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TRICARE Operations Manual 6010.62-M, April 2021
Clinical Operations
Chapter 7
Section 6
Clinical Quality Management Program (CQMP)
Revision:  C-5001, June 23, 2021
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.
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.
6.0  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 PSIs
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.
8.0  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:
PTSD
PTSD Checklist (PCL-5)
Anxiety Disorders
Seven-item Generalized Anxiety Disorder (GAD-7)
Depressive Disorders
Patient Health Questionnaire (PHQ-9 or A for ages 11-17)
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.
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