Since its founding in 1990, National Committee for Quality Assurance (NCQA) has been driving improvement through the development of quality standards and measures in the healthcare field. The NCQA measures are more commonly recognized as Healthcare Effectiveness Data and Information Set (HEDIS).

How can organizations incorporate Lean Six Sigma in their NCQA accreditation efforts? Lean Six Sigma can best assist a healthcare organization’s NCQA efforts by: 1) using the tools to support the organizational planning phase to achieve NCQA accreditation and, 2) improving patient quality and service.

Organizational Planning

Healthcare organizations generally conduct a baseline assessment that addresses the NCQA standards in order to better understand their strengths and where improvements are required.

Once the baseline is completed, a NCQA Team is established and staff members are assigned to each standard to ensure compliance. This is a great management concept and holds individuals accountable for how the organization meets that individual NCQA standard. Usually a NCQA Standards Plan is developed using spreadsheet software and includes such columns as: Task/Standard, % complete, start date, finish date, predecessors and the individual held accountable for meeting that standard.

Electronic master files are developed where documents can be uploaded showing “how” the standard is met. These electronic file names should be specific enough to easily identify the standard and sub-standard. The NCQA Team should limit the number of people who have access to this internal master file. This limitation prevents the wrong documents from being uploaded, documents from being lost or mishandled, and assists the staff in knowing when a standard has been met. The staff emails their documents to the master file “gate keepers,” who then review the documents to ensure they meet the standard and upload them to the appropriate master file. Documents loaded into this master file will eventually be uploaded to the NCQA Web portal.

Patient Quality and Service

The NCQA main website gives healthcare organizations a straightforward formula for quality improvement: “Measure. Analyze. Improve. Repeat.” Lean Six Sigma practitioners will recognize this formula as part of the Define, Measure, Analyze, Improve and Control (DMAIC) project phases.

While Lean Six Sigma organizations use a series of tollgates to track project improvements, NCQA uses what is known as a Quality Improvement Activity Form (QIA). The purpose of the QIA form is to summarize the clinical and service quality activities to demonstrate improvements with NCQA measures. The QIA Form incorporates similar information found in a traditional final Lean Six Sigma tollgate, including the rationale for project, project goal, baseline, post-intervention, and “holding the gains” results, intervention development, sampling and statistical methodologies.

To demonstrate how Lean Six Sigma for hospitals can be used to improve HEDIS, a project was conducted at a hospital where a team was chartered to use the process improvement methodology to improve the following HEDIS measures:

Breast cancer screening (Mammography, every 2 years from age 52-69) +8.1%
Cervical cancer screening (every 3 years, ages 24-64) +5.5%
Colon cancer screening (ages 51-70) +2.0%
Diabetics (over age 18) with HgbA1c in the past year +5.7%
Diabetics (over age 18) with LDL cholesterol less than 100 mg/ml +7.1%

By applying the Lean Six Sigma methodology to the NCQA accreditation process, organizations can develop a NCQA Standards Plan, apply statistical methods, develop interventions, and increase HEDIS results while improving patient care.

In another example, the author is assisting three small federal hospitals to build a medical home within their family practice and pediatric departments by implementing the NCQA Physician Practice Connections-Patient-Centered Medical Home (PPC-PCMH) standards. These standards target physician practices, whether they are associated with hospital-based systems, large practice associations or small independent practices. The application to community hospitals is equally important and immediate: improvement of key clinical processes, increased revenue and decreased operating costs and improvement of clinical efficacy.

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