1.0 The contractor shall operate
a CQMP which results in demonstrable quality improvement in the
quality and value of health care provided to beneficiaries, and
in the process and services delivered by the contractor. This CQMP
shall be designed to achieve the efficient and effective provision
of timely access to high quality, high value health care. The CQMP
shall be a fundamental contractor function.
2.0 CQMP PLAN
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:
• National Perinatal Information
Center (NPIC) (as available)
• National Surgical Quality Improvement
Program (NSQIP) (as available)
• The Joint Commission ORYX (as
available)
• Leapfrog® Hospital Safety Grades
(as available)
• Leapfrog® Hospital Survey (as
available)
• Healthcare Effectiveness Data
and Information Set (HEDIS)
• Consumer Assessment of Healthcare
Providers and Systems (CAHPS)
• Centers for Medicare and Medicaid
Services (CMS) Care Compare
3.0 CLINICAL QUALITY OUTCOMES DASHBOARD
AND DATA REPORTS
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.
3.2.1 The
contractor shall collect, monitor, analyze, identify, address and
report clinical quality and value data via submission of an electronic
Clinical Quality and Value Data Dashboard. A core set of measures
with goals will be provided annually by the Government Designated
Authority (GDA), 60 days prior to the start of the option year that shall
be included in the dashboard; the contractor may also propose additional
measures for the dashboard.
3.2.2 The
contractor shall ensure that the dashboard is accessible to Government
staff 24/7 except for periods of maintenance.
3.2.3 The contractor shall collaborate
with the GDA prior to the start of health care delivery (SHCD) and annually
thereafter to determine clinical quality and value improvement outcome
measures to be reported on the Clinical Quality and Value Data dashboard.
Topic areas for the measures include, but are not limited to, health outcomes,
patient experience, and health value care. In addition to measures
proposed by the contractor, the Government will strive to align
Private Sector Care (PSC) and Direct Care (DC) measures.
3.2.4 The contractor shall utilize
clinical data to determine clinical quality outcomes.
3.2.5 For dashboard 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.
4.0 CQMP STRUCTURAL AND FUNCTIONAL
REQUIREMENTS
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.
4.1.1 The contractor shall provide
DHA with all meeting materials at least three business days prior
to all scheduled meetings via eCommerce. If the three full business
day standard is not met, DHA reserves the right to require the contractor
to reschedule the meeting.
4.1.2 The
contractor shall schedule committee meetings on dates and times
mutually agreeable to the contractor and Government representatives.
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.
4.3.1 The
contractor shall identify, track, trend, and report interventions
to resolve the PQIs and Quality Issues (QIs), using the most current
indicators from:
• National Quality Forum (NQF)
Serious Reportable Events (SREs)
• CMS Hospital Acquired Conditions
(HACs)
• Agency for Healthcare Research
and Quality (AHRQ) Patient Safety Indicators (PSIs)
• Any other DHA required indicator
or event
4.3.1.1 For reporting requirements,
see DD Form 1423, CDRL, located in Section J of the applicable contract.
4.3.1.2 The contractor shall process
to completion 95% of all PQIs within 90 calendar days from the identification
and 99% within 180 calendar days of identification.The contractor
shall see approval from the GDA if they identify another category
of an indicator/event to add to the required reports.
4.3.2 The contractor’s electronic
PQI tool shall allow for any member of the healthcare team, including beneficiaries,
to submit a PQI. The tool shall be easily located on the portal
and intuitive.
4.3.3 The
contractor shall provide the GDA and their designees with training
and real time access to the PQI tracking and trending tool.
4.3.4 The contractor shall make PQI
investigation, provider Corrective Action Plans (CAPs), provider responses
to CAPs and contractor follow-up plans readily accessible within
the PQI tool.
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.
4.6.1 The Government may require
the contractor to reopen any SRE case in which the Government expresses
concern.
4.6.2 The
contractor shall complete their investigation addressing the Government’s
concerns and submit their report to the Government not later than
60 calendar days after the Government requests for a SRE case to
be reopened.
4.6.3 The
Government will approve case closure or request additional investigations
within five business days of receiving the contractor’s report for
SRE cases that have been reopened.
5.0 PATIENT SAFETY OR QI IDENTIFICATION
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.
6.0 PEER REVIEW
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:
6.5.1 When the Government identified
a patient safety issue where TRICARE beneficiaries are, or could
be at risk, the GDA may require the contractor to take the necessary
steps to safeguard the safety of TRICARE beneficiaries.
6.5.2 When the Government identifies
clinical quality concerns regarding the care rendered to a TRICARE beneficiary
or group of beneficiaries, the GDA may request the contractor to
conduct a clinical quality review and case investigation and report
their findings to the Government.
7.0 AHRQ PSI
s7.1 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.
8.0 BH STANDARDIZED MEASURES
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).
8.1.1 The
contractor shall collaborate with the Government to determine a
statistically valid sample size no later than 14 calendar days prior
to the audit.
8.1.2 The
contractor shall require providers to document in the medical record
total score results at treatment baseline, every 60-day intervals,
and at discharge for the following:
If diagnosed with:
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PTSD
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PTSD Checklist (PCL-5)
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Anxiety Disorders
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Seven-item Generalized Anxiety
Disorder (GAD-7)
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Depressive Disorders
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Patient Health Questionnaire
(PHQ-9 or A for ages 11-17)
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Note: Consistent with National Defense
Authorization Act (NDAA) for Fiscal Year (FY) 2016, Section 729
and Veterans Health Administration (VHA)/Department of Defense (DoD)
Clinical Practice Guidelines.
8.1.3 The
contractor shall educate providers and beneficiaries on the optimal
treatment dosage or frequency for best clinical outcomes for diagnosis
of PTSD, anxiety disorders, and depressive disorders.
8.1.3.1 The contractor shall educate
providers that administration of standardized measures shall be validated
for the age of the patient. The most current edition of the standardized
measures shall be used. The provider may use clinical discretion
to administer additional instruments as clinically indicated.
8.1.3.2 The contractor shall encourage
use of evidence based treatment and educate provider and beneficiaries
on current VHA/DoD Clinical Practice Guidelines.
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.
9.0 Centers For Medicare And Medicaid
Services (CMS) Care COMPARE
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.