1 - Ncqa Joint Accreditation Self Study 03-01-2012

National Committee for Quality Assurance
Joint Accreditation Self Study

March 1, 2012
CONTACT:
Victoria L. Street, CCMEP
Director, Education
NCQA
street@ncqa.org
202-955-1708
NCQA 2012 JOINT ACCREDITATION SELF STUDY

TABLE OF CONTENTS
I. Introduction
A. Intent to Apply Form................................................................................................ pages 4-5
B. CE Activity Lists ..................................................................................................... pages 6-11
C. Self Study Report Prologue ...................................................................................... pages 12-14
1. Brief History of the CE Program ........................................................................ pages 12-13
2. Leadership of the CE Program ............................................................................ pages 13-14
II.
Criterion 1 CE Mission ...................................................................................... page 15
Attachment CE Mission Statement ........................................................... page 15
Criterion 2 Overall Program Evaluation .................................................................. pages 16-28
Criterion 3 Integrating CE into Practice ................................................................... page 29
Criterion 4 Incorporating Practice Gap/Underlying Educational Needs ............... pages 30-31
Criterion 5 Designing Activities to Change SS-P-PO ............................................... pages 32-33
Criterion 6 Matching Content to Learners Scope of Practice ................................ page 34
Criterion 7 Selecting Educational Formats ............................................................... pages 35-36
Criterion 8 Developing Activities in Context of Desirable Attributes .................... page 37
Criterion 9 ACCME Standards for Commercial Support 1................................ pages 38-40
1) Activity Example 1 Jointly-Sponsored/Co-Provided ...................... pages 41-45
2) Activity Example 2 Directly Sponsored .......................................... pages 46-47
Criterion 9 ACCME Standards for Commercial Support 2-6 ............................... pages 48-58
1) Activity Example 1 .............. pages 59-73
2) Activity Example 2 .......................................................................... pages 74-86
Criterion 10 Non-Education Strategies
pages 87-105
Criterion 11 Identifying Factors Outside the Organizations Control
page 106
Criterion 12 Removing, Overcoming or Addressing Barriers to Change
pages 107-108
Criterion 13 Analyzing Changes in Learners C-P-PO
pages 109-110
Criterion 14 Maintaining Verification of Compliance/Records
pages 110-113
NCQAQ3Q42008ACCME+ANCCAccreditedActivities
PhysicianandHospitalQuality:AnInside
LookattheUpdatedStandards
9/11/2008
Online
InternetLiveCourse
IntroductiontoHEDIS
9/1516/2008
SanFrancisco,CA
Course
HEDISUpdateandBestPractices
9/1718/2008
SanFrancisco,CA
Course
9/19/2008
SanFrancisco,CA
Course
10/7/2008
10/2122/2008
10/23/2008
Chicago,IL
Alexandria,VA
Alexandria,VA
Course
Course
Course
10/24/2008
Alexandria,VA
Course
UpdateonHealthPlanAccreditation
NCQAAccreditation2009Updatesand
ClarificationsWorkshopforBCBSA
DiseaseManagement,ComplexCase
Management,andContinuityand
CoordinationofCare
NCQAUpdateforMichiganHealthPlans
IntroductiontoNCQAAccreditationfor
HealthPlansandMBHOs
11/14/2008
EastLansing,MI
Course
11/1718/2008
Washington,DC
Course
HandsOn:TheInteractiveSurveySystem
forNCQAAccreditation
11/19/2008
Washington,DC
Course
11/2021/2008
Washington,DC
Course
12/10/2008
Online
InternetLiveCourse
ImprovingOutcomesinDiabetesCare:
BenefitingPatientsandPractitioners
Launch6/1/2007
Online
InternetActivity
EnduringMaterial
BestPracticesinCOPDTreatment:HEDIS
andBeyondUpdate2008
Launch12/1/2007
Online
InternetActivity
EnduringMaterial
HRSAUnifiedHealthCommunications
Course
Launch10/20/2007
Online
InternetActivity
EnduringMaterial
IntroductiontoNCQACredentialing
UpdatestoHealthPlanAccreditation
2008and2009PlustheDraftCLAS
StandardsforaBluePlanAudience
NCQAJointAccreditationSelfStudy
March1,2012
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NCQA2009ACCME+ANCCAccreditedActivities
1/1/09
12/31/09
1/1/09
12/31/09
1/1/09
12/31/09
2/45/09
HRSAUnifiedHealthCommunication
BestPracticesinDepressionTreatment
BestPracticesinChildhoodandAdolescentImmunization
DisparitiesLeadershipProgram
InternetActivityEnduring
Material
Material
Material
Course
WellnessandHealthPromotionAccreditation
Course
2/27/2009
InteractiveSurveySystemHandsOn
Course
3/4/2009
AdvancedCredentialing
Course
3/5/2009
AdvancedDelegation
Course
3/2425/09
NewNCQASurveyorTraining
Course
3/3031/09
IntroductiontoNCQAAccreditation
Course
4/1/2009
IntroductiontoDelegation
Course
4/23/09
IntroductiontoCredentialing
Course
5/2728/09
DisparitiesLeadershipProgram
Course
6/25/2009
ImprovingHEDISMeasures
Course
6/25/2009
SpecialNeedsPlansSurveyorUpdateTraining
Course
6/26/2009
NCQASurveyorUpdateTraining
Course
7/22323/09
PPCPatientCenteredMedicalHome
Course
7/2829/09
Course
8/45/09
Course
8/5/2009
SurveyorUpdateTrainingMakeUpSession
InternetLiveCourse
2/26/2009
WellnessandHealthPromotionAccreditation
Course
InteractiveSurveySystemHandsOn
Course
9/10/2009
ImprovingHEDISMeasures
Course
9/10/2009
InstituteforHealthCareStudiesPPCPCMH
Course
10/1213/09
IntroductiontoHEDIS
Course
10/1415/09
Course
10/16/2009
Course
10/2829/09
Course
10/30/2009
Course
11/10/2009
PTICorporateTraining
Course
11/12/2009
InstituteforHealthCareStudiesNCQAUpdate
Course
11/1617/09
IntroductiontoCredentialing
Course
11/1819/09
IntroductiontoAccreditation
Course
11/20/2009
PreparingforanNCQASurvey
Course
12/9/2009
IHCCorporateTraining
Course
8/1920/09
20Aug
March1,2012
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2010 Surveyor Update Training
Course
Washington,
DC
06/25/2010
Advanced Credentialing
Course
Washington,
DC
03/17/2010
Advanced Delegation: Establishing and Maintaining

Successful Relationships
Course
Washington,
DC
03/18/2010
Disease Management Accreditation: New Standards

and Measures
Course
Washington,
DC
03/02/2010

and Measures
Course
Washington,
DC
09/14/2010

and Measures (Corporate Training for Active Health)
Course
Chantilly, VA
09/30/2010
Disease Management, Complex Case Management and

Continuity and Coordination of Care
Course
Orlando, FL
06/07/2010
Disparities Leadership Program 2009-2010 Closing

Meeting
Course
Disparities Leadership Program 2010-2011 Opening

Meeting
Course
Cambridge,
MA
05/19/2010
Hands-On: The Interactive Survey System for NCQA

Accreditation
Course
Washington,
DC
05/19/2010
HEDIS Update and Best Practices
Course
Denver, CO
10/13/2010
HEDIS Update and Best Practices
Course
Washington,
DC
10/27/2010
How To Facilitate Patient-Centered Medical Home

Recognition: A Hands-On Approach and Analysis
Through NCQA's Eyes
Course
Arlington, VA
01/25/2010
How to Facilitate Patient-Centered Medical Home

through NCQA's Eyes
Course
White Plains,
NY
11/10/2010

through NCQA's Eyes
Course
Redondo
Beach, CA
04/15/2010

through NCQA's Eyes
Course
Baltimore,
MD
09/15/2010

through NCQA's Eyes (Corporate Training for Louisiana
Primary Care Association)
Course

through NCQA's Eyes (Corporate Training for West
Virginia Primary Care Association)
Course
Charleston,
WV
03/24/2010
Improving HEDIS Measures: Putting QI Tools Into

Action
Course
Washington,
DC
07/15/2010
Introduction to HEDIS
Course
Denver, CO
10/11/2010
Introduction to Multicultural Health Care Distinction
Course
Washington,
DC
05/26/2010
Introduction to NCQA Accreditation for Health Plans

and MBHOs
Course
Washington,
DC
05/17/2010
Santa Monica,
02/03/2010
CA
Baton Rouge,
01/21/2010
LA
March1,2012
Page8
Introduction to NCQA Accreditation for Health Plans
and MBHOs
Course
Washington,
DC
11/15/2010
Introduction to NCQA's Credentialing Standards
Course
Washington,
DC
05/19/2010
Introduction to NCQA's Credentialing Standards
Course
Washington,
DC
11/18/2010
Introduction to NCQA's Delegation Standards
Course
Washington,
DC
05/21/2010
NCQA Update for Michigan Health Plans (Corporate

Training for the Institute for Health Care Studies,
Michigan State University)
Course
East Lansing, MI
11/08/2010
NCQA's Credentialing: Strategies for Success

(Corporate Training for NAMSS)
Course
Orlando, FL
10/03/2010
Preparing for an NCQA Survey
Course
Washington, DC
11/17/2010
Preparing for an NCQA Survey
Course
Washington, DC
09/15/2010
Relative Resource Use: Drilldown
Course
Denver, CO
10/14/2010
Relative Resource Use: Drilldown
Course
Washington, DC
10/28/2010
Update on Health Plan Accreditation
Course
Denver, CO
10/15/2010
Update on Health Plan Accreditation
Course
Washington, DC
10/29/2010
2010 Disease Management Training (for Surveyors)
Internet Live
Course
05/26/2010
Internet Live
Course
06/02/2010
Internet Live
Course
06/09/2010
2010 Surveyor Update Training Make-Up Session
Internet Live
Course
08/11/2010
The Disparities Solutions Center Web Seminar Series: Addressing

Disparities through HIT: Current Efforts and a Look towards the Future
The Disparities Solutions Center Web Seminar Series: The Cost of

Inaction: Going Beyond the Business Case for Addressing Racial and
Ethnic Disparities
Internet
Live
Course
03/30/2010
Internet
Live
Course
05/11/2010
Best Practices in Childhood and Adolescent

Immunization
Internet
Activity
Enduring
Material
01/01/2010
Best Practices in Depression Treatment: HEDIS and

Beyond
Internet
Activity
Enduring
Material
01/01/2010
Unified Health Communication: Addressing Health

Literacy, Cultural Competency, and Limited English
Proficiency
Internet
Activity
Enduring
01/01/2010
March1,2012
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OverviewofDelegation/Predelegation
Activities
DelegationAgreementsandFileScoring
1/26/11
Online
InternetLiveCourse
2/2/11
Online
InternetLiveCourse
DisparitiesLeadershipProgram201011
ClosingMeeting
DelegationOversight
2/23/11
SantaMonica,CA
Course
2/9/11
Online
InternetLiveCourse
DelegationAutoCredit
2/16/11
Online
InternetLiveCourse
2011StandardsandGuidelinesfor
OrganizationCertification
HowtoFacilitatePatientCentered
MedicalHomeRecognition(corporate
training)
ADayWithNCQA(corporatetraining)
2/25/11
Online
InternetLiveCourse
3/910/11
BatonRouge,LA
Course
3/17/11
Asheville,NC
Course
MedicalHomeRecognition
IntroductiontoNCQAAccreditationfor
HealthPlansandMBHOs
HandsOn:TheInteractiveSurvey
SystemforNCQAAccreditation
3/1718/11
Philadelphia,PA
Course
3/2224/11
Washington,DC
Course
3/25/11
Washington,DC
Course
training)
4/78/11
Asheville,NC
Course
DisparitiesLeadershipProgram201112
OpeningMeeting
4/2829/11
NewOrleans,LA
Course
5/1820/11
Cambridge,MA
Course
MedicalHomeRecognitionStandard1
(corporatetraining)
IntroductiontoNCQAsCredentialing
Standards
5/10/11
Online
InternetLiveCourse
5/1011/11
Washington,DC
Course
AdvancedCredentialing
5/12/11
Washington,DC
Course
AdvancedDelegation
5/13/11
Washington,DC
Course
IntroductiontoMulticulturalHealth
CareStandards
5/18/11
Baltimore,MD
Course
5/1920/11
Baltimore,MD
Course
NavigatingComplexCaseManagement
6/13/11
SanAntonio,TX
Course
MedicalHomeRecognitionStandard2
(corporatetraining)
SurveyorUpdateTraining
6/14/11
Online
Course
6/24/11
Washington,DC
Course
March1,2012
Page10
training)
6/2930/11
Boston,MA
Course
March1,2012
Page11
Introduction C
SELF STUDY REPORT PROLOGUE
1)
Brief History of the CE Program
The National Committee for Quality Assurance (NCQA) is a private, 501(c)(3) not-for-profit
organization dedicated to improving health care quality. Since its founding in 1990, NCQA has been a
central figure in driving improvement throughout the health care system, helping to elevate the issue of
health care quality to the top of the national agenda. NCQAs mission is to improve the quality of health
care. Its vision is to transform health care quality through measurement, transparency and accountability.
NCQA does this by evaluating and reporting on the quality of care delivered by health care
organizations and provider practices.
The NCQA seal is a widely recognized symbol of quality. Organizations that earn the NCQA seal must
pass a rigorous, comprehensive performance review. For consumers and employers, the seal is a reliable
indicator that an organization is well managed and delivers high-quality care and service.
NCQA has helped to build consensus around important health care quality issues by working with large
employers, policymakers, clinicians (including specialty societies), patients and health plans to
determine what is important, how to measure it and how to promote improvement. All NCQA
assessment products are developed using this broad-based consensus process, with measure advisory
panels and similar subgroups providing recommendations to the decision-making Committee on
Performance Measurement and the Standards Committee, both of which report directly to the NCQA
Board of Directors.
NCQAs programs and services reflect a straightforward formula for improvement: Measure. Analyze.
Improve. Repeat. NCQA makes this process possible by developing quality standards and performance
measures, including the Healthcare Effectiveness Data and Information Set (HEDIS), for a broad range
of health care entities. These standards and measures are the tools that organizations and individuals can
use to identify opportunities for improvement. Annual reporting of performance against HEDIS
measures is a focal point for the media, consumers and health plans, which use the results to set their
improvement agendas for the following year. With more than 75 measures, HEDIS is the most widelyused performance measurement set in U.S. health care. Outcomes from health plans annual HEDIS
reporting form the basis of NCQAs State of Health Care Quality Report (www.ncqa.org/sohc). More
than 90 percent of Americas health plans collect and report HEDIS data. Thirty-eight states collect or
require HEDIS reporting.
NCQA uses onsite and offsite surveys, audits, satisfaction surveys and clinical performance
measurement in a range of accreditation, certification, recognition and performance measurement
programs for different types of organizations, medical groups and individual clinicians. It is through
these programs that NCQA gathers the quality information it makes available to consumers, employers,
health plans and practices. Approximately 120 million Americansmore than 70 percent of all health
plan membersbelong to an NCQA-Accredited health plan. Currently, 41 states use or recognize
NCQA Health Plan Accreditation in either their commercial market or Medicaid managed care
programs. NCQAs health plan rankings are reported annually in Consumer Reports magazine.
March1,2012
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HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
The range of evaluative programs offered by NCQA is broad: there are six accreditation programs; five
certification programs; and five clinician and practice recognition programs. These programs apply to
organizations and individuals, from health plans (including health maintenance organizations [HMO]
and preferred provider organizations [PPO]) to physician networks, medical groups and individual
clinicians. NCQA also offers programs designed for newer health care entities, such as Accountable
Care Organizations (ACO). Information generated by these programs helps inform decisions and drive
quality improvement.
NCQA began accrediting health plans in 1991. The Education Unit delivered its first educational
offerings in 1994, and achieved ACCME and ANCC accreditation that year. It has maintained both
accreditations continuously from that time.
NCQAs education activities predominantly are and always have been directly-sponsored classroombased seminars and occasionally live webinars that focus on HEDIS, accreditation and certification
requirements, including their scientific and quality-improvement bases. NCQA provides education to
clinicians through four methods: live, directly-sponsored courses; live, jointly-sponsored courses; live
Internet activities; and Internet activity enduring materials. CME and nursing education Contact Hours
are awarded for approximately 90 percent of each years education offerings. Virtually all accredited
activities provide both CME and Contact Hours. The programs have been developed for health plans
(HMOs and PPOs), managed behavioral health care organizations, credentials verification organizations,
provider organizations, disease management organizations and recently accountable care organizations.
Education programs for clinicians and practices, based on our clinician Recognition Programs for
excellence in Diabetes care, Heart/Stroke care, Back Pain care and the practice-based Patient Centered
Medical Home, have taken the form of live seminars and webinars as well as learner-access web based
programs. In addition, NCQA offers a performance improvement CME activity for physicians, focusing
on the HEDIS measure Follow-Up Care for Children Prescribed ADHD Medication, and has been a
collaborator on two additional PI programs covering immunization and depression.
In addition to these activities, each year NCQA conducts training sessions for our surveyors and
reviewers that are developed in accordance with ACCME and ANCC requirements.
The majority of NCQAs CE activities are supported through participant registration fees. In 2011, about
11 percent of NCQA Education Unit revenue was from four grant-funded activities; for each activity,
NCQA was a collaborating subcontractor, with the prime serving as CME credit provider (two academic
medical centers, a medical specialty society, and an accredited Medical Education Communications
Company).
2)
Leadership and Structure of the CE Program
The NCQA Education Unit is part of the NCQA Finance and Administration Department. Victoria
Street, Director of Education, has been responsible for ACCME and ANCC compliance and day-to-day
management of the unit since December 2004. Prior to this position, she was Education Senior Program
Manager, beginning in July 2000. She reports to Elizabeth Usher, Assistant Vice President of Customer
Resources, who has had oversight of the Education Unit since January 2004 and Publications and
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Customer Support since 1998. Ms. Usher is well versed in NCQA products and services and has worked
closely with the Education Unit since she joined NCQA. Ms. Usher reports to Scott Hartranft, CPA,
MBA, NCQA Chief Financial Officer. The Education staff are Vashon Coehins, Assistant Director;
Jennifer DAlessandro, Jackie Lombos and Nichole Sutton, Program Managers; Tina King, Training and
Development Manager; Angela Williams, Senior Conference Planner; and Felicia Worthy, Education
Coordinator. The mean NCQA Education tenure of the eight core members of the staff is 7.3 years.
The Education Unit works closely with Kathleen Mudd, MBA, RN, our lead Nurse Planner and Vice
President for Product Delivery. Ms. Mudd has been with NCQA since 1995. Mr. Hartranft and Ms.
Mudd report to Esther Emard, MSN, RN, MSLIR, NCQA Chief Operating Officer.
The Education program is an integral part of NCQAs overall mission and goals. The NCQA Review
Oversight Committee serves as the Continuing Education Advisory Committee, and functions in an
advisory and oversight capacity for the program.
Live, directly-sponsored courses are offered throughout the year in locations across the United States;
however, to take full advantage of NCQA staff resources, many programs are held in Washington, DC.
In 2011, NCQA offered 16 live, directly-sponsored CE courses a total of 26 times.
NCQA also provides focused corporate training. NCQA can present already-developed courses at an
organizations location or can develop customized content upon request. NCQA held 13 corporate
trainings in 2011; one of them was a series of live Internet activities.
NCQA held six live, directly-sponsored Internet activities for an external, open-enrollment audience in
2011. Effective presentation of live Internet activities is enhanced by online training for speakers that
enhances their presentation skills, as well as by incorporating quizzes and handouts, expanding question
and answer capabilities, and using polling.
Surveyor training is a live course or live online activity that occurs at least once a year. Clinicians who
contract with NCQA to become surveyors receive education on the NCQA standards and survey
process, as well as on standards changes for the upcoming survey year. The Education Unit takes a lead
role in training new surveyors and in surveyor update training. Depending on the content, training is
conducted through an onsite conference or consists of study materials and online instruction.
Live, jointly-sponsored (co-provided) courses are developed in collaboration with an entity that is not an
accredited provider. In 2011 there were two jointly sponsored/co-provided programs: the Disparities
Leadership Program of Massachusetts General Hospital (CME and nursing Contact Hours) and a
Webinar, Meeting the Health Care Needs of Underserved Women, for the Agency for Healthcare
Research and Quality (AHRQ) and its subcontractor, Westat (nursing Contact Hours only).
Internet activity enduring materials currently include one performance improvement activity (FollowUp Care for Children Prescribed ADHD Medication) that provides CME for physicians. In previous
years, NCQA provided voice-over-slide programs, with post-test and supplemental materials; for
example, an activity that was live 2009 through 2010 on CECitys CE Medicus site, on best practices in
immunization, was based on the HEDIS Childhood Immunization Status and Immunization for
Adolescents measures.
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CONTINUING EDUCATION MISSION STATEMENT 2011
The mission of the National Committee for Quality Assurance is to improve the quality
of health care. Continuing education is an integral part of NCQAs mission.
[PURPOSE:] The goal of NCQAs education activities is to educate health care
professionals about improving health care quality through measurement, transparency
and accountability. Emphasis is placed on value to the health care organization and the
practice-level health care team as well as the professional effectiveness of the participant.
[CONTENT:] The programs scope includes providing education and information to
improve health care quality, shape health care policy, and share best practices in
improving patient care. [TARGET AUDIENCE:] Our target audience includes all
members of the health care team, other professionals in the health care field, and other
relevant stakeholders in the administration and delivery of the health care system.
[TYPES OF ACTIVITIES:] This is accomplished by offering educational programs to
assist our target audience to prepare for surveys, which reflect practices that improve
overall patient care, and to improve care through HEDIS measures and Recognition
Program requirements. Programs are also offered to train surveyors, who are physicians,
nurses and other health care administrators, to evaluate organizations compliance with
NCQAs standards.
NCQA Education achieves its goals in a number of ways. Using the principles of adult
learning, activities include live seminars, workshops and online programs, learner-access
enduring materials, and Performance Improvement activities. [EXPECTED RESULTS:]
The desired result of these activities is improvement in competence, performance or
patient outcomes. NCQA Education is committed to formal evaluation of its programs
and their outcomes, including by monitoring performance against NCQA standards and
HEDIS measures.
Original Statement
Approved:
Board of Directors, May 6, 1992
Revised Statement
Most Recent Review and Revision:
Review Oversight Committee/CME Advisory Committee, June 2011
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CRITERION 2: OVERALL PROGRAM EVALUATION
A.
Describe and include examples of information gathered as a result of overall program

evaluation.
The effectiveness of the NCQA Education Unit is continuously evaluated. An annual in-depth
evaluation takes place each summer involving review of all Education activities and their outcomes; a
review of the goals and processes (including refinement of or changes to strategic direction); review of
high-level needs assessment data; and recommendations for future activities.
Note: Refer to Planning Day agenda, expected outcomes and summary notes on the following pages,
and the formal Unit Evaluation day agenda.
Continuous quality improvement assessments follow the delivery of each education activity or series of
activities, and in annual goal-setting and evaluation sessions. The ongoing evaluation process is guided
by the unit director, with input from the assistant vice president, Customer Resources; the vice president
of Product Delivery (our lead nurse planner); the Review Oversight Committee (our Continuing
Education advisory committee); all Education staff, faculty members, internal and external subject
matter experts and learners.
Overall program ratings (per evaluation forms) and attendance levels provide meaningful feedback
about CE program effectiveness. Participant evaluation results for repeated activities are aggregated, the
overall rating is calculated and input from learners on the programs evaluation forms is reviewed.
Based on learner participation and input, a change implemented in 2011 transformed a one-day seminar
on delegation into a series of Webinars covering the information. Participation grew from 14 attendees
at the classroom seminar in 2010 to an average of 98 attendees for each of the four 2011 Webinars.
Subsequent to each activity or series of activities, the staff engages in Continuous Quality Improvement
at its bi-weekly staff meetings to determine opportunities to improve processes and program offerings.
During the first half of each year, an extensive (but easy to complete) needs assessment survey is
distributed electronically to all participants in NCQA Education activities over the previous three years
and a selection of additional stakeholders. In 2011 the survey was distributed to more than 10,000
individuals; our return rate was 3.3 percent. We receive at least 300 responses each year. Results data
help us plan for the coming year and are thoroughly examined during Planning Day.
Unit policies and procedures are reviewed and revised annually, as necessary.
Pricing for each activity is evaluated annually.
The Education Unit holds regular meetings with NCQA Leadership Team (LT) members, to ensure
alignment of the units activities with NCQA business and strategic plans. The LT (especially through
Kathi Mudd, Vice President, Product Delivery, and Scott Hartranft, Chief Financial Officer and head of
Finance and Administration, the department that includes Education), actively participates in planning
and developing the slate of educational activities and the review of the Education Units progress toward
its goals.
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2012 NCQA EDUCATION PLANNING DAY

July 13, 2011 8:30 AM4:30 PM
Board Room
Agenda
8:308:40
Arrival/Introductions
8:408:45
Agenda Review/Revision
Review Expected Outcomes
8:459:15
Financial and Performance Review

2011 programs to date
Previous years programs
Registration trends
9:15 10:00
Needs Assessment Review

Needs assessment survey summaryVashon
Surveys scheduledNichole
Plans challenging issuesJennifer
Accred survey process resultsVicki
Standards releaseElizabeth/Vicki
10:0010:15
BREAK
10:1510:45
Identification of Professional Practice Gaps of our learners
10:4511:00
Learning and Development UpdateTina
11:0011:30
Brainstorming: Needs assessment questions for The Experts
11:3011:40
WELCOME Guest Panelists/Introductions
11:4012:00
Brainpicking: Getting answers to brainstormed list of questions/

Beginning brainstorming for 2012 programs
12:001:30
LUNCH, Resumed brainpicking/brainstorming, summarizing outcomes
1:301:45
BREAK
1:452:00
Assessing the Calendar

Holidays
Competing meetinginternal
Competing meetingsexternal
Release datesISS updates, etc.
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2:003:45
Scheduled vacations
2012 Seminar Offerings

What, Where and When?
Legacy seminars
o Introduction to NCQA Accreditation
o Introduction to HEDIS
o HEDIS: Update and Best Practices
o Delegation Standards and Strategies (online, 4 modules)
o Introduction to NCQAs Credentialing Standards
o Advanced Credentialing
o Advanced Delegation (offer every other year?)
o ISS Hands-On/Preparing for a Survey
o Accreditation Update
o Policy Conference
o Introduction to MHC Standards
o Improving Organizational Performance
o Navigating Complex Case Management
o Facilitating PCMH Recognition
o Intro to WHP
o Intro to ACO
o Disease Management Standards Update
o RRU Drilldown
Additional seminar topics
o Top Performers
o Advanced PCMH
o Others? Boutique or Other
Online Programs
o HEDIS Basic Stats
o ISS Documentationnumber, roadmapping (per ROC)
o Helping plans with hybrid data collection?
o URAC-type emerging topics (especially public policy)?
o Others
Corporate Training
o IHCS (MSU)
o Disparities Leadership Program (Mass General)
o Others
Corporate-Sponsored Programs
o CECity and other Learner-Access
o Performance Improvement Activities
o Others
Assisting SNPs and others
o SNPs
o SUT
o CHIPRA
o Others
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3:454:15
Marketing and Communicationscompetitive analysis, creative ideas
4:154:30
Wrap Up/Next Steps
March1,2012
Page19
2012 PLANNING DAY EXPECTED OUTCOMES

At the conclusion of this planning day, we will have:
1. Reviewed needs assessment data from numerous sources, and identified
professional practice gaps.
2. Analyzed Education program performance data to discern trends that influence our
program planning.
3. Gathered information on Product Development, Accreditation, Policy, Recognition
Programs, RPMA, Marketing and Corporate and Foundation Relations 2012 plans
and expectations that inform our planning.
4. Produced initial plan for what 2012 programs will be offeredwhere, when and
why.
5. Brainstormed potential new opportunities for Education programs.
6. Established next steps for our 2012 program planning process.
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Education Dept. Planning Day notes

July 13, 2011
Our dept goal is 4.25 overall score as excellent; in 2011 we are achieving 4.39 on average.
PCMH demand for 2008 applications, webinar opportunities for PCMH, number of program offerings
have increased by 30% this year.
Change tag line for scheduling corporate training in e-blasts. (Vashon)
Email to primary care associations on PCMH seminars, with dates
2012 will be a heavy survey year. Will include standards from 2011 (through 6/30) & 2012.
Appendix LAdv Delegation numbers decreasing. Improving HEDIS Measuresrevamping content and
moving to Dec.
Appendix MBack to back seminar offerings, Cred & HEDIS week most frequent
Appendix Nother category is confusing as a catch all bucket. The new eCommerce system will break
down categories in a more refined way. We will need to think about relabeling org categories
Tina said when people sign up for the mailing list from the website they select their interests and types
of programs.
Appendix O & PEarly bird discount still most freq used. What does other include? Felicia to check.
Appendix Q -- Web site most frequent way to register. System does not allow discounts by phone.
Elizabeth will have to investigate taking electronic checks through ecommerce.
Appendix RCA, TX, NY and FL are our most frequent customers home states. Consider Pittsburgh,
Boston for future programs.
Needs Assessment survey review (Vashon):
Consider e-copies of materials on thumb drives with PDF to avoid altering content and copying. The
team decided that content of seminar will drive the move to e-copies.
Video capability for webinars to improve high touch would be nice.
Overall challenges for PCMH/ACOadd this question to needs assessment
Accred Schedule
PCMH resurvey in RPS
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4th Quarter 12 & 13, corporate training opportunity for HPAs

Prod DevelopmentDiscussion this afternoon on Exchange plans. We would need to train for 2013
standards. Release July 12. Changes to core HPA program. Need to identify the value of content.
Goal20 new HP applications this year. In June hit their goal and exceeded revenue target. Half of the
applications in 2012 want to come from HP & WHP. Any need for new HP training? Corp Training?
Ask Accred in afternoon.
Do we have the capability to record training programs and access later? KM suggested Tina go to MT
and ask interest / higher level topics. Development plans for staff.
QUESTIONS TO ASK THE SMEs:
Changes for Accred
Health Exchanges
PCMH distinction option for practices that field CAHPS can obtain special recognition. We would
certify those survey vendors. In Sept we hope for board approval on this. Vendors wont be certified
until Nov.
Medicare 5 star ratingHEDIS, HOS, CAHPS
DMs submitting measures in 2012. CCM Vendor programdoing a feasibility study in case
management.
What are the customer issuesAccred staff? Need suggestions for programs.
Guests Joined:
(on phone Ann Carson, Robyn Goddard, Dayna McKnight)
Jennifer DziekanPCMH, ACO, Best practices, 5 star CMS rating, exchanges, MHC
Paul CottonStates & HPs, drill down to state level, may time with policy conf, Dec. 13th
AnnBest practices needed
Bob RehmIdentify folks that make big jumps from our data, QC, Special appeals
Alan HoffmanTie to Medicare 5 star rating
5 star HP with Medicare advantage plans (Alan, Sarah and Suzy)
Lindsey KingRRU feedback from HPs, essential and use of data
Wellpoint has shared RRU data and findings. How are much plans willing to share/competition
Raena Akin-DekoMHC probably wont end up in HP accred
What is coming down the pike?

ACOs, PCMH 2011
Update PHQwebinar, small audience
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EMRs and meaningful use. Potential alignment to PCMH & meaningful use. We recognize practices and
meaningful use.
Affordable Care ActExchanges, going into 2013 HP standards? Still unknown.
MHC (Robyn)Collaborative training with Johns Hopkins?
GW research work?
Performance Measurement Update (Robert):
Re-eval of behavioral health measures
CHIPRApediatric quality measures.
SNPs-related: Avoidable hospitalizations/readmissions/care transitions
Jen Dz: BI would support care coordination/case management; potential tie-in to HEDIS measures?
SNPs (Brett Kay): Care transitions after March/April when plans submit; late 2011 or Q1 2012.
Accreditation (Dayna): How to prepare documentation; preparing for a survey; better display/tracking
for surveyors, highlighting/bookmarking/feedback.
New P&P for ISS document library (re-do that section in Hands-On)
Policy (Frank Stelling): DM 20122nd year in a row, new program requirementsmeasure reporting,
better worksheet.
Updated WHP standards (Nov.)
HPAppeals update, big changes to CCM, UM; file audit of delegation to non-accredited entity.
CredentialingNPS added to file review; P&P need to follow our requirements if youre credentialing
other practitioners
Question about observed status
UM questions about medical necessity/ER denials
Webinar series on file review requirements (different products)?
Education for employers regarding WHP
PCMH locations: NY, FL, TX, CT, MA, WI, Chicago
PCMH Hands-OnOnboarding to record review workbook by Peggy R.
Advanced PCMHROI, business case; Sarah Scholles research on difference in practice between level
1 & level 3 PCMH accred
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NCQA Education 2011 Unit Evaluation

July 14, 2011Board Room
Agenda
8:308:40
Arrival/breakfast
8:409:20
Appreciative Inquiry Lite

Describe a time in the past year when you were proud of something Education did
(or you did as part of an Education activity)
What do you think Education does especially well?
How can we capitalize on that strength?
9:209:30
Review of mission statement
9:3010:00
Moving toward higher level outcomes/evaluation

Moores hierarchy
IOM/ACGME/ABMS Core Competencies
ACCME PARS tracking
10:0010:15 BREAK
10:1511:30 Review of Self-Study requirements for Joint Accreditation
(pg. 11 of Guide to the Accreditation Process)
How do we meet the requirement?
What changes should we implement to do a better job?
11:3012:00 Technology updates
Electronic files in 2012
o What questions do we have for IT Ops?
o How will we organize our files?
Moving toward providing materials electronically
12:0012:25 Faculty
Replacing Bill
Following up with surveyors who expressed interest
12:2512:30 Next steps/adjourn
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B.
Describe conclusions regarding the organizations success at meeting its CE mission,

including the degree to which the organization has:
1.
Reached its target audience: Our target audience includes all members of the health care
team, other professionals in the health care field, and other relevant stakeholders in the
administration and delivery of the health care system. Participants in NCQA Education
activities span the health care spectrum. Our live activities frequently include representatives
from health plans and related organizationsoften those directing quality improvement units
or those responsible for submission of HEDIS data, including medical directors and chief
medical officers, nurses and nursing directors, pharmacy directors, and administrators;
physician practices and medical groups, including physicians, nurses, PAs and NPs, medical
assistants and office staff; state and federal government representatives; representatives from
employers and coalitions; health care consultants and other stakeholders.
2. Provided CE on the content areas outlined in the CE mission: The programs scope
includes providing education and information to improve health care quality, shape health
care policy, and share best practices in improving patient care. All of NCQAs CE activities
support NCQAs mission of improving health care quality and are grounded in quality
measurement and assessment. The practices examined in our CE activities, when implemented
by organizations, practices or clinicians, serve to improve quality. For example, the content in
our seminars Introduction to NCQAs Credentialing Standards and Advanced Credentialing
focuses on patient safety, proper oversight and delivery of quality care. We discerned that one
activity for which we had provided CE (Hands On: The Interactive Survey System for NCQA
Accreditation) more reasonably falls into the category of in-service training and we are no
longer provide credit for that activity, as of this year. Although shaping health care policy takes
place at the NCQA organizational level, the extent to which it results from CE activities is
questionable; our annual Policy Conference, which does shape health care policy, is not a CE
activity. Best practices in improving patient care are included in our two most popular
seminars, HEDIS Update and Best Practices and Facilitating Patient-Centered Medical Home
Recognition, as well as in Internet enduring materials, such as our performance improvement
activities.
3. Produced the types of activities stated in the CE mission: This is accomplished by offering
educational programs to assist our target audience to prepare for surveys, which reflect
practices that improve overall patient care, and to improve care through HEDIS measures and
Recognition Program requirements. Programs are also offered to train surveyors, who are
physicians, nurses and other health care administrators, to evaluate organizations compliance
with NCQAs standards. NCQA Education achieves its goals in a number of ways. Using the
principles of adult learning, activities include live seminars, workshops and online programs,
learner-access enduring materials, and Performance Improvement activities. We have
produced the types of activities and formats described here; they are fundamental to our CE
program.
4. Fulfilled its purpose: The goal of NCQAs education activities is to educate health care
professionals about improving health care quality through measurement, transparency and
accountability. Emphasis is placed on value to the health care organization and the practicelevel health care team as well as the professional effectiveness of the participant. Our CE
March1,2012
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activities educate health care professionals about the importance of measuring quality and
value, providing transparency regarding practices and being accountable to stakeholders. Each
activity evaluation includes the statements, This program will enhance my professional
effectiveness and The content will be of value to my organization. Using a 5-point Likert
scale, these statements exceed 4 (agree) for nearly every education activity. The evaluation
also includes an open-ended question regarding specific practice changes the learner expects to
undertake, such as, Based on what you learned in this seminar, what actions will you
undertake at your organization to improve practice? Furthermore, we deliver three-to-sixmonth follow-up surveys for some seminars, to determine the extent to which a learner has
made practice changes from participating in the educational activity.
5. Achieved its expected results. The desired result of these activities is improvement in
competence, performance or patient outcomes. NCQA Education is committed to formal
evaluation of its programs and their outcomes, including by monitoring performance against
NCQA standards and HEDIS measures. Each activity has a specific desired result. For many
NCQA Education activities, we expect improvement at the level of competence
(skills/strategy), as measured by our post-activity evaluation. For example, for the HEDIS
Update and Best Practices seminar, we ask, Based on the information you learned, are there
any new processes you can implement to help improve your HEDIS rates? For our
performance improvement activity, we specifically measure Level 5 (performance) outcomes.
We also measure performance through the follow-up surveys described above. For changes in
patient outcomes, we use a longitudinal view to discern changes in patient outcomes based on
improvement in health plans HEDIS scores, as demonstrated in the State of Health Care
Quality Report.
C.
As a result of program-based analysis, describe identified changes that could help the
organization better meet its CE mission. Explain how each change, if implemented, could
impact a component of the CE mission (purpose, content areas, target audience, type of
activities, or expected results).
In 2011 we identified the following potential changes:

1.
Chunking content from a full-day seminar into several Webinars, as we have done
successfully with our Delegation seminar. Most seminars do not lend themselves to this
treatment, but we should consider it for the handful that will (it may be possible for the Wellness
and Health Promotion and Introduction to Multicultural Healthcare Standards seminars). Given
our experience with transforming Delegation into a Webinar series (expanding enrollment from
14 to 98), this would enable us to reach our target audience and achieve expected results,
expanding improvement in health care quality.
2. Creating an Advanced Patient-Centered Medical Home seminar focusing on best practices,
operational and process issues for those who have achieved PCMH recognition (or who are
familiar with the requirements and are starting to build the medical home model in their
practice). We currently survey registered participants before the PCMH seminar to gather
information on specific needs; we would do this for an advanced seminar. Furthermore, several
thousand participants in previous introductory PCMH seminars could be surveyed to gain their
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recommendations for advanced content. This would help us fulfill our purpose and enable us to
better address content areas and serve our target audience.
3. Moving to Web-based activity evaluation submission and certificate generation. We have
discussed making this improvement for some time. It would streamline our processes, ease staff
workload from compiling hard-copy evaluation results and allow easier and more sophisticated
data analysis. This would help us better achieve (and analyze) our expected education program
results.
4. Establishing a process for providing activity materials electronically (for classroom-based
seminars). We need to approach this thoughtfully because many in our core audience have
expressed that they appreciate receiving printed copies of slides and other seminar materials for
taking notes. Many of these people are long-time attendees at our seminars and we want to
continue to serve them well. Transitioning to electronic distribution of materials may enable us
to offer more of the activities described in our mission statement because we would realize
savings on printing seminar manuals.
5. Expanding staff. Our PCMH seminars are always sold out, and there is demand for more
sessions, in addition to the Advanced PCMH seminars described above. Also, we are
participating in more performance improvement activities, which are labor intensive. This
change would enable us to offer more of the activities described in the mission statement and
expand our reach to our target audience.
D.
Based on the changes identified that could be made, describe the changes to the CE program
that were implemented. For any potential changes that were not implemented, explain why
they were not implemented and plans to address them in the future.
Expanding staff: We added a program manager position in 2011 and expect to add at least one
more, plus a coordinator, in 2012.
Creating an Advanced Patient-Centered Medical Home seminar: With the expanded staffing,
we plan to offer this new seminar twice in fall 2012, as well as a series of PCMH webinars.
Moving to Web-based activity evaluation submission and certificate generation: We
successfully moved to electronic evaluation and certificates mid-2011.
Chunking content/creating webinars from seminars: We have not done this for any seminar
except Delegation, though we have discussed the possibility for two others and may pursue this in
2013.
Providing live seminar materials electronically: This is in discussion. We will gather more
specific information regarding our target audiences preferences in our needs assessment survey
this spring.
E.
Describe how the organization has measured the impact of these implemented changes on its
ability to meet the CE mission.
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Expanding staff + Advanced PCMH Seminars: We have expanded our seminar offerings; we
had planned five PCMH seminars in 2012 and are contracting for our sixth seminar, with plans to
add Advanced PCMH seminars and Webinars.
Moving to Web-based evaluation submission and certificate generation: We noticed that the
percentage of evaluations completed has declinedfrom the 80 percent range with hard copy
forms, submitted on site, to in the 60 percent range with electronic submission. We initially
encountered difficulty with the vendor making the Web link available to participants immediately
following the activitythere was a delay of up to two weeks. The issue has been resolved and
links are now available immediately at the conclusion of the activity. Our overall program scores
(The overall program met my expectation) have remained in the same range (usually well above
4 out of 5), so we seem to get post-activity evaluations from a strong representative sampling of
the audience.
Chunking seminar content to create a Webinar series: The only activity for which this has been
done experienced a seven-fold increase in participation in 2011. To date, 2012 registration has
been more than four times higher than for the 2010 live seminar.
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CRITERION 3: INTEGRATION OF CE INTO IMPROVEMENT OF

PROFESSIONAL PRACTICE
Describe how the organization integrates CE into the process for improving the professional
practice of the healthcare team. Include examples of explicit organizational practices that have
been implemented.
Continuing Education activities are provided to clarify and amplify nearly every NCQA Accreditation,
Certification, Recognition or HEDIS product for those who must understand and implement the
practices required by these assessments. For core products such as health plan accreditation and HEDIS,
a variety of activities have been created and updated at the introductory, advanced, and specialty (e.g.,
credentialing) level for those responsible for improving the quality of care offered by Americas health
plans.
The Education Unit plays an integral role in NCQAs development of new quality assessment products
or modifications and improvements to existing products. Recent examples include inclusion of CE
activity planning in the ongoing development, revision and public reporting of the HEDIS Relative
Resource Use (RRU) measures; development and roll-out of the Accountable Care Organization
accreditation standards and measures; and the 2011 revisions to the Patient-Centered Medical Home
Recognition standards and processes. By participating in the evolution of these products, Educationin
collaboration with Product Development, Performance Measurement, Product Delivery, Marketing and
Communicationshas created CE activities that enable health care professionals to develop competence
in guiding their organizations to demonstrate quality improvement.
NCQAs missionto improve the quality of health carecannot be accomplished to any degree
without the dedicated efforts of the entire health care team. Primary and specialty care physicians,
nurses, nurse practitioners, physician assistants, pharmacists, case managers, medical assistants,
technicians, administratorseveryone who provides or supports the provision of health care at any level
has a role in improving health care quality. Most of our education activities are relevant to all.
For example, among the 200 learners at our most recent Facilitating Patient-Centered Medical Home
Recognition seminars were chief operating officers, chief medical officers, medical directors, chief
nursing officers, directors of nursing and of clinical systems, directors and managers of quality
management, physicians, nurses, office managers and case managers. The practice transformation they
will undertake to meet NCQA PCMH requirements will ultimately result in substantial improvement in
their individual practices and the delivery of health care to patients.
In terms of assessing individual clinician needs, the extensive survey we distribute each spring gathers
such information. Post-activity evaluations also provide valuable needs assessment information.
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CRITERION 4: INCORPORATING THE EDUCATIONAL NEEDS THAT UNDERLIE

LEARNERS PROFESSIONAL PRACTICE GAPS INTO CE ACTIVITIES
Describe how the organization incorporates the educational needs (knowledge, skills/strategy, or
performance) that underlie the professional practice gaps of learners into CE activities. Use the
following as an outline for your description:
1. How the organization identifies the professional practice gaps of its learners;
2. How the organization identifies the educational need(s) that underlie those gaps; and
3. How the organization incorporates these needs into activities or a set of activities.
HEDIS data are consolidated each summer into Quality Compass, a comprehensive database of health
care outcomes from U.S. health plans. The aggregated data are collected at the health plan level and
reflect practice-based performance. They are the source for NCQAs State of Health Care Quality
Report (available as a free download at www.ncqa.org/sohc). This nationally-recognized publication is
as an excellent source for identifying professional practice gaps, and includes year-by-year results for
each reported measure. A small sample from among the more than 75 HEDIS measures includes the
extent to which appropriate care is provided in the areas of:
Breast Cancer Screening.

Colorectal Cancer Screening.
Childhood Immunization Status.
Glaucoma Screening in Older Adults.
Use of Appropriate Medications for People With Asthma.
Controlling High Blood Pressure.
Comprehensive Diabetes Care.
Follow-Up After Hospitalization for Mental Illness.
Potentially Harmful Drug-Disease Interactions in the Elderly.
Medical Assistance With Smoking and Tobacco Use Cessation.
Fall Risk Management.
Professional practice gaps also are evident from accreditation, certification and recognition outcomes.
Standards that show the lowest compliance levels, such as Complex Case Management and Continuity
and Coordination of Care, point toward gaps at both the practice and systemic levels. Seminars have
been designed and presented to address both issues.
Some practice gaps are simpler in nature. Professionals new to NCQAs assessment processes, including
HEDIS, need an introduction to the requirements. Those unfamiliar with quality improvement basics,
such as Demings PDSA model, would benefit from an overview to enable them to implement such
practices. Those who have gone through NCQA reviews or who have submitted HEDIS data appreciate
the opportunity to learn from NCQA experts about accreditation, certification, recognition or HEDIS
updates.
NCQA Education issues a yearly comprehensive needs assessment survey each spring to contacts on
several levels in health plans, from chief medical officers to quality improvement managers. We also
reach out to clinicians in practices that have participated in our Web-based activities and our PatientNCQAJointAccreditationSelfStudy
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Centered Medical Home seminars. We always receive at least 300 responses to the survey, which
provides excellent data about our audiences needs and the educational activities that would be of
benefit to them in the coming year.
We also gather extensive information from our subject matter experts on their recommendations for
forthcoming changes to NCQAs programs and products and education activities they believe would be
of value to our target audience. Our day-long planning session, held each summer, features SMEs from
throughout NCQA and provides a lively and helpful forum for helping us plan educational offerings for
the coming year.
Through the individual activity planning process, guided by the activitys expert Planning Committee,
NCQAs educational offerings always directly incorporate and address identified practice gaps and
educational needs. For example, HEDIS Update and Best Practices, for which the target audience is
experienced HEDIS professionals at health plans, focuses on updates to the coming years HEDIS
measures and data collection requirements. HEDIS Update also incorporates another educational need
identified by our target audience as well as our SMEs: Best practices in improving HEDIS results.
Each year, six health plans are chosen from a pool of applicants to submit a poster and prepare a short
presentation describing how they improved their outcomes for a specific HEDIS measure. These
presentations are always very popular and highly evaluated by learners.
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CRITERION 5: PROCESS OF DESIGNING ACTIVITIES TO CHANGE SKILLS/STRATEGY,

PERFORMANCE OR PATIENT OUTCOMES
Describe the organizations process of designing activities to change skills/strategy, performance

or patient outcomes.
Comprehensive planning for each years NCQA Education activities begins in the preceding summer.
During an intensive, day-long planning retreat, the unit and subject matter experts (including Kathi
Mudd, Vice President for Product Delivery, LT member and the units lead nurse planner) discuss
professional practice gaps; results of our global needs assessment survey; the previous years activity
evaluations; and marketing data, such as the location of the target audience for a particular activity.
Activities for the succeeding year are planned at this retreat and are refined as locations are secured and
additional data are gathered through early fall. A program manager (PM) is assigned to develop each
activity.
The PM forms a multidisciplinary planning committee to develop activity content. Planning committee
members are selected by subject matter expertise; members typically are NCQA staff and external
subject matter experts, including contracted surveyors, Measure Advisory Panels members, and others
recognized in their fields. The activitys faculty members serve as members of the planning committee.
The planning committee follows a four step process:
1.
2.
3.
4.
Review/obtain additional needs assessment data as needed.

Formulate objectives.
Develop the activity (the educational intervention).
Evaluate results.
Needs assessments. The Planning Committee has several types of needs assessment data available.
These may be a comprehensive assessment done by NCQA (such as HEDIS or accreditation updates),
the Education Unit or an external entity; focused assessments by the PMs on a specific subject; or
feedback from previous offerings of the activity or other activities.
Formulate objectives. The Planning Committee uses the needs assessment to formulate objectives for
the target audience. Input is received from subject matter experts, faculty and others about areas that
should be addressed in the activity content. When agreement is reached, activity objectives are
formulated and revised until there is consensus.
Develop the activity. We use principles of adult education to develop the activity. Most activities
consist of presentations and exercises in a highly interactive environment. Committee members develop
the curriculum and create activity materials. Materials (e.g., slides, exercises, handouts, pre- and posttests) are reviewed by the activitys nurse planner (and, as needed, by NCQAs lead nurse planner) and
by the physician on the planning committee. Adherence to disciplined timelines and commitment to
varied learning modalities strengthens this process.
Evaluate the results. Participants complete a Web-based evaluation and a summary is provided to the
PM and faculty. Evaluations use the Likert scale for self-reported data and encourage individual
comments. Faculty members also complete a review of the PM and provide suggestions for process
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improvement. Planning Committee and faculty participate in a debriefing meeting and recommend
changes.
Outcome results are also available for some activities. Comparing HEDIS data with the following years
HEDIS data suggests that requirements are better understood and quality improvement activities have
been undertaken. Also, satisfaction surveys fielded for organizations that have received NCQA
Accreditation or NCQA Certification contain questions about participation in NCQA educational
offerings and measure how well activities helped them prepare for their Accreditation Survey.
Planning Live, Jointly-Sponsored Activities
In planning jointly sponsored activities, NCQA is rigorous in its participation in the development
process. Through participating on the Planning Committee, the Education Units assigned PM, plus the
activitys nurse planner and physician, review needs assessment data and ensure its relationship to the
activitys learning objectives, presentation content and evaluation. Content is also reviewed to ensure
that it is free from commercial bias, if the activity is commercially supported.
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CRITERION 6: MATCHING CONTENT TO SCOPE OF PRACTICE
Describe how the organization, at the CE program or activity planning level, matches the content
of its activities to learners current or potential scope of practice.
We have experience with and understand the predominant target audience for NCQAs education
activities at the CE program level:
Clinicians and administrators who are employed by health plans and are responsible for quality
improvement and (usually) NCQA compliance or HEDIS data collection and submission.
Clinicians and others at the practice level that seek to transform their practices into PatientCentered Medical Homes or Accountable Care Organizations.
A few activities focus on a particular HEDIS measure and are targeted to clinicians responsible for
patients with a specific disease.
In every case, the learners scope of practice is a key component in the Planning Committees
development of activity content. They are aware of their target audience and have substantial needs
assessment data available to inform their design of the activity.
Our marketing materials (e.g., Web site, e-blasts, fliers distributed at related conferences) clearly
describe the nature of each activity. Enrollment is voluntary, and for about 90% of the activities a
substantial registration fee is charged.
A post-activity evaluation is distributed after each activity. Our target for excellence on a key metric,
The overall program met my expectations, is 4.25 out of a possible 5. In 2011, for live classroom
activities (including corporate trainings), that goal was exceededoften substantiallyin 28 of 40
activities. Rarely do we receive feedback that an activity did not meet learners needs. In the very
unusual case of one activity in 2011 that fell far short of expectations, substantial Continuous Quality
Improvement was performed quickly and a major overhaul of the activity undertaken in case there is a
call to offer the content in the future.
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CRITERION 7: EDUCATIONAL FORMATS UTILIZED FOR ACTIVITIES, INCLUDING

RATIONALE AND CRITERIA FOR SELECTION
Describe the different educational formats (i.e., activity type and methodology) the organization
has utilized for its activities. Explain the rationale or criteria used in the selection of formats to
ensure the format is appropriate for the setting, objectives, and desired results of an activity.
The experts on an activitys Planning Committee hold the decision-making power regarding the
educational format chosen for an activity. Factors in the decision-making process include whether an
activity has been presented in a given format before and its level of success; a review of needs
assessment information from our target audience regarding format preference; and what format best fits
the content that is to be presented (e.g., didactic presentations, exercises, case studies, table discussions,
post-tests).
NCQAs primary educational format is live, directly-sponsored, classroom-based seminars. In 2011, 40
of 50 CE activities fell into this category. Generally an activity that is chosen for this format is one for
which the content is substantial enough to merit a full day (or more) of instruction. Another determining
factor is if exercises based on the seminar content would be a useful tool for anchoring learning,
especially exercises completed in a team setting. Live classroom activities receive the highest postactivity evaluation scores and are popular with learners because they provide personal interaction with
faculty and professional networking.
Because NCQAs education activities are almost always supported by learner registration fees,
classroom-based activities must generate enough revenue to cover all expenses, including Education
staff salaries and related expenses. Activities that do not have sufficient registration to meet expenses
especially when they have been offered more than twiceare usually considered for presentation in
another format (e.g., as a live online activity or series, or, as with our Managed Behavioral Health
Organization Accreditation, as a breakout series within the health plan accreditation seminar, which
contained similar content). For many live classroom activities, a follow-up survey is distributed three to
six months post-activity to determine changes in performance as a result of participation.
We also offer live, directly-sponsored online activities. Webinars focus on a specific topic or on a
related series of topics, such as the Delegation Webinar series. The introductory Delegation seminar was
undersubscribed and the content was quite straightforward, with no special need for exercises to anchor
learning. By chunking the content into four related, independent Webinars, registration increased from
14 in 2010, to an average of 98 sites for each of 2011s 4 Webinars. The registration fee for a Webinar is
per site; the participating organization may have as many learners in the room for the activity as it wants
(so actual participation exceeded 98 per Webinar). Webinars are appropriate when the objectives for an
activity are limited and content is intended to improve competence (skills/strategy).
Occasionally, NCQA develops directly-sponsored Internet activity enduring materials. Our ADHD
Performance Improvement program, a PI-CME activity that has been open for registration since May
2009 and will close in May 2012, is a prime example of a current program. This format is appropriate
for using a HEDIS measure for an activity where improvement in performance is the desired outcome.
In previous years, Internet activity enduring-material activities used voice-over-slides with post-tests and
focused on a specific HEDIS measure.
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Occasionally we will serve as joint sponsor/co-provider for an organization with related goals to
NCQAs. For six years, we have been joint sponsor/co-provider for the opening and closing meetings of
the nine-month Disparities Leadership Program of Massachusetts General Hospitals Disparities
Solutions Center. In this case, we must be assured that the organization will comply with all
requirements for joint sponsorship/co-providership, as outlined by the assigned program manager.
NCQAs nurse planner and the Planning Committees physician member review all content for
accuracy, relevance and to assure that there is no bias.
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CRITERION 8: DEVELOPMENT OF CE ACTIVITIES IN THE CONTEXT OF DESIRABLE

ATTRIBUTES OF THE HEALTH CARE TEAM
Describe how the organization has developed CE activities in the context of desirable attributes of
the health care team (e.g., IOM competencies, professional competencies, health care team
competencies).
With NCQAs missionto improve the quality of health carethe context of the IOM competency,
Apply quality improvement, is always present. The description of the competency includes,
continually understand and measure quality of care in terms of structure, process, and outcomes in
relation to patient and community needs; and design and test interventions to change processes and
systems of care, with the objective of improving quality. This attribute forms a major context for the
vast majority of NCQAs educational activities. HEDIS, NCQA Accreditation and the clinician and
practice recognition programs call for baseline quality measurement and a plan for changes to practices;
these form the basis for improvement in care.
Work in interdisciplinary teams, another IOM competency, is also a context for NCQA education.
Transforming health care quality cannot happen without the commitment of all members of the care
team, and without leadership from clinicians across the health care spectrum. Our activities are almost
always accredited for both CME credit and nursing education Contact Hours.
Some activities have additional competencies as a context. See the activity files for examples.
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CRITERION 9 - 1: ACCME STANDARDS FOR COMMERCIAL SUPPORT
Describe how the organization makes the following decisions free of the control of a
commercial interest: (a) identification of needs; (b) the determination of educational
objectives; (c) the selection and presentation of content; (d) the selection of all persons and
organizations in a position to control the content; (e) the selection of educational methods,
and (f) the evaluation of the activity.
The Education Unit accepts commercial support for an activity only if the activity would be
consistent with our Units mission statement and NCQAs mission statement. Furthermore, the
activity in discussion must be demonstrably linked to content that NCQA advances, such as
HEDIS measures or Accreditation, Certification or Recognition standards.
When we participate in a commercially-supported activity, we often are a subcontracting
collaborator with the accredited provider that receives the grant for the activity, such as an
academic medical center. In 2011, for all sources (including as a subcontractor), NCQAs
revenue from commercial support totaled 11% of all education revenue.
When commercial support is provided for an activity, Education obtains a letter of agreement
with the supporter that addresses the ACCME Standards for Commercial Support. We ensure
that the activity will not promote the companys products, that NCQA is responsible for control
of the content and selection of presenters, and that there will be no ancillary promotional
activities by the company connected to the activity. In addition the agreement states that
disclosure of any real or apparent conflict of interest by faculty or planning committee members
will occur prior to the beginning of the activity. COI disclosure statements are collected from
each faculty or planning committee member at the beginning of the planning process, and any
COI is resolved (see description of the process in the next section).
(a) Identification of needs: NCQA does not participate in education on any topic that is not
demonstrably linked to a HEDIS measure or represented in the requirements for an NCQA
Accreditation, Certification or Recognition product. Furthermore, we require needs assessment
data that point to the topics relationship to a practice gap for our target audience. Our State of
Health Care Quality report or the Quality Compass data from which it is drawn are key sources
for our needs assessment. Commercial support is formally sought through a proposal process
that often includes data linked to the research that supported development of a HEDIS measure
or Accreditation standards. The commercial supporter does not provide needs assessment data.
(b) Determination of educational objectives: Our planning process for commercially
supported activities is identical to that of all of our directly-sponsored activities: Once a
commitment is made that a program will be developed, an Education Program Manager (PM) is
assigned, and she ensures that the content development process is conducted with a high degree
of rigor and independence from bias. The PM forms a multidisciplinary planning committee to
develop the course content. Planning committee members are selected based on their subject
matter expertise. Typically they are NCQA staff, contracted surveyors, and other recognized
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experts in their fields, as well as a qualified nurse planner and at least one physician. The course
faculty are also members of the planning committee.
Each education activitys planning committee develops the seminar objectives. When there is a
commercial supporter, that supporter never interacts with the planning committee. The Director
of Education, who serves as the liaison with commercial supporters, does not discuss content
specifics such as educational objectives with the supporter.
(c) Selection and presentation of content: While the commercial supporter may approve at a
high level the proposed presentation method (e.g., live webinar, Web-based enduring material),
the planning committee has sole input on presentation specifics such as use of case studies,
metrics for chart abstraction, or use of didactic presentations v. group exercises. The commercial
supporter is not part of the planning committee and has no input.
(d) Selection of all persons and organizations in a position to control the content: The
activity planning committee is composed of the activitys nurse planner, a physician who is a
subject matter expert, the Education program manager, and other NCQA staff and affiliated
subject matter experts. In the case of jointly-sponsored/co-provided activities, NCQAs nurse
planner serves on the committee along with a physician approved by NCQA; both of them
thoroughly review the content to ensure that it is fair-balanced and free from bias. The program
manager and planning committee choose the activitys faculty. In no case is the commercial
supporter represented on the planning committee.
(e) Selection of educational methods: While the commercial supporter may approve at a high
level the proposed presentation method (e.g., live webinar, Web-based enduring material), the
supporter does not have input on the presentation specifics such as use of case studies, metrics
for chart abstraction, or use of didactic presentations v. group exercises. These are all decisions
made solely by the planning committee.
(f) Evaluation of the activity: NCQA education activities utilize the same online evaluation
platform and set of metrics; any modifications are made by the planning committee, and usually
are very minor. A commercial supporter has no input into the creation or revision of evaluation
questions.
i. If the organization enters into joint sponsorship/providership relationships with nonaccredited providers, describe the process used to ensure that these organizations are not
commercial interests.
NCQA has served as joint sponsor/co-provider for only two activities over the past four years,
both at the request of the organization and both for several years. One was a government
agency, the other a nationally-recognized, award-winning hospital. Given our requirement that
content be related to NCQA HEDIS or assessment, the amount of joint sponsorship/coprovidership that we would choose to do is very limited. We do not have a specific mechanism
for determining that an organization is a commercial interest but we will develop one should we
seek more opportunities in this area.
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ii. Provide a list of joint sponsors (or co-providers).

The Health Resources and Services Administration (HRSA)
The Disparities Solutions Center of Massachusetts General Hospital
Include two activity examples that illustrate all of the steps of the planning process that
were described.
See the examples on the next pages from the Disparities Leadership Program Closing Meeting in
February 2011 and Accountable Care Organizations: An Introduction to NCQAs Accreditation
Standards in November 2011.
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NOTE: A version of this form is completed for each NCQA Education activity as part of the planning
process. Language in the left column has been updated to reflect information requested for this
Joint Accreditation example.
NCQA Education Activity Planning

Activity/Educational Intervention: Disparities Leadership Program
Dates: Feb. 2-3, 2011 (Closing meeting)
Location: Santa Monica, CA
1. The problem, or
professional practice gap the
activity addressed (JAC4)
Leaders in healthcare do not fully understand the ways in which

members of different ethnic and racial groups respond to treatment
(knowledge gap). Additionally, these leaders are not aware that
differences in patients attitudes along with cultural or linguistic barriers
affect how they obtain care and respond to treatment (knowledge gap).
Additionally, leaders in the health care setting lack the knowledge and
skills to develop a strategic plan towards eliminating health care
disparities (skills/strategy). They do not know how to make this issue a
priority in their organization and do not have adequate skills to develop
quality initiatives to reduce disparities (skills/strategy).
Per the IOMs study, Unequal Treatment: Confronting Racial and
Ethnic Disparities in Health Care:
Research demonstrates significant variation in the rates
of medical procedures by race, even when insurance
status, income, age, and severity of conditions are
comparable. This research indicates that U.S. racial and
ethnic minorities are less likely to receive even routine
medical procedures and experience a lower quality of
health services.
The congressional committee's recommendations for
reducing racial and ethnic disparities in health care
include increasing awareness about disparities among the
general public, health care providers, insurance
companies, and policy-makers.
Institute of Medicine Report, Unequal Treatment: Confronting Racial and
Ethnic Disparities in Health Care, March, 2002.
The Institute of Medicine (IOM) Report Crossing the Quality Chasm,

released in 2001, highlights that there is a significant gap between the
quality of health care people should receive, and the quality of health
care people do receive.
The Disparities Leadership Program (DLP) is a yearlong executive
education program designed for leaders from hospitals, health plans and
other health care organizations who need to develop a strategic plan or
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advance a project to eliminate racial and ethnic disparities in health care

through quality improvement.
The closing meeting of the leadership program was held of February 23, 2011 and offered the opportunity for participants to present the results
of their yearlong projects and obtain assistance from the faculty in
progressing their project further towards the elimination of racial/ethnic
disparities in health care.
This leadership education program strives to address the attitudes
(cultural sensitivity/awareness), knowledge (multicultural approach) and
skills (cross cultural approach) of the health care leadership team.
2. The educational need that
was underlying this gap for
learners (JAC4)
A thorough review of current issues surrounding disparities in health

care coupled with participants year-long project at the practice or
organization level have proved to be an excellent model for closing the
gap in care for diverse populations. The DLP has employed this model
successfully for six years.
As a result of the Disparities Leadership Program, participants gain
practical experience implementing personalized quality improvement
strategies aimed at eliminating racial and ethnic disparities in health
care.
Participants are provided with:
a) an indepth knowledge of the field of disparities, including
root causes and research to date (knowledge)
b) quality improvement strategies for identifying and addressing
disparities (strategy)
c) the leadership skills to implement these strategies and help
transform their organizations (strategy)
3. What the activity was

designed to change
(competence, performance
or patient outcomes) (JAC
5)
At the conclusion of this program, the learner will be able to:

Identify ways to secure buy-in by having health care leaders better
understand the issues of disparities and become invested in doing
something to address them. (skills/strategy)
List techniques and technology for race and ethnicity data collection
and disparities performance measurement. (skills/strategy)
Identify interventions to reduce disparities in health care.
(skills/strategy)
Identify ways to message the issue of disparities both internally and
externally. (skills/strategy)
Describe a concrete step that their organization will take toward the
elimination of racial/ethnic disparities in care. (skills/strategy)
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Participants projects address the following content areas:
Developing a Strategic Plan Towards Addressing Health Care

Disparities
Enhancing Race and Ethnicity Data Collection, Measuring and
Reporting
Developing and Implementing Quality Improvement
Interventions
Developing Training and Educational Interventions
4. Activity matched current The DLP is designed for leaders from hospitals, health plans, physician
or potential scope of
organizations, community health centers, and other health care
learners. (JAC 6)
organizations who want to implement strategies to improve quality,
eliminate racial and ethnic disparities in health care, and achieve equity.
Participants may include, but are not limited to: executive leadership,
medical directors, directors of quality, and directors of multicultural
affairs or community benefits. To maximize the benefits of the yearlong
DLP, participants should have strong commitment from their
organization, as well as resources available, to advance an action plan to
address disparities.
The DLPs curriculum focuses on defining disparities and root causes;
developing quality improvement strategies to identify and address
disparities; and fostering leadership skills to implement these strategies
and help transform their organizations. Some of the topics covered
during the year long training include:
Racial and Ethnic Disparities in Health Care: Background on the
issue of racial and ethnic disparities in health care, including a
review of root causes and strategies to address them
Getting Disparities on the Leadership Agenda: Encouraging leaders
in the organization to become invested in identifying and
addressing racial/ethnic disparities in health care, including the
presentation of the business and quality case for addressing this
issue
Where to Begin: Tools and activities to help organizations get started
with efforts to identify and address disparities, including the
strategies, techniques and technology for collecting race and
ethnicity data
Analyzing and Comparing Your Race and Ethnicity Data: How to
compile data in a meaningful and effective way, and create
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comparative benchmarks
Creating Disparities Measures and Reporting Mechanisms:
Guidance on how to stratify quality measures by race and
ethnicity, and report them appropriately via dashboards,
scorecards, or other standard or innovative mechanisms
Adding the Community, Patient, and Staff Voice to the Disparities
Agenda: Strategies for bringing in key perspectives to disparities
and patient safety work, including those of the community, the
patient, and the health care staff
Developing Disparities Interventions: Developing and implementing
innovative approaches to address disparities organizationally and
through quality improvement
Disparities and Health Information Technology: Planning for the
current and future use of health information technology as a
mechanism for identifying and addressing disparities
Identifying and Preventing Medical Errors in Limited-English
Proficient Patients: Strategies to identify clinical situations that
are high-risk for medical errors among limited-English proficient
patients, as well as mechanisms to address them
Making Systems Responsive to the Needs of Diverse Populations:
Review of tools to improve the cultural competency of the health
care delivery system and capacity to address the needs of patients
with limited English proficiency
Communicating Broadly and Clearly: Developing an approach to
communicating the issue of disparities both internally and
externally
Organizational Transformation and Assuring Sustainability: How to
assure pilot programs become standard practice within the
organization and how to disseminate successes broadly
5. Format of the activity (JAC This is a live, classroom-based activity held over two full days. NCQA
7)
serves as joint sponsor/co-provider for the activity, with Mass Generals
Disparities Solutions Center.
6. The desirable healthcare
team or individual healthcare
team member attribute
associated with the activity
(JAC8)
The Institute of Medicine's landmark report Crossing the Quality Chasm

highlighted equity as one of the essential pillars of health care quality.
For an organization to improve quality for all patients it must be able to
measure disparities by race/ethnicity and develop interventions to
address them.
Between now and the year 2050, racial/ethnic minorities will account for
90% of the projected increase in the U.S. population.
The IOM competencies addressed include patient centered care, working
in interdisciplinary teams, employing evidence-based practice as well as
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applying quality improvement.

7. The activity was designed
to ensure independence from
commercial interests (JAC 9
SCS1.1)
This activity received no commercial support. NCQA ensures that

everyone in a position to control the content disclosed relevant financial
relationships and that these relationships did not present any bias or
promote any commercial interests.
March1,2012
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NOTE: A version of this form is completed for each NCQA Education activity as part of the planning
process. Language in the left column has been updated to reflect information requested for this
Joint Accreditation example.
NCQA Education Activity Planning

Activity/Educational Intervention:
Accountable Care Organizations: An Introduction to NCQAs Accreditation Standards
Date: November 30, 2011
Location: Washington, DC
1. The problem, or professional
practice gap the activity
addressed (JAC4)
The Accountable Care Organization is an entity created through the

Affordable Care Act. NCQA developed a quality assessment for
ACOs; the Accreditation standards were released November 21, 2011,
in the same timeframe as the final CMS regulations governing ACOs.
Health Care Professionals in many cases do not understand what
constitutes an ACO, and do not know what is required for NCQA
Accreditation. (Source = CMS, Physician-led NCQA ACO Task
Force, NCQA Board of Directors, NCQA Leadership Team, NCQA
Product Development Team)
2. The educational need that

was underlying this gap for
learners (JAC4)
Those organizations that are seeking to become or create quality ACOs

need the basics on NCQAs ACO Accreditation. From the seminar
content Why ACOs matter:
ACOs embrace the Triple Aim and health care quality
improvement on the levels of experience of care, population
health and costs
For providers ACOs are an efficient mechanism for providers
to collaborate to deliver better care
For plans, purchasers and consumers ACOs mean more health
for the health care dollar
Why Accreditation?
1. Variation in capabilities and readiness make ACOs an
uncertain endeavor for payers, patients
2. Accreditation assures patients that their ACO focuses on them
and their care
3. Provides a common set of expectations for purchasers
3. What the activity was

designed to change
(skills/strategy, performance
or patient outcomes) (JAC 5)
Change in skills/strategy leading toward change in performance:

Enabling the learner to lead or support an organization in becoming an
NCQA Accredited Accountable Care Organization and improve the
quality of care delivered to the ACOs patients.
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These are the activity learning objectives:

At the conclusion of this seminar, you will be able to:
Explain eligibility requirements for NCQA ACO Accreditation
(skills/strategy)
Discuss the standards for ACO Accreditation (skills/strategy)
Describe the function of the Patient-Centered Medical Home
with the ACO (skills/strategy)
Be prepared to assess your organizations readiness for NCQA
ACO Accreditation (performance)
4. Activity matched current
or potential scope of
learners. (JAC 6)
The target audience for this activity is health care professionals that
can provide leadership for their organizations toward becoming an
Accredited ACO: Chief Medical Officers, Chief Nursing Officers,
health care organization executives, physician practice leads, nurse
leads and others from organizations that can form or become ACOs -provider-based organizations (e.g., IPAs), physician organizations,
possibly health plans, clinics and hospitals.
5. Format of the activity (JAC
This a live directly-sponsored activity, presented over the course of one

day.
7)
6. The desirable healthcare
team or individual healthcare
team member attribute
associated with the activity
(JAC8)
The IOM competencies addressed include:
7. The activity was designed to

ensure independence from
commercial interests (JAC 9
SCS1.1)
This activity received no commercial support. NCQA ensures that

everyone in a position to control the content disclosed relevant
financial relationships and that these relationships did not present any
bias or promote any commercial interests.
Provide patient centered care

Work in interdisciplinary teams
Apply quality improvement
Utilize informatics (EHRs are required for some of the
standards)
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CRITERION 9: ACCME STANDARDS FOR COMMERCIAL SUPPORT 2-6
A: Describe the mechanism(s) used by the organization to ensure that all individuals in a
position to control educational content have disclosed relevant financial relationships with
commercial interests. In the description, include the organizations mechanism for
disqualifying individuals who refuse to disclose.
This is NCQAs policy on disclosure in Education activities:
POLICY TOPIC:
Faculty and Planning Committee Disclosure of Potential Conflicts

of Interest and Resolution of Potential Conflicts of Interest
DATE:
December 2006
APPROVED:
Elizabeth Usher, Assistant Vice President,

Customer Resources
LATEST REVIEW/
REVISION:
November 2011
POLICY STATEMENT:
Faculty and Planning Committee members for NCQA education

activities shall annually disclose in writing potential conflicts of
interest, or certify their lack thereof. Any potential conflicts of
interest shall be resolved by judgment of the Education Program
Manager. If s/he cannot resolve the conflict, s/he shall seek the
counsel of an appropriate independent, credentialed (MD, DO or
RN) professional who has served as an NCQA faculty and/or
planning committee member to resolve the conflict. If the conflict
cannot be resolved, the faculty or planning committee member
may not serve in that capacity.
PROCEDURE:
1.
NCQA Education Program Managers shall once every calendar year obtain from each
faculty and planning committee member a signed disclosure form which meets
current requirements for ACCME and ANCC compliance for disclosure of potential
conflicts of interest.
2.
If any faculty or planning committee members state potential conflicts of interest on

their disclosure forms, such forms will be reviewed by the Education Program
Manager who will resolve the conflict. If s/he cannot resolve the conflict, s/he shall
seek the counsel of an appropriate independent, credentialed (MD, DO, RN)
professional, who will complete a conflict resolution form indicating his/her
judgment that the stated conflict does not disqualify the signatory from serving in a
bias-free capacity on the faculty and/or planning committee.
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3.
Completed disclosure forms and conflict resolution forms will be stored in an area
accessible to all Education program managers.
4.
All reported potential conflicts of interest shall be disclosed to learners in education

activity materials.
5.
Program Managers shall request of each education activitys faculty or planning

committee member in writing, via phone or email a confirmation that the information
reported earlier in the year has not changed. Documentation of this confirmation shall
be included in the program file. In the event that the information has changed, the
Program Managers shall ask that they submit a new disclosure form and any conflicts
will be resolved as stated above.
These are the first three paragraphs from the form completed by all faculty and planning
committee members:
The National Committee for Quality Assurance provides high-quality continuing medical education (CME) and continuing
nursing education (CNE), and, towards that end, conducts its CME/CNE activities in a manner that is as objective and free from
outside influence as possible. This is especially important in those activities that are funded in some part by private companies
whose business could either be directly or indirectly influenced by the outcome of the activities, or give them cause to direct an
activity's instruction. NCQA expects faculty and planning committee members participating in any activities that result in AMA-PRA
credit and/or ANCC contact hours to disclose to the audience any real or apparent conflict(s) of interest, including interests of an
immediate family member or partner, that may have a direct or indirect bearing on the subject matter of the CME/CNE activity. This
pertains to relevant financial relationships with commercial interests that produce, market, re-sell, or distribute health care goods or
services consumed by, or used on, patients. Relevant financial relationships are financial relationships in any amount occurring
within the past 12 months that create a conflict of interest. Should such a relationship be disclosed, and confirmed by the program
manager to exist, the conflict(s) of interest must be resolved through review and judgment by a health care professional experienced
in the development of NCQA Education programs who is known to NCQA to have no conflicts of interest. Planning committee and
faculty members who refuse to disclose real or apparent conflicts of interest will be disqualified from participating NCQA Education
activities.
This disclosure requirement is not intended to prevent a speaker with a potential conflict of interest from making a
presentation, or a planning committee member with a potential conflict of interest from participating in the preparation of an
educational activitys content, assuming such conflicts can be resolved. Rather, it is intended to identify and resolve any potential
conflict so that learners may form their own judgments about the presentation with the full disclosure of the facts.
This form must be completed annually by all planning committee and faculty members and will be kept on file. Should
changes to the individuals status, and/or a partners or a family members status, occur during the year, reflecting a potential conflict
of interest, s/he must inform the education activitys Program Manager prior to beginning the activity planning, and complete an
updated disclosure form.
Individuals who refuse to sign the disclosure form are disqualified from participating on a
planning committee or as faculty for a CME activity.
B. Describe the mechanism(s) used by the organization to identify conflicts of interest
prior to an activity.
See the procedure described above, especially item 6.
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C. Describe the mechanism(s) used by the organization to resolve conflicts of interest prior
to an activity.
If a faculty or planning committee member discloses a real or potential conflict of interest, using
the process outlined in (A) above, the activity program manager determines if in the context of
the activity the financial interests/arrangements and/or affiliations present a conflict of interest in
planning the activity. If she determines that the arrangement could be perceived as a real or
apparent conflict of interest, she seeks resolution from one of a number of physicians who have
served as faculty for NCQA Education activities. The form indicates the physicians judgment
that the potential conflict of interest does not disqualify the faculty or planning committee
member from serving in a bias-free capacity in the development and presentation of the activity.
This is the text of the form:
Per the attached disclosure form, a _____faculty member _____planning committee member for
an NCQA Education program has disclosed a financial interest/arrangement or affiliation with one
or more organizations.
I, (insert name), Program Manager for the seminar (insert name), affirm that in the context of the
subject matter of this CME/CNE seminar, the financial interests/arrangements and/or affiliations of
the individual listed at the bottom of this page:
do not present a conflict of interest in his/her planning or presentation.
could be perceived as a real or apparent conflict of interest and require resolution by a member
of NCQAs faculty. (See box below for resolution)
As a _____physician _____registered nurse who serves as a member of NCQAs faculty, I

certify that, in my judgment, the aforementioned potential conflict of interest does not disqualify
the signatory from serving in a bias-free capacity on the _____faculty _____planning committee
for this program.
_____________________________________________________________________
Name and Most Recent Seminar/Program Served as NCQA Faculty
Signature
Date
_________________________________________________________________________________
Faculty or Planning Committee Members Name
__________________________________________________________________________________
Seminar Name and Location
Seminar Date
Name of Program Manager
Signature
Date
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D. Describe the organizations process(es) and mechanism(s) for disclosure to the learners
prior to the activity of:
(1) Relevant financial relationships of all persons in a position to control educational
content: This is disclosed in the activitys front matter. See the example on the
following page.
(2) The source of support from commercial interests, if applicable: This also is disclosed
in the activitys front matter.
See an example of disclosure to the learners, from the front matter in a seminar manual, on the
following page.
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Disclosure of Relevant Financial Relationships with

Commercial Companies/Organizations
Facilitating Patient-Centered Medical Home Recognition
March 17-18, 2011
The National Committee for Quality Assurance (NCQA) endorses the Standards of the
Accreditation Council for Continuing Medical Education which specify that sponsors of
continuing medical education activities and presenters at and planners for these activities
disclose any relevant financial relationships either party might have with commercial companies
whose products or services are discussed in educational presentations.
For sponsors, relevant financial relationships include large research grants, institutional
agreements for joint initiatives, substantial gifts, or other relationships that benefit the institution.
For presenters or planning committee members, relevant financial relationships include the
receipt of research grants from a commercial company, consultancies, honoraria, travel, or
other benefits, or having a self-managed equity interest in a company; or having an immediate
family member or partner with such a relationship.
Disclosure of a relationship is not intended to suggest or condone bias in any presentation, but is
made to provide participants with information that might be of potential importance to their
evaluation of a presentation.
Relevant financial relationships exist with the following companies/organizations:
Patricia Barrett: None

Jennifer DAlessandro: None
Mina Harkins: None
Elizabeth Kraft: None
Kathleen C. Mudd: None
Johann Chanin
Stockholder
Altria Group Inc., American New

World, Hewlett Packard, Co., Home
Depot, Inc., Honeywell International,
Inc. Del, McDonalds Corp, Medco
Health Solutions, Calamos Conv
Opp, Inc., Blackrock Mun, Teva
Pharmaceutical, Linds Adr
Consultant
Heartland Regional Genetics &

Collaborative; University of
Oklahoma Health Sciences Center
Program content was peer reviewed to ensure that it is fair-balanced and free from
commercial bias.
This program was developed by NCQA staff.
This program received no commercial support.
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E. Attach written policies and procedures governing honoraria and reimbursement of

expenses for planners, teachers and/or authors.
POLICY TOPIC:
Faculty and Planning Committee Honoraria
DATE:
January 19, 1995
APPROVED:
Elizabeth Usher, Assistant Vice President, Customer Resources
LATEST REVIEW/
REVISION:
November 2011
PURPOSE:
To establish a standard and consistency in the offering of honoraria

that supports maintenance of budget and integrity of NCQA.
POLICY STATEMENT:
Faculty and planning committee members will receive an

honorarium that reflects the following guidelines:
PROCEDURE:
1. Guidelines
Each honorarium will be established in advance by the Education Unit.
2. Honoraria will be awarded as follows:
Review Oversight Committee members - $600 for a one-day program and $1,200 for
a 1.5 day or two-day program.
Other faculty - $500 for a one-day program and $1,000 for a 1.5 day or two-day
program.
Planning committee participation - $50 per hour of service performed, up to $250 per
program developed. Faculty members who serve on the planning committee also are
eligible for this honorarium.
NCQA staff no honoraria for service as either faculty or planning committee
members.
3. Faculty will not be paid for travel days.
4. Faculty may be offered a complimentary registration to any NCQA conference in lieu of
an honorarium. Any employee of the faculty members organization may use this comp
registration.
5. The Director, Education may make exceptions to the above policies.
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F. Describe how the organization ensures that social events do not compete with or take
precedence over educational activities.
No NCQA social events are held during the same hours as NCQA educational activities. For
two of our larger seminars (1.5 days each, with attendance of 150-200), we hold a networking
reception at the conclusion of the first day. The activity may receive commercial support. It is
not part of the CE activity.
G. Describe process(es) for the receipt and disbursement of commercial support (both
funds and in-kind support).
The Education Unit accepts commercial support for an activity only if it is consistent with our
Units mission statement and NCQAs mission statement. Furthermore, the activity in
discussion must be demonstrably linked to content that NCQA advances, such as HEDIS
measures or Accreditation, Certification or Recognition standards.
A formal proposal process for acceptance of commercial support includes extensive review by
others within NCQA, in addition to Education:
NCQAs Research, Performance Measurement, and Analysis unit, or a similar unit

depending on the content, works with Education to define the specific direction of the
activity, including supplementing available needs assessment to support the proposal.
NCQAs Finance unit works with Education to develop a budget for the proposed
activity. The budget includes staff salary and fringe, overhead, and direct expenses. This
budget information is reflected in the proposal.
Funds are budgeted, forecast and disbursed according to the information included in the grant
proposal.
See the following page for our policy regarding relationships with commercial supporters.
March1,2012
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POLICY TOPIC:
NCQA Relationships with Non-Accredited Commercial

Organizations
DATE:
February 28, 1994
APPROVED:
LATEST REVIEW/
REVISION:
November 2011
PURPOSE:
To ensure that NCQA maintains appropriate behavior in planning,

designing, implementing and evaluating accredited CME/CNE
activities for which commercial support is received.
POLICY STATEMENT:
In all NCQA-sponsored CME/CNE programs supported financially or non-financially by a
private company or companies, it is the official policy of NCQA to:
maintain responsibility and control for all aspects of identification of educational needs,
determination of educational objectives, selection and presentation of content, selection
of educational methods and evaluation of an activity.
maintain program content free of commercial bias;
prohibit promotional activities on the part of the company or companies that are
providing financial support for the program to be displayed or distributed in the same
room immediately before, during or immediately after an accredited educational activity;
appropriately manage funds from commercial sources;
provide program participants with full disclosure of the source of funding of the program,
and of the extent of the relationship if any between speakers and faculty and the
company or companies supporting the program;
maintain responsibility for marketing material content and provide authorization, if

applicable, for a commercial supporter to disseminate information about a CME/CNE
activity;
not engage or work in joint sponsorship with non-accredited providers that produce,
market, re-sell, or distribute health care goods or services consumed by or used on
patients. (Note: When NCQA plans and presents one or more activities with nonACCME accredited providers, we are engaging in joint sponsorship.)
March1,2012
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H. Describe how the organization ensures that all commercial support is given with the
organizations full knowledge and approval. Include in the response all policies and
processes to ensure that no other payment is given to the director of the activity, planning
committee members, teachers or authors, joint sponsor, or any others involved in the
activity.
When NCQA receives a grant for an educational activity, a written agreement is made with the
commercial supporter ensuring that all funds will be paid directly to NCQA. Commercial
supporters are not informed in advance regarding names, titles or organizations of the members
of the activity planning committee. The Education Unit reports to the Chief Financial Officer,
who reports to the Chief Operating Officer (COO). The COO is kept apprised of and approves
all funds received, promised or expected from commercial entities and the functions that they are
intended to support. Furthermore, NCQAs Finance and Administration Department is vigilant
regarding budgeting and monitoring all funds received and disbursed. The Director of Education
includes accounting for all funds received (or expected) and disbursed (or expected to be
disbursed) in monthly forecasts. She receives updates monthly from Accounting on all revenue
and expenses, through financial statements.
I. Attach an example of a written agreement documenting terms, conditions, and purposes
of commercial support used to fulfill relevant elements of SCS.
See Lilly agreement at the back of this section.
J. If commercial exhibits are associated with any of the organizations CE activities,
describe how the organization ensures that arrangements for commercial exhibits do not
(1) influence planning or interfere with the presentation and (2) are not a condition of the
provision of commercial support for CE activities.
The only NCQA CE activity that includes exhibits is our twice-annual HEDIS Update and Best
Practices seminar. Exhibits at that seminar are limited to NCQA-Certified HEDIS Software
Vendors. (1) As with all our CE activities, the activity planning committee is in charge of the
content. Exhibitors have no role in the content planning. Their booths are set up outside the
seminar room, and hours for visiting are limited to non-CE times. (2) The vendors purchase
booth space only; they are not invited to and do not provide commercial support for the CE
activity itself.
K. If advertisements are associated with any of the organizations CE activities, describe
how the organization ensures that advertisements or other product-promotion materials
are kept separate from the education. Distinguish between processes related to
advertisements and/or product promotion in each of the following types of CE activities:
(1) print materials; (2) computer-based materials; (3) audio and video recordings; and (4)
face-to-face.
NCQA does not accept advertising in association with any of its CE activities.
March1,2012
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L. Describe planning and monitoring used to ensure that:

1. The content of CE activities does not promote the proprietary interests of any
commercial interests.
For commercially supported activities, a letter of agreement between the supporter and
NCQA clearly states that the supporter may not influence content. During the planning
process the planning committee has no contact with the commercial supporter. The
planning committee includes at least one physician and one nurse planner, for whom any
real or perceived conflicts of interest have been resolved. The physician and nurse
planner review all content, and if they determine that bias exists the activity must be
modified to remove the source of the bias.
2. CE activities give a balanced view of therapeutic options.
The planning committees physician and nurse planner, who have completed our
disclosure process and are known to NCQA to be free from commercial bias and
impartial in their therapeutic judgment, review all content to ensure that it is fair-balanced
and free of commercial bias. In the rare instances that a specific drug or class of drugs is
mentioned, these health care professionals ensure that other viable treatments also are
presented.
3. All the recommendations involving clinical medicine in a CE activity must be based
on evidence that is accepted within the health profession being addressed as
adequate justification for their indications and contraindications in the care of
patients.
All references to clinical medicine in NCQAs CE activities are linked to HEDIS
measures. The scientific evidence supporting NCQAs HEDIS measures is widely
recognized as among the broadest and deepest in the health care field. It is deeply rooted
in evidence-based medicine. Measure advisory panels (MAPs) include representatives
from academic medical centers, medical specialty societies, federal and state agencies,
health plans and private practice (and do not include commercial supporters).
Developing a HEDIS measure is a multi-step process. It involves identifying the clinical
area to evaluate; conducting an extensive literature review; developing the measure with
the appropriate MAP and other panels; vetting it with various stakeholders; and
performing a field-test that examines feasibility, reliability and validity.
In no case do we make recommendations involving clinical medicine in a CE activity that
are not evidence-based and thoroughly validated by the clinicians on the activity planning
committee.
No research or recommendations that conflict with any research that supports any HEDIS
measure are presented in any NCQA Education activity, and no activities are developed
March1,2012
Page57
that do not relate to a HEDIS measure, other NCQA products or services, or health care
quality improvement.
4. All scientific research referred to, reported or used in CE in support or justification

of a patient care recommendation must conform to the generally accepted standards
of experimental design, data collection and analysis.
Any research referred to in an NCQA CE activity must come from a respected source
approved by NCQAs Research unit, led by Sarah Scholle, PhD, Vice President of
Research and Analysis. Her unit endorses that the research is appropriate for inclusion in
an Education activity and that it reflects appropriate experimental design, data collection
and analysis.
March1,2012
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The Disparities Leadership Program CME

__________________________________________________________
Planning Committee
Joseph R. Betancourt, MD, MPH
Alexander R. Green, MD, MPH
Roderick K. King, MD, MPH
Lenny Lopez, MD, MDiv, MPH
Aswita Tan-McGrory, MSPH
Kathleen C. Mudd, MBA, RN
Megan Renfrew, MA
Alden Landry, MD, MPH
Elizabeth Taing
Jacob D. Nudel
Wanda Vega
Faculty
Joseph R. Betancourt, MD, MPH
Alexander R. Green, MD, MPH
Roderick K. King, MD, MPH
Lenny Lopez, MD, MDiv, MPH
At the conclusion of this program, the learner will be able to:
1. Identify ways to secure buy in by having health care leaders better understand the issues
of disparities and become invested in doing something to address them.
2. List techniques and technology for race and ethnicity data collection and disparities
performance measurement.
3. Identify interventions to reduce disparities in health care.
4. Identify ways to message the issue of disparities both internally and externally.
5. Describe a concrete step that their organization will take toward the elimination of
racial/ethnic disparities in care.
_____________________________________________________________________________________________________________________
The Disparities Leadership Program 2010-2011

Copyright 2011 by the Disparities Solutions Center at Massachusetts General Hospital. All rights reserved.
Page 59
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Conflict of Interest Resolution

Per the attached disclosure form, a __X___faculty member __X___planning committee member
for an NCQA Education program has disclosed a financial interest/arrangement or affiliation with
one or more organizations.
I, Jennifer DAlessandro, Program Manager for the seminar Disparities Leadership Porgram,
affirm that in the context of the subject matter of this CME/CNE seminar, the financial
interests/arrangements and/or affiliations of the individual listed at the bottom of this page:
X do not present a conflict of interest in his/her planning or presentation

for this program.
_____________________________________________________________________
Signature
Date
Joseph R. Betancourt

Disparities Leadership Program
Feb. 2-3, 2011
_______________________________________________________________________________
Seminar Date
Jennifer DAlessandro
Jan. 24, 2011
Signature
Date
NCQA Joint Accreditation Self Study
March 1, 2012
Page 71

Per the attached disclosure form, a __X___faculty member __X___planning committee member
for an NCQA Education program has disclosed a financial interest/arrangement or affiliation with
one or more organizations.
I, Jennifer DAlessandro, Program Manager for the seminar Disparities Leadership Porgram,
affirm that in the context of the subject matter of this CME/CNE seminar, the financial
interests/arrangements and/or affiliations of the individual listed at the bottom of this page:
X do not present a conflict of interest in his/her planning or presentation

for this program.
_____________________________________________________________________
Signature
Date
Alexander Green

Feb. 2-3, 2011
_______________________________________________________________________________
Seminar Date
Jennifer DAlessandro
Jan. 24, 2011
Signature
Date
March1,2012
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The Disparities Leadership Program CME

__________________________________________________________
Disclosure of Significant Relationships with Relevant

Empowering Leaders. Getting to Solutions.
February 2-3, 2011
Santa Monica, CA
continuing medical education activities and presenters at and planners for these activities
disclose any relevant financial relationships either party might have with commercial companies
whose products or services are discussed in educational presentations.
agreements for joint initiatives, substantial gifts, or other relationships that benefit the institution.
For presenters or planning committee members, relevant financial relationships include the
receipt of research grants from a commercial company, consultancies, honoraria, travel, or other
benefits, or having a self-managed equity interest in a company; or having an immediate family
member or partner with such a relationship.
Disclosure of a relationship is not intended to suggest or condone bias in any presentation, but is
made to provide participants with information that might be of potential importance to their
evaluation of a presentation.
Joseph Betancourt: Shareholder in Manhattan Cross Cultural Group; Merck and Co., Inc.
Consultant
Alexander Green: Shareholder in Manhattan Cross Cultural Group; Merck and Co., Inc
Roderick King: None
Additional Planning Committee Members: None
commercial bias.
This program was developed in part by NCQA staff.
_____________________________________________________________________________________________________________________
The Disparities Leadership Program 2010-2011

Copyright 2011 by the Disparities Solutions Center at Massachusetts General Hospital. All rights reserved.
Page 73
Manual
Frontmatter:
INDIVIDUALS IN A POSITION TO CONTROL CONTENT
Intro to
ACO
Standards
Planning Committee
Patricia Barrett, MHSA
Vice President
Product Development
NCQA
Washington, DC
Duane E. Davis, MD
Vice President, Chief Medical Officer
Geisinger Health Plan
Danville, PA
Raena Grant Akin-Deko, MHSA

Assistant Vice President
Product Development
NCQA
Washington, DC
Mina Harkins, MBA, MT (ASCP)

Recognition Programs
NCQA
Washington, DC
Kiran Johal, MPH

Manager
Product Development
NCQA
Washington, DC
A. Ginelle Jurlano, MHA

Analyst
Product Development
NCQA
Washington, DC
Kathleen C. Mudd, RN, MBA

Vice President
Product Delivery
NCQA
Washington, DC
Robert Rehm, MBA

Performance Measurement
NCQA
Washington, DC
Victoria L. Street, CCMEP

Director
Education
NCQA
Washington, DC
March1,2012
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Manual
Frontmatter:
INDIVIDUALS IN A POSITION TO CONTROL CONTENT
Intro to
ACO
Standards
Faculty
Patricia Barrett, MHSA
Raena Grant Akin-Deko, MHSA
Vice President
Product Development
NCQA
Washington, DC

Product Development
NCQA
Washington, DC
Mina Harkins, MBA, MT (ASCP)

Recognition Programs
NCQA
Washington, DC
Kiran Johal, MPH

Manager
Product Development
NCQA
Washington, DC
Robert Rehm, MBA

Performance Measurement
NCQA
Washington, DC
March1,2012
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Page 80
Page 81
Page 82
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Page 84

Per the attached disclosure form, a _____faculty member _____planning committee member for
an NCQA Education program has disclosed a financial interest/arrangement or affiliation with one
or more organizations.
I, (insert name), Program Manager for the seminar (insert name), affirm that in the context of the
subject matter of this CME/CNE seminar, the financial interests/arrangements and/or affiliations of
the individual listed at the bottom of this page:
do not present a conflict of interest in his/her planning or presentation

for this program.
_____________________________________________________________________
Signature
Date
_________________________________________________________________________________
__________________________________________________________________________________
Seminar Date
Signature
Date
1100 13th St., NW | Suite 1000 | Washington, DC 20005 | www.ncqa.org | 202.955.3500 phone | 202.955.3599 fax
Page 85
Disclosure of Relevant Financial Relationships with

Accountable Care Organizations:
An Introduction to NCQAs Accreditation Standards
November 30, 2011
Washington, DC
continuing medical education activities and presenters at and planners for these
activities disclose any relevant financial relationships either party might have with
commercial companies whose products or services are discussed in educational
presentations.
agreements for joint initiatives, substantial gifts, or other relationships that benefit the
institution. For presenters or planning committee members, relevant financial
relationships include the receipt of research grants from a commercial company,
consultancies, honoraria, travel, or other benefits, or having a self-managed equity
interest in a company; or having an immediate family member or partner with such a
relationship.
Disclosure of a relationship is not intended to suggest or condone bias in any
presentation, but is made to provide participants with information that might be of
potential importance to their evaluation of a presentation.
Patricia Barrett: None
Duane Davis: None
Raena Grant Akin-Deko: None
Mina Harkins: None
Kiran Johal: None
Ginelle Jurlano: None
Bob Rehm: None
Victoria Street: None
commercial bias.
This program was developed in part by NCQA staff.
Page 86
CRITERION 10: UTILIZING NON-EDUCATION STRATEGIES TO ENHANCE CHANGE AS

AN ADJUNCT TO EDUCATIONAL ACTIVITIES
Describe how the organization utilizes non-education strategies to enhance change as an adjunct
to its educational activities. Include an explanation of how the non-education strategies were
connected to either an individual activity or group of activities. Include examples of non-education
strategies that have been implemented.
Nearly every NCQA educational activity includes non-education strategies that reinforce learning and
provide useful references for learners post-activity. A frequent strategy is the inclusion of the HEDIS,
accreditation, certification or recognition requirements, usually in the form of a printed and bound
volume, for all live classroom activities that include content based on these requirements. Materials are
referenced frequently during the activity, often as part of a group discussion or exercise, and faculty
explain intent and design of requirements. NCQA seeks transparency with regard to its assessment
processes and requirements; therefore these volumes are an excellent guide and implementation of the
measures and standards is a proven driver of quality improvement.
These are some examples of seminars that include the most recent editions of NCQA publications as
non-education strategies:
Introduction to HEDIS: HEDIS Volume 1 (Narrative) and Volume 2: Technical Specifications.
HEDIS Update and Best Practices: HEDIS Volume 2: Technical Specifications.
Introduction to NCQA Accreditation for Health Plans and Managed Behavioral Healthcare
Organizations: Health Plan Accreditation Standards and Guidelines (for health plans) and
MBHO Accreditation Standards and Guidelines (for MBHOs) there is substantial overlap in
the accreditation requirements.
Facilitating Patient-Centered Medical Home Recognition: PCMH Standards and Guidelines.
Disease Management Update: Disease Management Accreditation and Certification Standards
and Guidelines.
Introduction to NCQAs Credentialing Standards and Advanced Credentialing: A summary
volume of credentialing requirements from all NCQA Accreditation and Certification products.
See the following pages for examples from HEDIS Volume 1, HEDIS Volume 2 and health plan
accreditation standards and guidelines.
Other non-education strategies used in NCQAs educational activities (referenced during the activity and
available for reference post-activity) are:
Frequently Asked Questions (FAQ) relevant to the activitys content.
Quality Profiles, an annual volume of best practices in quality improvement from health care
organizations on specific topics (e.g., Smoking Cessation, Patient Engagement, Health
Information Technology).
Bound volumes of NCQAs annual State of Health Care Quality Report.
Summarized notes from activities that include substantial learner brainstorming or have
questions meriting follow-up information.
E-mailed links to resources (before and after the activity).
March1,2012
Page87
Sample pages from the following volumes begin on the next page (learners are given the entire
publication at the activity):
What Makes a Measure Desirable? from HEDIS 2012, Volume 1: Narrative.
Use of Appropriate Medications for People with Asthma from HEDIS 2012, Volume 2:
Technical Specifications.
Quality Improvement Standard 10, Continuity and Coordination of Medical Care, from 2012
Standards and Guidelines for the Accreditation of Health Plans.
March1,2012
Page88
What Makes a Measure Desirable?

Whether considering the value of a new measure or the continuing worth of an existing one, we must define what
makes a measure useful. HEDIS measures encourage improvement. The defining question for all performance
measurementWhere can measurement make a difference?can be answered only after considering many
factors. NCQA has established three areas of desirable characteristics for HEDIS measures, discussed below.
1. Relevance:
Meaningful
Measures should address features that apply to purchasers or consumers, or which

will stimulate internal efforts toward quality improvement. More specifically, relevance
includes the following attributes.
What is the significance of the measure to the different groups concerned with health
care? Is the measure easily interpreted? Are the results meaningful to target
audiences?
Measures should be meaningful to at least one HEDIS audience (e.g., individual
consumers, purchasers or health care systems). Decision makers should be able to
understand a measures clinical and economic significance.
Important to
health
What is the prevalence and overall impact of the condition in the U.S. population?
What significant health care aspects will the measure address?
We should consider the type of measure (e.g., outcome or process), the prevalence
of medical condition addressed by the measure and the seriousness of affected
health outcomes.
Financially
important
What financial implications result from actions evaluated by the measure? Does the
measure relate to activities with high financial impact?
Measures should relate to activities that have high financial impact.
Cost effective
What is the cost benefit of implementing the change in the health care system? Does
the measure encourage the use of cost-effective activities or discourage the use of
activities that have low cost-effectiveness?
Measures should encourage the use of cost-effective activities or discourage the use
of activities that have low cost-effectiveness.
Strategically
important
What are the policy implications? Does the measure encourage activities that use
resources efficiently?
Measures should encourage activities that use resources most efficiently to maximize
member health.
Controllable
What impact can the organization have on the condition or disease? What impact can
the organization have on the measure?
Health care systems should be able to improve their performance. For outcome
measures, at least one process should be controlled and have an important effect on
outcome. For process measures, there should be a strong link between the process
and desired outcome.
Variation across
systems
Will there be variation across systems?

There should be the potential for wide variation across systems.
March1,2012
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Potential for
improvement
2. Scientific
soundness:
Clinical evidence
Will organizations be able to improve performance?

There should be substantial room for performance improvement.
Perhaps in no other industry is scientific soundness as important as in health care.

Scientific soundness must be a core value of our health care systema system that
has extended and improved the lives of countless individuals.
Is there strong evidence to support the measure? Are there published guidelines for
the condition? Do the guidelines discuss aspects of the measure? Does evidence
document a link between clinical processes and outcomes addressed by the
measure?
There should be evidence documenting a link between clinical processes and
outcomes.
Reproducible
Are results consistent?

Measures should produce the same results when repeated in the same population
and setting.
Valid
Does the measure make sense?

Measures should make sense logically and clinically, and should correlate well with
other measures of the same aspects of care.
Accurate
How well does the measure evaluate what is happening?

Measures should precisely evaluate what is actually happening.
Risk adjustment
Is it appropriate to stratify the measure by age or another variable?

Measure variables should not differ appreciably beyond the health care systems
control, or variables should be known and measurable. Risk stratification or a
validated model for calculating an adjusted result can be used for measures with
confounding variables.
Comparability of
data sources
3. Feasibility:
Precise
specifications
How do different systems affect accuracy, reproducibility and validity?

Accuracy, reproducibility and validity should not be affected if different systems use
different data sources for a measure.
The goal is not only to include feasible measures, but also to catalyze a process
whereby relevant measures can be made feasible.
Are there clear specifications for data sources and methods for data collection and
reporting?
Measures should have clear specifications for data sources and methods for data
collection and reporting.
Reasonable cost
Does the measure impose a burden on health care systems?

Measures should not impose an inappropriate burden on health care systems.
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Confidentiality
Does data collection meet accepted standards of member confidentiality?

Data collection should not violate accepted standards of member confidentiality.
Logistical
feasibility
Auditability
Are the required data available?

Is the measure susceptible to exploitation or gaming that would be undetectable in
an audit?
Measures should not be susceptible to manipulation that would be undetectable in an
audit.
March1,2012
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Use of Appropriate Medications for People With Asthma
92
Use of Appropriate Medications for People With Asthma (ASM)

SUMMARY OF CHANGES TO HEDIS 2012
Increased the upper age limit to 64 and added new age stratifications.
Deleted ICD-9 Diagnosis code 493.2 from Table ASM-A.
Added required exclusions (formerly optional exclusions) to eligible population criteria.
Added mometasone-formoterol to "Inhaled steroid combinations" description in Tables ASM-C and ASM-D.
Added a new data element to Table ASM-1/2 to capture the required exclusions.
Description
The percentage of members 564 years of age during the measurement year who were identified as having
persistent asthma and who were appropriately prescribed medication during the measurement year.
Definitions
Oral medication
dispensing
event
One prescription of an amount lasting 30 days or less. To calculate dispensing events

for prescriptions longer than 30 days, divide the days supply by 30 and round down to
convert. For example, a 100-day prescription is equal to three dispensing events
(100/30 = 3.33, rounded down to 3). The organization should allocate the dispensing
events to the appropriate year based on the date on which the prescription is filled.
Multiple
prescriptions
dispensed on
the same day
Multiple prescriptions for different medications dispensed on the same day should be
assessed separately. If multiple prescriptions for the same medication are dispensed
on the same day, sum the days supply and divide by 30. Use the Drug ID to
determine if the prescriptions are the same or different.
Two prescriptions for different medications dispensed on the same day, each
with a 60-day supply, equals four dispensing events (two prescriptions with two
dispensing events each)
Two prescriptions for different medications dispensed on the same day, each
with a 15-day supply, equals two dispensing events (two prescriptions with one
dispensing event each)
Two prescriptions for the same medication dispensed on the same day, each
with a 15-day supply, equals one dispensing event (sum the days supply for a
total of 30 days)
Two prescriptions for the same medication dispensed on the same day, each
with a 60-day supply, equals four dispensing events (sum the days supply for a
total of 120 days)
Inhaler/Injection
dispensing
event
Inhalers and injections count as one dispensing event. For example, an inhaler with a
90-days supply is considered one dispensing event. In addition, multiple dispensing
events of the same medication (identified by Drug ID in the NDC list) filled on the
same date of service should be counted as one dispensing event. For example, a
member may obtain two inhalers on the same day (one for home and one for work),
but intend to use both during the same 30-day period. The organization should
March1,2012
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93
allocate the dispensing events to the appropriate year based on the date on which the
prescription is filled.
March1,2012
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94
Eligible Population
Product lines
Commercial, Medicaid (report each product line separately).
Ages
564 years by December 31 of the measurement year. Report four age stratifications
and a total rate.
511 years
5164 years
1218 years
Total
1950 years
The total is the sum of the age stratifications.
Continuous
enrollment
The measurement year and the year prior to the measurement year.
Allowable gap
No more than one gap in enrollment of up to 45 days during each year of continuous
enrollment. To determine continuous enrollment for a Medicaid beneficiary for whom
enrollment is verified monthly, the member may not have more than a 1-month gap in
coverage during each year of continuous enrollment year.
Anchor date
December 31 of the measurement year.
Benefits
Medical. Pharmacy during the measurement year.
Event/
diagnosis
Follow the steps below to identify the eligible population for the measure.
Step 1
Identify members as having persistent asthma who met at least one of the following
criteria during both the measurement year and the year prior to the measurement
year. Criteria need not be the same across both years.
At least one ED visit (Table ASM-B) with asthma as the principal diagnosis
(Table ASM-A)
At least one acute inpatient claim/encounter (Table ASM-B) with asthma as the
principal diagnosis (Table ASM-A)
At least four outpatient asthma visits (Table ASM-B) with asthma as one of the
listed diagnoses (Table ASM-A) and at least two asthma medication dispensing
events (Table ASM-C)
At least four asthma medication dispensing events (Table ASM-C)

TableASMA:CodestoIdentifyAsthma
Description
ICD-9-CM Diagnosis
Asthma
493.0, 493.1, 493.8, 493.9
Table ASM-B: Codes to Identify Visit Type

Description
CPT
UB Revenue
Outpatient
99201-99205, 99211-99215, 99217-99220, 99241-99245,

99341-99345, 99347-99350, 99382-99386, 99392-99396,
99401-99404, 99411, 99412, 99420, 99429
051x, 0520-0523, 0526-0529, 057x- 059x, 0982,

0983
Acute inpatient
99221-99223, 99231-99233, 99238, 99239, 99251-99255,

99291
010x, 0110-0114, 0119, 0120-0124, 0129, 01300134, 0139, 0140-0144, 0149, 0150-0154, 0159,
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95
016x, 020x,021x, 072x, 0987

ED
99281-99285
045x, 0981
Table ASM-C: Asthma Medications

Description
Antiasthmatic combinations
Dyphylline-guaifenesin
Antibody inhibitor
Omalizumab
Inhaled steroid combinations
Budesonide-formoterol
Inhaled corticosteroids
Beclomethasone
Budesonide
Ciclesonide
Leukotriene modifiers
Montelukast
Long-acting, inhaled beta-2
Aformoterol
agonists
Mast cell stabilizers

Methylxanthines
Short-acting, inhaled beta-2
agonists
Cromolyn
Aminophylline
Dyphylline
Albuterol
Levalbuterol
Prescriptions
Guaifenesin-theophylline
Fluticasone-salmeterol
Nedocromil
Flunisolide
Fluticasone CFC free
Mometasone
Zafirlukast
Formoterol
Potassium iodide-theophylline
Mometasone-formoterol
Triamcinolone
Zileuton
Salmeterol
Oxtriphylline
Theophylline
Metaproterenol
Pirbuterol
Note: NCQA will post a comprehensive list of medications and NDC codes to www.ncqa.org by November
15, 2011.
Step 2
Step 3:
Required
exclusions
A member identified as having persistent asthma because of at least four asthma

medication dispensing events, where leukotriene modifiers were the sole asthma
medication dispensed in that year, must also have at least one diagnosis of asthma
(Table ASM-A), in any setting, in the same year as the leukotriene modifier (i.e.,
measurement year or year prior to the measurement year).
Exclude any members who had at least one encounter, in any setting, with any code to
identify a diagnosis of emphysema, COPD, cystic fibrosis or acute respiratory failure
(Table ASM-E). Look as far back as possible in the members history through December
31 of the measurement year.
Table ASM-E: Codes to Identify Required Exclusions
Description
ICD-9-CM Diagnosis
Emphysema
492, 506.4, 518.1, 518.2
COPD
491.2, 493.2, 496, 506.4
Cystic fibrosis
277.0
Acute respiratory failure
518.81
_______________
Current Procedural Terminology 2011 American Medical Association. All rights reserved.
March1,2012
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Administrative Specification
Denominator
The eligible population.
Numerator
Dispensed at least one prescription for a preferred therapy during the measurement year
(Table ASM-D).
Table ASM-D: Preferred Asthma Therapy Medications

Description
Antiasthmatic combinations
Antibody inhibitor
Inhaled steroid combinations
Inhaled corticosteroids
Leukotriene modifiers
Mast cell stabilizers
Methylxanthines
Dyphylline-guaifenesin
Prescriptions
Guaifenesin-theophylline
Potassium iodide-theophylline
Fluticasone-salmeterol
Flunisolide
Fluticasone CFC free
Mometasone-formoterol
Mometasone
Triamcinolone
Zileuton
Omalizumab
Budesonide-formoterol
Beclomethasone
Budesonide
Ciclesonide
Montelukast
Cromolyn
Aminophylline
Dyphylline
Zafirlukast
Nedocromil
Oxtriphylline
Theophylline
Note: NCQA will post a comprehensive list of medications and NDC codes to www.ncqa.org by November
15, 2011.
Note
The HEDIS age strata for asthma measures are designed to align with both clinical practice guidelines
and reporting requirements for child health quality improvement programs. Clinical guidelines specify
appropriate age cohorts for measuring use of asthma medications as 511 years of age and 1250 years
of age to account for the differences in medication regimens for children vs. for adolescents and adults.
Implementation requires further stratification of the age ranges to enable creation of comparable cohorts
that align with child health populations.
Data Elements for Reporting

Organizations that submit HEDIS data to NCQA must provide the following data elements.
Table ASM-1/2: Data Elements for Use of Appropriate Medications

for People With Asthma
Administrative
Measurement year
Data collection methodology (Administrative)
9
9
Eligible population
For each age stratification and total
Number of required exclusions
Numerator events by administrative data
Reported rate
Lower 95% confidence interval
Upper 95% confidence interval
QI 10: Continuity and Coordination of Medical Care
97
QI 10: Continuity and Coordination of Medical Care1.10 points

The organization monitors and takes action, as necessary, to improve continuity and
coordination of care across the health care network.
Intent
The organization uses information at its disposal to facilitate continuity and coordination
of medical care across its delivery system.
Summary of Changes
Clarifications
Added examples of inpatient and outpatient settings (Element A)
Element A: Opportunities for Improvement0.30 points

The organization annually identifies and acts on opportunities to improve coordination of
medical care by:
1. Collecting data
2. Conducting quantitative and causal analysis of data to identify improvement opportunities
3. Identifying and selecting one opportunity for improvement
4. Identifying and selecting a second opportunity for improvement
5. Taking action on the first opportunity
6. Taking action on the second opportunity.
Scoring
100%
The
organization
meets all 6
factors
80%
The
organization
meets 5
factors
50%
The
organization
meets 3-4
factors
20%
The
organization
meets 2
factors
0%
The
organization
meets 0-1
factors
Data source
Reports
Scope of
review
NCQA reviews and scores this element once for all product lines/products brought
forward for accreditation that are administered the same. If HMO and POS products
are administered differently, NCQA reviews each product using one Survey Tool, and
the score for the element is based on the average of the scores for each product.
If PPO products are administered differently from HMO or POS products, NCQA uses
a separate Survey Tool to review and score the PPO products.
If product lines are administered differently in any product (e.g., HMO, POS, PPO),
NCQA reviews each product line, and the score for the element is based on the
average of the scores for each product line.
Look-back
period
For Initial Surveys: 12 months

For Renewal Surveys: 24 months
Explanation
98
Inpatient settings
Hospital
Medical
Surgical
Rehabilitation
Labor and delivery
Pediatrics
Orthopedics
Skilled nursing
Extended care facility
Inpatient hospice
Outpatient settings
Outpatient rehabilitation
Physicians office
Surgery center
Urgent care center
Emergency center
Outpatient hospice
Home health
Home respiratory therapy
Data collection and analysis

The organization must collect and analyze data to identify opportunities to improve
coordination of medical care. Data collection methodology must be sound enough to
produce valid and reliable results. NCQA does not require the methodology to be as
rigorous as that required for HEDIS, nor does it require the organization to perform
statistical analysis.
The organization collects data to assess coordination of care across settings or
transitions in care. The organization may use information collected in QI 7: Complex
Case Management and QI 8: Disease Management to identify continuity of care
issues.
Settings
Different settings include inpatient, residential, ambulatory and other types of location
where care may be rendered. An organization that collects data by setting must
collect continuity and coordination of care data from a minimum of two different
settings where these issues are likely to exist.
Transitions
Transitions in care include changes in management of care between practitioners,
changes in settings or other changes in which different practitioners become active or
inactive in providing ongoing care for a patient.
Patient safety
Activities related to patient safety, as required by QI 1: Program Structure, satisfy this
element if they involve monitoring coordination of care across settings or transitions in
care.
Activities used to demonstrate performance with UM 13: Pharmaceutical Safety
Issues may not be used to demonstrate performance with this element.
Selecting opportunities to improve coordination
The organization uses quantitative and qualitative analysis to prioritize and select
opportunities for improvement. The organization may identify multiple areas in need
of improvement (where there is a lack of continuity and coordination of care
throughout the system); it must take action to address at least two opportunities.
NCQA evaluates whether the organization has begun to address issues where they
exist. For this element, NCQA does not accept activities related to:
2012 Standards and Guidelines for the Accreditation of Health Plans
99
Coordination between medical and behavioral healthcare, as required in QI 11:

Continuity and Coordination Between Medical Care and Behavioral Healthcare
Clinical quality not directly related to continuity/coordination of care.
NCQA assumes the existence of at least two opportunities for improvement of
continuity and coordination of care across settings or transitions of care.
Opportunities may be different each time the organization analyzes the data.
Collaboration through patient-centered medical home (PCMH) initiative
The use of a medical home initiative is acceptable to meet QI 10, Element A. The
initiative must be a direct result of the data collected and the analysis performed in
meeting factors 1 and 2. If analysis indicates that a medical home initiative is an
appropriate opportunity, the following is required:
The organization must demonstrate that the medical home population
represents a relevant or significant size of the total population.
The organization must provide evidence of support for the medical home.
Support could include financial incentives, information system integration and
marketing.
Automatic credit does not apply if the organization uses a medical home initiative to
meet the requirements. The evidence must be reviewed against the requirements.
Examples
Inpatient settings
Outpatient settings
Hospital
Medical surgical
Rehabilitation
Labor and delivery
Pediatrics
Orthopedics
Skilled nursing
Extended care facility
Inpatient hospice
Outpatient rehabilitation
Physicians office
Surgery center
Urgent care center
Emergency center
Outpatient hospice
Home health
Home respiratory therapy
Data collection
Combine lab results with claims or pharmacy data
Sentinel events data
Discharge planning data
Practitioner survey about communication and coordination issues
Case management data
Data from electronic health records (EHR) that integrate information from several
sources
Data from programs that steer practitioners and patients to centers of excellence
Taking action
Prompt patients to return to primary care after a visit or episode of care from a
specialist
Prompt specialists to send summaries of recommendations to practitioners who
provide primary care services
Educate inpatient discharge planners or home health agencies on the use of
discharge instructions
Use incentives to promote rapid communication of discharge notes to practitioners
providing primary care
Notify practitioners about patients with prescriptions from multiple practitioners
100
Element B: Notification of Termination0.35 points

The organization notifies members affected by the termination of a practitioner or practice group
in general, family and internal medicine or pediatrics, at least 30 calendar days prior to the
effective termination date, and helps them select a new practitioner.
Scoring
100%
The
organization
notifies
members at
least 30 days
prior to the
effective date
of termination
80%
The
organization
notifies
members less
than 30 days
prior to the
effective date
of termination
50%
No scoring
option
20%
The organization
has policies and
procedures for
notifying
members, but
has not
implemented
them
0%
No process
exists for
notifying
members
Data source
Reports, Materials
Scope of
review
Look-back
period
Explanation
Documentation
NCQA reviews reports or materials for evidence that the organization notifies
members affected by termination of a practitioner. The organization must document
the date of termination and date of notification of the member.
The termination date is the date on which a termination becomes effective. The
organization must notify members that their practitioner will no longer be available at
least 30 calendar days before the effective termination date. This element applies
when a practitioner who provides primary care services terminates a contract with the
organization or when the organization terminates a contract with the practitioner, even
if the practitioner is a member of a group whose contract with the organization
continues. If a member selects a group or practice site rather than an individual
practitioner, this element applies to the selected group or practice site.
Notification must be in writing and may be distributed via the Internet. Written
notification about the availability of information on the Web site and on paper must be
mailed to members and a printed copy of the information must be made available
upon request. Notice of termination through a member newsletter is not adequate.
All communication must include the following information.
The practitioners name and the effective termination date
Procedures for selecting another practitioner
The organization may obtain the information from claims or from the practitioner or
practice sites records. This process may be delegated to a physician organization
(PO) if it maintains data regarding primary care.
101
The organization is not responsible for notifying members of practitioner relocations

or office closures as long as the practitioner remains available to members as part of
the organizations network.
If a practitioner notifies the organization of termination less than 30 days prior to the
effective date, the organization should notify the affected members as soon as
possible, but no later than 30 calendar days after receipt of the notification.
Distributing termination notice to members
The organization may distribute the termination notice through the following methods.
In writing by mail, fax or e-mail
On the Web, if it notifies members that the information is available
If the organization uses fax or e-mail to distribute the termination notification to
members who have fax or e-mail access; it must use an alternate approach for
members without fax or e-mail access. If the organization uses a Web site to
distribute information, it may use mail, fax or e-mail to notify members that the
information is available on the Web site.
Examples
Methods to define affected members

The number of visits to the practitioner within a specified time period
Serial referrals for the same type of care over a specified time period
Receipt of periodic preventive care by the same practitioner or practice site
Member notification
This letter is to inform you that [physician] is no longer a family practitioner in our
network. Since [physician] was your primary care practitioner, we want to make sure
you have the opportunity to choose another primary care practitioner from our
network.
If you have not already chosen a new primary care practitioner, please review your
provider directory, the directory on our Web site [www.organization.com] or call our
Member Services Department at [phone number] to have the directory sent to you.
After you choose a primary care practitioner, please call Member Services with your
new doctors name and we will issue you a new ID card.
If you have any questions, please call Member Services at the number above. Our
office hours are Monday through Friday, from 8:00 a.m. to 6:00 p.m.
102
Element C: Continued Access to Practitioners0.35 points

If a practitioners contract is discontinued, the organization allows affected members continued
access to the practitioner, as follows.
1. Continuation of treatment through the current period of active treatment, or for up to 90
calendar days whichever is less, for members undergoing active treatment for a chronic or
acute medical condition
2. Continuation of care through the postpartum period for members in their second or third
trimester of pregnancy
Scoring
100%
The
organization
meets both
factors
80%
No scoring
option
50%
The
organization
meets 1 factor
20%
No scoring
option
0%
The
organization
does not meet
either factor
Data source
Records or files, Documented process, Reports, Materials
Scope of
review
Look-back
period
Explanation
Documentation
NCQA reviews an organizations documented process and reviews reports, materials

or files for evidence that that the organization met the requirements for continued
access in its practitioner policies and procedures, when appropriate.
This element applies when a practitioner or organization terminates a contract for
reasons other than because of professional review actions, as defined in the Health
Care Quality Improvement Act of 1986, or when a practitioner within a group decides
to discontinue a contract with the organization while the rest of the group continues the
contract. A professional review action is based on competence or professional
conduct which affects or could affect adversely the health or welfare of a patient or
patients.
An active course of treatment typically involves regular visits with the practitioner to
monitor the status of an illness or disorder, provide direct treatment, prescribe
medication or other treatment or modify a treatment protocol. Discontinuing an active
course of treatment could cause a recurrence or worsening of the condition under
treatment and interfere with anticipated outcomes. The organization must act to ensure
continuity of care, despite discontinuation of a contract between it and a practitioner,
for any members receiving an active course of treatment for an acute episode of
chronic illness or acute behavioral health conditions. The 90 calendar days begin on
the date the contract is terminated.
The organization must work with practitioners who are no longer under contract to
develop a reasonable transition plan for each member in active treatment.
103
This element applies only if the practitioner agrees to the following.

To continue the members treatment for an appropriate period of time (based on
transition plan goals)
To share information regarding the treatment plan with the organization
To continue to follow the organizations UM policies and procedures
To not charge the member an amount beyond a required copayment
Identifying members
The organization must have a mechanism for identifying members regularly seen by
practitioners and practice groups within its network. Identified members are not eligible
for continued access if the care they are receiving does not meet the definition of
active treatment provided above. The organization must notify members affected by
practitioner termination that the opportunity for continued access may be available if
criteria are met and that they may contact the organization for more information.
An organization that contractually requires its in-network practitioners to notify
members when they leave the network and to provide access for continued care for at
least 90 calendar days meets the intent of this element. NCQA reviews examples of
organization contracts and other documentation demonstrating its continued access,
when applicable.
Exceptions
The organization is not expected to provide continued access in the following
circumstances.
When a member requires only routine monitoring for a chronic condition; for
example, if a member sees a practitioner for monitoring of chronic asthma but is
not in an acute phase of the condition
When the organization has discontinued a contract based on a professional
review action, as defined in the Health Care Quality Improvement Act of 1986
(as amended, 42 U.S.C. section 11101 et seq.)
When a practitioner is unwilling to continue to treat the member or accept the
organizations payment or other terms.
When a member has been assigned to a practitioner group rather than to an
individual practitioner who discontinues his or her contract with the organization,
and the member has continued access to alternate practitioners in the
contracted group
If no practitioner contracts have been discontinued
Examples
Evidence of implementation
Letters to members showing continued access

UM cases showing continued access
Claims paid showing continued access
Case management records showing continued access
104
Element D: Transition to Other Care0.10 points

The organization helps with a members transition to other care, if necessary, when benefits end.
Scoring
100%
The organization
has policies and
procedures for
transition and
provided
evidence of
implementation
80%
No scoring
option
50%
The
organization
has incomplete
policies and
procedures in
place to assist
with transition
to other care
20%
No scoring
option
0%
The organization
does not have
policies and
procedures for
transition and
there is no
evidence of
implementation
Data source
Records or files, Documented process, Materials
Scope of
review
Look-back
period
Explanation
Documentation
NCQA reviews written policies and procedures and documentation for evidence that
the organization helped members transition to other care.
If the organizations coverage of services ends while a member still needs care, the
organization must offer to educate the member about alternatives for continuing care
and how to obtain care, as appropriate.
NCQA does not expect the organization to develop alternative resources, only to
notify members of existing available resources.
Examples
Transition to other carePolicy

Qualifications: This policy applies to members who are receiving approved services
but whose benefit coverage will end while the members still need the medically
necessary care.
[Organization] offers qualified members assistance in transitioning to other care.
Identifying qualified individuals: Qualified individuals are identified from daily case
manager reports or requests for an extension of previously approved services that
could not be granted due to benefit limitations but which the member needs.
Identifying available resources and educating members: The case manager is
responsible for identifying available resources within the local community. The case
manager discusses alternative care and resources available to the member.
Additionally, [organization] provides notification of alternative resources within the
denial notification.
105
Member letter implementing transition of care

Your doctor has requested that we extend your inpatient behavioral health
coverage for an additional 8 days. Our records indicate that you will exhaust your
behavioral health benefits on [date], which is 10 days before your treatment is
complete.
There are several alternative resources for care available to you through local and
state-funded agencies. We have included a list of them and their contact information.
CRITERION 11: IDENTIFICATION OF FACTORS OUTSIDE THE ORGANIZATIONS

CONTROL WITH AN IMPACT ON PATIENT OUTCOMES
Describe how the organization identifies factors outside of its control that will have an impact on
patient outcomes. These instances might be specific to the planning of a CE activity or at the
overall CE program level. Include examples of identifying factors outside the organizations
control that will have an impact on patient outcomes.
At an organization level, NCQAs standards and performance measures frequently point to factors
outside the providers control that can affect patient outcome. These factorsand examples of how the
organization might overcome themare incorporated into the publications. For example, health plan
accreditation standard QI 10: Continuity and Coordination of Medical Care (attached in its entirety in
Criterion 10) includes this text in the Explanation section of Element D, Transitions to Other Care:
NCQA reviews written policies and procedures and documentation for evidence that the
organization helped members transition to other care.
If the organizations coverage of services ends while a member still needs care, the
organization must offer to educate the member about alternatives for continuing care and
how to obtain care, as appropriate.
NCQA does not expect the organization to develop alternative resources, only to notify
members of existing available resources.
Factors outside the providers control are often verified through the Education Units annual needs
assessment. For example, an annual retinal eye examination for patients with diabetes is included in the
HEDIS Comprehensive Diabetes Care measure. As reported in the State of Health Care Quality 2011,
the Medicare HMO population results for eye exams actually declined between 2001 and 2010, from
66% to 64.6%. In the intervening years, it was never higher than 68.4%. In our annual needs assessment
survey, we ask organizations which HEDIS measures are most challenging for them; the eye exam
measure is cited frequently. One factor outside the provider or health plans control is tracking patient
visits to vision centers out of the network; a patient may be getting the needed care, but the diabetes care
provider has no record of the visit and no recommendations from the patients ophthalmologist.
Another example comes from the HEDIS Follow Up Care for Children Prescribed Attention DeficitHyperactivity Disorder Medication measure. The Initiation Phase of this measure reports the percentage
of children between 6 and 12 years of age diagnosed with ADHD who had at least one follow-up visit
with a practitioner with prescribing authority within 30 days of their first prescription of ADHD
medication. Medications used to treat ADHD have known side effects and, like all medications, must be
closely monitored by a practitioner with prescribing authority. However, from 2006 to 2010, commercial
health plan rates for this measure improved only from 33% to 38.8%. NCQA produced a performance
improvement CME activity based on this HEDIS measure, which included a learner self-assessment
survey. In that survey we asked participants for their perceived barriers to patient compliance with 30day follow-up. Among the barriers identified were family concern with cost of a second provider visit;
patients or parents stopping the medication because of side effects; and parents rescheduling the visit
outside the 30-day follow-up window.
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CRITERION 12: IMPLEMENTATION OF ORGANIZATIONAL STRATEGIES TO REMOVE,

OVERCOME OR ADDRESS BARRIERS TO PRACTITIONER CHANGE
Describe how the organization implements educational strategies to remove, overcome, or address
barriers to practitioner change. These instances might be specific to the planning of a CE activity
or at the overall CE program level. Include examples of educational strategies that have been
implemented to remove, overcome, or address barriers to healthcare team or individual change.
At the organization level, NCQA standards and guidelines for its Accreditation, Certification and
Recognition programs include a wealth of examples of how an organization or practice might address,
remove or overcome barriers to change. Continuing with the example from Criterion 11, Continuity
and Coordination of Medical Care, an organization with a patient facing exhaustion of a benefit may
employ a policy such as follows.
Examples
Transition to other carePolicy

Qualifications: This policy applies to members who are receiving approved services
but whose benefit coverage will end while the members still need the medically
necessary care.
[Organization] offers qualified members assistance in transitioning to other care.
Identifying qualified individuals: Qualified individuals are identified from daily case
manager reports or requests for an extension of previously approved services that
could not be granted due to benefit limitations but which the member needs.
Identifying available resources and educating members: The case manager is
responsible for identifying available resources within the local community. The case
manager discusses alternative care and resources available to the member.
Additionally, [organization] provides notification of alternative resources within the
denial notification.
Member letter implementing transition of care
Your doctor has requested that we extend your inpatient behavioral health
coverage for an additional 8 days. Our records indicate that you will exhaust your
behavioral health benefits on [date], which is 10 days before your treatment is
complete.
There are several alternative resources for care available to you through local and
state-funded agencies. We have included a list of them and their contact information.
At a CE activity level, our HEDIS Update and Best Practices seminar provides an excellent forum for
health plans to showcase their replicable success stories in overcoming barriers to care. For example
(following up on Criterion 11), over the past 10 years, health plans have not shown improvement in the
Retinal Eye Exam measure for their patients with diabetes. At a HEDIS Update and Best Practices
seminars, a health plan shared its practice that helped improve performance and is easy for plan,
practitioner and patient to implement: practitioners emphasize the importance of a retinal eye exam to
their patients with diabetes. If the practitioner cannot set up an in-network exam while the patient is on
site or if the patient indicates a desire to see a specific out-of-network eye care provider, the patient
receives a card for the provider to complete at the patients visit. The card verifies the visit and includes
March1,2012
Page107
the providers contact information and any needed follow-up for the practitioner. The patient returns the
card to the practitioner.
Another example of addressing, removing or overcoming barriers to change is associated with the
HEDIS ADHD measure described in Criterion 11. As part of NCQAs ADHD Performance
Improvement Program, learners at Stage B (educational intervention)having reviewed their patient
data and assessed their performance in stage Areceive Caring for Children With ADHD: A Resource
Toolkit for Clinicians, produced by the American Academy of Pediatrics. Among the resources in this
toolkit are the AAPs ADHD Clinical Practice Guideline, tools for ADHD assessment and diagnosis, an
ADHD medication guide, a coding guide, a booklet for parents (English and Spanish versions) and a
brochure on ADHD medications for teenage patients. The materials reference the importance of the 30day follow-up visit and help practitioners encourage their patients to make this visit a priority.
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CRITERION 13: CONCLUSIONS FROM ANALYSIS OF CHANGES IN LEARNERS

COMPETENCE, PERFORMANCE, OR PATIENT OUTCOMES
Describe the conclusions drawn from analysis of changes in learners competence, performance,
or patient outcomes achieved as a result of the organizations overall programs
activities/educational interventions. Provide a summary of the data upon which analysis of
changes in learners was based.
It appears that NCQAs educational activities are hitting the mark in changing learners competence and,
in some cases, performance. Patient outcomes data can be extrapolated from HEDIS and accreditation
results (see example below), but this is not learner-to-outcome comparison because data are collected at
the health plan rather than the clinician level.
This summary is from Educations annual needs assessment survey, distributed in June 2011 (363
respondents, a 3.3% response rate):
Key Finding #10
When asked which activity learners participated in during 2010 and the first half of 2011 that had the
most impact on their job function, respondents noted the following NCQA education programs most
frequently:
- HEDIS Update and Best Practices.
- Update on Health Plan Accreditation.
- Introduction to Accreditation.
- Facilitating Patient-Centered Medical Home Recognition.
- Delegation Webinars.
Respondents reported that they made the following changes based on what they learned:
- Ensured readiness for accreditation.
- Looked into innovative methods of data collection.
- Increased member engagement.
- Increased collaboration.
- Streamlined activities.
- Strengthened policies and procedures.
- Improved policies, procedures and data reporting.
At the conclusion of each NCQA educational activity, learners complete a Web-based evaluation form
(see examples in the activity files). Physicians and registered nurses each answer the question, What
degree of confidence do you have that you will apply some of the knowledge gained from this seminar
at your organization? Using a scale of 0%, 25%, 50%, 75% or 100% confidence, responses are
predominantly in the 75% or 100% categories across all activities.
Three- to six-month follow-up surveys are distributed to learners for some activities. A typical question,
Based on the information you learned during the seminar, what activities have you implemented in
order to prepare your organization for your next survey? generated high-scoring responses made sure
March1,2012
Page109
all standards updates are implemented into business practices and reviewed policies & procedures and
program description to ensure inclusion of all requirements.
For NCQAs ADHD Performance Improvement Program, as of the end of 2011, physicians that had
completed Stage A (measurement) and Stage B (educational intervention) indicated that they planned
these changes in performance:
83% share the Stage B educational interventions with their care team.
81% utilize the AAP toolkit.
64% provide patient education materials to the family.
41% issue reminders regarding upcoming office visits.
38% develop a registry.
20% contact patients who do not show up for their appointment to reschedule.
11% collaborate with the patients school and teachers to monitor the management plan.
Of the 112 physicians who completed the entire activity as of the end of 2011, between Stage A and
Stage C, the time interval for initial follow-up of a patient 612 years of age who was started on ADHD
medication decreased from an average of 37 days to 26 days.
Finally, at an organizational level, NCQAs HEDIS data show changes in patient outcomes. Here is an
excerpt from the Executive Summary of the 2011 State of Health Care Quality Report, based on health
plan data from calendar year 2010:
Of the 32 HEDIS Effectiveness of Care measures, 23 show clear trends of improvement.
While year-to-year gains are often quite small, they are steady over time. Only one
measure showed unmistakable signs of worseningAvoidance of Antibiotic Treatment in
Adults With Acute Bronchitis.
One example of progress is Colorectal Cancer Screening, with an almost 2 percentage
point increase (to 62.6 percent) between 2009 and 2010 for commercial HMOs.
Introduced in 2004, this measure has shown steady gains. Similar gains have transpired
for Medicare HMOs, although they have not reached the same level overall.
HbA1c Screening for People With Diabetes, introduced with a suite of diabetes measures
in 1999, is another example of growth. The screening rate has risen steadily over the past
11 years, progressing from 75 percent in 1999 to almost 90 percent in 2010 for
commercial HMOs.
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CRITERION 14: MAINTAINING VERIFICATION OF COMPLIANCE WITH

ACCREDITATION REQUIREMENTS AND LEARNER PARTICIPATION RECORDS
Describe how the organization maintains verification of compliance with accreditation

requirements and records of learners participation in its CE activities.
NCQAs Director of Education is responsible for keeping up to date on our accrediting
organizations requirements and maintaining NCQAs compliance with those requirements. She
also ensures that our lead nurse planner and all Education staff are aware of any changes and that
they incorporate such changes into all Education activities as needed. Continuous Quality
Improvement is performed by the Education staff at the conclusion of each activity, and any
aspects of the activity that are observed to be out of compliance are marked to be corrected in
any subsequent presentations of the activity.
This is our policy regarding maintaining compliance:
POLICY TOPIC:
Maintaining Compliance with Current ANCC Commission on

Accreditation and the ACCME Criteria, Policies and Procedures
DATE:
November 15, 1994
APPROVED:
LATEST REVIEW/
REVISION:
November 2011
POLICY STATEMENT:
NCQA will consistently operate in compliance with the policies,

procedures and criteria of the ANCC Commission on Accreditation
and the ACCME throughout the accreditation period. As
accreditation and approval criteria, policies and procedures are
revised by the ANCC or ACCME, NCQA will comply with such
changes, implementing appropriate revisions in its program as
indicated.
1. The administrator of the provider unit will notify the department staff of the
changes in criteria, policies and procedures upon notification by ANCC/ACCME
of revisions.
2. NCQAs relevant policy statement(s) will be reviewed.
3. If necessary, the statement(s) will be revised to reflect the changes in criteria or
policies and procedures.
This is the policy regarding records of learners participation in NCQAs CE activities:
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POLICY TOPIC:
Record Maintenance
DATE:
November 15, 1994
APPROVED:
LATEST REVIEW/
REVISION:
November 2011
POLICY STATEMENT:
Records from all NCQA-sponsored educational programs will be

stored in a central filing system that contains all appropriate
information for each continuing education activity. NCQA will
maintain a system for the storage of educational records which
assures confidentiality and retrieval of participant records. Secure
electronic record-keeping will serve as an acceptable storage
system. These records will be kept at NCQA for six (6) years.
PROCEDURE:
1. Store complete registration information for all participants at NCQA-sponsored education
programs in the designated computerized registration database, which is managed
through a comprehensive registration software package.
2. Limit access to these educational records by access code and password to Customer
Resources staff. No information from those records may be released without the
written permission of the individual attendee.
3. Keep complete program information in a separate education department file in a
secured area. A secure online file is an acceptable storage system.
4. Retain all records on Continuing Education activities for six years, and maintain the
security of these files.
5. Ensure that records for each educational offering include:
title of activity
description of professional practice gap and needs assessment
description of target audience
names and titles of the planning committee and documentation of the planners
expertise
disclosure information for each planning committee and faculty member, and
resolution of conflict of interest, if any
name, title and biographical data for each faculty member
starting and ending dates of activity
name and address of facility where the educational activity was held
March1,2012
Page112
purpose, objectives, content, time frames, teaching methods and method used to
evaluate the activity
names and addresses of participants
sample certificate of attendance, indicating number of CME and CNE hours
awarded for the activity
determination of number of CME credits and CNE hours
summary of participants evaluations
a copy of the specific coprovidership or joint sponsorship agreement for each
activity where applicable
a copy of the letter of agreement with commercial entity of educational grant where
applicable
March1,2012
Page113

1 - Ncqa Joint Accreditation Self Study 03-01-2012

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National Committee for Quality Assurance

Joint Accreditation Self Study

NCQA 2012 JOINT ACCREDITATION SELF STUDY

Criterion 11 Identifying Factors Outside the Organizations Control

Criterion 12 Removing, Overcoming or Addressing Barriers to Change

Criterion 13 Analyzing Changes in Learners C-P-PO

Criterion 14 Maintaining Verification of Compliance/Records

Advanced Delegation: Establishing and Maintaining

Disease Management Accreditation: New Standards

Disease Management Accreditation: New Standards

Disease Management Accreditation: New Standards

Disease Management, Complex Case Management and

Disparities Leadership Program 2009-2010 Closing

Disparities Leadership Program 2010-2011 Opening

Hands-On: The Interactive Survey System for NCQA

HEDIS Update and Best Practices

HEDIS Update and Best Practices

How To Facilitate Patient-Centered Medical Home

How to Facilitate Patient-Centered Medical Home

How to Facilitate Patient-Centered Medical Home

How to Facilitate Patient-Centered Medical Home

How to Facilitate Patient-Centered Medical Home

How to Facilitate Patient-Centered Medical Home

Improving HEDIS Measures: Putting QI Tools Into

Introduction to Multicultural Health Care Distinction

Introduction to NCQA Accreditation for Health Plans

Introduction to NCQA's Credentialing Standards

Introduction to NCQA's Credentialing Standards

Introduction to NCQA's Delegation Standards

NCQA Update for Michigan Health Plans (Corporate

NCQA's Credentialing: Strategies for Success

Preparing for an NCQA Survey

Preparing for an NCQA Survey

Relative Resource Use: Drilldown

Relative Resource Use: Drilldown

Update on Health Plan Accreditation

Update on Health Plan Accreditation

2010 Disease Management Training (for Surveyors)

2010 Disease Management Training (for Surveyors)

2010 Disease Management Training (for Surveyors)

2010 Surveyor Update Training Make-Up Session

The Disparities Solutions Center Web Seminar Series: Addressing

The Disparities Solutions Center Web Seminar Series: The Cost of

Best Practices in Childhood and Adolescent

Best Practices in Depression Treatment: HEDIS and

Unified Health Communication: Addressing Health

Brief History of the CE Program

Leadership and Structure of the CE Program

CONTINUING EDUCATION MISSION STATEMENT 2011

CRITERION 2: OVERALL PROGRAM EVALUATION

Describe and include examples of information gathered as a result of overall program

2012 NCQA EDUCATION PLANNING DAY

Financial and Performance Review

Needs Assessment Review

Identification of Professional Practice Gaps of our learners

Learning and Development UpdateTina

Brainstorming: Needs assessment questions for The Experts

WELCOME Guest Panelists/Introductions

Brainpicking: Getting answers to brainstormed list of questions/

LUNCH, Resumed brainpicking/brainstorming, summarizing outcomes

Assessing the Calendar

2012 Seminar Offerings

Marketing and Communicationscompetitive analysis, creative ideas

As a _physician _registered nurse who serves as a member of NCQAs faculty, I