Current through Register Vol. 54, No. 44, November 2, 2024
(a) A
plan shall have an ongoing quality assurance program that includes review,
analysis and assessment of the access, availability and provision of health
care services. The quality assurance program shall provide for a mechanism
allowing feedback to be reviewed and used for continuous quality improvement
programs and initiatives by the plan.
(b) The quality assurance program shall meet
the following standards:
(1) The plan shall
maintain a written description of its quality assurance program outlining its
structure and content.
(2) The plan
shall document all quality assurance activities and quality improvement
accomplishments.
(3) The activities
of the plan's quality assurance program shall be overseen by a quality
assurance committee that includes plan participating health care providers in
active clinical practice.
(4) The
plan's quality assurance structures and processes shall be clearly defined,
with responsibility assigned to appropriate individuals.
(5) The plan shall demonstrate dedication of
adequate resources, in terms of appropriately trained and experienced
personnel, analytic capabilities and data resources for the operation of the
quality assurance program.
(6) The
plan shall ensure that all participating health care providers maintain current
and comprehensive medical records which conform to standard medical
practice.
(7) The plan's review of
quality shall include consideration of clinical aspects of care, access,
availability and continuity of care.
(8) The plan's quality assurance program
shall have mechanisms that provide for the sharing of results with health care
providers in an educational format to solicit input and promote continuous
improvement.
(9) The plan shall
provide to the Department a description of the annual quality assurance work
plan, or schedule of activities, which includes the objectives, scope and
planned projects or activities for the year.
(10) The plan shall present a report of the
plan's quality assurance activities documenting studies undertaken, evaluation
of results, subsequent actions recommended and implemented, and aggregate data
annually to the plan's board of directors, and shall provide a copy of the
report to the Department.
(c) In administering a quality assurance
plan, the plan shall do the following:
(1)
Include in its quality assurance plan regularly updated standards for the
following:
(i) Health promotion.
(ii) Early detection and prevention of
disease.
(iii) Injury prevention
for all ages.
(iv) Systems to
identify special chronic and acute care needs at the earliest possible
time.
(v) Access to routine, urgent
and emergent appointments that shall be approved by the plan's quality
assurance committee. The plan shall conduct annual studies of access and
availability, the results of which shall be incorporated into the report
referenced in subsection (b)(10).
(2) Notify health care providers and
enrollees of these standards.
(3)
Involve health care providers and enrollees in the updating of its quality
assurance plan.
This section cited in 28 Pa. Code §
9.631 (relating to content of an
application for an HMO certificate of authority); 28 Pa. Code §
9.654 (relating to HMO external
quality assurance assessment); and 28 Pa. Code §
9.675 (relating to delegation of
medical management).
