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.