Save Document changes require reloading

28. 28 Link Documents and Enter Text for Explanations Click here to link documents Click here to enter explanatory text

29. 29 ISS Survey Tool Organizational Background Tab Inside the ISS Survey Tool

30. 30 ISS Organizational Background Tab Complete Practice Site Information Attach more information about the practice. Give it a face to our reviewers.

31. 31 Complete Recognized Clinicians List the practice’s clinicians with these current Recognitions for auto-credit: Diabetes Recognition Program Heart/Stroke Recognition Program Back Pain Recognition Program

32. 32 Pre-submission Completeness Check ISS Completeness Check Functionality – Shows incomplete elements – Multi-Site corporate tools will always show incomplete elements Readiness of ISS Tool – Check complete score and level – Check Must Pass elements and critical factors – Check that documents are linked to elements Verify Online Application was accepted, if not an error message will appear when trying to submit

33. 33 Reediness of ISS Tool Review RESULTS: Summarized & Detailed Must Pass Critical Factors Meaningful Use

34. 34 Submit Program Fees and Surveys Each practice site will have a separate application fee based on the number of clinicians that see patients at that site – this is the 2 nd payment to NCQA Find current fees, check cover sheet and credit card forms in Online Application payment tab Applicable fees are those current on the day of submission NCQA will contact you if payment is not received or correct when survey is submitted Survey review is not initiated until full payment is confirmed No time limit on survey submission

35. 35 The Review Process

36. 36 Recognition Review Process NCQA Checks licensure of all clinicians for restrictions Evaluates Survey Tool responses, documentation, and explanations by –Reviewer – initial evaluation –Executive reviewer – NCQA PCMH managers –Peer review – Recognition Program Review Oversight Committee member (RP-ROC) –Audit (5%) – by email, teleconference, or on- site audit

37. 37 Recognition Review Process NCQA Issues final scoring decision and level to the practice within 30 – 60 days by email Reports results –Recognition posted on NCQA Web site –Not passed - not reported Mails PCMH certificate and Recognition packet

38. 38 NCQA Evaluation: Example Text/Notes Entry Reviewer Note Practice Note Justify all N/As In Text/Notes

39. 39 Receive Recognition Decision

40. 40 Recognition Decisions Recognition awarded at the practice site level Level 1, 2 and 3 3-year Recognition period Denial of Recognition – PCMH score below 35 points – PCSP score below 25 points – One or more must pass elements <50% – Not made public or distributed to P4P Manager sends auto email to practice’s primary contact Levels reported to public; scores are not made public

41. 41 How to See Results in ISS To view final results, DON’T open the survey here. Open the survey here.

42. 42 NCQA Recognition Directory Website Listing Includes: Clinician name, title (MD, DO, NP, PA) Practice name and address Current Recognition Recognition Program

43. 43 Certificates Name of Practice Routinely sent within 3 weeks of Recognition Site-level Fee for replacements or additional certificates Request at http://ncqa.force.com/pcs/login select Certificateshttp://ncqa.force.com/pcs/login

44. 44

45. 45 Start-to-Finish

46. 46 How to Request Approval Login to the Online Application Choose the account to work in Submit Approval/Eligibility Requests through the Online Application Obtain an account through the NCQA website http://www.ncqa.org/Publication sProducts/RecognitionProducts/P CMHPublications.aspx http://www.ncqa.org/Publication sProducts/RecognitionProducts/P CMHPublications.aspx

47. 47 How to Request Approval NCQA sets up a teleconference with a Recognition Manager within several days Preparation materials for the call are sent in advance Manager will explain corporate elements, submission process, and answer any questions Last day to submit for PCMH 2011 Approval Calls is June 15 First day to request PCMH 2014 Approval call June 1 Click to Submit a Multi-site Approval Request Answer the Eligibility Questions

48. 48 Approval Request The system will ask practice to wait for a call from NCQA to schedule your teleconference

49. 49 Conference Call Agenda Practice and NCQA must be on-line in the practice’s Application NCQA’s Recognition Manager: –Confirms Multi-Site eligibility –Assesses organization’s ISS Tool naming convention –Reviews Online Application process –Explains potential Corporate and Site elements –Confirms estimated timing of submissions –Produces Multi-Site ISS Tool order form

50. 50 Approval Teleconference E-mail When teleconference is scheduled, practice receives documents via e-mail. SEE NEXT SLIDES

51. 51 Approval Teleconference–Multi-Site Process Overview Detailed instructions for getting the application ready – using the NCQA naming convention

52. 52 Approval Teleconference Multi-Site Fee Calculator Fee Calculator also found in Online Application Payment tab Multi-site fees are already discounted Corporate fee based on number of sites Site fee based on number of clinicians

53. 53 Print Order Form After teleconference this is where the Online Application can be found

54. 54 Multi-Site ISS Tool Order Form Print Order Form from Online Account for approved sites Designate which sites to order first Buy more ISS Survey Tools as needed Add future sites to the order form later Sites must be submitted within 12 months after NCQA finalizes Corporate score NCQA Customer Support sells tools

55. 55 Print Order Form

56. 56 Multi-site Policies and Fees Submit “Order Form” to purchase the required number of survey tools for the sites identified and the corporate survey Clinicians can be listed at multiple sites Not all sites need to be included All sites must be submitted within 12 months of receiving the corporate score Application fees are determined by site and based on listed clinicians for each site along with a multi- site review fee These areas will be covered in depth during the approval teleconference

57. 57 What is the Multi-Site/Multi-Specialty Survey Process? 1.An Online Application precedes each ISS Survey Tool 2.Corporate ISS Tool is prepared and submitted first 3.Corporate tool is scored within 30 days 4.NCQA will merge the score of the multi-site survey with each site survey tool 5.Sites will receive Recognition decision within 60 days of submitting the site tools

58. 58 Corporate Elements Elements selected for Multi-site Corporate Survey Tool, must include: Data from largest site OR Aggregated data from all sites except 6A,B,C 1B1C2B 2C3A3B3D*3E 4D 4E5A5B*5C6A6B6C 6F * Must Pass Elements below can be selected in corporate survey tool:

59. 59 Select Corporate Elements This is the PCMH 2014 ISS Corporate Survey Tool Organizational Background

60. 60 Prepare and Submit Site Tools NCQA copies Corporate elements into the site tools Practice completes site tools and submits Site-specific tools must be submitted within 12 months of Corporate Tool score date Site tool turn around time target is 60 days Additional sites that share the same systems, processes may be added and submitted within the 12 month period

61. 61 NCQA Contact Information Contact NCQA Customer Support at 1-888-275-7585 M-F, 8:30 a.m. - 5:00 p.m. ET to: Acquire standards documents, application account, survey tools Questions about your user ID, password, access Visit NCQA Web Site at www.ncqa.org to:www.ncqa.org Follow the Start-to-Finish Pathway View Frequently Asked Questions View Recognition Programs Training Schedule For questions about interpretation of standards or elements to submit a question to PCS (Policy/Program Clarification Support) submit a question to PCS