Quality Improvement Program Description

Transcription

1 2015 Quality Improvement Program Description Approved by the Board of Directors: March 19, 2002; April 22, 2003; April 20, 2004; April 26, 2005, April 25, 2006, February 27, 2007, March 25, 2008, March 24, 2009, March 23, 2010, April 26, 2011, April 24, 2012, April 23, 2013, April 24, 2014, April 2015

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3 2015 Revisions Page Addition/Revision Rationale Throughout the To reflect current staffing and title changes Staff titles and committee composition document 17 No longer functioning committee, activities Deleted Benefit Interpretation Committee incorporated into the Ops Committee Updated to reflect activities for current product Behavior Health Services lines. 26 Refined Cultural and Linguistic objectives To clearly define purpose of the objectives 27 Added High Risk to title with Complex Case Management. Listed types of members with complex health issues being addressed by the Complex Care To indicate the complex case management is high risk case management. To define complex health issues being addressed (High Risk) Management Program 50 Specific components to be included in the Annual To document NCQA critical factors Work Plan Throughout the Changed Physician Reviewer to Medical Medical Director is responsible for clinical document Throughout the document Throughout the document 66 Director Added who holds an unrestricted license to practice medicine in the state of California to description of Chief Medical Officer and to Medical Director. Changed Director of Health Care Operations to Director of Pharmacy Services Added definition of medical necessity 73 Added Community Health Group s Chief Medical Officer, who holds an unrestricted license to practice medicine in the state of California, is responsible for Delegation Oversight. Updated P & T Committee membership 74 composition review To comply with state regulations Title change To comply with DHCS and CMS requirements for the coordinated care initiative. To comply with state regulations To reflect current Committee membership 78 Eliminated reference to Healthy Families Program To reflect current processes and practices 78 Added clarification regarding Medicare formulary review process To reflect current processes and practices 81 Added statement regarding communication of future Medicare formulary changes To reflect current processes and practices 85 Added statement that provider standing with both Medicare and Medicaid is monitored To reflect current processes and practices

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5 Table of Contents Mission Statement... 1 Authority and Responsibility... 3 Purpose... 3 Goals... 3 Functions... 4 Objectives... 4 Scope of Quality Improvement Program... 6 Annual Review and Update of Quality Improvement Program... 6 Organizational Structure... 7 Role of the Chief Medical Officer... 7 Designated Behavioral Health Practitioner... 8 Lines of Communication and Informational Flow... 8 QIP Committees Members... 8 QIP Committees Meetings... 9 Quorum... 9 QIP Committees Minutes Committee Agenda Corporate Quality Improvement Committee (CorpQIC) Clinical Quality Improvement Committee Credentialing Sub-Committee Pharmacy and Therapeutics (P&T) Committee Utilization Management Committee (UMC) Technology Assessment Sub-Committee Service Quality Improvement Committee Member Appeal Committee Corporate Compliance Committee Public Policy Committee (Member Advisory Committee) Delegated Oversight Committee Behavioral Health Advisory Committee Other Meetings Corporate Quality Department Credentialing Department Role of Participating Practitioners Conflict of Interest Confidentiality Behavioral Health Services Member Safety Quality Issue Identification Cultural and Linguistic Objectives Complex Case (High Risk) Management Data Sources and Staff Resources Health Information System Quality Improvement Program Activities Prioritization Use of Committee Findings Clinical Practice Guidelines Preventive Health/HEDIS Disease Management Continuity and Coordination of Care Risk Management Member Complaint and Grievance/Appeals Monitoring Practitioner Compliance Monitoring i

6 Table of Contents continued Practitioner Credentialing Process Practitioner Peer Review Process Member Health Education Delegation Annual Quality Improvement Work Plan Approval of the Quality Improvement Program Utilization Management Program Description Philosophy Purpose Scope Goals Objectives Functions Accountability and Organizational Structure Utilization Management Committee Technology Assessment Sub-Committee Utilization Management Staffing, Qualifications, Training Confidentiality Integration and Linkage with Other Activities Communication Services Medical Review Criteria Review of Requests for Health Care Services Denial Process Appeals Delegated Utilization Management Utilization Management Program Evaluation and Process Monitoring Pharmacy and Therapeutics Committee Scope Structure Member Selection Criteria Term of Service Meetings Record Keeping and Reporting Major Responsibilities Conflict of Interest Confidentiality Committee Functions Formulary Review Process and Criteria Development of Review Material for Formulary Consideration Selection Criteria for Formulary Drug Status Distribution of Formulary and Communication of Pharmaceutical Management Procedures Medical Exception Request Review Criteria and Process Pharmacy Patient Safety Over- and Under-Utilization Monitoring and Prevention Delegation Oversight Appendixes A Quality Improvement Program Committees Structure Organizational Chart B Quality Improvement Program Information Flow Chart C Confidentiality and Conflict of Interest Statements D Continuous Quality Monitoring Cycle E Delegated Services Agreement Template & Delegation Grid F Organizational Charts G Policies ii

7 Quality Improvement Program Description Mission Statement Community Health Group is dedicated to maintaining and improving the health of our members by providing access to quality care and offering exceptional service to diverse populations. 1 QIP 2015

8 QIP Quality Improvement Program Description

9 Authority and Responsibility Community Health Group s Board of Directors (Board) assumes ultimate responsibility for the Quality Improvement Program (QIP) and has established the Quality of Care Committee to oversee this function. The Board passed a resolution defining the QIP as an organization-wide commitment. This resolution ensures the Board a central role in monitoring the quality of health care services provided to members and striving for quality improvement in health care delivery. The Board authorizes and designates the Chief Executive Officer (CEO) as the individual responsible for the implementation of the QIP. The CEO has delegated oversight of the day-to-day operations of the QIP to the Chief Medical Officer. The Corporate Quality Improvement Committee (CorpQIC), and the Chief Medical Officer have the responsibility of planning, designing, implementing, evaluating, and coordinating the patient care and clinical quality improvement activities. The CorpQIC reports the QIP activities to the Board of Directors. The Board of Directors has delegated this authority to its Quality of Care Committee. Performance accountability of the Board of Directors includes: Annual review and approval of the Quality Improvement Program Description, Quality Improvement (QI) Work Plan and Quality Improvement Program Evaluation. Review status of the QIP quarterly. Evaluate effectiveness of QI activities and provide feedback to the CorpQIC as appropriate. Establish direction and strategy for the QIP. Purpose The Quality Improvement Program provides a formal process to objectively and systematically monitor and evaluate the quality, appropriateness, efficiency, safety, and effectiveness of care and service utilizing a multidimensional approach. This approach enables Community Health Group to focus on opportunities for improving operational processes as well as health outcomes and satisfaction of members and practitioners/providers. The QIP promotes the accountability of all employees and affiliated health personnel for the quality of care and services provided to our members. The goals of the QIP are to: Goals Provide timely access to high-quality healthcare for all members, through a cost-effective, safe health care delivery system that objectively and systematically monitors and evaluates the quality and appropriateness of health care and services; Pursue opportunities to improve health care, services and safety; and Resolve identified problems in a timely manner. 3 QIP 2015

10 Community Health Group will achieve these goals through the implementation of well-established health management techniques that allow continuous monitoring of the entire health care process plus clinical outcome evaluations. Through these goals, Community Health Group will continually improve health care delivery and achieve the best outcomes of care possible. Functions The Quality Improvement Program functions include, but are not limited to: Implement a multidimensional and multi-disciplinary QIP that effectively and systematically monitors and evaluates the quality and safety of clinical care and quality of service rendered to members. Improve health care delivery by monitoring and implementing corrective action, as necessary, for access and availability of provider services to members. Improve health outcomes for all members by incorporating health promotion programs and preventive medicine services into all the primary care delivery sites. Evaluate the standards of clinical care and promote the most effective use of medical resources while maintaining acceptable and high standards. This includes an annual evaluation of the Quality Improvement Program. Ensure effectiveness of continuous quality improvement activities across the organization. Conduct effective oversight of delegated providers. Objectives Design and maintain the quality improvement structure and processes that support continuous quality improvement, including measurement, trending, analysis, intervention, and remeasurement. Comply and coordinate with all governmental agency requirements. Support practitioners with participation in quality improvement initiatives of Community Health Group and all governing regulatory agencies. Establish clinical and service indicators that reflect demographic and epidemiological characteristics of the membership, including benchmarks and performance goals for continuous and/or periodic monitoring and evaluation. Maintain an ongoing up-to-date credentialing and recredentialing system that complies with Community Health Group s standards, including primary verification, the use of quality improvement, and other performance indicators in the recredentialing process. Measure availability and accessibility to clinical care and service. Measure member satisfaction, identify and address areas of dissatisfaction in a timely manner through: quarterly analysis of trended member complaint data; member satisfaction surveys; and solicitation of member suggestions to improve clinical care and service. Monitor, at least annually, member and practitioner satisfaction with the Utilization Management Program. Continue to develop, adopt, and adapt practice guidelines (including preventive health) reflective of the membership. Measure compliance with a minimum of two guidelines annually. QIP

11 Measure the conformance of contracted practitioners medical records against Community Health Group s medical record standards at least once every two years. Take steps to improve performance and re-measure to determine organization-wide and practitioner specific performance. Develop studies or quality activities for member populations using demographic data. Studies and/or activities are designed to identify barriers to improved performance and/or validate a problem or measure conformance to standards. Oversee delegated activities by: establishing performance standards; monitoring performance through regular reporting; and evaluating performance annually. Evaluate under and over-utilization, continuity, and coordination of care through a variety of methods and frequencies based upon members needs. These methods include, but are not limited to, an annual evaluation of: medical record review; rates of referral to specialists; hospital discharge summaries in office charts; communication between referring and referred-to physicians; quarterly analysis of member complaints regarding difficulty obtaining referrals; identification and follow-up of non-utilizing members; profiles of physicians; rates of referrals per 1000 members; and performance measurement of practice guidelines. Coordinate QI activities with all other activities, including, but not limited to, the identification and reporting of risk situations, the identification and reporting of adverse occurrences from UM activities, and the identification and reporting of potential quality of care concerns through complaints and grievances collected through the Member Services Department. Evaluate the QI Program Description and Work Plan at least annually and modify as necessary. The evaluation addresses: a description of completed and ongoing QI activities that address the quality and safety of clinical care and the quality of services; trending of measures to assess performance in quality and safety of clinical care and the quality of service indicator data; analysis of the results of QI initiatives, including barrier analysis that evaluates the effectiveness of QI interventions for the previous year (demonstrated improvements in the quality and safety of clinical care and in the quality of services); an evaluation of the overall effectiveness of the QI program, including progress toward influencing safe clinical practices throughout the network that determines the appropriateness of the program structure, processes, and objectives; recommendations that are used to re-establish a Work Plan for the upcoming year which includes a schedule of activities for the year, measurable objectives, and monitoring of previously identified issues, explanation of barriers to completion of unmet goals, and assessments of goals. Implement and maintain health promotion activities and disease management programs linked to QI actions to improve performance. These activities include, at a minimum, identification of highrisk and/or chronically ill members, education of practitioners, and outreach programs to members. Maintain accreditation through the National Committee for Quality Assurance (NCQA) or other national accrediting body as appropriate. 5 QIP 2015

12 Scope of Quality Improvement Program Quality Improvement Program Description The QIP provides for the review and evaluation of all aspects of health care, encompassing both clinical care and service provided to external and internal customers. External and internal customers are defined as Members, practitioners, employers, governmental agencies, and Community Health Group employees. All departments participate in the quality improvement process. The Chief Medical Officer and/or the Director, Corporate Quality integrate the review and evaluation of components to demonstrate the process is effective in improving health care. The measurement of clinical and service outcomes and member satisfaction is used to monitor the effectiveness of the process. The scope of quality review will be reflective of the health care delivery systems, including quality of clinical care and quality of service. All activities will reflect the member population in terms of age groups, disease categories and special risk status. The scope of services include, but are not limited to, services provided in institutional settings, ambulatory care, home care and behavioral health (as provided by product line), and services provided by primary care, specialty care and other practitioners. Annual Review and Update of Quality Improvement Program The purpose of the annual QIP evaluation by the CorpQIC is to determine if quality improvement processes and recommendations made throughout the year result in demonstrated quality improvements in health care, disease prevention and the delivery of health care services to members. The annual evaluation assesses whether the QIP activities are systematically tracking improvement projects, resulting in improved clinical care and services, and providing appropriate follow-up of corrective actions to monitor their effectiveness. The CorpQIC is responsible for assessing reports, analyzing study and survey findings, and identifying areas of care which demonstrate improvement, and other areas which may still require interventions. Once a determination is made, the program plan is evaluated to see if certain processes require modification. A final report, including QIP program recommendations is submitted to the Board of Directors for annual approval. The following aspects of the Corporate Quality Department activities are assessed during the annual plan evaluation: Ongoing surveillance of quality indicators for the year; Quality improvement projects (goals and objectives) for the year; Tracking of previously identified issues requiring continued surveillance; Quality Improvement review of the QIP and outcome results from the previous year; Evaluation and modification, if necessary, of the QIP for the upcoming year; Implementation of the quality improvement strategy; Promotion of the development of an effective quality improvement program based on quality improvement strategies; Completion of the work plan in a timely basis; Determination if additional resources are necessary to accomplish the quality improvement strategy; and Recommendations for needed changes in the quality improvement program strategy or administration. QIP

13 Practitioners and members are notified annually that a summary of the QIP is available upon request. This summary includes information about the QIP s goals, processes, and outcomes as they relate to member care and service. Organizational Structure Oversight of the Quality Improvement Program is provided through a committee structure, which allows for the flow of information to and from the Board of Directors. An organizational chart is shown in Appendix A. Role of the Chief Medical Officer The Chief Executive Officer has appointed the Chief Medical Officer as the designated physician to support the Quality Improvement Committees outlined in this program by providing day to day oversight and management of quality improvement and credentialing activities. The Chief Medical Officer is responsible for: All activities requiring day-to-day physician involvement. The Chief Medical Officer may delegate performance of any of these responsibilities to other physicians within the network. Directing the Health Care Services Division and the various functions under its umbrella, including Quality Improvement, Credentialing, Clinical Review, Preventive Health, Behavioral Health Services (as covered by product line) and Pharmacy. The Chief Medical Officer consults with a contracted psychiatrist (designated behavioral health care practitioner), as necessary, for behavioral health issues. Communicating with the Board of Directors (Board) information from the Corporate Quality Improvement Committee (CorpQIC), the Clinical Quality Improvement Committee, (CQIC), the Credentialing Sub-Committee, the Utilization Management Committee (UMC), and the Pharmacy and Therapeutics Committee (P&T). Communicating feedback from the Board to the above listed committees. Serving as chair for the CQIC, the Credentialing Sub-Committee and the Technology Assessment Sub- Committee. Serving as co-chair for the CorpQIC, UMC, P&T and Benefits Interpretation committees. Overseeing meeting preparations for the above committees, educating committee members regarding the principals of quality improvement, keeping the committees and corporation current with the regulations and standards of the California Department of Health Care Services, Center for Medicare and Medicaid Services (CMS) and NCQA. Attending the Service Quality Improvement Committee (SQIC) meetings as needed and serving as advisor to the committee. Ensuring that the goals, objectives and scope of the QIP are interrelated in the process of monitoring the quality of clinical care, clinical safety and services to members. The Chief Medical Officer will not be influenced by fiscal motives in making medical policy decisions and establishing medical policies. Ensuring that a review and evaluation of the components of the QIP are performed annually in order to demonstrate that the process is effective in improving member care, safety, and services. Providing oversight to the implementation of the Quality Improvement Program (QIP). Guiding the formulation of quality indicators and clinical care guidelines in collaboration with network practitioners. Providing direct oversight of the credentialing and re-credentialing processes. 7 QIP 2015

14 Developing or approving policies and procedures for quality improvement, credentialing, preventive health, utilization management, pharmacy management and behavioral health. Reviewing aggregated outcomes from member complaints and grievances, member satisfaction surveys and practitioner satisfaction surveys. Overseeing the development of member and practitioner education in relation to QIP issues. Ensuring that quality of care is a component in all policy development related to health care services. Communicating directly with practitioners on any issues of the QIP to include quality of care, peer review, credentialing, or clinical care guidelines. Assisting the senior management team in the analysis, design and implementation of interventions to improve health care service delivery. Serving as an advisor to the Member Appeals Committee. Communicating information and updates regarding the QIP to Community Health Group leadership and staff via General Staff meetings, senior management team meetings, and other internal meetings. Delegating staff from other divisions to perform QI Program activities through the agreement of appropriate division chief. Designated Behavioral Health Practitioner Community Health Group utilizes a contracted network psychologist as the designated behavioral health practitioner for the QIP. The designated behavioral health practitioner advises the Clinical Quality Improvement Committee to ensure that the goals, objectives and scope of the QIP are interrelated in the process of monitoring the quality of behavioral health care, safety and services to members. Lines of Communication and Informational Flow Methods of communication include, but are not limited to, quality improvement reports, oral presentations and discussions, memorandums, policies and procedures and meeting minutes. Community Health Group monitors providers through quality monitors and on-site inspections and audits. The Director, Corporate Quality is the focal point for convergence of quality improvement related activities and information. The Director, Corporate Quality is responsible for the coordination and distribution of all quality improvement related data and information. The Corporate Quality Improvement Committee reviews, analyzes, makes recommendations, initiates action, and/or recommends follow-up based on the data collected and presented. The Chief Executive or the Chief Medical Officer communicates the CorpQIC s activity to the Board. The Board reviews the QI activities. Any concerns of the Board are communicated back to the source for clarification or resolution. (See Appendix B) QIP Committees Members For staff participants, qualifications and term of service as a committee member is determined by the duration of time a staff member holds the position, which initially qualified him/her for Committee membership (i.e., term of service continues as long as the Director, Corporate Quality holds his/her position which is also a designated position on the CorpQIC). Selected contracted practitioners and providers are invited to serve as members of a QIP Committee by the chairperson or co-chair. Selection is based on the following attributes: QIP

15 Availability/accessibility Board certification Communication skills/diplomacy Credentials/re-credentials verification Interest/enthusiasm Knowledge/expertise Managed care knowledge/experience Medical/surgical experience Peer/personal recommendation Previous quality committees experience QM audit results greater than average Reputation/ethical standards Specialty type A practitioner representative selected to participate on any QIP Committee continues to serve as long as she/he continues to qualify as a contracted practitioner whose specialty is required on the Committee panel and meets acceptable standards of behavior, with the following exceptions: Practitioner requests voluntary removal or Involuntary request for removal may be made when a provider: is no longer qualified is repeatedly unavailable (unexcused absences from three consecutive meetings) develops a conflict of interest behavior is disruptive and not conducive to effective, professional discussions and performance of business fails to meet QIP expectations QIP Committees Meetings The Corporate Quality Improvement Committee and subcommittees convene at regularly scheduled meetings, or more often if the chairperson deems it necessary; minimum frequency for CorpQIC meetings will not extend beyond a quarterly basis. A quorum consisting of either four members or 50% of the members, whichever is less, must be present for any QIP committee to conduct business, unless the chairperson has attempted to reschedule and notify participants of the meeting and a quorum still does not exist. If a quorum cannot be assembled within thirty (30) minutes of the scheduled meeting, those in attendance will select an alternate date and time. If at the alternate meeting time a quorum is still not present and cannot be obtained within thirty (30) minutes, the committee may either elect to meet and conduct business or disband. The chairperson, with the assistance of the co-chair, is ultimately responsible for notifying committee members about the meeting schedules. Reminder phone calls will be placed to the committee members a minimum of three (3) days prior to the scheduled meeting to encourage participation. An agenda and any necessary reading materials will be mailed to participants in advance to expedite the meeting time and prepare for discussion. 9 QIP 2015

16 QIP Committees Minutes Comprehensive, accurate minutes are prepared and maintained for each QIP regular or ad hoc meeting. Minutes include at a minimum, the name of the committee, date, list of members present, and the names and titles of guests, if applicable. The minutes reflect all decisions and recommendations, including rationale for each, the status of any activities in progress, and a description of the discussions involving recommended studies, corrective action plans, responsible person, follow-up and due date. Minutes will be maintained in a confidential secure file. Each committee chairperson will sign and date all minutes at the time of approval. Minutes of QI Program committees meetings are provided for review to the: Committee members, Board of Directors, and Regulatory bodies (as required and applicable). Committee Agenda The QIP Committees agendas shall follow the basic outline: Review of Minutes Unfinished Business Ongoing Reports Review of Protocols/Policies New Business Copies of all minutes, reports, data, medical records and other documents used for quality or utilization review purposes, are maintained in a manner that will ensure confidentiality of the members and providers involved in each case. Access to these records is restricted to the QIP committees members and selected administrative personnel as deemed necessary (i.e., CEO, legal staff/counsel, Board). All sensitive information, medical records and CorpQIC findings are maintained in locked files. QIP reports, minutes, audit results and other Quality Improvement documentation are only distributed for review to the: Chief Medical Officer Chief Executive Officer Board of Directors QIP Committee members Regulatory bodies (as required and applicable) All distributed copies are collected and destroyed after review; originals are maintained in secured files by committee chair and/or co-chair. Corporate Quality Improvement Committee (CorpQIC) The Corporate Quality Improvement Committee establishes strategic direction, recommends 2 policy decisions, analyzes and evaluates the results of QI activities, and ensures practitioner participation in the QI program through planning, design, implementation, or review. The CorpQIC ensures that appropriate actions and follow-up are implemented and evaluates improvement opportunities. The CorpQIC meets and reports at least quarterly to the Board s Quality of Care Committee. The CorpQIC is a multidisciplinary committee, the membership includes: QIP

17 Chief Executive Officer, Chair Chief Medical Officer, Co-chair Chief Regulatory Affairs and Human Resources Officer Chief Information Systems Officer Director, Corporate Quality Support Staff and Guests will be invited to attend the meetings as reporting requirements dictate. Responsibilities and Functions: Review the QI Program Description that establishes strategic direction for Community Health Group and forward to the Board for approval. Evaluate the Quality Work Plans, which includes providing feedback and recommendations to the appropriate sub-committee or department and forward to the Board for approval. Evaluate the effectiveness of the QI Program with input from other communities and departments annually. Receive, review, and analyze status reports on the implementation of Work Plans, including aggregate trend reports and analysis of clinical and service indicators. Appoint subcommittees and ad hoc committees as needed. Ensure that system-wide trends are identified and analyzed. Ensure that quality improvement efforts are prioritized, resources are appropriate, and resolutions occur. Prioritize quality improvement efforts and assure that resources are allotted. Approve Quality Improvement Program policies. Ensure appropriate oversight of delegated activities. Ensure integration, coordination, and communication among committees reporting to CorpQIC. Clinical Quality Improvement Committee (CQIC) The Clinical Quality Improvement Committee advises the CorpQIC of the QIP program activities and procedures performed to monitor and evaluate the quality, safety, and appropriateness of health care. The Clinical QIC meets quarterly or more frequently as needed and reports to the CorpQIC quarterly. Responsibilities: Analyzing demographic and epidemiological data Identifying risk member populations Selecting disease management clinical practice guidelines and quality activities Developing, communicating and implementing clinical practice guidelines based on current medical standards of care. These guidelines include, but are not limited to, standards instituted and approved by the American Academy of Family Physicians, American Board of Internal Medicine, American Academy of Pediatrics, American Academy of Ophthalmology, American College of Obstetricians and Gynecologists, California's Child Health and Disability Prevention Program, Health Care Effectiveness Data and Information Set (HEDIS) and United States Preventive Services Task Force. Identifying sub-optimal care through the analysis of data referred from all departments QIP 2015

18 Reviewing and approving identified trends and opportunities for improvement and recommendations for strategies to prevent adverse outcomes. Identifying practitioners/providers not complying with Community Health Group medical care standards, service standards, guidelines and/or policies and procedures. Reviewing and approving action plans for practitioners/providers in collaboration with companywide departments. Members The Clinical Quality Improvement Committee consists of the representatives listed below. Regular physician participants determine the most appropriate follow-up action to take when physician peer review issues are confirmed. There must be a minimum of three physicians in attendance to conduct committee business. Physician attendance may be in person or telephonic. Additional participants and staff representatives provide useful information and/or serve as liaisons to their respective departments. Community Health Group s Chief Medical Officer, co-chair Community Health Group s Director, Corporate Quality, co-chair Contracted IPA and medical group representatives Selected contracted, practicing physicians with diverse specialty representation (including at least two (2) who are primary care physicians (PCPs) representing Internal Medicine, Family Practice, and/or Pediatrics Obstetrician/Gynecologist Behavioral Health Physician Consultant, as needed Non-Physician Medical Practitioner Community Health Group Staff Members: Medical Director Director of Pharmacy Services Director of Utilization Management Services Provider Relations representative Corporate Quality Analyst Corporate Quality Specialist Credentialing Services Manager Physicians of other specialties as needed Ancillary Services Providers (radiology, physical therapy, etc.), as needed Major Responsibilities Chief Medical Officer: Serves as Committee co-chairperson Reports CQIC activities to the CorpQIC Director, Corporate Quality: Serves as Committee co-chairperson Reports CQIC activities to the CorpQIC, in the absence of the Chief Medical Officer Conducts literature searches to help develop potential indicators based on accepted standards of care Develops mechanisms to collect, store and profile data Reports summaries of site inspections; quality indicator screens; medical records audits; Member complaints and grievances; environmental health and safety/infection control issues; risk management issues and other issues as indicated to the Committee QIP

19 Credentialing Sub-Committee The Credentialing Sub-Committee is a sub-committee of the CQIC. This sub-committee is responsible for the review of credentialing files and makes decisions regarding credentialing and recredentialing of practitioners. The Credentialing Sub-Committee makes decisions regarding provider organizational credentialing/recredentialing. The sub-committee is responsible for the review of performance data at the time of recredentialing and making on-going contract recommendations as a result of recredentialing. The Credentialing Sub-Committee serves as the practitioner Peer Review and Appeals Committee. In this role the committee makes a reasonable effort to obtain the facts, provide adequate notice and conduct hearing procedures for health care practitioners. The members are the practitioners from the CQIC. The committee meets at least quarterly prior the CQIC and conducts telephonic meetings monthly between the quarterly meetings. The Chief Medical Officer is the chairperson. The functions of the Credentialing Committee are: Review, recommend, and approve procedures for practitioner/provider credentialing /recredentialing. Review and approve practitioner/provider credentials. Review and approve a practitioner/provider profile with input from all departments that analyze performance in conjunction with the recredentialing process. Review and approve credentialing/recredentialing standards/policy and procedures. Review and approve quality of care and service indicators for recredentialing. Review of delegated credentialing performance. 4 Pharmacy and Therapeutic (P&T) Committee The P&T Committee meets and reports to the CorpQIC quarterly. The Chief Medical Officer and Director of Pharmacy Services serve as co-chairs. The membership includes: 5 Chief Medical Officer Director of Pharmacy Services Network primary and specialty care practitioners Network pharmacy directors Pharmacy benefit management company representative Responsibilities and Functions Formulating policies on the evaluation, selection, distribution, use and safety procedures relating to medication therapy Developing and maintaining the Drug Formulary Monitoring activities related to the Formulary Exception Policy Monitoring prescribing practices and drug utilization for appropriateness Submitting a quarterly report to the CorpQIC of the status of all activities Utilization Management Committee (UMC) The Utilization Management Committee provides direction to and oversight of the Utilization Management Program. The UMC meets quarterly and reports to the CorpQIC quarterly. The Chief 13 QIP

20 The UMC is a multi- Medical Officer and Director of Utilization Management serve as co-chairs. disciplinary committee whose members include: Chief Medical Officer Network primary care and specialty practitioners Contracted IPA and medical groups representatives Director of Pharmacy Services Corporate Quality Representative Responsibilities and Functions Reviews and approves the UM Program Description that establishes direction for the organization Receives, reviews and analyzes utilization reports on the progress of the UM Program Conducts new technology assessment Reviews recommendations for delegation of utilization management and makes recommendations to the CorpQIC Formalizes UM policies and procedures Reviews, approves and distributes medical criteria and criteria for review at least annually Monitors continuity and coordination of care Conducts under/over utilization monitoring on practitioner specific and organizational-wide dimensions Evaluates satisfaction with the UM Program using member and practitioner input Technology Assessment Sub-Committee The Technology Assessment Sub-Committee (TASC), a sub-committee of the Utilization Management (UM) Committee, meets at least four times each year, with ad hoc meetings as necessary, or called by the chairperson. TASC reviews and assesses existing and emerging medical technologies, drugs, procedures and therapeutic modalities on an as-needed basis. The Chief Medical Officer is the chairperson and members include: 7 Community Health Group Chief Medical Officer, who will chair the sub-committee Director of Utilization Management Director of Pharmacy Services Corporate Quality Representative Clinicians who are credentialed and contracted by Community Health Group for both primary care and specialty care Clinicians and external experts who are not credentialed and contracted may be invited as guests of the sub-committee Service Quality Improvement Committee (SQIC) The Service Quality Improvement Committee monitors and evaluates the quality, safety, and appropriateness of non-clinical services to members, practitioners and providers and operations of the organization. The Service Quality Improvement Committee meets at least quarterly and reports to the CorpQIC quarterly. The Chief Regulatory Affairs and Human Resources Officer is the chairperson. The Service QIC membership includes: 8 QIP

21 Chief Regulatory Affairs and Human Resources Officer Chief Information Systems Officer Director of Health Plan Operations Director, Corporate Quality Director of Pharmacy Services Director of Utilization Management Director of Contract Administration Regulatory Affairs/Compliance Manager Member Services Auditor/Trainer Responsibilities and Functions Responsibilities of the Service QIC include reviewing and making recommendations for interventions to improve all service activities relative to: Complaints Grievances Member and Provider Appeal trends Telephone and turnaround time standard performance Access and Availability Claims service standards Enrollment service standards Plan Operations Member and practitioner satisfaction/dissatisfaction as identified by surveys including monitoring of PCP change requests and results of access and availability monitoring Committees and departments reporting to Service QIC are: Committees Member Appeals Transition Task Force Departments Claims Client Services Member Services Clinical Management Contracts Provider Relations Information Systems Corporate Quality Member Appeals Committee The Member Appeals Committee meets on an ad hoc basis depending on the need. Reports are generated in the aggregate and by category of Grievance/Appeal and reported to the Clinical and Service QICs, the CorpQIC, the Public Policy Committee and the Board of Directors on a quarterly basis. Membership includes: 9 Chief Medical Officer Appeals Supervisor 15 QIP 2015

22 Chief Regulatory and Legal Affairs Officer Director of Health Plan Operations Responsibility and Function The Appeals Committee provides for and defines the mechanism for processing appeals from members based on a fair and timely manner in accordance with state and federal regulations. Corporate Compliance Committee The purpose of the Corporate Compliance Committee is to address fraud prevention and detection and corporate confidentiality compliance. The committee oversees the Anti-Fraud Plan and determines appropriate responses to reported or suspected fraud. The Corporate Compliance Committee reports operational activities to the Chief Executive Officer and a summary report to the CorpQIC quarterly. The Corporate Compliance Committee meets on an ad hoc basis, but at least quarterly. The members are: 10 Regulatory Affairs/Compliance Manager, Chair Compliance Officer Chief Regulatory Affairs and Human Resources Officer Chief Financial Officer Director of Health Plan Operations Director Corporate Quality Director of Pharmacy Services Director of Utilization Management Director of High Risk Case Management System Manager/Privacy Officer Corporate Quality Analyst Public Policy Committee (Member Advisory Committee) The Public Policy Committee s purpose is to assure an avenue for member involvement in the development of educational materials, improvement of the customer service interface and in making recommendations for system changes as they affect the member. The goal of the committee is to provide a forum for member input, and to increase consumer satisfaction and member retention. The committee meets and reports to the CorpQIC and the Board of Directors quarterly. The Director of Utilization Management Services is the co-chair of the meetings with the Board of Directors representative. The membership includes: 11 Member of the Board of Directors Director of Health Plan Operations Members representing each product line Network Primary Care Practitioner Member Services representative Responsibilities and Functions Assure member input to the quality improvement process for user friendly access. Recommend to practitioners, solutions and strategies for improving membership materials and member access issues. Review prospectively new material under development. Review complaint/grievance trends for clarity of member information to facilitate changes to the system, which will produce positive outcomes. QIP

23 Delegation Oversight Committee The Delegation Oversight Committee provides a formalized mechanism to monitor and act on all delegated activities. The Committee meets at least quarterly and reports to the Corporate Quality Improvement Committee and other appropriate committees as necessary. The Chair is the Chief Regulatory Affairs and Human Resources Officer. Membership includes: 13 Chief Financial Officer Director of Pharmacy Services Regulatory Affairs/Compliance Manager Director of Health Plan Operations Director of Contract Administration Credentialing Services Manager Behavioral Health Advisory Committee The Behavioral Health Advisory Committee establishes strategic direction and recommends policy decisions relating to Community Health Group s Behavioral Health Program. The Behavioral Health Advisory Committee meets and reports at least bi-annually to the Corporate Quality Improvement Committee (CorpQIC). The Behavioral Health Advisory Committee is a multi-disciplinary committee, chaired by the Chief Medical Officer. The Committee s membership includes: Chief Medical Officer Medical Director Director of Pharmacy Services Behavioral Health Services Manager Director, Corporate Quality Staff Psychologist Behavioral Health Consultant Contracted Psychiatrist Contacted Psychologist Contracted Licensed Clinical Social Worker Contracted Marriage Family Therapist Contracted Pediatrician/PCP Psychiatric Hospital Utilization Review RN Mental Health Consumer Advocate Public Mental Health Representative/United Behavioral Health Responsibilities and Functions Review of Authorization Criteria and Process. The Committee, in conjunction with the UM Committee, is charged to develop, review, evaluate and update Community Health Group s criteria and process for authorizing Behavioral Health Services to members. Advisory Panel. Each member of the Committee serves in an advisory capacity to the Chief Medical Officer when such services are needed, particularly on an emergent or urgent basis. Continuity and Coordination of Care with Medical Practitioner. The Committee collaborates with Community Health Group and primary care practitioners to monitor and improve coordination between medical and behavioral health care. This coordination is accomplished through review, recommendation, and approval of: QIP 2015

24 mechanisms for exchange of information guidelines for diagnosing, treating and referring of behavioral health disorders commonly seen in primary care appropriate uses of psychopharmacological medications protocols for management of treatment access and follow-up for members with coexisting medical and behavioral disorders, and primary and secondary preventive behavioral health program implementation. Review of Aberrant Practice Patterns. The Committee reviews potential aberrant practice patterns or potential fraudulent activity identified by the Behavioral Health Department, Case Management Department, Claims Department, Pharmacy Services Department, Preventive Services Department and/or Corporate Quality Department and recommends corrective actions and/or policies and procedures to prevent recurrence. Quality of care issues are referred to the Quality Improvement Committee for action or review, tracking and trending. Recommendation and Implementation of Corrective Action. The Behavioral Health Advisory Committee may recommend corrective action, including practitioner sanctions, when trends or patterns of inappropriate health care resource use are identified. Such corrective actions may include formal or informal educational programs. The "Provider Fair Hearing" policy outlines procedures for imposing sanctions. Statistical Outcome Studies. The Behavioral Health Advisory Committee, in conjunction with the Utilization Management Committee, Quality Improvement Committee and Pharmacy and Therapeutics Committee produce statistical outcome studies utilizing information obtained from Community Health Group's management information system that: o support the process of evaluation and continuous quality improvement of the clinical process; o identify those clinical processes which are statistically more effective than others in order to o provide a resource for clinical quality improvement; and disseminates appropriate health care information to practitioners that will assist in promoting improved quality and cost effectiveness in health care. Establishment of Behavioral Health Studies and Criteria. The Committee may develop special studies to identify at risk populations for Behavioral Health disease management programs and to identify utilization and/or quality problems that affect the outcome of member care wellness. o o o Medical records shall be provided for the Committee's review when there is evidence of aberrant use of Plan resources. If a specialty area is not represented on the Committee, the Chief Medical Officer or the Committee may delegate the review to a qualified specialist or request a local qualified specialist to participate on the Committee for the review. Quality of care issues shall be referred to the Quality Improvement Committee for action or review and trending. Recommendations shall be made regarding population and disease management programs. Other Meetings The following meetings are designed for information sharing. Issues requiring resolution are referred to the appropriate committee, sub-committee or taken to the CorpQIC for assignment: Administrative Meeting General Staff Meeting Case Managers Meeting Leadership Strategies Team (LDT) Meeting Operations Meeting QIP

25 Corporate Quality Department The Corporate Quality Department reports to the Chief of Operations. department include: Responsibilities of the provide staff support to the Corporate Quality Improvement Committee, Clinical Quality Improvement Committee, and Sub-Committees; develop initial drafts of the QI Program documents for review and approval by the CorpQIC; develop a Work Plan identifying the responsibilities of the operations that support the program implementation; review and evaluate the Work Plans and quarterly reports of the sub-committees reporting to the CorpQIC; participate in the initial evaluation of potential delegates, reviewing and evaluating delegates reports and participate in the annual review of the delegates; assist in data collection for selected components of contractual reporting requirements for external review agencies; develop and implement systematic data collection methodologies; assist in the development of research design and methodologies for disease management programs; monitor the QI Program to assure compliance with regulatory and accrediting agency requirements; and assist in the development of company-wide policies and procedures related to Quality Improvement. Credentialing Department The Credentialing Department reports to the Director of Contract Administration, and is responsible for developing policies, procedures and forms used in the credentialing and recredentialing of practitioners. The Credentialing Unit assists the Contracts Department in development of polices, procedures and forms used in the credentialing and recredentialing of health care delivery organizations. The credentialing staff implements the policies and procedures, including gathering all applications, primary source verification, and presents a completed file for the Chief Medical Officer s review and action by the Credentialing Sub-Committee. Role of Participating Practitioners Participating practitioners serve on the QIP Committees as necessary to each committee s function. Through these committees activities, network practitioners: Review, evaluate and make recommendations for credentialing and recredentialing decisions; Review individual medical records reflecting adverse occurrences; Review and provide feedback on proposed medical guidelines, preventive health guidelines, clinical protocols, disease management programs, quality and HEDIS results, new technology and any other clinical issues regarding policies and procedures; Review proposed QI study designs; and Participate in the development of action plans and interventions to improve levels of care and service. 19 QIP 2015