1. Performance Improvement
Projects for Health Plans
A Brief Overview
By Paula Roddenberry, RN, MS, CCM CDMS

2.  A Performance Improvement Project (PIP) is a
concentrated effort on a particular problem in a
health care system; typically addressing health care
outcomes and processes.
 It involves gathering information systematically to
clarify issues or problems, and intervening for
improvements.
WHAT
By Paula Roddenberry, RN, MS, CCM CDMS

3. • A little background: By improving
processes and outcomes relevant
to high-priority health needs, an
organization reduces waste and
costs associated with system
failures and redundancy.
• Often QI processes are budget-
neutral, where the costs to make
the changes are offset by the cost
savings incurred.
• Required for some government
contracts
Quality
Improvement (QI)
By Paula Roddenberry, RN, MS, CCM CDMS

4. For Example
 An MCO does not have
women between the ages
of 45-65 completing their
annual mammograms at a
preferred rate.
 Percent of women 40
years of age and over
who had a mammogram
within the past 2 years:
66.8% (2013) per the CDC
website
By Paula Roddenberry, RN, MS, CCM CDMS

5. 0
20
40
60
80
100
2013
MCO
National
Compare the Actual Statistics
By Paula Roddenberry, RN, MS, CCM CDMS

6.  Action Step: Prioritize Quality Opportunities &
Charter PIP Teams
 Prioritize work based on priority – areas that affect
members first; high risk areas and opportunities for
improvement
 Write SMART goals (specific, measurable, attainable,
relevant and time-bound)
 Establish a PIP Team
THE PROCESS
By Paula Roddenberry, RN, MS, CCM CDMS

7.  Action Step: Plan, Conduct and Document PIP Teams
 Utilize a problem solving model
 Focus work and create timelines
 ID supplies, select measurement tools and
documentation plan for the results
 Steering committee to oversee and guide PIP team
 Employ a problem solving methodology such as PDCA
THE PROCESS
By Paula Roddenberry, RN, MS, CCM CDMS

8. Plan
Do
Check (or study)
Act
PDCA
By Paula Roddenberry, RN, MS, CCM CDMS

9.  Many PIPs are driven by
government requirements
(e.g.. Medicaid contracts
require PIPs to be done in
order for an MCO to provide
services to Medicaid
Members).
 The government assigns an
advisory group
Oversight
By Paula Roddenberry, RN, MS, CCM CDMS

10. ANALYZE AND INTERPRET STUDY RESULTS
 Data analysis begins with examining the performance
on the selected clinical or non-clinical indicators.
 The examination should be initiated using statistical
analysis techniques defined in the data analysis plan.
By Paula Roddenberry, RN, MS, CCM CDMS

11. In Conclusion
• An External Quality of Care Review Organization
(EQRO) may send a report to the State with the results
of the study after review of the results.
• The EQRO should develop an outline that is approved
by the State.
• Since the State may use the report to meet its
reporting requirements to federal or State agencies,
the State legislature, local advocacy groups, as well as
other interested parties, the report may need certain
types of information presented in a specific format.
By Paula Roddenberry, RN, MS, CCM CDMS