Current through Register Vol. 47, No. 12, March 26, 2025
(a) A PPO shall develop and implement on a
continuous basis a quality assurance and improvement program that includes
organizational arrangements and ongoing procedures for the identification,
evaluation and resolution of potential and actual problems in health care
administration and delivery to claimants. These organizational arrangements and
ongoing procedures shall be fully described in written form, provided to all
members of the governing authority, providers and staff, and made available to
eligible employees of an affected employer.
(b) The organizational arrangements for the
quality assurance and improvement program must be clearly defined and should
include, but need not be limited to, the following:
(1) a quality assurance and improvement
committee, responsible for quality assurance activities, consisting of the
medical director, the administrator, at least one member of the governing body
and provider representatives including physicians;
(2) accountability of the committee to the
governing body, with requirements for periodic written and oral reports to the
governing body;
(3) participation
from an appropriate base of providers and support staff;
(4) supervision by the medical
director;
(5) regularly scheduled
meetings at appropriate intervals but at least quarterly; and
(6) written minutes of the meetings of the
quality assurance and improvement committee describing in detail the actions
taken by the committee, the medical charts reviewed, problems discussed,
recommendations made, and any other pertinent discussions and
activities.
(c) The
content of the quality assurance and improvement program shall reflect the
scope of services provided and address all of the following:
(1) high risk procedures;
(2) sentinel events or occurrences; screens
to identify potential failures in quality of care;
(3) development of explicit criteria and
protocols for evaluating the quality of care;
(4) review and documentation of all claimant
complaints and written evaluations described in section
732-2.6(e)(12) of
this Subpart and reasons given by those who opt out. Such written evaluations
from claimants and any data extracted from such forms shall be made available
to the commissioner and chair upon request;
(5) review and assessment of the continuity
of care;
(6) review and assessment
of the appropriateness and timeliness of referrals;
(7) review of the education and training of
all primary treating physicians to ensure their knowledge and training in
occupational medicine and Workers' Compensation Law requirements, including but
not limited to:
(i) regulatory and reporting
requirements under the workers' compensation program; and
(ii) familiarity with workplace hazard
causes, restrictions, disability evaluation and rehabilitation; and
(8) review of the adequacy of
access to care as demonstrated by records of complaints pertaining to waiting
periods for appointments and telephone access.
(d) A PPO shall document the manner by which
it examines actual and potential problems in health care administration and
delivery to eligible employees. While a variety of methods may be utilized, the
following components shall be addressed:
(1)
the establishment of procedures for the analysis, monitoring and assessment of
the quality of care provided, including review criteria developed in accordance
with generally accepted standards of medical practice;
(2) the acquisition of sufficient data to
perform a meaningful analysis; for example, through a statistically valid
sample size for medical chart review; and
(3) involvement of appropriate clinical
personnel, including physicians and other providers, in peer review
activities.
(e) The
quality assurance and improvement program shall include the development and
documentation of timely and appropriate recommendations for addressing problems
that are identified in health care administration and delivery to claimants.
The PPO shall demonstrate operational mechanisms for responding to those
problems.
(f) The PPO shall
document the steps taken to follow-up on recommendations made by the quality
assurance and improvement committee. The PPO shall be able to demonstrate that
recommendations of the committee responsible for quality assurance activities
are reviewed and acted upon in a timely manner, in order to:
(1) assure the implementation of appropriate
action relative to the recommendations;
(2) assess the results of such action;
and
(3) provide for revision of
recommendations or actions and continued monitoring when necessary.
