Medical Management (MM), Utilization Management (UM), And Quality Management (QM)
The Managed Care Support Contractors
(MCSCs), Uniformed Services Family Health Plan (USFHP) contractor,
and the TRICARE Overseas Program (TOP) contractor (from this point
forward to be referred to as the contractor) shall operate a CQMP
which results in demonstrable quality improvement in the quality
of health care provided beneficiaries, and in the process and services
delivered by the contractor. The CQMP is defined as the integrated
processes, both clinical and administrative, that provide the framework
for the contractor to objectively define and measure the quality
of care received by beneficiaries. This CQMP shall demonstrate how
the contractor’s goals and objectives, leadership, structure, and
operational components are designed to achieve the efficient and
effective provision of timely access to high quality health care.
As part of the CQMP, the contractor shall develop a CQMP Plan with
goals and objectives followed by a CQMP Annual Report (AR) describing
the results of the quality activities performed during each program
year.
1.0 CQMP PLAN
The contractor shall develop a written
CQMP Plan which is defined as a detailed description of the purpose,
methods, proposed goals and objectives designed to meet the intent
of the program. The contractor shall fully describe in a written
CQMP Plan the structural and functional components of the program.
Details for submission of this plan are identified
by DD Form 1423, Contract Data Requirements List
(CDRL), located in Section J of the applicable contract.
2.0 Clinical
Quality Management Program Annual Report (CQMP AR)
Details for reporting are identified in
DD Form 1423, CDRL, located in Section J of the applicable contract.
The appropriate Defense Health Agency (DHA) Program
offices, Clinical Operations Division (COD), TRICARE
Overseas Program Office (TOPO), and Clinical Support Division (CSD)
will provide relevant comments to the contractors based on review
of the annual CQMP report. The report will be reviewed in conjunction
with the annual plan for the particular period of performance. Recommendations
for revision or acceptance of the annual report shall be provided
in a written format through the appropriate Contracting Officer
(CO) to the contractor within 45 calendar days of receipt of the
annual program report.
3.0
Common
Terms And Definitions
3.1 Quality Improvement
Initiative (QII)
The purpose of a QII is to improve
processes internal to the organization and may include improvements
in clinical administrative processes, program related issues or
new methods in accomplishing outcomes of the program such as cycle
time, effectiveness, efficiency, reporting tools, related processes
between departments affecting desired outcomes, etc. Common tools
for improvements in processes may include various methods that include
core elements such as baseline data, interventions/actions, re-measurement,
monitoring and follow-up. Process improvements shall be appropriately
documented to demonstrate purpose of improvement, baseline measure(s),
actions/interventions, re-measurement(s) and outcomes.
3.2 Quality Improvement
Projects (QIP)
A QIP is a set of related activities
designed to achieve measurable improvement in processes and outcomes
of care. Improvements are achieved through interventions that target
health care providers, practitioners, plans, and/or beneficiaries.
QIPs may address administrative processes, beneficiary health, error
reduction or safety improvement, beneficiary functional status,
beneficiary or provider satisfaction, program related issues or
to serve as a valid proxy for high-volume or high-risk issues. They
may result after being identified from a Clinical Quality Study
(CQS) as an opportunity for improvement. QIPs should be structured
with appropriate elements such as clearly defined sample sizes and
inclusions/exclusion criteria. They shall be appropriately operationalized,
meaning appropriate scientific methodology and rigor should be applied
such as using written research questions and statistically significant
analysis as applicable. Lastly, QIPs shall be appropriately documented
by including the following common elements of a QIP:
• Description and purpose of topic.
• Description
of the population.
• Rationale for
selection of the QIP baseline data.
• Description
of data collection.
• Goals and time
frames.
• Action plan/interventions.
• Periodic re-measurements
and outcomes.
3.3 CQS
An assessment
conducted of a patient care problem for the purpose of improving
patient care through peer analysis, intervention, resolution of
the problem, and follow-up. A CQS should be appropriately operationalized,
meaning appropriate scientific methodology and rigor should be applied
such as using written research questions and statistical significant
analysis as applicable. Typically these do not require evidence-based
interventions, multiple measurement cycles, or sophisticated statistical
analysis. Common elements of CQS:
• Description of CQS and purpose of topic.
• Rationale for the selection of the CQS.
• Define the study question.
• Description of methodology used.
• Select the indicators/measures.
• Description of data collection.
• Description of the population and sampling
techniques (if applicable).
• Report of findings to include a definition
of the study, description of data collection, statement of hypothesis,
analytic methods and population employed, data analysis and interpretation.
• Plan for follow-up of the CQS to include
interventions and measurements as applicable.
3.4 Potential
Quality Issue (PQI)
A clinical or system variance warranting
further review and investigation for determination of the presence
of an actual Quality Issue (QI).
3.5 Quality Issue (QI)
A verified deviation
from acceptable standards of practice or standards of care as a
result of some process, individual, or institutional component of
the health care system.
4.0
CQMP
Structural And Functional Requirements
4.1 The
contractor shall allow the appropriate clinical staff
from the DHA COD/TRICARE Area Office (TAO), TOPO, COD
Medical Director/Chief, and CSD clinical staff, acting on behalf
of the Uniformed Services Family Health Plan Program Office (USFHP
PO) active participation in their CQMP and non-voting
membership in their region level Quality Management Committees,
peer review committees both medical-surgical and behavioral health,
and Credentialing Committees. The contractor shall develop and implement
written policies and procedures to identify PQIs, steps to resolve
identified problems, suggest interventions to resolve problems,
and provide ongoing monitoring of all components of the contractor’s
operations and the care and treatment of TRICARE beneficiaries.
4.2 Using
the most current National Quality Forum (NQF) Serious Reportable
Events (SREs), Centers for Medicare and Medicaid Services (CMS)
Hospital Acquired Conditions (HACs), Agency for Healthcare Research
and Quality (AHRQ) Patient Safety Indicators (PSIs), and any other
DHA required indicator/event, the contractor
shall identify, track, trend, and report interventions to resolve
the PQIs and QIs. Details for reporting are identified
in the DD Form, 1423, CDRL, located in Section J of the applicable contract. Additionally,
the contractor shall report potential SREs to the Medical
Directors of the COD/TAO or CSD within two business
days from when the contractor becomes aware of the event. At a minimum,
the report shall include the beneficiary’s name, last four digits
of sponsor’s Social Security Number (SSN) or Department of Defense
(DoD) identification number, beneficiary Date
of Birth (DOB), enrollment
status, beneficiary type (Active Duty (AD), AD dependent, retiree,
retiree family member), Primary Care Manager (PCM) (name of civilian
PCM or Military Treatment Facility (MTF)/Enhanced Multi-Service
Market (eMSM)), a synopsis of the event, location of the event (to
include provider name, address, city and state or country, if applicable),
provider status, and any contractor actions taken to date. The contractor
shall report, by a secure means, closure of the reported SRE within
two business days to include closure date, outcome of review (to
include the determination of whether a QI occurred, and if so, the
severity level) and summary of actions taken. Details for reporting SREs
are identified in DD Form 1423, CDRL,
located in Section J of the applicable contract.
5.0 Patient Safety
Or QI Identification
The contractor shall apply medical
judgment, evidence based medicine, best medical practice and follow
the TRICARE criteria as set forth in
paragraphs 4.1 and
4.2 for
the identification, evaluation and reporting of all PQIs and confirmed
QIs. The contractor shall assess every medical record reviewed for
any purpose and any care managed/observed/monitored on an ongoing
basis for PQIs. The contractor shall process to completion 95% of
all PQIs within 90 calendar days from date of identification and
99%
within 180 calendar days of identification.
Details
for reporting PQIs and QIs
are contained
in the CQM Monthly Quality Intervention Reporting CDRL, DD
Form 1423
, located in Section J of the applicable
contract.
5.1
Quality
Intervention
The contractor shall implement appropriate
quality interventions using evidence based medicine/guidelines and
best medical practices to reduce the number of QIs and improve patient safety.
When the contractor confirms a QI or determines there is deviation
in the standard of practice or care, the determination shall include
assignment of an appropriate severity level and/or sentinel event, and
describe the actions taken to resolve the quality problem. Details
for the submission of a CQM Intervention
Report are identified by DD Form 1423,
CDRL, located in Section J of the applicable contract.
5.2 Definitions
5.2.1 PQI
A
PQI is a clinical or system variance, warranting further review
and investigation for determination of the presence of an actual
QI.
5.2.2 No QI
Following
investigation there is NO QI finding.
5.2.3 QI
A QI is a verified
deviation, as determined by a qualified reviewer, from acceptable
standard of practice or standard of care as a result of some process,
individual, or institutional component of the health care system.
• Severity Level 1. QI is present
with minimal potential for significant adverse effects on the patient.
• Severity Level 2. QI is present
with the potential for significant adverse effects on the patient.
• Severity Level 3. QI is present
with significant adverse effects on the patient.
• Severity Level 4. QI is present
with the most severe adverse effect and warrants exhaustive review.
• Sentinel Event. A sentinel
event is defined by the TRICARE program
utilizing the most current definition as published by the Joint
Commission.
5.3
PQI Jurisdiction
The contractor with geographic jurisdiction
has the ability to have meaningful “quality interventions,” and
has the best opportunity to demonstrate improved quality by providers
within its jurisdiction. Thus, consistent with the TRICARE Operations
Manual (TOM) requirements, cross-region PQI issues are handled as
follows: the contractor who receives and/or identifies PQI shall
conduct an initial clinical assessment based upon the information
on hand and if a PQI exists, forward the case and all supporting
information to the contractor with the geographic jurisdiction for
the case review, investigation, and intervention(s).
5.4 Peer Review
All
claims submitted for health services are subject to review for quality
of care and appropriate utilization. In all cases, peer review activities
under the Quality and Utilization Review Peer Review Organization
(PRO) program (
32 CFR 199.15)
are carried out by physicians and other qualified health care professionals.
The PRO program is concerned primarily with medical judgments regarding
the quality and appropriateness of health care services. Issues
regarding such matters as benefit limitations are similar but, if
not determined on the basis of medical judgments, are governed by
Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)
rules and procedures other than those provided in this section.
(See, for example,
32 CFR 199.7 regarding
claims submission, review and payment.) Based on this purpose, a
major attribute of the PRO program is that medical judgments are made
by (directly or pursuant to guidelines and subject to direct review)
reviewers who are peers of the health care providers providing the
services under review. Broadly, the program of quality and utilization
review has as its objective to review the quality, completeness,
and adequacy of care provided, as well as its necessity, appropriateness
and reasonableness. (Refer to
Section 1, paragraph 3.0 for peer reviewer
qualifications and participation.)
5.4.1 All QIs, regardless of the source,
shall be reviewed and confirmed by a peer review committee composed,
at a minimum, of qualified peer reviewers to determine deviations
from standards of care, severity levels, recommending interventions
to include Corrective Action Plans (CAPs), reporting to licensure
boards, and follow-up monitoring through resolution. All standard
of care determinations shall be approved by the peer review committee(s).
5.4.2 The CQMP
shall describe the peer review committee(s) composition, quorum
of voting members to conduct peer review and frequency of the meetings.
5.4.3 The peer
review committee shall assure all identified issues are tracked,
trended, patterns identified, reported to committee and appropriately
addressed until resolution is achieved.
5.5 The Medical
Directors of the
DHA COD/TAOs, TOPO
,
and CSD (acting on behalf of the USFHP PO), acting as Government
representatives and as the CO’s Technical Experts, may perform
the following functions:
5.5.1 When the Government identifies a patient
safety issue where TRICARE beneficiaries are or could be at risk,
the DHA COD/TAO/TOPO/CSD Medical
Directors may request the contractor
to take the necessary steps to safeguard the safety of TRICARE beneficiaries.
5.5.2 When the Government
identifies clinical quality concerns regarding the care rendered
to a TRICARE beneficiary or group beneficiaries, the DHA
COD/TAO/TOPO/CSD Medical
Directors may request the contractor
to conduct a clinical quality review and case investigation and
report their findings to the Government.
6.0 AHRQ PSI
sThe contractor shall utilize the
current PSI software, provider level, available from the AHRQ, to evaluate
the safety of care delivered in the network. The software is designed
for use with administrative data sets and will not require manual
chart abstraction. The contractor shall run the appropriate data
for all of the PSIs and use the analysis of the results to identify
PQIs and patient safety issues for individual providers, groups
or facilities. Analysis will also be used to provide focus for specific patient
safety interventions and/or study activity that will be implemented
at the direction of the contractor. The contractor shall report
their findings, interventions and outcomes on 100% of the cases that
meet the AHRQ PSI criteria on semi-annual and annual reports to
the Government. Details for reporting are
contained in DD Form 1423, CDRL, located in Section
J of the applicable contract.
7.0 Hospital
Compare
The contractor shall utilize the
CMS Hospital Compare web site (measures, readmission, mortality
and other reported data) to evaluate and analyze institutional performance
for each network facility in the respective region and provide a
report of the analysis. The results of the analysis are to be used
for identification of facility or specific patient safety performance
improvement, network credentialing activities and/or study activity
that will be implemented at the direction of the contractor and
included in the report. Details for reporting are
contained in DD Form 1423, CDRL, located in Section
J of the applicable contract.