Health.mil: the official website of the Military Health System (MHS) and the Defense Health Agency (DHA)

2.1  The contractor shall develop and submit a written CQMP plan which includes a detailed description of the purpose, methods, proposed goals and objectives designed to meet the intent of the program. For plan submission requirements, see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.

2.2  The contractor shall include clinical quality metrics in their network provider steerage model, including but not limited to, current indicators outlined by the organizations including:

3.1  The contractor shall collect, monitor, analyze and report clinical quality data, quarterly, semiannually, and annually. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.

3.2  The contractor shall partner with network facilities and providers and recommend performance improvement strategies and work with them to achieve measureable improvements in outcomes when unfavorable data trends greater than (>) three months (as compared with national and Defense Health Agency (DHA) benchmarks and goals) are identified. The Government reserves the right to identify changes in benchmarks 60 days prior to the exercise of each option year. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.

3.3  The contractor shall develop and submit a minimum of four Quality and Value Improvement Initiatives (QVIIs).

3.4  The contractor shall develop QVII topics in consultation with the Government and QVIIs shall be designed to test new and innovative strategies to improve clinical outcomes and beneficiary quality of life. Topics may address administrative processes, beneficiary health, error reduction, patient safety improvement, beneficiary functional status, beneficiary or provider satisfaction/experience, high-value, and high-risk issues. Appropriate scientific methodology and rigor shall be applied in written research questions and statistically significant analysis, as applicable. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.

4.1  The contractor shall allow the appropriate GDA active participation in their CQMP and non-voting membership in their regional level Quality Management Committees, including, but not limited to, Peer Review Committees both medical-surgical and Behavioral Health (BH), Clinical Quality Management Committees, and Credentialing Committees.

4.2  The contractor shall develop and implement written policies and procedures to identify Potential Quality Issues (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.

4.3  The contractor shall provide and maintain a Health Insurance Portability and Accountability Act (HIPAA)-complaint electronic-based PQI submission, tracking and trending tool for collecting all quality of care concerns regardless of source.

4.4  The contractor shall report, by a secure means, potential SREs to the GDA within two business days from when the contractor becomes aware of the event. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.

4.5  The contractor shall submit attestation to the GDA when the notification was received verbally, identifying the source, with time and date of receipt.

4.6  The contractor shall report, by a secure means, closure of the reported SRE to the GDA within two business days. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.

5.1  The contractor shall identify, evaluate and report all PQIs and confirmed QIs.

5.2  The contractor shall assess every medical record reviewed for any purpose, including, but not limited to, every medical record reviewed for any care managed, observed, or monitored on an ongoing basis for quality of care and appropriate utilization.

5.3  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. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.

5.4  The contractor who receives or identifies a cross-region 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 geographic jurisdiction for the case review, investigation, and intervention(s), consistent with TRICARE Operations Manual (TOM) requirements. 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.

5.5  The contractor shall implement appropriate quality interventions 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 sentinel event, when applicable, and describe the actions taken to resolve the quality problem. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.

5.6  Refer to https://manuals.health.mil/pages/v3/DownloadManualFile.aspx?Filename=Definitions.pdf for commonly used quality terms and definitions including, but not limited to, QVII, PQI, and QI to include severity levels.

6.1  The contractor shall operate a Peer Review Organization (PRO) in accordance with 32 CFR 199.15; all claims submitted for health services are subject to review for quality of care and appropriate utilization.

6.2  The contractor shall ensure all QIs, regardless of the source, are 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 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).

6.3  The contractor shall send cases for external peer review regardless of severity level when the contractor does not have an actively participating like-specialist (peer) on their committee. A like specialty peer reviewer should have comparable education, training, experience, licensure, certification, clinical privileges and scope of practice as the practitioner under review. The GDA reserves the right to determine appropriateness of like-peer reviewer. All standard of care determinations shall be approved by the Peer Review Committee(s).

6.4  The Peer Review Committee shall assure all identified clinical quality issues are tracked, trended, patterns identified, reported to committee and appropriately addressed until resolution is achieved.

6.5  The GDA may perform the following functions:

7.1  The contractor shall utilize the current provider-level PSI software, 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.

7.2  The contractor shall run the appropriate data for all 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.

7.3  The contractor shall report their findings, interventions, and outcomes on 100% of the cases that meet the AHRQ PSI criteria. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.

8.1  The contractor shall conduct a semi-annual statistically valid sample size audit of network providers documentation for the following standardized measures, Post-Traumatic Stress Disorder (PTSD), anxiety disorders, and depressive disorders; when age appropriate, across all BH settings (outpatient mental health (MH) and SUD, Opioid Treatment Programs (OTPs), Intensive Outpatient Programs (IOPs), partial hospitalization, psychiatric RTCs, and inpatient/residential Substance Use Disorder Rehabilitation Facilities (SUDRFs).

8.2  The contractor shall report audit results of the standardized behavioral health measures to the Government. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.

9.1  The contractor shall utilize the CMS Care Compare website (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. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.

9.2  The contractor shall partner with network facilities and recommend performance improvement strategies and work with them to achieve measurable improvements in outcomes when unfavorable trends are shown within all CQM data monitored in the applicable contract.