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/CSD or
TAO Executive Directors 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 Market/Military Medical Treatment
Facility (MTF)), 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
, TOPO,
CSD
,
and TAO Executive Directors (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/TOPO/CSD Medical
Directors and TAO Executive 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/TOPO/CSD Medical Directors and
TAO Executive 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.