Credentialing... 2 Investigations of Complaints related to Practitioner Office Site... 3

Transcription

1 Credentialing A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association BCBSIL Provider Manual Rev 12/15 1

2 Credentialing BCBSIL Provider Manual Rev 12/15 2

3 Policy Name: Policy Number: Credentialing 08 Effective Date: 05/01/2013 Revision Date: 09/01/15 Review Date: 09/01/15 Approval Signature Senior Medical Director Line of Business Commercial Retail, Exchange Affected Markets Government HMO HMO HMO PPO PPO PPO Approving Body BCBSIL Policy and Procedure Committee Date: 08/27/15 BCBSIL QI Committee Date: 09/02/15 Details Policy: Blue Cross and Blue Shield of Illinois (BCBSIL) has established standards for practitioner office site quality and will monitor and investigate member complaints related to the quality of all practitioner office sites to determine whether the office site meets these standards. Purpose: To monitor the quality, safety and accessibility of all practitioner office sites where care is delivered in response to a member complaint. To define the standards and thresholds for the quality of network practitioner office sites including: o Physical accessibility o Physical appearance o Adequacy of waiting and examining room space o Adequacy of confidential medical record keeping To define the methodology for investigating complaints about quality, safety and accessibility in office sites where care is delivered. Procedure: Site Standards 1. Physical Accessibility: BCBSIL Provider Manual Rev 12/15 3

4 Page 2 of 6 Ease of entry into the building or practice site. (Ramps are present.). Accessibility of space within the building: Restrooms, doorways and hallways should be easily accessible therefore wide enough for wheelchairs and free from debris or other obstructions. There are restrooms for physically disabled members. Handrails are present in the restrooms. Office hours are clearly posted. Physical Appearance; Waiting areas, exam rooms and floors should be clean, well lit and uncluttered. Corridors leading to exits are clear; no storage of any kind. 3. Adequacy of waiting and exam room space: The waiting room should have adequate seating for the volume of patients seen per practitioner. There should be an adequate number of exam rooms based on the number of practitioners. Exam room space includes provisions for privacy during examinations and procedures. 4. Safety Measures: The Practitioner and his/her staff should follow the Centers for Disease Control and Prevention Universal Precautions guidelines when providing patient care. **Bio-hazardous waste must be discarded according to OSHA guidelines. **Sharp disposal containers must be available. Medication Maintenance/Storage: Sample drugs, over-the-counter medications, prescription drugs, and vaccines should be stored in restricted patient areas. Controlled substances, if present, should be stored in a locked area. Medical Supply Storage: **Sharps should be stored in restricted patient areas. Prescription pads should be stored in restricted patient areas. 5. Adequacy of Medical/Treatment Record Keeping: Medical records should document current, detailed and organized data to facilitate communication, coordination and continuity of care and promote efficiency and effectiveness of treatment. Electronic: Health information and data is immediately accessible. The system allows for storing of prescription orders, test orders and other services ordered. Automatic reminders, prompts or alerts to assist in member care and best clinical practices. Paper: Medical records should be kept in a secure place, away from member access. BCBSIL Provider Manual Rev 12/15 4

5 Page 3 of 6 Medical records are consistently organized, clearly marked and easily identified and located. Site Visit Performance Threshold To pass the site visit, the practitioner office site must meet these thresholds: Physical Accessibility must score a minimum of 90% or be subject to corrective action. Physical Appearance must score a minimum of 90% or be subject to corrective action. Adequacy of Waiting and Exam room space must score a minimum of 90% or be subject to corrective action. Adequacy of Medical /Treatment Record Keeping must score a minimum of 90% or be subject to corrective action. The auditor will provide feedback about any of the above or other deficiencies. Monitoring 1. The Practitioner Office Site Quality policy is made available to all providers in the Provider Manual. 2. Complaints related to the quality of a practitioner office site will be routed to Network Quality and Customer Service Department for investigation. The complaint will be reviewed. 3. If the complaint indicates a quality issue or a potential member safety issue, a site visit will be performed within sixty days after receipt of the complaint. 4. When a site visit is scheduled for investigation of a complaint, the practitioner will be provided with a copy of the Practitioner Office Site Quality policy, including the performance thresholds. 5. Site visits will be performed to assess compliance with the site standards outlined in this policy. 6. Identified deficiencies will be reviewed with the practitioner (or office staff, if the practitioner is not available) at the time of the site visit. 7. The practitioner will receive a written report summarizing the site visit findings. 8. If a practitioner office site scores below the threshold standards, BCBSIL will request that the practitioner office site develop and implement a Corrective Action Plan (CAP) to improve the deficiencies that did not meet the requirements. The CAP must be sent to BCBSIL within 30 days of receipt of the letter requesting of CAP. 9. BCBSIL will evaluate the effectiveness of the CAP by conducting a follow-up audit within six months of audit failure. A follow up site visit will be conducted within 6 months again if the site does not pass the initial reaudit. 10. If any subsequent complaints are received for the same office site, the Network Quality Staff will perform another site visit, unless the complaint is directed at the same office site standard. Staff will follow up with the practitioner but is not required to perform another site visit. BCBSIL Provider Manual Rev 12/15 5

6 Page 4 of If a site visit is performed in response to a member complaint about the quality of the practitioner office site and the site fails to meet the standards established in this policy, the findings will be reported to Network Management, Corporate Credentialing, and the Provider Selection Committee (PSC). 12. Reports summarizing complaints about practitioner office site quality will be brought to the BCBSIL Quality Improvement Committee at least semi- annually. 13. Practitioners failing three consecutive practitioner office site audits will be presented to PSC for further review and recommendations. BCBSIL Provider Manual Rev 12/15 6

7 Page 5 of 6 Attachment I Practitioner Office Site Quality Audit Tool Physical Accessibility Ease of entry into the building or practice site. (Ramps are present) Accessibility of space within the building. Restrooms, doorways and hallways should be easily accessible; wide enough for wheelchairs and free of debris. Handrails are present in the restrooms. Office hours are clearly posted. The site should be accessible to those with disabilities. Physical Appearance Waiting areas, exam rooms and floors should be clean, well lit and uncluttered. Corridors leading to exits are clear, no storage of any kind. Adequacy of waiting and exam room space The waiting room should have adequate seating for the volume of patients seen per practitioner. There should be an adequate number of exam rooms based on the number of practitioners. Exam room space includes provisions for privacy during examinations and procedures. Gowns available in exam rooms. Safety Measures The Practitioner and his/her staff should follow the Centers for Disease Control and Prevention Universal Precautions guidelines when providing patient care. Bio-hazardous waste must be discarded according to OSHA guidelines. Sharp disposal containers must be available. Gloves, masks should be available in all exam rooms. Medication Maintenance / Storage Sample drugs, over-the-counter medications, prescription drugs, and vaccines should be stored in restricted patient areas.* Controlled substances, if present, should be stored in a locked area. Medical Supply Storage Sharps should be stored in restricted patient areas. Prescription pads should be stored in restricted patient areas. Adequacy of Medical /Treatment Record Keeping All records document current, detailed and organized data to facilitate communication, coordination and continuity of care and promote efficiency and effectiveness of treatment. Electronic: Health Information and data is immediately accessible. The system allows for storing of prescription orders, test orders and other services ordered. Automatic reminders, prompts or alerts to assist in member care and best clinical practices. Paper records: Medical records are kept in a secure place, away from member access, to ensure confidentiality. Office has a mechanism in place to monitor and prevent breech of records. Medical records are consistently organized, clearly marked and easily identified and located. To pass the site visit, the practitioner office site must score with the minimum threshold stated above. The auditor will provide feedback about any other deficiencies. Reviewed and revised: 9/1/15 BCBSIL Provider Manual Rev 12/15 7

8 Page 6 of 6 Attachment II Practitioner Office Site Quality Audit Date of Audit: Auditor: Onsite Audit Findings: Score: Audit findings reviewed with: Practitioner Date of Review: Reviewed and revised: 9/1/15 BCBSIL Provider Manual Rev 12/15 8