Performance Improvement Projects: From Idea to PIP Amy McCurry Schwartz, Esq., MHSA EQRO Consultant Behavioral Health Concepts, Inc. Amie Miller, Psy.D., MFT Quality Improvement Manager Monterey County Behavioral Health

Performance Improvement Projects The purpose of PIPs To assess and improve processes, and thereby outcomes, of care. 42 CFR 438.240(d) defines PIPs as having a “focus on clinical and non-clinical areas.”

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

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

Step 1: Select the Study Topic Bilingual Treatment Plans Why is this an important topic?

Impact Affects a significant portion of consumers Study Topic Impact Affects a significant portion of consumers Has a potentially significant impact on consumer health, functional status or satisfaction Desire to provide client centered care

Data Sources of data used to select this topic Average person remembers 15 – 20% of things discussed after a visit Need to employ a variety of tools to communicate what treatment looks like 78% of population is Latino in Monterey County, data showed MCBH that only 11% of their clients that spoke Spanish had treatment plans in Spanish.

Data

Data

Step 2: Define the Study Question Do interventions increase the number of bilingual(Spanish/English) treatment plans completed for individuals receiving Outpatient County services whose primary language is identified as Spanish? Is this client focused? Does this go to client outcomes?

Step 2: Define the Study Question The outcomes are framed in a way that sets MCBH up to measure only staff performance, not client outcomes. This is a measure of the effectiveness of an intervention…it is an indicator of success. Measuring how many more treatment plans are providing in Spanish, is not focused on the client outcomes that having a treatment in your language of choice may bring.

Step 2: Define the Study Question Study Questions should be stated in a way that: Supports the ability to determine whether the intervention has a measurable impact for a clearly defined population

Step 2: Define the Study Question This study question should focus on the outcomes for the consumer: Increased client participation in treatment Client satisfaction with treatment received Ability to accomplish next step in treatment plan

Step 2: Define the Study Question Better Study Question? Will clients who receive a treatment plan in their language of choice report they are more satisfied with their treatment? Will clients who receive a treatment plan in their language of choice be more engaged in treatment? Will providing treatment plans in the client’s language of choice…

Step 2: Define the Study Question How to measure satisfaction? How to measure engagement?

Step 3: Use a Representative and Generalizable Study Population Two options Review all EHR data for Treatment Plans in language of choice Review a sample of EHR data for Treatment Plans in language of choice

Step 4: Select the Study Indicator(s) A study indicator is: A quantitative or qualitative characteristic reflecting a discrete event or continuous status to be measured Used to track performance and improvement over time

Step 4: Select the Study Indicator(s) If goal is: More participation/engagement in treatment Indicator – “More treatment plans are provided to clients in Spanish. Indicator – “On follow up visit, clinician reported the consumer was engaged in treatment and willing to work towards treatment goals.” If goal is: Consumer satisfaction Indicator – “Pre and post satisfaction testing”

Step 5: Sampling If sampling applies here – is sampling technique reliable and valid? Probability sampling Non-probability sampling

Step 6: Reliably Collect Data Data must be valid and reliable. Valid – indication of accuracy The data measures what is intended to be measured Reliable – indication of repeatability Produces consistent results

Step 6: Reliably Collect Data Baseline data showing that 11% of treatment plans were provided to consumers in Spanish. This collects number of treatment plans in Spanish…may be an indicator of satisfaction…but, is not an outcome. How was this data collected? EHR Improving Quality Report – IQ Report…very relevant…by each MHSA age groups…looks at which age ranges are struggling to engage non-English speaking people Who collected this data? UR Review Annual Satisfaction Tool Plan to collect data for this and other indicators in the future?

Reliably Collect Data UR tool – is there evidence that a client was substantively involved in their treatment Increasing engagement of Latino clients – client frequency

Reliably Collect Data

Reliably Collect Data This chart displays the count of clients served grouped by clients who received 3 or less services and clients who received 4+ services

Step 6: Reliably Collect Data Develop a data collection plan: Clearly identify data to be collected For satisfaction, participation Identify data sources and how/when the baseline and repeat indicator data will be collected Surveys, treatment notes Specify who will collect the data and that they are qualified to collect the data Clinicians Identify the data collection instruments to be used

Step 6: Reliably Collect Data Will the data be collected on the entire population or a sample? Entire population vs. children Time needed to replicate data Will collected data be compared to the results of previous studies? If so, will the data gathered be comparable to the earlier study? Satisfaction surveys Previous data regarding treatment participation Numbers who graduate?

Step 6: Reliably Collect Data

Step 7: Analyze Data and Interpret Study Results Valid interpretations occur when: Analysis is conducted according to the data analysis plan Results present numerical data that is accurate, clear and easily understood Analysis addresses the comparability of initial and repeat measurements, including factors that threaten validity A conclusion is drawn as to the success of the PIP and planned follow-up activities are described

Step 8: Implement Intervention and Improvement Strategies Interventions should: Relate to causes/barriers identified through data analysis Be culturally and linguistically appropriate Be “implementable” system-wide Not be “one time” efforts

Step 8: Implement Intervention and Improvement Strategies Interventions proposed by MCBH: 1. Use script (when Spanish is primary language) to include a window prompt when a treatment plan form is opened “friendly reminder to complete treatment plan in English followed by Spanish language”. 2.  Staff training (bilingual staff and supervisors only)  to educate on expectations for bilingual Tx plans and use of Google Translate. 3.   Immediate QIAR when conducting UR and Tx plan not in Spanish language. 4.   Include a radio button that is activated for the treatment plan participation consent  and/or Treatment plan (when Spanish is identified language). 5.    Make it a supervision issue/ performance issue; supervisors must review Tx plan for bilingual plans for the next 6 months.

Step 8: Implement Intervention and Improvement Strategies Goal (as stated by MCBH): Increase the number of bilingual treatment plans from 10% to 50% by June 2015, to 80% by December 2015, and to 90% by Feb 2016 in order to improve cultural sensitivity services in the individual’s primary language.

Step 9: Plan for “Real” Improvement When a change in performance occurs, determine whether the change is real, attributable to an event unrelated to the intervention, or random chance Results of the intervention must be “statistically significant”

Step 10: Achieve Sustained Improvement If real change has occurred, the project should be able to achieve sustained improvement. Sustained improvement is demonstrated through repeated measurements over time.