Quality Management and Improvement Program Description
2015
Quality Management and Improvement Program Description
TABLE OF CONTENTS INTRODUCTION ............................................................................................................................................. 3 PURPOSE ....................................................................................................................................................... 3 GOALS AND OBJECTIVES ............................................................................................................................... 3 AUTHORITY AND ACCOUNTABILITY .............................................................................................................. 5 SCOPE OF QUALITY MANAGEMENT AND IMPROVEMENT PROGRAM ......................................................... 8 WORK PLAN ................................................................................................................................................ 12 DELEGATION ............................................................................................................................................... 13 HEALTH INFORMATION SYSTEMS ............................................................................................................... 13 EXTERNAL REPORTING AND REVIEW .......................................................................................................... 13 CONFIDENTIALITY ....................................................................................................................................... 13 ANNUAL EVALUATION ................................................................................................................................ 14 REVIEW AND APPROVAL ............................................................................................................................. 15
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Quality Management and Improvement Program Description
INTRODUCTION Trillium Community Health Plan (Trillium) is a community based organization serving members in Lane County and offering health plans throughout Oregon. Trillium embraces the Triple Aim: lower healthcare costs, enhance patient experience and quality care, and improve health of individuals in the community. Trillium collaborates with medical and behavioral health practitioners/providers to support the health of individuals, families and communities, while identifying opportunities to improve care and access to services. Trillium’s integrated Quality Management and Improvement (QMI) Department provides the operational framework to assist in the achievement of the Triple Aim. The QMI Program is comprehensive and establishes standards, goals and objectives to maintain a culture of quality and to promote sharing of information.
PURPOSE The QMI Program provides structure and key processes to objectively and systematically monitor and evaluate quality, safety, access, efficiency and effectiveness of medical and behavioral healthcare services. Trillium focuses on opportunities to improve operational processes (e.g., health outcomes and satisfaction of members, practitioners and providers). The QMI Program supports accountability for quality of care and services provided to Trillium members.
GOALS AND OBJECTIVES Trillium’s integrated medical and behavioral healthcare model is committed to Continuous Quality Improvement (CQI) to conduct meaningful activities internally and externally to ensure members receive care to improve their health and well‐being. Trillium’s commitment to the integrated model is reflected in the following goals and objectives: Build and promote quality throughout Trillium’s organizational structure, processes and practitioner/provider community. □ Monitor data for outcomes and health disparities to identify gaps in systems of care. □ Provide information and education to practitioners/providers and members regarding status of quality activities and applicable measurements. Promote member safety. □ Monitor data to identify and address trends in member safety issues, including: Claims, pharmacy and utilization management data. Health risk stratifications and assessments. Model of Care (MOC) guidelines for Complex Case Management (CCM) and Disease Management (DM). Clinical site reviews and medical record audits. Complaints, grievances, appeals and adverse events. Member experience and satisfaction surveys. □ Collaborate with practitioners/providers and establish mechanisms to support and promote safe clinical practices and delivery of care (e.g., information and education regarding status of member safety initiatives). Rev. 02/27/15
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Quality Management and Improvement Program Description □
Evaluate practitioner/provider credentialing and re‐credentialing documentation/licensure to verify qualifications for established standards of care and service. □ Promote clinically appropriate, safe and cost‐effective use of pharmaceuticals based on sound clinical evidence and decision making. □ Educate members to broaden their knowledge of clinical safety and encourage patient‐ centered care, including: Information posted to member and practitioner/provider websites. Member and practitioner/provider newsletters. CCM and DM educational materials. Ensure access to appropriate medical and behavioral healthcare services. □ Collaborate with practitioners/providers to ensure sufficient access and capacity. □ onitor practitioner/provider data to ensure member has access to timely, effective and efficient healthcare services. Ensure members receive quality care in a culturally and linguistically appropriate manner. □ Maintain a practitioner/provider network linking members with services to meet cultural, racial, ethnic and linguistic needs and preferences. □ Assess practitioner/provider chart and site review reports to identify differences in provided care and outcomes achieved. □ Provide training and tools to staff and practitioners/providers to support culturally‐ competent communication. □ Analyze cultural, ethnic, racial and linguistic data to determine disparities and ensure member needs are met. □ Provide appropriate translation and interpretative services to members. Identify and reduce barriers to services for members with special or complex medical and/or behavioral healthcare needs. □ Data sources include: Health Assessment. Mental Health Assessment. Claims and pharmacy data. Hospital discharge and Emergency Department data. Chart notes and Electronic Health Record (EHR) reviews. Medical risk stratification. Activities of Daily Living. Referrals by Trillium CCM and DM program staff, Trillium Behavioral Health (TBH) Care Coordinators, hospital discharge planners, medical and behavioral healthcare practitioners/providers, members and caregivers. □ Coordinate care and facilitate delivery of appropriate and effective medical and behavioral healthcare to assist members in regaining optimum health or improved functional capacity, in the most appropriate setting and cost‐effective manner. □ Maximize health outcomes by developing and adopting evidence‐based clinical practice guidelines providing criteria for delivery of medical and behavioral healthcare services. Ensure high level member satisfaction. □ Provide member education regarding rights to file complaints, grievances and appeals. □ Monitor member complaints, grievances and appeals data to identify trends in dissatisfaction and concerns related to medical and behavioral healthcare disparities.
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Quality Management and Improvement Program Description □
Collaborate with practitioners/providers regarding member satisfaction to address identified medical and behavioral healthcare trends. Maintain compliance with state and federal regulatory requirements and accreditation standards. □ Monitor and incorporate updated regulatory requirements and accreditation standards. □ Revise annual QMI Program Work Plan to incorporate accreditation and regulatory audit findings and actions.
AUTHORITY AND ACCOUNTABILITY The Trillium Board of Directors is the governing body of Trillium, who retains final authority and responsibility for quality and safety of medical and behavioral healthcare services provided to members. The Board of Directors delegates oversight of the QMI Program to the Trillium Executive Committee. The Executive Committee assigns accountability of QMI Program functions to the Quality Management and Improvement Committee (QMIC) as an action body, empowering QMIC to make operational decisions. QUALITY MANAGEMENT AND IMPROVEMENT COMMITTEE QMIC voting membership represents primary care, behavioral health and specialty practitioners, and community partners (clinical and non‐clinical representation). The committee Chair and Co‐chair are selected by majority vote from current voting membership; Trillium staff members attend as non‐voting members. The committee meets monthly to provide and promote oversight and direction for the QMI Program goals and objectives. The committee documents the following in monthly meeting minutes: Policy decision recommendations providing evidence of review and consideration of changes in policies, procedures and Work Plan. Analysis and evaluation of results from quality improvement activities. Actions to improve quality and prioritize activity based on analysis and significance. Appropriate follow‐up in reviewing and evaluating actions to determine effectiveness of quality initiatives. QMIC roles and responsibilities include: Review and approval of QMI Program Description, Work Plan, Annual Evaluation and quality activities assessing effectiveness and value to members. Review and approval of applicable medical and behavioral health policies. Promote safe clinical practices and delivery of care to ensure member safety, including clinical guidelines and criteria. Evaluate, monitor and analyze medical and behavioral health data including: □ Results of regulatory, contracting or accrediting agency reviews and audit findings. □ Complaints, grievances, appeals and adverse events. □ Credentialing and re‐credentialing. □ Consumer Assessment of Healthcare Providers & Systems Survey (CAHPS®). □ Healthcare Effectiveness Data & Information Set (HEDIS®) performance measures. □ Health Outcomes Survey (HOS). □ Behavioral Healthcare and Services Assessment. □ Practitioner/provider access and availability, satisfaction surveys and opioid prescribing trends. □ Member demographics and episodes of care. □ Utilization Management (UM) □ Utilization Management of CCM. Rev. 02/27/15 Page 5 of 15
Quality Management and Improvement Program Description
□ Utilization Management of DM. □ Quality Improvement Projects. Identify barriers, prioritize goals and develop actions to improve quality. Monitor effectiveness of actions to improve quality. Review QMIC sub‐committee minutes. Provide periodic feedback and education to peers regarding status of quality management initiatives. Other roles and responsibilities as determined by Executive Committee.
QUALITY MANAGEMENT WORK TEAMS/SUBCOMMITTEES Trillium’s quality management sub‐committees and work teams are dedicated to ensure safe clinical practices and implement quality management and improvement activities identified by QMIC. Quality Management/Process Improvement Team (QM PIT): an integrated medical and behavioral health team representing Analytics/Information Technology, Care Coordination, Operations, Pharmacy, QMI and UM, with a focus on clinical and non‐clinical aspects of quality management and improvement. □ QMI Department staff organizes and facilitates QM PIT, which convenes twice per month to review and analyze outcome measures associated with medical and behavioral health, practitioner/provider accessibility and availability, grievances/requests for grievance review, appeals, HEDIS®, hospital re‐admissions, member experience and satisfaction surveys (e.g., Behavioral Healthcare and Services Assessment, CAHPS®, HOS), special needs populations, statewide accountability metrics and assessment results of information systems to collect, process and safeguard claims, encounter and enrollment data. □ QM PIT develops quality improvement recommendations for QMIC review, identifies goals and objectives, and assesses barriers to program effectiveness. Credentialing and Peer Review Committee (CPRC): an integrated medical and behavioral health committee responsible for all credentialing and re‐credentialing decisions regarding practitioner/provider ability to deliver care, decisions based on whether credentialing information collected and verified meets Trillium panel participation requirements, and whether the practitioner/provider is approved to participate in Trillium’s panel. □ CPRC membership represents primary care, behavioral health and specialty practitioners participating in Trillium’s network. CPRC members provide advice and expertise for credentialing decisions. □ Trillium Medical Director serves as a voting committee member. □ CPRC convenes monthly to monitor potentially adverse credentialing and re‐ credentialing information; determines peer review activities; and reviews, modifies, and approves all credentialing and re‐credentialing policies, procedures and related documents at least annually. The CPRC provides oversight of delegated credentialing and re‐credentialing, and makes decisions regarding practitioners not meeting Trillium’s established approval criteria. Trillium Pharmacy and Therapeutics Committee (P&T) for Medicaid: develops, maintains and follows policies and procedures for formulary management activities including objective evaluation, review and guidance for therapeutic use of drugs contained in Trillium formularies. The committee meets, at minimum, quarterly depending on quantity of drugs requiring review to maintain formularies. Rev. 02/27/15
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Quality Management and Improvement Program Description □ □
Trillium committee voting members include practicing primary care and specialty practitioners, and at least one practicing clinical pharmacist. Committee members are responsible for exercising professional judgment in making formulary management decisions based on clinical/scientific evidence and analyses.
QUALITY MANAGEMENT AND IMPROVEMENT DEPARTMENT STAFF Trillium’s medical and behavioral health staff collaborates to develop and implement the QMI Program during workgroup and committee meetings. The Chief Operations Officer directs the QMI Supervisor in providing oversight and coordination to QMI Department staff. The integrated QMI team is responsible for quality management and improvement activities to: Institute state and federal quality improvement initiatives. Comply with national accreditation standards. Coordinate external quality review evaluations. Oversee CAHPS®, HEDIS®, HOS and other measurement outcomes. Collect, analyze and report quality data. Participate in QMIC and QM PIT committee meetings. Implement initiatives to improve member safety. Analyze, process and resolve complaints and appeals. Input, validate, maintain and archive legal documentation regarding third party access to a member’s protected health information (PHI). Trillium Medical Director and Licensed Behavioral Health Practitioner provide leadership with implementation of QMI Program goals and objectives. Directors collaborate with QMI staff and participate on QMIC, QM PIT, various sub‐committees and work teams to ensure QMI activities are consistent with healthcare standards and clinical appropriateness. Directors are involved in key aspects of medical and behavioral healthcare components of the QMI Program including: Liaison between Trillium medical and behavioral healthcare practitioners, specialists and providers. Review medical and behavioral health QMI policies and procedures. Assist in analysis of utilization data for problem identification, prioritize development, implement and evaluate corrective action plans. Monitor continuity and coordination of medical and behavioral healthcare. Review and make decisions regarding: □ Medical necessity denials. □ Potentially cosmetic or experimental procedures. □ Benefit exceptions. □ Out‐of‐network practitioners. □ Appropriateness of new technology. □ Individual needs and assessment of local delivery system when UM criteria are not appropriate for member. □ Adoption and update of clinical practice guidelines. □ Results of quality improvement activities. □ Member experience with service. □ Coordination of services for members with complex and chronic conditions. Directors provide clinical expertise in the review and subsequent reporting of the following: Performance aligned with key indicators for quality improvement. Quality and utilization of clinical care and services provided by hospitals, practitioners and ancillary providers. Rev. 02/27/15
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Quality Management and Improvement Program Description
Evaluation of continuity and coordination of care including over and underutilization of services and pharmaceuticals. Monitoring and evaluation of member and practitioner/provider satisfaction information. Review of indicators measuring member care outcomes. Evaluating access to routine, urgent and emergent care. Access and availability to medical and behavioral healthcare.
SCOPE OF QUALITY MANAGEMENT AND IMPROVEMENT PROGRAM A focus and attitude toward improving processes to enhance the quality of outcomes is embedded in Trillium’s mission and promoted to reflect how Trillium conducts internal and external business. QMI Program activities include review and evaluation of medical and behavioral healthcare members receive. The QMI Program is structured to monitor, analyze, process and implement quality measures internally and externally to improve outcomes and the overall health of the community. Trillium Medical Director, Licensed Behavioral Health Practitioner and QMI staff collaborate and participate in QM PIT and QMIC, and review data measuring clinical care, service outcomes and member satisfaction to evaluate effectiveness of healthcare improvement projects. Improvement projects reflect member population age groups, medical and behavioral health disease categories, complex needs and special risk status. PERFORMANCE IMPROVEMENT PROJECTS (PIPs) The QMI Department is responsible for coordination of quality improvement projects. Medical and behavioral health PIPs are based on research and current clinical knowledge. PIPs are designed with goals, objectives, measures, inclusion/exclusion criteria and analysis time frames. Measurement of indicators is based on systematic collection/analysis of valid and reliable data. Re‐measurement is conducted at least annually to assess effectiveness of implemented interventions. Trillium conducts barrier analysis to identify intervention effectiveness. If goals are not accomplished, barrier analysis results determine additional interventions or termination of projects. QMIC reviews and approves PIPs prior to implementation, and receives periodic status and progress reports by the QMI Department. Current PIPs include: Depression screening and treatment in the primary care medical home in the Medicaid Population. Diabetes monitoring for members with schizophrenia or bipolar disease in the Medicaid Population. Hospital readmissions. Tobacco cessation in pregnancy incentive program. CHRONIC CARE IMPROVEMENT PROGRAM (CCIP) Trillium Medical Management and QMI Department design the CCIP to improve health outcomes for individuals on Medicare with multiple and/or severe chronic conditions. CCIPs are clinical programs identifying and monitoring members who could benefit from participation. CCIPs are specific to plan type and membership demographics. Current H2174 CCIPs include: Prevention of Primary and Secondary Heart Disease in the Medicare Elderly Population. Prevention of Primary and Secondary Heart Disease in the Medicare Dual Population and Special Needs Plan (SNP) Community Institutional Equivalent. Prevention of Primary and Secondary Heart Disease in the Medicare Institutional SNP (ISNP). Rev. 02/27/15 Page 8 of 15
Quality Management and Improvement Program Description Current H6951 CCIPs include: Prevention of Primary and Secondary Heart Disease in the Medicare Elderly Population. QUALITY IMPROVEMENT PROJECTS (QIP) The QIP is designed to identify improvement opportunities and interventions, and to improve health outcomes resulting in a reduction of hospital readmissions for individuals on Medicare. QIPs are clinical programs used to monitor and identify areas where hospital readmissions can be decreased. QIPs are also specific to plan type and membership demographics. Current H2174 QIPs include: Reducing Hospital Readmissions in the Dual SNP Population. Reducing Hospital Readmissions in the ISNP Population. Reducing Hospital Readmissions in the ISNP‐E Population. Reducing Hospital Readmissions in the Non‐SNP Population. Current H6951 QIP: Reducing Hospital Readmissions in the Non‐SNP Population COMPLEX CASE MANAGEMENT/DISEASE MANAGEMENT (CCM/DM) The CCM and DM Programs proactively assist members who have experienced a critical event and/or diagnosis in regaining or maintaining optimal health in a cost‐effective manner. The programs provide tools and resources to assist members and practitioners in managing chronic illness, and empower members to improve their health and chronic conditions. Care coordination utilizes predictive modeling software embedded in an electronic platform to support assessment and management of members. Participation in CCM and/or DM programs is optional. For members choosing not to participate, Trillium offers educational materials, counseling, mentoring, community resources and opportunities for members, practitioners and caregivers to coordinate care, set goals and monitor progress for a more independent lifestyle, overall better gauging of health and activities, and improved medical and/or behavioral health outcomes. QM PIT reviews effectiveness of materials, programs, monitoring activities and makes recommendations to QMIC. CREDENTIALING AND RE‐CREDENTIALING New applicants are evaluated for practitioner/provider network participation, to verify qualifications including licensure and accreditation. Applicants are monitored for potentially adverse information and systematic re‐evaluation for maintaining established licensure, certification and quality care/service standards. Trillium monitors and trends member grievances involving practitioners/providers for significant patterns to be considered during each re‐credentialing evaluation. In addition to routine site visits, practitioner site review and/or medical record review may be required when a complaint is received regarding site, medical record keeping practices, clinical care and patient safety concerns. MONITORING QUALITY INDICATORS Trillium monitors quality indicators to identify trends and performance opportunities in specific areas and facilitate improvements in all aspects of medical and behavioral healthcare services. Quality performance measures are based on nationally recognized quality indicators such as HEDIS® and CAHPS®. Medicaid and Medicare establish standards for data collection, validation and interpretation of various performance measures. Trillium monitors the results of selected quality performance metrics and reports them to quality committees for action to improve service delivery. Rev. 02/27/15
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Quality Management and Improvement Program Description
Access and Accessibility, and Appointment Availability and After Hours Monitoring Trillium monitors medical and behavioral health practitioner accessibility and availability to ensure established standards for: □ Geographical distribution of practitioners located within an acceptable driving distance or time from member residence. □ Ratio of practitioners to members. □ Hours of operation. □ Appointment availability. □ Provisions of routine, urgent or emergent care and after‐hours service. Monitoring activities include: □ Practitioner access surveys. □ On‐site visits. □ Monitoring of grievances and grievance dispute resolutions (includes complaints, grievances and appeals). Trillium addresses specific deficiencies with a corrective action plan and conducts a subsequent assessment to ensure compliance.
Behavioral Health Practitioner/Provider and Member Satisfaction Survey Trillium assesses practitioner/provider and member satisfaction using a behavioral health satisfaction survey. Trillium administers the survey bi‐annually. The survey addresses practitioner/provider and member satisfaction with access and quality of care; knowledge of right to file and receive timely resolution of grievances; and coordination of care with medical services and community resources. Trillium analyzes and presents results to quality management committees for recommended improvement activities.
CAHPS® CAHPS® survey is conducted annually to assess member experience or perception of key aspects of their care and not how satisfied they were with their care. The survey focuses on services received from Trillium and network practitioners/providers in delivery of care.
Grievances and Request for Grievance Review; Appeals Trillium compiles, analyzes and trends medical and behavioral healthcare complaint, grievance and appeal data, and hearing outcomes to assess member satisfaction. Trillium combines trending and analysis results and presents to QM PIT quarterly to develop recommendations addressing member satisfaction. QM PIT presents recommendations to QMIC for approval.
Coordinated Care Organization (CCO) Metrics Centers for Medicare & Medicaid Services choose quality measures for transformation, expansion and accountability of Oregon’s Medicaid program. The Oregon Health Authority has selected a subset of measures to establish outcomes and quality measures, and financially incentivize CCOs for achieving performance improvement targets.
External Quality Review (EQR) and Information Systems Capabilities Assessment (ISCA)
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Quality Management and Improvement Program Description EQR and ISCA evaluate how states design and conduct activities and programs meeting federal requirements in managed care delivery systems on an annual basis. EQR related activities: □ Validate PIPs. □ Monitor compliance with federal and state regulatory and contractual standards. □ Validate and calculate performance measures. □ Validate accuracy and completeness of encounter data. □ Assess information system capabilities. □ Evaluate federally mandated Medicaid quality assessment and performance improvement strategies.
HEDIS® A comprehensive measurement tool containing a variety of medical and behavioral healthcare related areas including: effectiveness of care, access to care, use of healthcare services, member experience (CAHPS®), health plan stability and health plan descriptive information. Trillium collects, analyzes and evaluates Medicare data annually. Trillium submits the subset of HEDIS® measures for each Medicare special needs plan meeting established enrollment minimums. Trillium contracts with a certified HEDIS® vendor to calculate the complete set of measures and SNP subset measures.
HOS A member‐reported outcomes measure used in Trillium Medicare managed care. The survey focuses on members’ current activities and changes in health status. The survey is administered to a different group each year. The same respondents are surveyed again two (2) years later as a follow‐up measurement. Trillium contracts with an NCQA certified HOS vendor to administer the survey and review results to identify trends in healthcare for members, develop quality improvement activities and assist members in making informed healthcare choices.
Practitioner Medical and Behavioral Health Record Reviews and Site Visits Trillium ensures contracted practitioners/providers adhere to requirements of their contract regarding: □ Practices and maintenance of medical and behavioral health records. □ Administrative and personnel policies and procedures. □ Documentation of treatment and planning. □ Cultural competency. □ Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy and security compliance regulations. Trillium evaluates access, adequacy and safety of medical and behavioral health facilities during on‐site visits. Trillium Medical Management clinical staff, or delegated entity, presents results of practitioner/provider record reviews to quality committees for recommended action.
SNP Model Of Care (MOC) Dual eligible members for Medicaid and Medicare represent a population with a high incidence of frailty, behavioral health and developmental issues, and complex chronic
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Quality Management and Improvement Program Description conditions. The SNP MOC is designed to integrate and coordinate program services and benefits, incorporating structure and process of administrative functions. MEDICAL AND BEHAVIORAL HEALTH GUIDELINES AND CRITERIA Trillium adopts nationally recognized medical and behavioral health clinical practice guidelines, and reviews and implements guidelines annually, or sooner, if updates are published prior to scheduled review. Trillium Medical Director and Licensed Behavioral Health Practitioner participate in review of criteria presented to QMIC for approval. Trillium disseminates guidelines and criteria to staff and to practitioners/providers through the Trillium website, newsletters, fax or email notification.
WORK PLAN Trillium prepares the QMI Work Plan annually to focus on medical and behavioral health program goals and objectives, and identifies planned activities for the following year. QMIC monitors the Work Plan to guide quality management activities/reports, and reviews and approves significant changes. Trillium uses the Work Plan as a CQI process to review and update progress and revisions to QMI activities, addressing the following: Quality of Service: □ Conduct CAHPS® and experience/satisfaction surveys to assess member perceptions of service received from Trillium network practitioners/providers. Quality of Clinical Care: □ Adopt clinical guidelines to assist practitioners/providers in decisions regarding appropriate healthcare delivery, providing members with increased preventative care while decreasing preventable hospital re‐admissions. Safety of Clinical Care: □ Distribute member information improving knowledge about clinical safety of their care. □ Distribute member information facilitating informed decisions based on safety. □ Collaborate with network practitioners/providers to develop incentives for achieving safer clinical practices. □ Focus existing quality improvement activities on improving patient safety. Program Scope: □ Coordinate all QMI and administrative activities, performance metrics, activities related to audit findings and other monitoring/reporting, which addresses quality of service and safety of clinical care. Yearly Objectives: □ Measure predetermined expectations annually against outcomes to provide options for improvements and to address areas of concern. Yearly Planned Activities: □ Develop and conduct areas of performance in specific time frames ensuring orderly administration of care, patient education, accountability, timely reporting and identifying improvements. Time Frame: □ Allot specific time ensuring completion of each activity/intervention in a manner conducive to meeting established quality service, care and safety goals. Staff Members: □ List lead/team members assigned to specific activities/interventions for each item addressed in annual Work Plan. Rev. 02/27/15 Page 12 of 15
Quality Management and Improvement Program Description
Previously Identified Issues: □ Develop QMI activities/interventions addressing previous outcomes to optimize quality, appropriateness and safety of medical/behavioral healthcare and services. QMI Program: □ Evaluate QMI Program annually to assess effectiveness of goals and objectives for quality improvement of medical/behavioral health delivery systems.
DELEGATION Trillium delegates portions of QMI, UM, pharmacy and credentialing programs. Delegation oversight is the responsibility of appropriate Trillium committees and staff. Trillium reviews a delegate’s program prior to delegation and, at least annually, for compliance with Trillium policies and procedures, federal and state rules, regulations and accreditation standards.
HEALTH INFORMATION SYSTEMS Trillium maintains a proprietary health information system allowing for collection, analysis and integration of medical and behavioral health data to conduct quality management activities. Data includes claims, enrollment, credentialing, practitioner/provider network, care coordination, complaints, grievances and appeals. Trillium establishes policies and procedures to ensure appropriate and accurate data collection for internal use and submission to external sources. Trillium monitors data for accuracy and validity, and implements program changes to remain consistent with national standards.
EXTERNAL REPORTING AND REVIEW Trillium cooperates with reviews conducted by regulatory, contracting or accrediting agencies; documents and maintains QMI Program and information collected in response to required reporting measures; makes information available to external entities during reviews and upon request; promptly addresses findings and recommendations; and presents results of medical and behavioral health external reviews to QMIC for recommendations and implementation of interventions and improvements.
CONFIDENTIALITY Trillium implements policies and procedures for data use, submission and transmittal of PHI in compliance with state and federal laws and HIPAA. Employees sign confidentiality agreements upon hire and are required to maintain confidentiality at all times. Trillium provides mandatory staff training periodically to ensure continued compliance. Contractors, temporary employees, volunteers and practitioners/providers participating in Trillium committees or other advisory roles, also sign confidentiality agreements. QMI activities involve collection and analysis of member, practitioner/provider data. Trillium de‐ identifies, or presents reports in aggregate, to QMIC or to external entities as part of review processes to protect member and practitioner/provider confidentiality. Trillium limits access to information with Rev. 02/27/15
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Quality Management and Improvement Program Description individual identifiers and secures information in a manner following professional standards of data security compliant with federal and state requirements. QMIC activities and documentation are considered privileged and confidential. QMIC distributes minutes and related documents to staff, practitioners and providers directly involved in specific QMI activities or processes. External sources may review QMIC minutes as required by contract or regulations.
ANNUAL EVALUATION QMIC evaluates the QMI Program annually to assess effectiveness of goals and objectives for quality improvement of medical and behavioral health delivery systems. Annual evaluation of medical and behavioral health programs include: Description of QMI Program and accomplishments for year in review. Identification of strengths, weaknesses and opportunities for improvements. Evaluation of resources and program structure. Description and assessment of completed and ongoing QMI activities and projects, and whether yearly planned activities were completed with objectives met. Analysis of quantitative measures trended over time to compare performance objectives. Assessment of performance in quality and safety of clinical care, and quality of service. Assessment of barriers and recommended interventions to achieving program goals and objectives, and overall effectiveness of QMI Program. QMIC structure and activities. Leadership and involvement of practitioners and directors. Identification of restructure or changes to QMI Program for subsequent year. Recommendations for future QMI projects. QMIC reviews and approves the Annual Evaluation. QMI Program documents, including Program Description, Work Plan and Annual Evaluation, are available in printed form to members and practitioners/providers upon request.
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Quality Management and Improvement Program Description
REVIEW AND APPROVAL QMI Program Approval QMIC Approval Date:
03/04/15 Date
Date
Date
INTERNAL REVIEWS Date Revised By
Description of Revision
QMIC Committee Approval Required (Y/N) Internal Review by Medical Director Required (Y/N) MD Signature
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1/13/2015 Cheryl Yook, Lisa Ruth, Mae Sarrica Changes in formatting, grammar, and organization.
2/27/2015 QMI Staff and QM PIT committee members. Content revisions for 2015 based on 2014 performance and department expansion.
N
Y
N
N
N/A
N/A
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