Standards and Guidelines for PCSP Recognition

Transcription

1 Standards and Guidelines for PCSP Recognition

2 No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without the written permission of NCQA by the National Committee for Quality Assurance (NCQA) th Street, NW, Suite 1000 Washington, DC All rights reserved. NCQA Customer Support: Item #

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4 Acknowledgments The Patient-Centered Specialty Practice Advisory Committee NCQA began planning for the Patient-Centered Specialty Practice (PCSP) Recognition program in spring Initial preparation included an extensive review of the literature, interviews with those researching and implementing the neighbor model and a feasibility study. In early 2012, the PCSP Advisory Committee, a diverse, 22-member committee composed of practice, medical association, physician group, health plan and consumer and employer group representatives, was created. The committee met throughout 2012 to discuss and analyze draft standards, PPC-PCMH data analysis and Public Comment results. The committee was charged with guiding the development of a robust set of standards, based on sound principles and lessons learned from NCQA s Patient-Centered Medical Home Recognition program. The goal was to drive the industry to reach a higher level of coordinated, collaborative, patient-centered specialty care. The standards represent a set of criteria that evaluate key aspects of patient-centered care in the specialty practice setting. The importance of this committee cannot be overstated. Its members gave their time, energy, enthusiasm and willingness to listen, share and reach consensus. The PCSP standards are a reflection of their hard work and collaboration. Neil Kirschner, PhD (Co-chair) American College of Physicians Bruce Bagley, MD American Academy for Family Physicians John Cox, DO, MBA Texas Oncology Methodist Dallas Cancer Center Carol Greenlee, MD Western Slope Endocrinology Pamela Hymel, MD, MPH Walt Disney Parks & Resorts Talmadge King Jr., MD University of California Ronda Kotelchuk Primary Care Development Corporation Kevin Malone SAMHSA Rhonda Medows, MD UnitedHealthcare Craig Pollack, MD, MHS Johns Hopkins Medical University Jacob Reider, MD Office of the National Coordinator for Health Information Technology, HHS Lee Partridge (Co-chair) National Partnership for Women and Families Maureen Corry, MPH Childbirth Connection Allen Dobson, MD Community Care of North Carolina Greg Holm, PhD, NP Yampa Valley Medical Center Craig Jones, MD Vermont Blueprint for Health Carrie Klett, MD Westside OB-GYN Center, PA J. Kersten Kraft, MD Santa Clara County Individual Practice Association David May, MD, PhD Cardiovascular Specialists, PA Marci Nielsen, PhD, MPH Patient Centered Primary Care Collaborative Richard Popiel, MD Horizon Health Innovations (Retired) Fan Tait, MD American Academy of Pediatrics March 25, 2013 PCSP Recognition 2013

5 Table of Contents Table of Contents Overview Background... 1 Objectives... 1 Improving Quality of Care by Organizing Care Around Patients... 2 Coordinating Care and Managing Information... 2 The PCSP Recognition Program... 2 Development... 2 The Consumer Perspective... 3 Public Comment... 3 The Standards... 3 The Must-Pass Elements... 3 Recognition Levels and Point Requirements... 4 Resources... 5 Policies and Procedures Section 1: PCSP Eligibility and the Application Process... 9 Definitions... 9 Eligibility... 9 Eligible Clinicians... 9 Eligible Clinicians With Considerations Ineligible Clinicians Eligible Practices Fee Schedule Information The PCSP Initiative The PCSP Online Application Process The Online Application The PCSP Multi-Site Application Determine Multi-Site Eligibility Multi-Site Corporate and Site-Specific Survey Tool Submission Practice Readiness Evaluation Complete the Application Complete the Submission Section 2: The Recognition Process NCQA Review of the Survey Tool The Offsite Survey The Audit PCSP Standards A Standard s Structure Scoring Guidelines CMS Meaningful Use Requirements Final Decision and Recognition Levels Recognition Levels Section 3: Additional Information Add-On Survey Renewing Recognition Reconsideration Applicant Obligations Complaint Review Process Discretionary Survey Revoking Decisions Notification to Regulatory Agencies Revisions to Policies and Procedures Disclaimer March 25, 2013 PCSP Certification 2013

6 Table of Contents PCSP Standards & Guidelines PCSP 1: Track and Coordinate Referrals PCSP 2: Provide Access and Communication PCSP 3: Identify and Coordinate Patient Populations PCSP 4: Plan and Manage Care PCSP 5: Track and Coordinate Care PCSP 6: Measure and Improve Performance March 25, 2013 PCSP Recognition 2013

7 Overview

8 PCSP Recognition 2013 March 25, 2013

9 Overview 1 Overview Background NCQA Patient-Centered Specialty Practice (PCSP) Recognition is an innovative program for improving specialty care. With a set of standards that describe clear and specific criteria, the program gives practices information about organizing care around patients, working in teams and coordinating and tracking care over time with primary care and other specialty care colleagues. The PCSP standards build on the success of the patient-centered medical home (PCMH) standards and make NCQA Recognition available to specialty practices. The program is designed to improve quality while reducing the redundancies and negative patient experiences associated with poorly coordinated care. The PCSP program focuses on proactive coordination and information sharing among specialists and primary care practices, and requires specialty practices to organize care across all the practices a patient visits and center care around the patient as opposed to the setting of care. The patient and family or other caregivers are included as partners in managing conditions treated by the specialist. The standards guide practices toward using systems including electronic health records (EHR) to support tracking care and align closely with specific elements of the federal Meaningful Use Requirements, which reward clinicians for using health information technology (IT) to improve quality. We anticipate that payers and sponsors of programs to improve care delivery will find the PCSP program a valuable way to build delivery system reforms that go beyond primary care, while strengthening the roles of both primary care and specialty practices. We also expect that this will enhance patient-centeredness and quality in care delivery. Objectives With this program, NCQA seeks to: Enhance coordination between primary care and specialty care. Strengthen relationships between primary care clinicians and clinicians outside the primary care specialties. Improve the experience of patients accessing specialty care. Align requirements with processes demonstrated to improve quality and eliminate waste. Have practices use clinical performance measurement and results to demonstrate improvement. Identify requirements appropriate for various specialty practices seeking recognition for excellent care integration with the medical home. Align with the Centers for Medicare & Medicaid Services (CMS) proposed Measures of Meaningful Use. March 25, 2013 PCSP Recognition 2013

10 2 Overview Improving Quality of Care by Organizing Care Around Patients The NCQA PCSP standards reflect elements that make specialty care successful. The quality of the clinician/patient relationship and the clinician s ability to track care over time are important. The vast majority of specialists must coordinate care with their primary care colleagues. Some specialty care clinicians need to refer patients to other specialists, making communication among providers important and often challenging. Coordinating Care and Managing Information Just as patient-centeredness is an integral part of the program, so too is a practice s ability to track care over time and across settings. The amount of clinical information for some patients particularly those with chronic illnesses and the fragmented nature of the U.S. health system make this aspect of care challenging. Experts agree that health IT can help clinicians coordinate patient care, but merely having an EHR system in a practice is not enough. The system itself must be useful, and practices must use it to achieve the goals of coordination and high quality of care. We recognize that the federal government is making a major investment in encouraging clinicians to use health IT to improve the quality of care, and where possible, we have aligned the PCSP standards with government laws and regulations. We want to reinforce incentives for clinicians to invest in improving quality. The PCSP Recognition Program Development The American College of Physicians white paper, The Patient-Centered Medical Home Neighbor, and the Agency for Health Care Policy and Research paper, Coordinating Care in the Medical Neighborhood, provided an intellectual foundation for the PCSP program. The program was developed through a multi-stakeholder process, drawing on a wide range of expertise. NCQA convened a panel of experts to develop the program elements, standards and scoring weights, and determine the program s must-pass elements and the critical factors in the evaluation. A draft of the program elements was made available for Public Comment. We received comments from a variety of perspectives, in particular from physician specialty groups. NCQA pilot-tested the standards with specialty practices, which gave us insight into practice capabilities and showed us how effectively our standards captured practices interactions and functions, and presented the program to various stakeholder committees (i.e., the Consumer Advisory Committee, the Public Sector Advisory Committee and the Purchaser Advisory Committee). Responding to Public Comment feedback, the panel revised the standards and sent the final program to NCQA s Clinical Programs Committee (a multi-stakeholder committee) for review and approval. NCQA s Board of Directors had final approval. PCSP Recognition 2013 March 25, 2013

11 Overview 3 The Consumer Perspective NCQA s PCSP Recognition program is designed to improve quality while reducing the redundancies and negative patient experiences associated with poorly coordinated care. The PCSP program focuses on proactive coordination and information sharing among specialists and primary care practices, and requires specialty practices to organize care across all practices a patient visits and to center care around the patient as opposed to around the care setting. The patient and family or other caregivers are partners in managing the conditions treated by the specialist. In developing the PCSP standards, we were guided by a strong consensus that we must expand the patientcentered perspective. To ensure that we captured this vantage point, the advisory committee included representatives of consumer organizations and researchers working on related patient-centered areas, and we encouraged consumer participation during the Public Comment process. Public Comment The draft PCSP standards were posted on the NCQA Web site and comments were solicited from a wide group of stakeholders. We received more than 600 comments from health care providers, health plans, consumer groups and government agencies. There was a high degree of support for the proposed standards, especially for the emphasis on patient-centered, team-based care coordinated across the health care system. In addition to the formal Public Comment period, we received useful suggestions from others for further revisions and changes, which we incorporated into the final version of the standards after review by our stakeholder advisory committee and the NCQA Board of Directors. Many organizations expressed interest in using the new standards, including physician membership associations, community health centers, the Veterans Administration, the Department of Defense Tri-Care Services, state-led projects and a multi-payer demonstration project. The Standards The PCSP program s six standards align with the core components of specialty care. 1. PCSP 1: Track and Coordinate Referrals. 2. PCSP 2: Provide Access and Communication. 3. PCSP 3: Identify and Coordinate Patient Populations. 4. PCSP 4: Plan and Manage Care. 5. PCSP 5: Track and Coordinate Care. 6. PCSP 6: Measure and Improve Performance. The Must-Pass Elements Five must-pass elements are considered essential to the patient-centered specialty practice, and are required at all recognition levels. Practices must achieve a score of 50% or higher on the must-pass elements: 1. PCSP 1, Element A: Referral Process and Agreements. 2. PCSP 1, Element C: Referral Response. 3. PCSP 2, Element E: The Practice Team. 4. PCSP 4, Element B: Medication Management. 5. PCSP 6, Element C: Implement and Demonstrate Continuous Quality Improvement. March 25, 2013 PCSP Recognition 2013

12 4 Overview Recognition Levels and Point Requirements There are three levels of NCQA PCSP Recognition; each level reflects the degree to which a practice meets the requirements of the elements and factors that comprise the standards. For each element s requirements, NCQA provides examples and requires specific documentation. The NCQA Recognition levels allow practices with a range of capabilities and sophistication to meet the standards requirements successfully. The point allocation for the three levels is as follows. Level 1: points and all 5 must-pass elements. Level 2: points and all 5 must-pass elements. Level 3: points and all 5 must-pass elements. Table 1: Summary of NCQA PCSP Standards Standard PCSP 1: Track and Coordinate Referrals PCSP 2: Provide Access and Communication PCSP 3: Identify and Coordinate Patient Populations PCSP 4: Plan and Manage Care PCSP 5: Track and Coordinate Care PCSP 6: Measure and Improve Performance Content Summary The practice has formal and informal agreements and specified methods of communication with PCPs and other referring clinicians. The practice has a monitored process to track referrals that includes consideration of the urgency and type of referral. The practice has a monitored process to ensure a timely response to PCPs, referring clinicians and patients. To provide access, the practice has a written process, defined standards and demonstrates that it monitors against those standards. Patients have access to culturally and linguistically appropriate services and clinical advice. The focus is on team-based care with trained staff. The practice collects demographic and clinical data for population management. The practice assesses and documents patient risk factors. The practice identifies patients for proactive reminders. The practice assesses patient/family self-management abilities. The practice works with patient/family to develop a self-care plan and provide tools and resources, including community resources. The practice reconciles patient medications at visits and post-hospitalization. The practice uses e-prescribing. The practice tracks, follows-up on and coordinates tests, referrals to secondary specialists and care at other facilities (e.g., hospitals). The practice manages care transitions. The practice uses performance and patient experience data to continuously improve. The practice tracks utilization measures such as rates of hospitalizations and ER visits. The practice identifies vulnerable patient populations. The practice demonstrates improved performance. PCSP Recognition 2013 March 25, 2013

13 Overview 5 Resources American College of Physicians (ACP) The Patient-Centered Medical Home Neighbor: the Interface of the Patient-Centered Medical Home with Specialty/Subspecialty Practices. Position paper. Arora, V.M., et al Problems after discharge and understanding of communication with their primary care physicians among hospitalized seniors: a mixed methods study. Journal of Hospital Medicine 5 (7), Beaser, R., E. Okeke, J. Neighbours, J. Brown, K. Ronk, W.W. Wolyniec Coordinated primary and specialty care for type 2 Diabetes, guidelines, and systems: An educational needs assessment. Endocrine Practice,6, Chen, A.H., M.B. Kushel, K. Grumbach, H.F. Yee Practice profile: a safety-net system gains efficiencies through e-referrals to specialists. Health Affairs 29 (5), Chen, A.H., H.F. Yee Improving the primary care-specialty care interface: getting from here to there. Arch Intern Med 169 (11), Forrest, C.B Primary care gate-keeping and referrals: Effective filter or failed experiment? British Medical Journal 326, Frequent Users of Health Services Initiative Summary report of evaluation findings: A dollars and sense strategy to reducing frequent use of hospital services. Accessed March 13, Friedberg, M.W., P.S. Hussey, E.C. Schneider. May Primary care: A critical review of the evidence on quality and costs of health care. Health Affairs 29 (5), Han, P.K.J., and D. Rayson The coordination of primary and oncology specialty care at the end of life. Journal of the National Cancer Institute Monographs 40, Kirchner, J., C.N. Edlund, K. Henderson, L. Daily, L.E. Parker, J.C. Fortney Using a multi-level approach to implement a primary care mental health (PCMH) program. Families, Systems, & Health 28 (2), Kirschner, N., M.S. Barr Specialists/subspecialists and the patient-centered medical home. Chest 137 (1), Kirpalani, S., F. LeFevre, C.O. Phillips, M.V. Williams, P. Bassviah, D.W. Baker Deficits in communication and information transfer between hospital-based and primary care physicians: Implications for patient safety and continuity of care. Journal of the American Medical Association 297, Mehrotra, A., C.B. Forrest, C.Y. Lin Dropping the Baton: Specialty Referrals in the United States. The Milbank Quarterly 89 (1), Morgan, M.A., H. Lawrence, J. Schulkin Obstetrician-Gynecologists approach to well-woman care. Obstetrics & Gynecology 116, O Malley, A.S., and J.D. Reschovsky Referral and consultation communication between primary care and specialist physicians: finding common ground. Arch Intern Med 171 (1), Peikes, D., E.F. Taylor, T. Lake, J. Nysenbaum, G. Peterson, D. Meyers, D Coordinating Care in the Medical Neighborhood: Critical Components and Available Mechanisms. AHRQ. Pham, H.H Good neighbors: How will the Patient-Centered Medical Home relate to the rest of the health-care delivery system? Journal of General Internal Medicine 25 (6), Scholle S.H., J. Chang, J. Harman, et al. April Characteristics of patients seen and services provided in primary care visits in obstetrics/gynecology: Data from NAMCS and NHAMCS. Am J Obstet Gynecol 190 (4): Scroggs, J.A., L.P. Griffin, M. Bayerl, J. Schulkin Obstetrician-Gynecologists as primary care physicians: The perspectives of Health Maintenance Organization medical directors and obstetriciangynecologists. Obstetrics & Gynecology 90 (2), Seal, K.H., G. Cohen, D. Bertenthal, B.E. Cohen, S. Maguen, A. Daley Reducing barriers to mental health and social services for Iraq and Afghanistan veterans: Outcomes of an integrated primary care clinic. Journal of General Internal Medicine. [Epub ahead of print] Snow, V., D. Beck, T. Budnitz, D.C. Miller, J. Potter, R.L. Wears, K.B. Weiss, M.V. Wiliams Transitions of care consensus policy statement American College of Physicians-Society of General Internal Medicine- Society of Hospital Medicine-American Geriatrics Society- American College of Emergency Physicians- Society of Academic Emergency Medicine. Journal of General Internal Medicine 24 (8), March 25, 2013 PCSP Recognition 2013

14 6 Overview Stovall, D.W., M.B. Loveless, N.A. Walden, N. Karjane, S.A. Cohen Primary and preventive healthcare in Obstetrics and Gynecology: A study of practice patterns in the mid-atlantic region. Journal of Women s Health 16 (1), Taylor, E.F., T. Lake, J. Nysenbaum, G. Peterson, D. Meyers Coordination care in the medical neighborhood: critical components and available mechanisms. White paper. AHRQ Publication No Tew, J., J. Klaus, D.W. Oslin The Behavioral Health Laboratory: Building a stronger foundation for the Patient-Centered Medical Home. Families, Systems & Health 28 (2), Yee, H.F The patient-centered medical home neighbor: a subspecialty physician s view. Ann Intern Med 154 (1), PCSP Recognition 2013 March 25, 2013

15 Policies and Procedures

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17 Policies and Procedures Section 1: Eligibility and the Application Process 9 Section 1: PCSP Eligibility and the Application Process Definitions Practice: One or more clinicians who practice together and provide patient care at a single geographic location and may include either all eligible specialty clinicians at the site or all eligible clinicians of a single specialty at a single geographic location. Practicing together means that, for all the clinicians in a practice: The practice care team follows the same procedures and protocols. Medical records (paper and electronic) for all patients treated at the practice site are available to and can be shared by all clinicians, as appropriate. The electronic and paper-based systems and procedures support clinical and administrative functions (e.g., scheduling, treating patients, ordering services, prescribing, maintaining medical records and follow-up). The NCQA PCSP Recognition program is a practice-based evaluation for clinicians who provide care in nonprimary care specialties. Multi-Site Group: Three or more practice sites using the same systems and processes, including an electronic medical record system shared across all practice sites. Eligibility Eligible Clinicians Note: All applicants must have an unrestricted license. Nonprimary care specialty doctors of medicine, doctors of osteopathy, nurse practitioners, physician assistants, certified nurse midwives and any of the following behavioral health practitioners: Doctoral or master s-level psychologists who are state certified or licensed. Doctoral or master s-level clinical social workers who are state certified or licensed. Doctoral or master s-level marriage and family counselors who are state certified, registered or licensed by the state to practice independently. In a multi-specialty practice that includes primary care and other specialties: For one defined specialty, all eligible clinicians in the practice are included in the application for recognition. The practice identifies the specialty and all clinicians seeking recognition before its review. For multiple specialties, all eligible clinicians coming forward for review must practice together. The practice identifies the unit seeking recognition, the specific site and each clinician practicing at the site. In a multi-specialty practice that does not include primary care: All eligible clinicians practicing a defined specialty and all eligible nonprimary care clinicians are included in the application for recognition, or All eligible clinicians practicing as part of a defined practice unit and all nonprimary care clinicians are included in the application for recognition. The practice identifies the unit seeking recognition, the specific site and all clinicians in the practice. March 25, 2013 PCSP Recognition 2013

18 10 Policies and Procedures Section 1: Eligibility and the Application Process Eligible Clinicians With Considerations Nurse practitioner practices (NP-led practices) without a physician can earn NCQA Recognition with the following considerations: According to the scope of practice determined by state law. Practices are reviewed against the same requirements as physician-led practices. Behavioral healthcare practices without a physician can earn NCQA Recognition with the following considerations: According to the scope of practice determined by state law. Practices are reviewed against the same requirements as physician-led practices. Ineligible Clinicians Primary care clinicians who are eligible for NCQA PCMH Recognition are not eligible for NCQA PCSP Recognition: Physicians, nurse practitioners and physician assistants who practice in the specialty of internal medicine, family medicine or pediatrics, with the intention of serving as the personal, primary care clinician for their patients. All clinicians who do not have their own panel of patients. Physician assistants are eligible to be listed on NCQA s Web site as providers, if they have a panel of patients. Eligible Practices Note: Facilities such as rehabilitation facilities or hospitals cannot earn PCSP recognition; however, hospitalbased specialty care practices and residency clinics are eligible. Specialty practices: An incorporated group of three or more clinicians in an office site who use the same systems and staff, as described above. Individual clinicians who maintain their own systems and may or may not share an office with other clinicians. A group of clinicians at one location that is part of a larger medical group with several locations. A practice within a multi-site group. Fee Schedule Information There are four fee schedules. 1. Standard Survey pricing applies to a practice applying for the first time or for renewal. 2. Discounted Survey pricing may apply to practices that are in an initiative. 3. Multi-Site Group Survey pricing includes a multi-site survey fee based on the number of practices and a discounted survey fee for each site included in the group 4. Add-On Survey pricing is only applicable to practices with a current recognition status. NCQA periodically updates the fee schedules applicable to its recognition programs on the program Web site and in the resources published in the application materials. Organizations purchasing a Survey Tool are notified of fee schedule changes 30 days before a change is made. Survey pricing is determined by the fee schedule in effect when a practice submits its Survey Tool for evaluation. PCSP Recognition 2013 March 25, 2013

19 Policies and Procedures Section 1: Eligibility and the Application Process 11 An application fee is due for each practice site undergoing a survey and is based on the number of eligible clinicians that intend to be listed (in NCQA s online Recognition Directory) for the practice site if they achieve NCQA Recognition. Clinicians practicing at more than one practice site are considered in the fee calculation for each site. The addition of clinicians under a current recognition is subject to the same approval process and eligibility verification as that used with the initial set of clinicians applying for recognition. Added clinicians must be of the same specialty type as one or more of the currently recognized clinicians; if they are not, this is considered a separate survey. The PCSP Initiative A PCSP initiative encourages its eligible doctors of medicine, doctors of osteopathy, nurse practitioners, physician assistants, certified nurse midwives, behavioral healthcare practitioners, practices, members or program participants to earn NCQA Recognition in return for additional recognition, promotion or reward. Initiatives may be led by a health plan, a coalition of plans, a government entity, a business coalition, a collaboration of plans and businesses, a professional organization or a nonprofit quality improvement or disease awareness organization. Some initiatives are funded by grants or legislation and are part of a broader health care strategy. NCQA supports these positive collaborations among clinicians and organizations by offering a discount on application fees. Note: Practices must identify the entity leading the initiative on the application to qualify for a discounted application fee. Potential initiatives should contact NCQA to ensure alignment with NCQA policies and procedures. Only eligible clinicians and practices can be accepted for evaluation. NCQA shares the clinician or practice status with the initiative to the extent authorized by the clinician or practice. NCQA must approve the sponsor s external communications regarding its initiative, to ensure alignment with our policies. NCQA identifies initiatives on its Web site and is available to coordinate additional training or orientation programs. The PCSP Online Application Process NCQA uses a Web-based module (the online application) for the PCSP recognition application process. Applicants use this system to submit applications and to set up multi-site submissions, including multi-site Survey Tool orders. NCQA strongly recommends that practices complete the eligibility prereview before proceeding with the application process. The Online Application The online application contains the following components. Account information. The practice provides relevant demographic information, including the account name, the contact person, the telephone number and the address of the organization. NCQA legal documents. Before submitting the application, the practice must complete: The PCSP Recognition Program Agreement. The HIPAA Business Associate Agreement. March 25, 2013 PCSP Recognition 2013

20 12 Policies and Procedures Section 1: Eligibility and the Application Process Note: Unless state law requires modifications, all organizations are expected to sign NCQA s standard PCSP Template Agreement. Requests for proposed changes to the standard Agreement should be submitted at least three months before the preferred application submission date. Practice site information. The practice provides the name and address of each site in the organization, the sponsor identification (if applicable), the site contact information and the mailing address. Multi-site or multi-specialty eligibility request and eligibility call. For practices considering a multisite or multi-specialty evaluation, completing the eligibility request and eligibility call will determine if the practice is eligible for these options. Clinician information. The practice provides the number and name of each eligible clinician and identifies each practice site where they deliver care. Changes may be made to the clinicians linked to a practice site any time during the recognition period. Application form. After being declared eligible, the practice completes an online application form, the practice enters the license number of the Survey Tool, the practice specialty and practice type for each site. The PCSP Multi-Site Application The multi-site application process is an option for organizations or medical groups with three or more practice sites that share an electronic record system and standardized policies and procedures across all practice sites applying for NCQA PCSP Recognition at one time. The multi-site application process does not allow organizationwide recognition, but it does relieve eligible organizations from having to provide responses and documentation that are the same for all sites. Determine Multi-Site Eligibility The multi-site application requires organizations to have at least three sites and to share an electronic record system and standardized policies and procedures across all practice sites that apply. Organizations use their recognition account to submit a multi-site request form. Organizations enter the number of sites applying for recognition and answer eligibility questions. Note: Responses must reflect processes and systems that are in place currently and have been in place for a minimum of three months. To qualify for a multi-site application, the practice must answer yes to all of the following eligibility questions: 1. Can your organization sign one PCSP program agreement to cover all sites applying for recognition? 2. Currently and for a minimum of three months, have all practice sites applying for recognition shared and used in the same way a practice management system, registry or EHR to document patient care for administration and billing? 3. Currently and for a minimum of three months, have all practice sites applying for recognition operated under the same policies and procedures? After submitting a multi-site eligibility request, organizations will be contacted to set up a personal call with a recognition manager to determine if they are eligible for survey, and the manager will approve their sites to purchase Survey Tools. Organizations will prepare for the call by reviewing the materials provided before the call and entering their practice sites into their recognition account. PCSP Recognition 2013 March 25, 2013

21 Policies and Procedures Section 1: Eligibility and the Application Process 13 Multi-Site Corporate and Site-Specific Survey Tool Submission Note: Confirm eligibility before you purchase Survey Tools! It is not necessary to purchase all of the required Survey Tools at once. Corporate and site-specific Survey Tools will be submitted and reviewed in the following manner: An organization submits a Corporate Survey Tool with approved multi-site elements before submission of the first practice site survey. NCQA reviews and scores the Corporate Survey Tool within 30 days of submission. The organization completes site-specific Survey Tools for each site, with responses to the remaining elements. NCQA merges the Corporate Survey Tool scored elements with the practice site Survey Tools before submission. This allows practices to see full survey scoring before submission. All practice site Survey Tools must be submitted within 12 months of the Corporate Survey Tool submission date. NCQA reviews the submission, finalizes scoring and makes a recognition decision for each practice site within 60 days of submission of each site s Survey Tool (after merging Corporate Survey scoring). Practice Readiness Evaluation Practices can conduct a readiness self-evaluation on the PCSP standards and elements before submitting the Survey Tool to NCQA. To be most accurate, the evaluation should thoroughly assess the practice s systems, including responses to questions, completed worksheets (as needed) and evaluation of supporting documentation based on the eligibility determination. The Survey Tool estimates the score for each standard and element and provides an overall preliminary score. While a practice is conducting its readiness evaluation, NCQA reviewers do not have access to the Survey Tool, any data or any referenced documentation. The information is secure and confidential and for the practice s use only. NCQA does not access the practice s Survey Tool or information during this period, except for system maintenance. The practice may revise its readiness evaluation, enter comments and update or change attached documents as often as it wants. Complete the Application Step 1 Order the PCSP Online Application from NCQA. PCSP application materials can be obtained online, free of charge, at or by contacting NCQA s Customer Support staff at You will receive confirmation s from NCQA with the subjects Publication Order Confirmation and Accessing Your NCQA PCSP Recognition Online Application. Step 2 Access the PCSP Online Application system by following the instructions in the with the subject Accessing Your NCQA PCSP Recognition Online Application. Order a PCSP Survey Tool for each practice site you are submitting for PCSP Recognition. Confirm your practice s eligibility before you purchase Survey Tools! March 25, 2013 PCSP Recognition 2013

22 14 Policies and Procedures Section 1: Eligibility and the Application Process Step 3 Step 4 Sign the program agreement and the Business Associate Agreement electronically or submit signed agreements to NCQA before you submit the application. Submit the online application to NCQA. You must submit the application before you submit the Survey Tool. NCQA requires one week to process the application. You will receive a confirmation from NCQA when we receive your application, and a separate indicating that your Survey Tool is ready for document upload and survey submission. Step 5 Submit the application fee to NCQA before or concurrently with your PCSP Survey Tool. NCQA cannot review your Survey Tool for Recognition until payment is received. Complete the Submission Practices should review the PCSP standards to determine if they perform the functions required by the elements under each standard. To help determine the capabilities of the practice, review the Explanation section of each element. Two software applications are used to complete submission: the Interactive Survey Tool and the Online Application. Step 1 Step 2 Respond to questions. Indicate the response for each factor that corresponds to the practice's capabilities. Complete the worksheet (if applicable). The optional Quality Measurement and Improvement Worksheet is attached to the Survey Tool. You may need to complete it as documentation for PCSP 6, Element C: Implement and Demonstrate Continuous Quality Improvement. If you plan to use the worksheet, download it, save it to your computer and label it with the name of your practice. Enter the requested information and then reattach it to the Survey Tool following the directions provided in the Survey Tool. The Quality Measurement and Improvement Worksheet (in Microsoft Word). The worksheet relates to PCSP 6, Element C, and is a method of documenting quality measurement and improvement efforts. An alternative to the Quality Measurement and Improvement Worksheet is a report that your practice creates based on a query of its electronic system. Refer to the Explanation section of PCSP 6, Element C, for details. Step 3 Attach documentation. Attach documents that demonstrate how the practice meets each factor in every element. Each element provides explanations and describes the required documentation. To minimize document management and encourage an efficient review, attach no more than three documents per element. Some elements will only require one document. Multiple document sources may be combined into a single document (e.g., one Word document with several reports or examples or one PDF), labeled and ordered by factor and element. The ISS cannot accept documents in HTML format. Highlight or identify information in the documents that meets the standard. Only legible documents will be considered. The Survey Tool provides instructions for attaching documentation. After documents are attached, they are listed in a document library and referenced by element. Until the Survey Tool is submitted, you can revise responses, enter comments and update or change the attached documents. PCSP Recognition 2013 March 25, 2013

23 Policies and Procedures Section 1: Eligibility and the Application Process 15 Note: Protected health information (PHI), as defined by the Health Insurance Portability and Accountability Act (HIPAA) and implementing regulations, must be removed or blocked out from documents submitted, specifically patient identifiers, unless the Survey Tool indicates otherwise. NCQA does not request PHI, but to the extent that it is inadvertently included in documentation materials, NCQA s use and access to this information is governed by the HIPAA Business Associate Agreement. You may provide Web links to data or Web sites. For many elements, the best documentation is a screen shot from a computer your practice uses. Create a Word document and cut and paste the screen shots to that document, or scan documents and create a PDF. Block out PHI. Save Word documents as read-only. Step 4 Step 5 Step 6 Submit the application and the application fee. Note: You may not complete your submission until NCQA receives your application and establishes an electronic link between your Survey Tool and the NCQA server. Upload documents to the Survey Tool. This step enables you to upload your attached documents to the NCQA server (similar to attaching a document to an ) for review. The Survey Tool has instructions for uploading documents. Submit the Survey Tool with the attached documentation. The date when you submit the Survey Tool to NCQA is the date when NCQA officially begins to survey your data. You can view your copy of the completed Survey Tool and all of the attached documents and can modify the Survey Tool for your own purposes, but the official copy sent to NCQA, and all the data in it, are considered final for NCQA evaluation. You will not have access to NCQA s copy of your completed Survey Tool and you cannot change data after submission or view NCQA s review of the results until NCQA has finished. NCQA sends an confirming its receipt of the Survey Tool and the start of the evaluation period. NCQA staff review and assess the completeness of application data and Survey Tool materials and might notify you if additional information is required. NCQA lists eligible clinicians for practices that receive recognition; an eligible clinician can be listed at more than one practice site. After the decision, the recognized practice must submit updated clinician information to PCSP@ncqa.org if it wants to delete or add additional eligible clinicians to a current PCSP recognition. NCQA may charge a processing fee to list additional clinicians. All additional eligible clinicians will be listed on NCQA s Web site. March 25, 2013 PCSP Recognition 2013

24 16 Policies and Procedures Section 2: The Recognition Process Section 2: The Recognition Process NCQA Review of the Survey Tool The Offsite Survey NCQA internal and external surveyors access the Survey Tool after the practice submits it to NCQA. Surveyors evaluate the responses and documentation against program standards and determine scores for each relevant element and standard. NCQA makes its final scoring decision within 60 days of receiving a completed Survey Tool. If the practice is one of a group of practices participating in a Multi-Site Survey or a Multi-Specialty Survey, NCQA reviews the multi-site or multi-specialty survey first and applies the results to all practices in the group, then reviews the Survey Tools with site-specific data. The Audit NCQA reserves the right to audit any practice that has applied for or holds a current NCQA Recognition, including while the practice s survey is under review. An audit validates documentation and stated procedures and responses given by a practice in its application and Survey Tool. NCQA audits at least 5 percent of practices, either by specific criteria or randomly, 1 before deciding if the practice meets PCSP requirements. Audits may be completed by , teleconference, Webinar, other electronic means or by onsite review.. Failure to agree to an audit, failure to pass an onsite audit or failure to pass an audit of Survey Tool responses and documented elements may result in a status of Not Recognized. Practice sites selected for audit are notified and sent instructions. The established current operations procedures for audit will be applied in instances of an audit. In general, the first level of review is verification of the Survey Tool submitted by the practice. The practice may be asked to forward copies of the source documents and explanations, to substantiate the information in the Survey Tool submitted with its application. If the application is verified and no issues are discovered, the practice is notified that the audit is complete and the application for recognition is processed. If an audit requires an onsite review, NCQA conducts the review within 30 calendar days of notifying the practice of its intent to conduct an audit. If audit findings indicate that the information submitted by the practice is incorrect or that the documentation does not meet the PCSP standards, the application for NCQA Recognition may be denied, scores may be reduced or additional documentation may be required. NCQA notifies the practice of audit findings and the recognition decision within 30 days after conclusion of the audit. A practice whose application for recognition is denied because of an audit may request Reconsideration of the decision. Refer to Reconsideration for more information. 1 Random selection of applications is based on a predetermined target to achieve a 5 percent audit rate. PCSP Recognition 2013 March 25, 2013

25 Policies and Procedures Section 2: The Recognition Process 17 PCSP Standards There are six PCSP standards. Each standard consists of several elements. Standards evaluate a practice s ability to function as a PCSP: 1. PCSP 1: Track and Coordinate Referrals. 2. PCSP2: Provide Access and Communication. 3. PCSP 3: Identify and Coordinate Patient Populations. 4. PCSP 4: Plan and Manage Care. 5. PCSP 5: Track and Coordinate Care. 6. PCSP 6: Measure and Improve Performance. A Standard s Structure Standard name Element name Element Brief statement of the standard s purpose. Description of performance being evaluated. The scored component of a standard that provides details about performance expectations. NCQA evaluates each element in a standard to determine how well the practice meets the element s requirements. Of the 22 elements in PCSP, 5 are must-pass elements. Refer to The Must-Pass Elements in the Overview. Factor A scored item in an element. For example, an element may require the practice to demonstrate that its policies and procedures include four specific items; each item is a factor. When an element includes multiple numbered factors, the scoring indicates the number of factors that the practice must meet to achieve each scoring level. A critical factor is one that is required for practices to receive more than minimal points or, for some factors, any points. Critical factors are identified in the scoring section of the element. Scoring Explanation Examples The level of performance the practice must demonstrate to receive a specified percentage of element points. Each element has up to five possible scoring levels (100%, 75%, 50%, 25%, 0%). Specific requirements that the practice must meet and guidance for demonstrating performance against the factor. The explanation provides detailed information to the practice about what NCQA looks for, how the element relates to other elements, terms used and the evaluation process. Required documentation. Describes the evidence practices need to submit to demonstrate their performance related to specific elements. The list of documentation sources in each element is not prescriptive, nor does it exclude other potential sources. The practice may have acceptable alternative methods that demonstrate performance. The practice must show documentation of policies and processes that have been in place for at least 3 months. Generally, reports should be no more than 12 months old. March 25, 2013 PCSP Recognition 2013

26 18 Policies and Procedures Section 2: The Recognition Process Practices can use four basic types of documentation to demonstrate performance. 1. Documented process Written statements describing the practice s policies, and procedures. The statements may include protocols or other documents that describe actual processes or forms the practice uses in work flow such as referral forms, checklists and flow sheets. The documented process must include a date of implementation or revision and must be in place for at least three months before submitting the PCSP Survey Tool. 2. Reports Aggregated data showing evidence of action, including manual and computerized reports the practice produces to manage its operations, such as a list of patients who are due for a visit or test. 3. Records or files Actual patient files or registry entries that document an action taken. The files are a source for estimating the extent of performance against an element. 4. Materials Prepared materials the practice provides to patients or clinicians including clinical guidelines and self-management and educational resources such as brochures, Web sites, videos and pamphlets. Scoring Guidelines Elements Calculating the standard score Calculating the overall score The Survey Tool multiplies the element s scoring level by its points to determine the element score. As determined by NCQA and provided in each element s Explanation section, some elements may be scored NA if they do not apply to the practice. The Survey Tool adds the scores received for all elements in a standard to determine the score received for the standard. The Survey Tool adds the scores received for all standards to determine the final score. CMS Meaningful Use Requirements To the extent possible, PCSP standards are aligned with CMS Meaningful Use (MU) requirements. Individual factors are identified in the standards as either Core or Menu MU requirements and are designated with asterisks (i.e., *Core, **Menu). Refer to Appendix 2: NCQA s PCSP and CMS Stage 1 and 2 Meaningful Use Requirements for additional information. Although NCQA encourages practices to pursue achievement of MU requirements and acknowledges the significance of an accomplishment by indicating, within the standards, where recognition criteria align with MU criteria, meeting MU criteria is not a requirement for PCSP recognition. Any level of recognition may be achieved without meeting MU requirements. PCSP Recognition 2013 March 25, 2013

27 Policies and Procedures Section 2: The Recognition Process 19 Final Decision and Recognition Levels The practice s recognition determination is based on its overall performance (numeric score) against the standards and achievement of each must-pass element at the 50% scoring level. Recognition Level Points Must-Pass Elements Level points 5 of 5 Level points 5 of 5 Level points 5 of 5 Scoring decision results are shown in the Final Results section of the Survey Tool. This section consists of tabular findings on: Scores for each element and standard. Number of must-pass elements achieved. The total score. The NCQA Recognition Program Review Oversight Committee (RP-ROC) reviews findings, makes final scoring decisions and incorporates scores into the final version of the Survey Tool, which generates the practice s results. RP-ROC members are clinicians who have expertise in practice systems and who have no conflict of interest with the practice, as determined by NCQA. Certificates Duration of status Reporting results to the practice to the public to organizations NCQA issues an official recognition certificate acknowledging that the practice met the standards. Recognition status lasts three years. A practice that wants to achieve a higher level of recognition status can apply for an Add-On Survey (refer to Section 3: Additional Information). NCQA gives the practice access to a final version of the Survey Tool that includes the final status and level, as well as numerical scores and reviewer comments on all elements and all standards. Recognized practices and associated clinicians are added to the Recognition Directory, which is a list of practices and clinicians on NCQA's Web site ( NCQA does not report practices whose status is Not Recognized. NCQA reserves the right to release and to publish results of the practice s performance under specific standards, elements, factors and reporting categories. NCQA sends a list of recognized practices and clinicians and the levels they achieve to organizations that reward NCQA PCSP Recognition. NCQA reserves the right to release, and to authorize others to publish, results of the practice s performance under specific standards, elements, factors and reporting categories. March 25, 2013 PCSP Recognition 2013