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Ch 20: Quality Management
Quality Management Program Overview
VHP is committed to continuous and measurable improvement in the delivery of quality health care for its members. VHP’s culture, systems and processes are structured around its mission to continuously monitor performance to improve the health of all enrolled members.
The VHP Quality Management (QM) department oversees clinical quality assurance (QA), quality monitoring, and performance improvement (PI). One of the requirements of the National Committee for Quality Assurance is that VHP utilize provider performance data for quality and performance improvement. VHP agreements with providers require their cooperation with VHP’s QM and PI activities.
VHP conducts ongoing systematic review of health care services provided to members. Services are coordinated and monitored using applicable accrediting standards, regulatory requirements, and statutes, promulgated by the following organizations, including not but limited to: • National Committee for Quality Assurance (NCQA) • Accreditation Association of Ambulatory Health Care (AAAHC) • Centers for Disease Control and Prevention (CDC) • Centers for Medicare and Medicaid Services (CMS) • Department of Managed Health Care (DMHC) • California Health and Safety Code (HSC) • California Department of Insurance (CDI) • Office of the Patient Advocate (OPA) • Covered California (CoCA)
Quality Management, in collaboration with other teams throughout VHP, is responsible for the following activities: • Define, oversee, continuously evaluate, and improve the quality, efficacy and efficiency of health care delivered through its provider network. • Ensure that medically necessary covered services are available and accessible to members, taking into consideration the member’s cultural and linguistic needs. • Ensure VHP’s contracted network of providers cooperates with VHP’s PI and quality improvement (QI) initiatives. • Ensure that timely, safe, medically necessary, and appropriate care is available. • Ensure that VHP consistently meets quality standards as required by contract, regulatory agencies, accreditation bodies, recognized care guidelines, and the health care industry. • Promote health education and disease prevention designed to promote life-long wellness by
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encouraging and empowering each member to adopt and maintain optimal health behaviors. Maintain a quality network of providers based on NCQA credentialing standards.
Quality Management Structure and Committee
VHP’s QM Department is comprised of registered nurses and analysts. The three pillars of QM are quality monitoring, PI, and QA. Data analytics, information technology, and security are essential components in QM’s work.
The Quality Management Committee (QMC) has the responsibility of overseeing quality programs and overall quality of care. Committee membership includes staff from QM, Case Management, Utilization Management, Pharmacy, Provider Relations, and Member Services, as well as community providers (behavioral health, pediatrics, gerontology, obstetrics, and internal medicine). The QMC is physician-led and all voting members are physicians.
The QM staff also serve on other committees, including the Utilization Management Committee, Pharmacy & Therapeutics Committee, Credentialing Committee, Compliance Committee, and Appeals and Grievances Committee.
Annual Quality Management Work Plan
The QM annual work plan mirrors the VHP strategic plan and key performance metrics, as well as special initiatives. Providers are encouraged to offer input to the QM work plan. Provider participation in quality projects, including surveys and evaluations, assists QM in achieving work plan goals and is an essential component of the QM Department’s success at VHP.
The QM Department’s annual work plan includes monitoring clinical PI indicators and clinical areas to identify opportunities for improving population health, care coordination, member safety, and member experience. QM, with QMC’s approval, maintains clinical goals by which performance is measured, assessed, and evaluated. The QM annual work plan reflects progress of QI objectives and activities throughout the year.
These yearly, planned QI objectives and activities fall under the following categories: • Quality of clinical care • Safety of clinical care • Quality of healthcare service • Member experience • Others as needed
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Quality Monitoring
The QM program incorporates continuous PI (CPI) in the work plan, which addresses VHP's diverse membership, and includes objectives to: • Promote healthcare equity in clinical areas. • Improve network adequacy to meet the needs of underserved groups. • Foster VHP and provider compliance with cultural, linguistic, and disability access requirements. • Improve cultural, linguistic, and disability responsiveness in communications and materials. • Improve other areas of needs that VHP deems appropriate.
The following sources of information are monitored and may be considered for inclusion in the QM work plan: • Quality of care and adherence to guidelines, measured through Healthcare Effectiveness Data and Information Set (HEDIS) performance • Establishment of and compliance with preventive health guidelines • Establishment of and compliance with clinical practice guidelines • Acute and chronic care management • Provider network adequacy and capacity (access to care and availability of providers) • Selection and retention of providers (credentialing and recredentialing) • Behavioral health benefits • Delegated entity oversight • Continuity and coordination of care • Utilization management, including under- and over-utilization of services • Provider and employee cultural competency • Cultural, linguistic, and disability access requirements, including the accuracy of provider language capability • Member experience • Provider experience • Member appeal and grievance system • Provider dispute and complaint system • Patient safety • VHP organization performance and service
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QM annually reviews data, reports, and other performance measures as identified through the annual work plan to assess the effectiveness of initiatives. The evaluation includes a review of completed and continuing activities, audits, trending of performance data, and analysis of quality improvement projects.
The annual evaluation also addresses barriers, successes, and challenges in the determination of QI effectiveness. The annual evaluation report includes information on monitoring of clinical quality assurance activities, identification of quality of care and service issues, an assessment of the overall effectiveness of QI initiatives, progress toward influencing network-wide safe clinical practices, and qualitative analysis of annual goals with improvement plans for those that were not met.
Potential Quality Issues
A potential quality issue (PQI) is a suspected deviation from expected clinical performance, clinical care, or outcome of care, which requires additional review to determine if there is an actual quality concern or issue. The PQI process may be initiated by a member, a VHP member’s authorized representative, provider representative/practitioner or internal staff. PQIs require prompt attention from practitioners and medical staff. To report a PQI, submit a completed Potential Quality Issue Reporting Form to QM via secure email at vhpqmimprovement@vhp.sccgov.org or fax to 1.408.943.8125. A copy of the form is included in the Appendix.
VHP has a comprehensive review system to address PQIs. PQIs are forwarded to QM for clinical review that may include an evaluation and peer review by providers with similar clinical degrees and experience. A QI Registered Nurse (QI Coordinator) is responsible for collecting clinical health records and provider responses to support the comprehensive evaluation of a PQI.
PQIs are reviewed by a VHP Medical Director for final determination. When necessary, the case may also be reviewed by the QM Department’s Peer Review Committee. Based on the findings and case outcome, requests may be made to the provider for additional documentation or follow-up actions, depending upon the severity of the issue(s). PQIs require prompt attention from providers and clinical staff.
All completed PQIs are forwarded to VHP’s Credentialing Department for inclusion in the provider’s credentialing file. PQIs and related documentation, including corrective action plans (CAP) are reviewed during the credentialing and recredentialing processes.
The frequency and severity of PQIs are monitored. Depending on the number and severity of PQIs for a given provider or service location, an onsite audit may be conducted by VHP. Based on the severity and frequency of a provider’s PQIs, a provider may be terminated from VHP’s network.
Note: PQI reviews are protected from discovery by the Health and Safety Code Section 1370 and Evidence Code 1157.
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Hospital Quality
VHP’s current hospital quality activities include monitoring the cesarean section (C/S) and hospitalacquired condition (HAC)/ hospital-associated infection (HAI) rates.
To comply with CoCA requirements, hospitals must report quarterly to the Maternal Data Center of the California Maternal Quality Care Collaborative the number of nulliparous women with term, singleton baby in a vertex position delivered by C/S. VHP annually monitors the C/S rate through Cal Hospital Compare and the Smart Care California Hospital C-Section Honor Roll List.
Finally, to comply with CoCA and CMS requirements, hospitals must report quarterly to the CDC National Healthcare Safety Network HAC/HAI rates using CDC’s reporting criteria on: • Cather-associated urinary tract infection • Central line-associated bloodstream infection • Colorectal surgical site infection • Clostridium difficile infection • Methicillin-resistant Staphylococcus aureus infection
VHP annually monitors HAC/HAI rates through Cal Hospital Compare.
Healthcare Effectiveness Data and Information Set
Healthcare Effectiveness Data and Information Set (HEDIS) is a set of standardized performance measures designed to ensure that health care consumers have reliable information for performance comparison among health plans. Health plans are required to submit annual HEDIS reports to regulatory agencies such as NCQA and CMS. A subset of HEDIS measures are collected and reported for the commercial business lines each year. VHP monitors and tracks HEDIS scores to evaluate clinical quality performance and other important dimensions of care and services provided by VHP’s network of providers. VHP providers are required to actively contribute to HEDIS scoring by continuously closing gaps in care for members as well as making accessible member medical records during annual HEDIS audits.
Every year, members assess the quality of care they receive and their experience and satisfaction with VHP plans and services through NCQA and CMS. Also, every year, as part of ongoing efforts to gather additional feedback from members, VHP hires an outside vendor to administer member experience and satisfaction surveys. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) and the
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Qualified Health Plan Enrollee Survey (QHP for CoCA) uses standardized sets of questions to evaluate many health plans across the U.S. The surveys consist of 43 questions for the commercial employer group line-of-business (LOB) and 68 questions for the CoCA LOB. Member feedback is evaluated on the following:
Determination of member ratings of:
• Rating of Health Plan • Rating of Health Care • Rating of Personal Doctor • Rating of Specialist
Assessment of member perceptions related to:
• Customer Service • Claims Processing • Plan Information on Costs • Getting Care Quickly • Getting Needed Care • How Well Doctors Communicate • Shared Decision Making • Health Promotion and Education • Coordination of Care
Provider involvement with VHP members directly impacts VHP’s CAHPS and HEDIS scores. Therefore, taking the following actions can contribute to ensuring accurate reflection of VHP’s performance: 1. Inform members that they may receive a survey asking about their satisfaction (CAHPS). 2. Encourage members to complete and mail back the CAHPS survey. 3. Strive for timely and helpful customer service to members. 4. Make sure members receive appointments within the acceptable timely access requirements. See Chapter 12, “Timely Access Requirements” for access and appointment availability requirements. 5. Screen members for high blood pressure and high cholesterol. 6. Recommend and/or administer the flu shot during flu season. 7. Recommend and promote health education and wellness programs. 8. Make an extra effort to help every member get the care and support they need.
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The continued support of VHP providers is greatly appreciated and significantly contributes to VHP’s performance on the CAHPS and QHP surveys. Contact VHP’s Provider Relations Department at 1.408.885.2221 to learn more about the CAHPS and QHP surveys.
VHP supports the development and use of evidence-based clinical guidelines or resources to assist providers and members in selecting the best preventive, diagnostic, or screening options. Preventive health and clinical practice guidelines are reviewed and updated annually using the most current published medical evidence from the CDC and U.S. Preventive Services Task Force recommendations. The guidelines are updated annually by VHP’s Utilization Management Committee.
Maternal Mental Health Program
VHP’s Maternal Mental Health Program was created to improve and promote excellent quality of care and outcomes for women during their perinatal experience. In partnership with local providers, organizations, and agencies, VHP participates in a Maternal Mental Health Collaborative with the goal of strengthening the network that supports women receiving comprehensive services and care, including, education, preventive screening, and treatment resources throughout pregnancy and postpartum.
VHP’s network providers are contractually obligated to participate in quality assurance and safety, quality monitoring, population health, and PI activities. Some activities are required by regulatory bodies and others are optional. The list includes: • Participate on the QMC. • Provide expert consulting for peer review activities. • Act as an expert adviser for clinical quality activities. • Partner with VHP in quality clinical studies/projects. • Participate in routine health record and onsite audits. These procedures are outlined in QM policies COM 6004 - Health Record Standards and Requirements and COM 6007 - Evaluation of Provider/Practitioner Clinical Care and Service. Copies of these policies are available upon request from VHP’s Provider Relations Department at 1.408.885.2221. • Provide VHP with notice of PQIs, adverse or sentinel events • Participate in surveys and audits as mandated by the regulators or accrediting bodies (e.g., Provider Access and Availability, After Hours Survey and Provider Satisfaction Survey). • Provide/make accessible health records for the annual HEDIS audit to VHP’s contracted medical reviewer (without cost to VHP per the provider’s agreement).
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Assist in continuously improving VHP’s HEDIS scores, including timely submission of accurate claims and encounter data, participating in annual medical record reviews, and submission of electronic medical records data, which are obligations set forth in provider’s agreement with VHP. VHP providers, including hospitals, are required to participate in quality management activities and provide member information and health records, to the extent allowed by applicable state and federal laws, for quality of care and service reviews. VHP’s contracted providers are required to participate in PQI reviews and provide requested documents in accordance with the time frames specified by VHP.
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CH 21: Regulatory & Compliance Requirements
This Chapter Includes:
1. Compliance Program Overview 2. Audit and Oversight Activities 3. Provider General Responsibilities 4. About Health Insurance Portability & Accountability Act Privacy 5. Medical Record Confidentiality 6. Security 7. Storage and Maintenance 8. Misrouted PHI
9. Reporting a Breach of PHI 10.Fraud, Waste and Abuse 11. Investigations and Audits 12.Provider Education
13.Corrective Action Plans
14.Fraud, Waste and Abuse Training 15.Reporting Potential Fraud, Waste or Abuse
Alert
Alert draws attention to critical information that has changed this year.
Contact
Contact information on who to contact for assistance.
Book Table of Contents
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