1. Performance Improvement Projects Technical Assistance
Who? What? When? and How to Ask?
CalEQRO PIP Clinic
June 28, 2019
Amy McCurry Schwartz, Esq., MHSA
EQRO Consultant
Behavioral Health Concepts, Inc.

2. 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.”

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

4. Non-Clinical PIPs Might Target
Coordination of Care
Appeals, Grievances Process
Access or Authorization
Member Services

5. VALIDATING PERFORMANCE IMPROVEMENT PROJECTS (PIPs)
OMB Approval No.
EQR PROTOCOL 3:
VALIDATING PERFORMANCE IMPROVEMENT PROJECTS (PIPs)
A Mandatory Protocol for External Quality Reviews (EQR)

6. CMS Protocol: Validating Performance Improvement Projects
10 Protocol Steps:
Select the study topic(s)
Define the study question(s)
Use a Representative and Generalizable study population
Select the study variable(s)
Use sound sampling techniques

7. CMS Protocol: Validating Performance Improvement Projects
10 Protocol Steps Continued:
Reliably collect data
Analyze data and interpret study results
Implement intervention/improvement strategies
Plan for “real” improvement
Achieve sustained improvement

8. When should I request Technical Assistance (TA)?
Early and often
When you have a new idea
When your data shows an issue
When you are crafting a study question and aren’t sure if it will “work”
When you are designing interventions
When you are determining indicators
Outside of the onsite review process, CalEQRO provided individual TA to 39 MHPs for a total of 410 hours through May One of the most common areas of assistance involved PIP study question formulation and assisting MHPs in the development of a new PIP concept. The MHPs struggle to understand the concept of designing and implementing PIPs as part of the MHPs’ overall QI practices, instead attempting to construct PIPs as standalone projects. This is a substantial increase over the 20 MHPs who received TA and the hours of TA that were reported to be given during last year’s contract cycle.

9. When should I request Technical Assistance (TA)?
When you have a new idea
A PIP may be winding down and it is time to start a new one
PIPs should be active and ongoing during the twelve months prior to your onsite review
Continuous Quality Improvement

10. When you have a new idea
Notes from Quality Reviewer following TA call:
The MHP submitted a draft write-up for a non-clinical PIP, but both Amy and I determined that it does not meet the criteria for a PIP.
During the call with the MHP, we discussed at length the PIP process, how to identify potential PIP topics (using data), and then how to design them. They will be looking deeper into their data, and discussing internally with QI and leadership, possible PIP topics for a non-clinical PIP.
We will reconvene on another conference call on October 19 when they will present their ideas for discussion/feedback. Their goal is to have two active PIPs by the time of the review in January 2019.

11. When should I request Technical Assistance (TA)?
When your data shows an issue
Identify a problem area or opportunity for improvement in treatment or process, but do not take it “to the bank” without first reviewing your facts and data
Include information from beneficiaries, families, staff and community partners
Beneficiary, families, community partner and staff input should be obtained on problem
What do they see as the barriers to better care?
Why do they think the problem is happening?
What ideas do they have to fix it?

12. When your data shows an issue
Notes from Quality Reviewer following TA call:
Overall, the MHP has made significant progress in both PIPs.
Clinical PIP
The MHP took the suggestions from the last TA session seriously and applied it.
Most notably:
Reviewing the literature
Gathering local data
Including beneficiary input

13. When your data shows an issue
Non-Clinical PIP
Since the last session, the MHP gathered information and learned a lot about the reasons behind the assessment time lags.
The MHP embraced the use of data to inform the process.
The MHP changed the way they gather data and manage it.
The MHP is looking at the data monthly.

14. When should I request Technical Assistance (TA)?
When you are crafting a study question and aren’t sure if it will “work”?
This step is critical because it sets the framework for data collection and analysis of results

15. When you are crafting a study question and aren’t sure if it will “work”?
Notes from Quality Reviewer following TA call:
“This is a proposed new PIP. During the call, the study question was narrowed down to one, and the main emphasis changed from reducing hospitalization to reducing repeat emergency department visits with a secondary aim of reducing hospitalization.
The MHP was advised to better define the selection criteria based on the risk factors for recidivism, and thus accomplishing clearer definition of the study population.
The other tasks for the MHP are identifying the appropriate interventions and indicators that will capture the success of this PIP. A follow-up call is scheduled for February (Also, briefly touched base on the new interventions planned for the MHP's existing non-clinical PIP)

16. When should I request Technical Assistance (TA)?
When you are designing interventions
Interventions should not focus on procedures, but on beneficiaries.

17. When you are designing interventions
Notes from Quality Reviewer following TA call:
This PIP is focused on access for beneficiaries to receive a SUD Comprehensive Assessment once it has been identified at the initial MH Comprehensive Assessment that a SUD referral is needed.
The interventions need to include not only the steps for setting things up (training, etc.) but also for actual implementation (which are missing).

18. When you are designing interventions
Notes from Quality Reviewer following TA call:
Discussed non-clinical PIP (no-show rates psychiatry).
Next steps for non-clinical:
Examine impact of no show on individual, and system;
Choose intervention based on completed barrier analysis.

19. When should I request Technical Assistance?
When determining indicators
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
Beneficiary outcomes (e.g. health or functional status, enrollee satisfaction); or a valid indicator of these outcomes.

20. Study Indicator “tips”
The study indicator should be objective and clearly defined
The indicator must be “measurable” – do you have the necessary data (or can you get it)?
Use an existing, relevant health care guideline to develop the study indicator
Use an existing indicator generally accepted in the health care community (ex. HEDIS; Clinical Practice Guidelines…)

21. From whom should I request Technical Assistance?
Check out the PIP Library

22. From whom should I request Technical Assistance?
your assigned Quality Reviewer (QR)
Provide them with an idea of where you are in the process of designing a PIP
Provide any documentation you may have to support your planned PIP
Give your QR amble time to review the information.
Contact QR as soon as the idea begins
Always give them a week or two to respond to respond to a request

23. How do I ask for Technical Assistance?
Via
Via phone
Directory_EXTERNAL_KC_v8.9.pdf

24. What is PIP Technical Assistance from CalEQRO?
Technical Assistance is:
Sharing Information and expertise
Providing Instruction
Transmitting Working Knowledge
Consulting on an Idea

25. What is PIP Technical Assistance from CalEQRO?
Technical Assistance is not:
A “blessing” or “permission” to pursue a PIP
An “approval” of an idea

26. What should I have before asking for Technical Assistance?
As much information as possible
Know what data you have or can obtain on the topic
Have data to support that a problem exists

27. What should I expect from Technical Assistance?
Development of a plan to get to an Active PIP
Follow up TA as needed
Homework assignments
Back and forth communication

28. QUESTIONS