Current through Register Vol. XLI, No. 38, September 20, 2024
5.1.
Organizational arrangements and responsibilities for quality management and
improvement processes shall be clearly defined and assigned to appropriate
individuals.
a. There shall be a detailed written
description of the program which shall be reviewed annually and updated as
necessary.
b. A senior executive shall
be responsible for program implementation.
c. A medical director shall be employed by the
health maintenance organization and have substantial involvement in quality
improvement activities.
1. Upon application to and
approval by the commissioner, a health maintenance organization may employ a medical
director on a part-time basis during the first two years of the HMO's
operation.
2. All health maintenance
organizations are required to employ a full-time medical director no later than the
first day of the third year of the HMO's operation.
d. A committee shall be created to oversee quality
improvement and shall include HMO providers as active participants. The committee
shall keep contemporaneous written records reflecting all of its actions.
e. The role, structure and function, including
frequency of meetings, of the quality improvement committee shall be specified in
the program description.
f. Adequate
resources including, but not limited to, personnel, analytic capabilities and data
resources shall be dedicated to meet program needs.
g. A written quality improvement work plan shall
be prepared annually and shall include: the objectives, scope and planned projects
or activities for the year; planned monitoring of previously identified issues,
including tracking of issues over time; and planned evaluation of the quality
improvement program.
5.2. The
quality improvement committee shall be accountable to the governing body of a health
maintenance organization. The governing body shall consist of the board of directors
or a committee of senior management in instances where the board's participation
with quality improvement is indirect. There must be documented evidence of a
formally designated structure, accountability at the highest levels of the
organization and ongoing and/or continuous oversight of quality assurance.
a. The governing body shall formally designate a
subcommittee to provide oversight of quality improvement or formally decide to
provide such oversight as a committee of the whole.
b. There must be written documentation that the
governing body has reviewed and approved the written overall quality improvement
program and the annual quality improvement work plan.
c. The governing body or designated committee
shall regularly receive written reports from the quality improvement program
delineating actions taken and improvements made.
d. All quality assurance information shall be
considered in recredentialing, recontracting and/or annual performance
evaluations.
5.3. All
findings, conclusions, recommendations, actions taken, and results of actions taken
as a result of the quality improvement process shall be documented and reported to
the appropriate individuals and committees in the health maintenance organization
and through established quality improvement standards.
a. Quality improvement activities shall be
coordinated with other performance monitoring activities, including but not limited
to utilization management, risk management and resolution, monitoring of member
complaints and grievances, assessment of member satisfaction and medical records
review.
b. Quality improvement shall be
coordinated with other management functions of the health maintenance organization
such as network changes, benefits redesign, medical management systems, practice
feedback to providers and patient education.
5.4. Requirements to participate in quality
improvement activities shall be incorporated into all provider contracts and
employment agreements. Contracts shall specify that hospitals and other contractors
will allow the health maintenance organization access to members' medical records.
Contracts shall also specify that the health maintenance organization allows open
provider-patient communication regarding appropriate treatment alternatives and that
it does not penalize the provider for discussing medically necessary or appropriate
care for the patient.
5.5. The quality
improvement program must be ongoing and designed to objectively and systematically
monitor and evaluate the quality and appropriateness of care and service provided
members and to pursue opportunities for improvements.
a. The scope of the program shall be comprehensive
and shall include quality of clinical care and quality of service.
b. Members shall be afforded opportunities to
participate in and offer suggestions on quality improvement.
c. A health maintenance organization shall monitor
and evaluate clinical issues in institutional and non-institutional settings,
primary care and major specialty services including mental health, high volume
high-risk services, preventive care services, and the care of acute and chronic
conditions. Such monitoring and evaluation shall reflect the population served in
terms of age groups, disease categories and special risk status.
5.6. A health maintenance organization
shall adopt and use practice guidelines or explicit criteria that are based on
reasonable scientific evidence.
a. The guidelines
shall be reviewed and updated as needed.
b. The guidelines and any updates shall be
communicated in writing to all providers.
5.7. An HMO shall develop and implement mechanisms
for:
a. Assessing plan and provider performance
against practice guidelines;
b.
Evaluating member continuity and coordination of care;
c. Detecting under- and over-utilization; and
d. Assessing patient
outcomes.
5.8. A health
maintenance organization shall establish standards for the availability of primary
care providers and access which shall include but not be limited to routine, urgent
and emergency care; identification of members with chronic/high-risk illnesses and
the appropriate programmatic responses; telephone appointments, advice and member
service lines. The availability and access standards shall conform to the minimum
requirements set by the commissioner.
5.9. A health maintenance organization shall
develop indicators, a data collection system and data analysis capabilities to track
quality improvement.
a. Indicators shall be
objective, measurable and based on current knowledge and clinical experience and
shall be used to monitor and evaluate all aspects of care and services
identified.
b. An HMO shall have
performance goals and/or a bench marking process for each indicator.
c. Appropriate methods and frequency of data
collection shall be used for each indicator.
d. Appropriate clinicians shall be used to
evaluate data on the clinical performance of practitioners.
e. Multidisciplinary teams shall be used, where
indicated, to analyze and address systems issues.
5.10. If a health maintenance organization
receives ten or more complaints from members or enrollees within a six-month period
that relate to the same or similar subject matter, the health maintenance
organization shall develop a specific written plan of action as to the resolution of
the complaints and file a report with the commissioner on how the complaints were
successfully resolved.
