The Arizona Department of Health Services/Division of Behavioral Health Services
(ADHS/DBHS) is committed to establishing high quality behavioral health
services. One method for achieving this is through adherence to
the standards and guidelines set by the
Centers for Medicare and
Medicaid Services (CMS). ADHS/DBHS adheres to CMS standards and guidelines and,
in turn, promotes improvement in the quality of the behavioral health care provided
to behavioral health recipients through the development and implementation of
Performance Improvement Projects (PIPs). Performance Improvement Projects
consist of utilizing a comprehensive protocol endorsed by CMS, as described in the
AHCCCS Medical Policy Manual (AMPM), Chapter 900
42 CFR 438.240.
The protocol standards and guidelines help to ensure
that Medicaid managed care organizations meet these quality
assurance requirements when conducting Medicaid External Quality
performance improvement projects (PIPs)?
A PIP is a systematic process designed to:
- Identify, plan and implement
system interventions to improve the quality of care and services provided to behavioral
and monitor the effectiveness of system interventions and data on an ongoing basis; and
- Result in significant performance
improvement sustained over time through the use of measures and interventions.
PIPs are designed
achievement and sustainment of improvement for significant aspects
of clinical care and non-clinical services; and
- A clinical study topic would be one for which outcome indicators measure a
change in behavioral health status or functional status; and
- A non-clinical or administrative study topic would be one for which indicators measure changes in member satisfaction
or processes of care.
significant systemic issues that come to the attention of ADHS/DBHS
in part through:
- Data from
areas (e.g.: network, medical director's office);
- Statewide contractor
performance data and contract monitoring activities;
and trending of complaints, grievance and appeal data and
quality of care concerns;
credentialing and profiling as well as other oversight activities
such as chart reviews;
- Quality Management/Utilization
Management data analysis and reporting; and
and/or provider satisfaction surveys and feedback.
are currently included in the Quality Management Utilization Management Annual Plan and Work Plan?
Specific information concerning current PIPs can be found in the
ADHS/DBHS Quality Management Plan.
The following citations can serve as additional resources for this
To Whom Does this Apply?
T/RBHA contracted behavioral health providers.
Did you know…?
The PIP protocol
is based on a guidebook produced by the National Committee for Quality
Assurance (NCQA) under a contract with CMS. The guidebook is entitled
"Health Care Quality Improvement Studies Managed Care Settings:
A guide for State Medicaid Agencies."
To ensure that T/RBHAs and their subcontracted providers
understand and actively participate in the implementation of the PIPs.
purpose of a health care quality PIP
is to assess and improve processes and outcomes.
In order for such projects to achieve real improvements in care,
and for interested parties to have confidence in the reported improvements, PIPs must be designed, conducted and reported in manner that utilizes sound methodology.
T/RBHA contracted providers play an integral role in
the implementation of the ADHS/DBHS Performance Improvement Projects
(PIPs). Behavioral health providers shall participate
with any or all aspects of the PIP implementation process.
There are ten
(10) steps to be undertaken when conducting PIPs:
- Select the
study topic(s). In general, a clinical or non-clinical issue selected
for study should affect a significant number of behavioral health
recipients and have a potentially significant impact on health,
functional status or satisfaction.
- Define the
study question(s). It is important to clearly state, in writing,
the question(s) the study is designed to answer. Stating the question(s)
helps maintain the focus of the PIP and sets the framework for
data collection, analysis, and interpretation.
- Select the
study indicator(s). A study indicator is a quantitative or qualitative
characteristic reflecting a discrete event (e.g., a behavioral health recipient
has stopped taking medication and has experienced a crisis which resulted in
hospitalization), or a status
(e.g., a behavioral health recipient has/has not experienced a crisis
that resulted in hospitalization) that is to be measured. Each project should have one or
more quality indicators for use in tracking performance and improvement
- Use a representative
and generalizable study population. Once a topic has been selected,
measurement and improvement efforts must be system-wide. A decision
needs to be made as to whether to review data for the entire population
or use a sample of the population.
- Use sound
sampling techniques (if sampling is used). If a sample is to be
used to select members of the study, proper sampling techniques
are necessary to provide valid and reliable information on the
quality of care provided. When conducting a study designed to
estimate the rates at which certain events occur, the sample size
has a large impact on the level of statistical confidence in the
collect data. Procedures used to collect data for a given PIP
must ensure that the data collected on the PIP indicators are
valid and reliable. Validity is an indication of the accuracy
of the information obtained. Reliability is an indication of the
repeatability or reproducibility of a measurement. Potential sources
of data include administrative data (e.g., enrollment, claims,
encounters), medical records, tracking logs, results of any provider
interviews and results of any recipient interviews and surveys.
Data can be collected from either automated data systems or by
a manual review of records.
intervention and improvement strategies. Real, sustained improvements
in care result from a continuous cycle of measuring and analyzing
performance, and developing and implementing system-wide improvements
in care. Actual improvements in care depend on thorough analysis
and implementation of appropriate solutions.
data and interpret study results. Data analysis begins with examining
the performance on the selected clinical or non-clinical indicators.
The analysis of the study data should include an interpretation
of the extent to which the PIP was successful and what follow-up
activities are planned as a result.
- Plan for
“real” improvement. When a change in performance is
found, it is important to know whether the change represents “real”
change or random chance. This can be assessed in several ways,
but is most confidently done by calculating the degree to which
an intervention is statistically significant; and
sustained improvement. Real change results from changes in the
fundamental processes of health care delivery. Such changes should
result in sustained improvements. In contrast, a one-time improvement
can result from unplanned accidental occurrences or random chance.
If real change has occurred, the project should be able to achieve
Performance Improvement Project
Last Revised: 10/25/2011
Effective Date: 12/01/2011