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)
• 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.3.1.1 Reports shall include,
but are not limited to:
• HEDIS
• Agency for Healthcare
Research and Quality (AHRQ)
• Leapfrog®
• National Quality Forum
(NQF)
3.1.2 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 measurable 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 Clinical
Quality and Value Data 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 Dashboard.
3.2.3.1 TopicClinical
Quality and Value Data Dashboard topic areas for the
measures include, but are not limited to, process and
outcome measures regarding health utilization, health
outcomes, patient experience, and health value care.
3.2.3.2 In addition to
measures proposed by the contractor, theThe Government
will strive to align Private Sector Care (PSC) and Direct Care (DC)
measures in addition to the measure proposed by the contractor.
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.
The contractor's tool shall include a status
of “submitted,” “open,” or “closed,” viewable to the GDA and DHA
PQI submitter.4.3.1 The contractor shall
provide the GDA with unrestricted access to the tool, to include
the ability to track, trend and view the details of case investigation(s)
and status of all cases.
4.3.2 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
4.3.2.1 For reporting requirements,
see DD Form 1423, CDRL, located in Section J of the applicable contract.
4.3.2.2 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.
4.3.3 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.
4.3.4 The contractor shall provide
the GDA and their designees with training and real time access to
the PQI tracking and trending tool.
4.3.5 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 QI 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 like-specialty peer
reviewer should have comparable education, training, experience, and, 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, including in instances where there
is no confirmed QI. 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:
|
|
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)
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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 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.