Electronic ISSN 2287-0237

VOLUME

THE BENCHMARK BETWEEN THE NCQA DIABETES RECOGNITION PROGRAM (DRP) AND THE JCI CONDITION-SPECIFIC CERTIFICATION FOR DM TYPE 2 AT THE BANGKOK HOSPITAL MEDICAL CENTER

FEBRUARY 2014 - VOL.7 | OTHER FEATURE

Diabetes mellitus (DM) has become a major public health problem around the world. According to statistics from the World Health Organization (WHO) Diabetes Fact Sheet, this disease currently affects 347 million people worldwide. Due  to the increasing burden of diabetes patients, an excellent diabetes care center is needed to provide international standard quality care. To address this need, the Bangkok Hospital Medical Center (BMC)’s Diabetes Center applied for the Joint Commission International (JCI) Condition-Specific Certification (DCSC) Program for a DM Type 2 Pathway. The certification was awarded to the BMC in November 2011. Soon after, we achieved all the target performance indicators recommended by JCI, and we gradually added further performance indicators at our diabetes clinic. We are ready for re-certification this coming November 2014.

In an attempt to assess and identify performance measures based on management guidelines, we found that most of JCI measurements assess the care process being delivered. To better understand how to improve quality care for type 2 DM patients, we can draw on the tangible measure of the treatment’s outcomes. In other words, in addition to good standard processes of care we also focus on good treatment outcomes. These two must go hand in hand to achieve the maximum benefit for our patients. There are several disease-specific and specialty-specific professional organizations that have developed diabetes management guidelines. In consideration of the significant improvements we  have  seen   in recent years, we examined best practices to identify the best  tool to achieve even better clinical outcomes. After surveying many organizations already using diabetes performance measurements, we were impressed with the National Committee for Quality Assurance (NCQA) and its approach to address the clinical outcome even further. This paper is an introduction to NCQA and aims to compare JCI and NCQA standards in terms of measuring diabetes clinics’ performance and the clinical outcome. The purpose of using the NCQA standard as a benchmark for our expert care provision for Type 2 DM patients, we have assessed relevant clinical results and this process will continue for the next 6 months. We aim to report on the results in the next edition of the Bangkok Medical Journal.

The NCQA is a private, not-for-profit  organization dedicated  to improving health care quality. Since it was founded in 1990,   the NCQA has been a leading institution in driving improvement throughout the health care system, helping to raise the issue of health care quality to the top of the national agenda. The NCQA accredits and certifies a wide range of health care organizations. It also recognizes clinicians and practices in key areas of performance.

The NCQA is the first DM accreditation organization to use performance measures to assess the impact of programs on care for people with DM.

• Evidence-Based Programs

• Patient Services

• Practitioner Services

• Care Coordination

• Measurement and Quality Improvement

• Program Operations

• Performance Measurement

*For more information, please visit: http://www.ncqa.org

The DRP assesses the effectiveness of DM management by measuring theclinical outcome  aswellastheintervention process. The requisite quality indicators are shown below.

Outcome Measures:

       HbA1c Control > 9.0%* 

     HbA1c Control < 8.0%

    HbA1c Control < 7.0%

     Blood Pressure Control c 140/90 mm Hg*

    Blood Pressure Control < 130/80 mm Hg

   LDL Control c 130 mg/dl*

    LDL Control < 100 mg/dl

Process Measures:

• Eye Examination

• Foot Examination

• Nephropathy Assessment Smoking Status and Cessation Advice or Treatment

To receive certification for any JCI DCSC program,the health care organization must meet the following 5 standards:

  1. International Patient Safety
  2. Program Leadership and Management (PLM)
  3. Delivering or Facilitating Clinical Care (DFC)
  4. Clinical Information Management (CIM)
  5. Performance Measurement and Improvement (PMI)

JCI stands apart as a leading advocate for patient safety and quality improvement in the global community.  It was created in 1994 by The Joint Commission, and the JCI has a presence in more than 90 countries today. JCI works with health care organizations, governments, and international advocates to promote  rigorous  standards  of care and provide solutions for achieving peak perfor-mance. JCI experts help organizations help in three ways:  accreditation, education, and advisory services.

*For more information, please visit: www.jointcommission- international.org

There are several recommendations for DM management, such as an intensive therapy for poorly controlled diabetics,  therapy for hyperlipidemia, use of angiotensin-converting enzyme inhibitor (ACEI) or an angiotensin II receptor blocker (ARB) therapy for albuminuria and self-manage- ment education and ensuring the clinical documentation is kept complete. The table below presents our current performance measurements for the JCI DM DCSC program.

Overall, the NCQA and JCI accreditation processes are quite similar in format and general requirements. After the application is submitted, a detailed documents review takes place, and several days of surveyors conducting on-site visits are compulsory. Both organizations arrange for levels of accreditation ranging from rejected to full accreditation. They also have specific disease management certification programs. In terms of the DM management program, these two organisations are somewhat different in the choice of diabetes performance indicators. DRP gives more values to the clinical outcome indicators, while most of JCI standard measures focus on the process of providing essential treatments and care. NCQA accreditation is a comprehensive quality scorecard. Therefore, the DRP used a standardized data set for measuring plan perfor- mance and clinical outcomes. In the scoring process for accreditation, NCQA assigns a greater weight to clinical outcome measurements.

The table below list the indicators required by DRP, the grey row indicates the clinical indicators and the white row indicates the process indicators.

Table : Performance Measurement for JCI DM DCSC.

The BMC diabetes clinic pursues a consistent drive to improve quality and clinical outcomes. We found that the DRP standard is a helpful clinical outcome measurement tool to assess the efficiency of our DM management program. Only health care organizations located in the United States are eligible to apply for DRP, which is unfortunate. Nevertheless we plan to use the standard set by the DRP performance measurement as  a  benchmark  this  year.  In addition to the quality indicators required by JCI Type 2 DM DCSC, the clinical results of the patient who consents to participate in the DM pathway are also being recorded at present. Currently, we are verifying the percentage of patients in each level of HbA1C and LDL cholesterol and the percentage of patients with selected blood pressure levels. We are eager to deliver excellent service to our patients; we expect our patients will enjoy greater benefits as a result of the clinic benchmarking selected clinical performance measures appropriate for an international health care organization.

By comparing the performance levels with DRP scoring measures, we expect that our endocrinologists will achieve better clinical outcomes for the patients. The clinician will quickly see tangible improvements by increasing the level of attention paid to treatment and monitoring. We hope that these selected clinical outcome indicators will mirror the effectiveness of our DM management pathway and most importantly will deliver higher quality care to our DM patients.

In the future, more work is planned to assess the pos- sibility of using Type 2 DM clinical outcomes selected by NCQA as a Key Performance Indicator (KPI) to measure the proficiency of all endocrinologists who treat Type 2 DM patients at the Bangkok Medical Center.