HomeMy WebLinkAboutMINUTES - 01211997 - D1 Ts3: BOARD OF SUPERVISORS '
William Walker, M.D.
I-F:oM Health Services Director
Contra
January 7, 1997
Costa
DATE.;, County
SUBJECT: Approval of Contra Costa Health Plan's Quality Management Program, Quality Management Plan, and
Annual Work Plan
SPECIFIC REQUEST(S) OR RECOMMENDATION(S) & BACKGROUND AND JUSTIFICATION
RECOMMENDATION
A. Approve the attached document which contains Contra Costa Health Plan's Quality Management
Program, including the program structure, the Quality Management Plan and the Annual Work Plan.
B. Appoint two members of the Board of Supervisors to the CCHP Joint Conference Committee.
C. Delegate approval of credentialing policies and procedures to the Joint Conference Committee.
FINANCIAL IMPACT None
REASON FOR RECOMMENDATIONS BACKGROUND
Contra Costa Health Plan is required by state law and regulation to have a written Quality Management
Program and Plan approved by its governing body. CCHP has been operating under a Board of Supervisors
approved Quality Management Program and Plan. However, the State Department of Health Services, as
part of its approval process for the CCHP Local Initiative, has required that CCHP submit a new Quality
Management Program and Plan which covers CCHP's Health Partners (Kaiser and Community Providers)
as well as Merrithew Memorial Hospital and Clinics and that involves the Board of Supervisors as the
governing body more directly in the Quality Management process. In late October the State Department of
Health Services approved the attached QM Program and Plan. At its November 20, 1996 meeting the
Contra Costa Managed Care Commission endorsed the Quality Management Program goals and objectives,
the Annual Quality Management Work Plan and the organization and structures of the Quality Management
Program and Plan. The Managed Care Commission also voted to forward its endorsement to the Board of
Supervisors with a recommendation that the Board approve the Quality Management Program and Plan.
The Contra Costa Health Plan Quality Council approved the Quality Management Program and Plan at its
December 1996 meeting.
Quality Management Program
The Board of Supervisors is ultimately responsible for the quality of care and service provided to all
CCHP members. In that role the Board is to review and approve the QM Program and QM Plan;
review and authorize the QM Annual Work Plan and receive and approve CCHP credentialing,
recredentialing, and reappointment actions.
CONTINUED ON ATTACHMENT: >( YES SIGNATURE:
RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE
APPROVE OTHER
SIGNATURE(S)
ACTION OF BOARD ON January 21, 1997 APPROVED AS RECOMMENDED X OTHER X
APPROVED the recommendations as set forth above; and APPOINTED Supervisors DeSaulnier and Gerber to
the CCHP Joint Conference Committee.
VOTE OF SUPERVISORS
X UNANIMOUS (ABSENT V ) 1 HEREBY CERTIFY THAT THIS IS A TRUE
AYES- NOES: AND CORRECT COPY OF AN ACTION TAKEN
ABSENT: ABSTAIN: AND ENTERED ON THE MINUTES OF THE BOARD
Contact: Milt Camhi 313-6002 OF SUPERVISORS ON THE DATE SHOWN.
.
CC: Health Services Director ATTESTED January 21, 1997
CCHP (via HSD) hil Batchelor, Clerk of the Boa of
County {administrator
Supery rs and Co dmi ' atot
M3e2/7-e3 BY D UTY
P/
Page 2
The mechanism by which the Board of Supervisors will exercise general oversight of CCHP is through
a Joint Conference Committee of the Board of Supervisors. The Joint Conference Committee will
have no more than nine members. There are four voting members: two members of the Board of
Supervisors, appointed by the Board and two physician members appointed for a one year term by the
Board upon the recommendation of CCHP Medical Director.
There are five non-voting members: CCHP Medical Director, Director of Health Services, CCHP
Executive Director, Health Services Chief Financial Officer, and Chairperson of the Managed Care
Commission. The Joint Conference Committee will be a forum for communication among the Board
of Supervisors, CCHP administration, and the Quality Council. It will regularly assess and monitor the
overall performance of CCHP and make recommendations to the Board of Supervisors as needed
regarding activities and problems of CCHP.
The Joint Conference Committee will be the final level of appeal for member grievances and provider
appeals. When these grievances and/or appeals involve individual clinical grievances and quality of
care issues, the two members of the Board of Supervisors who sit on the Joint Conference Committee
will constitute the Professional Affairs Committee. This committee will serve as a closed forum for
Quality Assurance, Risk Management, Credentials and related topics within the limits allowed by law.
The physician members of the Joint Conference Committee will be invited to advise the Professional
Affairs Committee in decisions which require medical judgment.
Quality Management Plan &Annual Work Plan
The Quality Management Plan describes the goals, objectives, and activities of the Quality
Management Program. It also contains the 1997 Annual Quality Management Work Plan which
describes the quality improvement activities CCHP expects to develop and implement in 1997. As
part of the 1997 Work plan, CCHP will perform focused review studies required by the State
Department Of Health Services as part of the Local Initiative program.
Credentialing
The Board of Supervisors, by delegating approval of credentialing policies and procedures to the Joint
Conference Committee, retains overall oversight of the process.
ATTACHMENTS
1. Quality Management Program
2. Quality Management Plan
3. Annual Work Plan
F43:bdorder.bb
Contra Costa County
The Board of Supervisors HEALTH SERVICES DEPARTMENT OFFICE OF THE DIRECTOR
Jim Rogers, 1st District E sEWilliam B.Walker, M.D.
Jeff Smith,2nd District Director& Health Officer
Gayle Bishop,3rd District _;
Mark DeSaulnier,4th Districtf _ 20 Allen Street
Tom Torlakson,5th District = Martinez, California 94553-3191
n. '
V (510)370-5003
County Administrator FAX(510)370-5099
Phil Batchelor c�sTAco =cAti
County Administrator
MEMORANDUM
TO: Board of Supervisors
FROM: William Walker, M.D.
via Milt Camhi
DATE: January 17, 1997
On January 21, 1997, the Board of Supervisors will be asked to approve Contra Costa Health Plan's
Quality Management Program and Plan including the creation of a Joint Conference Committee.
Some members of the Board of Supervisors have had questions about the Joint Conference Commit-
tee; the reasons it is being formed,the distinction between it and the Merrithew Memorial Hospital
Joint Conference Committee and the frequency of its meetings.
The Contra Costa Health Plan Joint Conference Committee satisfies the State Department of Health
Services'requirement that the Board of Supervisors, as the governing body of Contra Costa Health
Plan, must be more directly involved in the Quality Management process. The Joint Conference
Committee will be a forum for communication between the Board of Supervisors and Contra Costa
Health Plan administration. It will regularly assess and monitor the overall performance of Contra
Costa Health Plan and make recommendations to the full Board of Supervisors. It is the final level
of appeal for member grievances and provider appeals.
The difference between the Contra Costa Health Plan Joint Conference Committee and Merrithew's
Joint Conference Committee is that Contra Costa Health Plan's Joint Conference Committee covers
all aspects of the Health Plan's operations including its contracting community providers, while
Merrithew's Joint Conference Committee provides oversight over the hospital and clinics only.
Meetings of the Contra Costa Health Plan Joint Conference Committee shall be held at least quar-
terly and may be held every other month or more frequently if needed.
Please let me know if I can provide additional information.
WBW:BB:km
k\wwmem.pm5
Merrithew Memorial Hospital 8 Health Centers • Public Health • Mental Health • Substance Abuse • Environmental Health
Contra Costa Health Plan • Emergency Medical Services • Home Health Agency • Geriatrics
A-345 (1/96)
i
CONTRA COSTA
HEALTH PLAN Ma Center Avenue, Suite
100
Martinez,California 94553-3-
4639
A division of Contra Costa Health Services
CCHP QUALITY MANAGEMENT PROGRAM AND STRUCTURE
I MISSION OF THE QUALITY MANAGEMENT PROGRAM
The mission of the Contra Costa Health Plan's Quality Management Program is to ensure
that high quality, appropriate, and cost effective health care and services are provided to its
members in accordance with Contra Costa Health Plan's mission statement:
• Committed to providing affordable, high quality, accessible health care with integrity
and compassion to all who use our programs
• Committed to making heath care a partnership between providers, members, and
families.
• Committed to serving the most vulnerable populations
• Committed to assuring an integrated system of ambulatory and inpatient care.
The Contra Costa Health Plan is also committed to an integrated system of care which forms an
effective partnership between its members, their families , and the individual providers of each
of the various CCHP Health Partners. The purpose of the Quality Management Program is to
help the Contra Costa Health Plan accomplish its mission and to maximize the health status of
the individual Contra Costa Health Plan members.
The Board of Supervisors is ultimately responsible for the quality of care and services provided
to the members of the Contra Costa Health Plan. The Board is committed to a program of
systematic assessment and improvement at every level of the Contra Costa Health Plan in order
to best serve the members' health needs. The Contra Costa Health Plan has been in existence
twenty-three years. During this time the Board of Supervisors and the leaders of the Contra Costa
Health Plan have gained extensive experience in serving the needs of a broad section of
members including the medically indigent, medically uninsured, Medi-Cal, Medicare, private
individuals, small and large businesses. The many years of accumulated knowledge serving this
population's health needs make the Contra Costa Health Plan well equipped to expand its
membership to include a large number of Medi-Cal members.
AFFORDABLE CARE„FPZ TS6 SERVICE
The Contra Costa Health Plan has developed a diverse network of Health Partners to
accommodate the additional Medi-Cal members. The Health Partners include a range of care
providers from complex Organized Hospital Systems,to individual Community Partners who are
office-based primary care providers. The CCHP Health Partners were selected because of their
extensive experience and traditional history of providing health services to Medi-Cal recipients.
To accommodate the wide range of quality management experience and abilities among the
various Health Partners, the Contra Costa Health Plan Quality Management Program has adopted
a delegation model of quality management functions which includes both delegated and non-
delegated activities.
II DELEGATION MODEL FOR QUALITY MANAGEMENT FUNCTIONS
The Contra Costa Board of Supervisors, as Contra Costa Health Plan's governing board, is
ultimately responsible for the quality of care and services provided to Contra Costa Health Plan's
members. The oversight , direction and management of the Quality Management Program is
delegated to Contra Costa Health Plan's Medical Director. The Medical Director will retain the
responsibility for setting the quality management standards, determining criteria by which care
will be measured, setting priorities for which aspects of care will be monitored, as well as the
responsibility to do analysis of quality of care studies, indicators, utilization reports, grievances,
and survey data. Day to day quality monitoring, including data collection for quality of care
studies, utilization review and management of health resources, initial handling of grievances,
credentialing of providers, and implementation and evaluation of improvement projects are
delegated fully to the Organized Health Systems and their affiliated providers. The Contra Costa
Health Plan Quality Management Unit will be responsible for the day to day quality management
activities for the non-delegated Community Partners
Delegated quality monitoring status is granted upon successful demonstration by the OHS
Partner that the required scope of quality monitoring activities are taking place. The Medical
Director will determine delegation status of the OHS Partner prior to assignment of members to
the CCHP Health partner and supply ongoing oversight through regular CCHP OHS Partner
reports, and a biannual reevaluation of the OHS Partner to determine if delegated status criteria
continue to be met.
III COMMITTEE STRUCTURE OF THE QUALITY MANAGEMENT PROGRAM
A. BOARD OF SUPERVISORS
Contra Costa County Board of Supervisors, which is elected through general elections, is
the governing board of the Contra Costa Health Plan. The Board of Supervisors is
therefore ultimately responsible for the quality of care and service provided to all Contra
Costa Health Plan members.
Purpose (related to the Quality Management Program
1. Develops and communicates policy direction
2. Reviews and approves Quality Management Program and Quality Management
Plan.
CCHP Quality Management Program and Structure - January , 1997 Page 2
3. Reviews/accepts annual Quality Management Reports and annual revisions to the
Quality Management Plan.
4. Reviews and authorizes Quality Management Annual Work Plan.
5. Appointment of Joint Conference Committee and Quality Council membership.
6. Reviews, evaluates and acts upon findings of the Joint Conference and
Professional Affairs Committees.
7. Receives and reviews periodic reports from Quality Management Unit and
Medical Director.
8. Receives and approves credentialing/recredentialing/reappointment actions of the
CCHP Health Partners and the Quality Management Unit.
9. Reviews, approves and authorizes sanctions and terminations.
10. Reviews, approves and authorizes, Medical Policy Guidelines.
11. Oversight of Protection of Confidentiality of Quality information as cited in
Evidence Code 1157 and Health and Safety Code 1370.
Membership
There are five (5) members of the Board of Supervisors. Each is elected through general
elections in one of the five districts of Contra Costa County for a term of four(4)years.
Chair
The chairmanship of the Board of Supervisors rotates among the five board members
annually.
Meetings
The Board of Supervisors holds weekly public meetings in accordance with the Brown
Act
B. JOINT CONFERENCE COMMITTEE
The mechanism by which the Board of Supervisors exercises general oversight of the
Contra Costa Health Plan is through the Joint Conference Committee of the Board of
Supervisors and the Contra Costa Health Plan. All meetings of the Joint Conference
Committee are open to the public because of the public nature of the Board of
Supervisors. This creates a conflict for the situations when the Board in its oversight role
needs to discuss professional matters where member or provider confidentiality is a
concern. The Board of Supervisors will, by way of going into executive session, discuss
such matters in the Professional Affairs Committee.
Purpose:
1. The Joint Conference Committee is a forum for communication among the Board
of Supervisors, the Contra Costa Health Plan administration, and the Quality
Council.
2. Regularly assesses and monitors the overall performance of the Contra Costa
Health Plan and its Health Partners, including but not limited to the quality of
care.
3. The Medical Director reports the findings of the Quality Management Unit and
the analysis and recommendations of the Quality Council to the Joint Conference
CCHP Quality Management Program and Structure - January , 1997 Page 3
Committee
4. Takes appropriate actions with respect to the CCHP Health Partners based on
reports by the Joint Conference Committee
5. Makes recommendations to the Board as needed regarding activities and problems
of the Health Plan;
Membership.
The total number of members of the Joint Conference Committee shall not exceed nine
(9)
1) Two(2)members from the Board membership, appointed by the Board. These
two (2)members shall have full voting privileges.
2) Two(2) physician members appointed by the Board from among any of the
providers of the CCHP Health Partners. To fill these positions, the Quality
Management Unit will solicit nominations from each of the CCHP Health
Partners by announcing the vacancy to all providers using direct communication
to the CCHP Health Partners and their affiliated providers. The Medical Director
will select the most qualified candidates and present them to the Board for
approval. These two(2) members shall each have a one year term and have full
voting privileges.
3) One (1) member shall be the Medical Director. This member shall have ex-officio
status without voting privileges.
4) One(1)member shall be the Director of Health Services of Contra Costa County.
This member shall have ex-officio status without voting privileges.
5) One (1) member shall be the Executive Director of the Contra Costa Health Plan.
This member shall have ex-officio status without voting privileges.
6) One (1)member shall be the Health Services Chief Financial Officer. This
member shall have ex-officio status without voting privileges.
7) One (1)member shall be the chairperson of the Managed Care Commission. This
member shall have ex-officio status without voting privileges.
Chair.
The Chair of the Joint Conference Committee shall be a member of the Board of
Supervisors or one of the physicians appointed to the Joint Conference Committee. The
Chair shall be elected annually and shall alternate yearly between a representative of the
Board and one of the physician members
Meetings.
Meetings of the Joint Conference Committee shall be held at least quarterly and shall be
open to the public.
C. PROFESSIONAL AFFAIRS COMMITTEE
Purpose:
1. The Professional Affairs Committee of the Governing Board serves as a closed
forum for discussion between the Governing Body and the Physician members of
the Joint Conference Committee regarding Quality Assurance, Risk Management,
CCHP Quality Management Program and Structure - January , 1997 Page 4
Credentials, and related topics within the limits allowed by law.
2. The Medical Director reports the findings of the Quality Management Unit and
the analysis and recommendations of the Quality Council to the Joint Conference
Committee
3. The Professional Affairs Committee shall serve as the final level of appeal for
individual clinical grievances and quality of care issues. The physician members
of the Joint Conference Committee shall be invited guests and will advise the
Professional Affairs Committee in decisions which require medical judgement.
4. The Professional Affairs Committee shall transmit written reports of its activities
to the Board of Supervisors and the Quality Council.
Membership:
The Professional Affairs Committee consists of the two (2)members of the Board of
Supervisors who sit on the Joint Conference Committee. The other members of the Joint
Conference Committee shall be invited guests.
Meetings:
The Professional Affairs Committee shall meet at least quarterly.
D. QUALITY COUNCIL
The Quality Council is the principal committee coordinating and directing Quality
Management Activities for the Contra Costa Health Plan.
Purpose:
1. The Quality Council reports to the Board of Supervisors as a quality review,peer
review, utilization management, and credentials committee. The Medical Director
will present the Quality Council report to the Board in person through
presentations to the Joint Conference and Professional Affairs Committees.
2. The Quality Council is supported by the Quality Management Unit. The Quality
Council also directs the Quality Management Unit's activities and priorities by
advising the Medical Director who leads the Quality Management Unit.
3. Duties and Responsibilities of the Quality Council :
a) Receives, reviews, evaluates reports of subcommittees.
b) Reviews and evaluates the delegation status of the Organized Health
System Partners to whom Quality Management Activities have been
delegated
C) Makes Credentialing recommendations to the Board for the Community
Partners by integrating provider specific quality of care, utilization
management, and any other available quality management data provided
by the Quality Management Unit Staff, with the information provided by
the Credentials Committee.
d) Receives Potential Quality Issues and recommends action re: quality of
care issues from Quality Management Unit.
e) Receives and reviews quarterly or more frequent Quality Management
reports from the Quality Management Unit consisting of aggregated
reports in each of the categories listed in 6.5.2.2 from each of the OHS
CCHP Quality Management Program and Structure - January , 1997 Page 5
Partners.
d) Receives, analyzes and reviews quarterly UM reports and recommends
action, and follow-up, where indicated.
e) Develops and submits (via the Medical Director) quarterly Quality
Management reports, including UM reports, to the Joint Conference and
Professional Affairs Committees and receives and appropriately
communicates Board feedback and Board policy to OHS and Community
Partners.
f) Acts as a second level appeal for grievances, credentialing issues and
quality of care (unresolved at OHS and Community Partners level).
g) Develops Annual Quality Management Work Plan, Annual Quality
Management Program Evaluation and other Quality Management reports
for Board approval.
h) Reviews provider-specific potential quality issues and selected provider
.grievances which could not be satisfactorily resolved within the Quality
Management Unit
i) Reviews and evaluates Quality Management reports pertaining to medical
policy development; reviews CCHP Health Partner medical policies;
reviews new technologies and formulate issues in light of the standard of
practice in the community.
j) Reviews, evaluates and directs the Contra Costa Health Plan formulary
and reviews pharmacy and therapeutics policies of the CCHP Health
partners
3. The Quality Council reports will be disseminated to OHS Partners' medical
departments by the Medical Director, and to their affiliated providers by the OHS
Partners. In addition, providers affiliated with OHS Partners will receive update
letters, reports, and other publications directly from the OHS Partners.
4. The Quality Council reports will be disseminated to Community Partners by the
Medical Director. Community Partners will also receive reports from the
Community Partner Peer Review Committee,which is a subcommittee of the
Quality Council.
5. The Quality Council reports will be distributed to all divisions of the OHS
Partners administration, as well as to the Joint Conference and Professional
Affairs Committees.
6. The Quality Council reports will be distributed to Contra Costa Health Plan senior
management for the purpose of planning and designing services and
administration of the Health Plan.
Membership
Members of the Quality Council will include:
1) The Medical Director of the Health Plan with full voting privileges.
2) The Assistant Medical Director of the Health Plan with full voting privileges.
CCHP Quality Management Program and Structure - January , 1997 Page 6
3) The Medical Director or QA Director of Merrithew Memorial Hospital & Health
centers. This members shall have full voting privileges.
4) The Medical Director or QA Director of Kaiser. This members shall have full
voting privileges.
5) The Chairperson of the Community Partner Peer Review Committee. This
members shall have full voting privileges.
6) Two (2) independent Physicians from any of the CCHP Health Partners. One of
these shall be a primary care physician,the other shall be a specialty care
physician. To fill these positions, the Quality Management Unit will solicit
nominations from each of the CCHP Health Partners by announcing the vacancy
to all providers using direct communication to the CCHP Health Partners. The
Medical Director will select and appoint the most qualified candidates. Both
members shall have serve one year terms and have full voting privileges.
7) The Quality Management Unit staff, without voting privileges.
8) The Contra Costa Health Plan Patient Services Director, without voting privileges
Chair
The Quality Council will be chaired by the Medical Director, or in his absence, the
Assistant Medical Director.
Meetings
The Quality Council will meet monthly, a minimum of nine--(9) times yearly.
E. QUALITY COUNCIL SUBCOMMITTEES
The Quality Council has two (2) standing subcommittees and their duties areas follows:
1. CREDENTIALS COMMITTEE
Purpose
1. The Credentials Committee receives reports regarding credentialing and
recredentialing actions and policies from the Quality Management Units of
the Organized Health System Partners; it will review the credentialing
activities and policies of the Organized Health System Partners and
recommend approval to the Board; arbitrate credentialing disputes, report
issues to other subcommittees and make recommendations regarding
potential providers and report to the Quality Council.
2. The Credentials Committee coordinates the credentialing and
recredentialing of the CCHP Community Partners by receiving and
analyzing applications. It will carefully review provider qualifications for
the CCHP Community Partners including, but not limited to education and
training, license status, board certification,hospital privileges, malpractice
history, DEA registration, history of license restriction or revocation,
changes in hospital privileges, results of Primary Care Facility Review,
and pertinent provider specific information from the Quality Management
Unit such as study results, grievances, access indicator monitoring, and
member satisfaction survey results.
CCHP Quality Management Program and Structure - January , 1997 Page 7
3. Makes recommendations to the Quality Council for eventual Board of
Supervisors approval regarding credentialing and recredentialing of CCHP
Community Partners.
4. Reports to the Medical Director in all credentialing matters
Membership
1) The Assistant Medical Director of the Health Plan with full voting
privileges.
2) The Credentials Committee Chairperson or his/her representative from
Merrithew Memorial Hospital & Health centers. This member shall have
full voting privileges.
3) The Credentials Committee Chairperson or his/her representative from
Kaiser Health Plan. This member shall have full voting privileges.
4) The Chairperson or a representative of the Community Partner Peer
Review Committee. This member shall have full voting privileges.
5) Two (2) independent Physicians from any of the CCHP Health Partners.
One of these shall be a primary care physician, the other shall be a
specialty care physician. To fill these positions, the Quality Management
Unit will solicit nominations from each of the CCHP Health Partners by
announcing the vacancy to all providers using direct communication to the
CCHP Health Partners. The Medical Director will select and appoint the
most qualified candidates. Both members shall have serve one year terms
and have full voting privileges.
6) The Quality Management Unit staff who will support the committee,
without voting privileges.
Chair
The Credentials Committee will be chaired by the Assistant Medical Director.
Meetings
The Credentials Committee will meet at least quarterly.
2. COMMUNITY PARTNER PEER REVIEW COMMITTEE
The Community Partner Peer Review Committee is the forum where all
Community Partners (non-delegated CCHP Health Partners) participate in the
Quality Management Program. Through the Community Partner Peer Review
Committee, the Community Partners will have access to the Quality Council for
the purpose of participating in analysis of the Quality Management Unit reports
and participating in the directing of Quality Management Activities.
The Community Partner Peer Review Committee will also serve as a forum for
professional peer review for the Community Partners who are not otherwise
participating in peer review activities.
Purpose
CCHP Quality Management Program and Structure - January , 1997 Page 8
The Community Partner Peer Review Committee will be the forum where
Community Partners and other CCHP Health Partners not affiliated with any other
quality management program will carry out their Quality Management and
Utilization Management activities.
1. The Community Partner Peer Review Committee reports to the Quality
Council as a quality review,peer review and a utilization management
committee for the Community Partners who are not otherwise represented
at the Quality Council. The Chairperson of the Community Partner Peer
Review Committee will present quality review, peer review and utilization
management reports to the Quality Council.
2. Duties and Responsibilities of the Community Partner Peer Review
Committee :
a) Receives, reviews, evaluates reports of represented Community
Partners.
b) Receives Potential Quality Issues and recommends action re:
quality of care issues from represented Community Partners.
C) Receives and reviews quarterly or more frequent Quality
Management reports from CCHP Quality Management Unit
consisting of aggregated reports in each of the categories listed in
6.5.2.2 from the represented Community Partners.
d) Receives, analyzes and reviews quarterly-(or more frequently) UM
reports and recommends action, and follow-up, where indicated.
e) Develops and submits (via the Community Partner Peer Review
Committee Chairperson) quarterly Quality Management reports,
including UM reports,to the Quality Council and receives and
appropriately communicates Quality Council feedback to
represented Community Partners.
f) Acts as a first level appeal for grievances and quality of care
unresolved at Community Partners level
g) Reports to Quality Council.
3. Reports from the Community Partner Peer Review Committee will
be disseminated to all members and other represented Community
Partners by the Community Partner Peer Review Committee
Chairperson.
4. The Community Partner Peer Review Committee will also serve as
the forum for the Community Partners' other business meeting
needs.
Membership
Each Community Partner who is an individual community provider not affiliated
with an OHS Partner will be a member of the Community Partner Peer Review
Committee.
CCHP Quality Management Program and Structure - January , 1997 Page 9
Subcommittees
Due to the potentially large number of members spread out geographically, the
Community Partner Peer Review committee will form regional subcommittees to
carry out its peer review function. The Community Partner Peer Review
Committee will determine how many subcommittees to form based on the needs
of the members.
Chair
The chair of the Community Partner Peer Review Committee will be appointed by
the Medical Director from among the members of the Community Partner Peer
Review Committee.
Meetings
The Community Partner Peer Review Committee will meet at least semi annually.
IV PUBLIC ADVISORY & OTHER COORDINATING COMMITTEES
A. MANAGED CARE COMMISSION
The Managed Care Commission is a public advisory commission which reports
directly to the Board of Supervisors. This commission replaced the CCHP
Advisory Board.
Purpose.
1. The Commission has broad oversight functions and advises the Board and
Health Plan on policy decisions,provides input from the community and
members, reviews the financial plan, rate setting, marketing, provider
relations surveys, etc.
2. receives appropriate aggregate Quality Management Unit reports without
confidential provider or member specific information from the Medical
Director and advises the Medical Director regarding its concerns related to
the quality of care and services provided to the Health Plan members.
3. The Chairperson of the Managed Care Commission advises the Health
Plan senior management and Medical Director by sitting on the Joint
Conference Committee of the Health Plan.
4. Participates in the appeals process by having the Chairperson of the
Managed Care Commission sitting on the Joint Conference Committee of
the Health Plan
Membership.
There are fifteen members, who are appointed by the Board of Supervisors. Six
positions are designated seats such as Medi-Cal subscriber, Medicare subscriber,
non-contracting physician,person sensitive to medically indigent needs,
commercial subscriber, and other providers (e.g., nurse). The remaining nine
seats are at large. The Health Services Director, Health Plan Executive Director,
and the Board of Supervisors are ex officio members.
CCHP Quality Management Program and Structure - January , 1997 Page 10
- Subcommittees.
The Commission has six (6) standing subcommittees:
1. Health Care Delivery/Quality Maintenance
2. Finance &Administration
3. Product Development& Marketing
4. Provider Issues
5. Member & Consumer Advocacy
6. Planning/Governance & Bylaws
Chair
The chair of the Managed Care Commission will be elected from among the
Commission members and serve a one year term
Meetings
The Managed Care Commission will meet monthly.
For more details, see the Managed Care Commission bylaws in section 6.2 of the
DDA.
B. CULTURAL & LINGUISTIC ADVISORY COMMITTEE
Pose
1. The Cultural and Linguistic Advisory Committee will advise the Board of
Supervisors and the Senior Management of the Contra Costa Health Plan
on the specific needs concerns of Contra Costa Health plan members who
have a different ethnic or cultural background or who speak a different
2. Receives appropriate aggregate Quality Management Unit reports without
confidential provider or member specific information from the Medical
Director and advises the Medical Director regarding its concerns related to
the quality of care and services provided to the Health Plan members.
Membership
The members of the Cultural and Linguistic Advisory Committee will be
members of the public representing the different languages and ethnic groups
served by the Contra Costa Health Plan.Nominations will be sought from among
all members of the Contra Costa Health Plan through mail and personal contacts
with community leaders. The CCHP Health Partners will assist in the search for
candidates for this committee. The Health Plan Director of Marketing and
Communications will select the most qualified candidates and present these to the
Board of Supervisors for approval
Chair
The chair of the Cultural and Linguistic Advisory Committee will be appointed
from among the members of the Cultural and Linguistic Advisory Committee.
Meetings
CCHP Quality Management Program and Structure - January , 1997 Page 11
The Cultural and Linguistic Advisory Committee will meet at least semi-annually
C. INTEGRATED QUALITY ASSURANCE COMMITTEE
Purpose
1. The Integrated Quality Assurance Committee serves to coordinate QA/QI
efforts among all the Contra Costa County Health Service Department
Divisions, all of which report to the same Board of Supervisors and the
same Health Services Director. As there is much overlap in the
populations served by each of the Divisions of the Health Services
Department, the goal of the Integrated Quality Assurance Committee is to
coordinate measurement, evaluation, and improvement projects across the
Divisions of the Health Services Department.
2. Receives aggregate Quality Management Unit reports without confidential
provider or member specific information from the Medical Director and
advises the Medical Director regarding its concerns related to the quality
of care and services provided to the Health Plan members.
Membership
1. The Director of the Health Services Department
2. The Executive Director of the Contra Costa Health Plan
3. The Director of the Contra Costa County Public Health Department
4. The Director of the Mental Health& Substance Abuse Division
5. The Executive Director of Merrithew Memorial Hospital & Health Centers
6. The Medical Directors and QA/QI Directors of each above mentioned
Division will be invited guests as appropriate for the topics on the agenda.
Chair
The chair of the Integrated Quality Assurance Committee will be the Director of
the Health Services Department of Contra Costa County.
Meetings
The Integrated Quality Assurance Committee will meet at least semi annually.
V. MEDICAL LEADERSHIP
The medical administration and coordination of medical management in the Contra Costa
Health Plan are directed by the Medical Director, who in turn, reports to the Executive
Director of the Contra Costa Health Plan for administrative issues. The Medical Director
also is responsible for coordination of medical policy, grievance review, credentialing
review and provider relations at all levels of the Contra Costa Health Plan. The Medical
Director and the staff which reports to him/her is responsible for QM and UM policy
implementation and monitoring activities at the Contra Costa Health Plan level. The staff
dedicated to quality of care issues comprise the Quality Management Unit of the Contra
Costa Health Plan.
CCHP Quality Management Program and Structure - January , 1997 Page 12
VI. QUALITY MANAGEMENT UNIT
A. The department consists of the Medical Director, the Assistant Medical Director,
the Quality Improvement and Utilization Manager, the QI/UM Coordinators, and
QI/UM staff. The Quality Management Unit is charged with the task of carrying
out the Quality Management Plan and Policies.
B. The Quality Management Unit ensures that the Quality Management Program is
properly implemented and continues to function as described in the Quality
Management Plan.
C. The Quality Management Unit has the organizational responsibility for oversight
and monitoring the OHS Partners' quality of care and service provided to Contra
Costa Health Plan Health members.
D. The Quality Management Unit staff assists and supports the Community Partner
Peer Review Committee and Community Partners in carrying out the quality
management program at their level. This will include but not be limited to support
with the following functions:
1. Medical Record Audits
2. Data collection for measuring activities
3. Designing audit and measurement tools
4. Producing reports
5. Assisting with analysis
E. This department provides administrative support, education and information to the
Board and its quality related committees. The Quality Management Unit
facilitates information flow to the Board,the Contra Costa Health Plan
organization and the CCHP Health Partners and providers for all quality related
issues, specifically, the department will:
1. Receive and analyze information from CCHP Health Partners,providers,
members, and other administrative entities.
2. Formulate recommendations and corrective actions.
3. Monitor implementation of results.
4. Report to CCHP Health Partners
5. Report to quality committees.
6. Report to the State Department of Health Services.
7. Report to public advisory, consumer, and other coordinating committees.
F. The function of the Utilization Management Program of the Quality Management
Unit are described in the Quality Management Plan. For the Community Partners,
the Quality Management Unit Staff will perform the actual day to day utilization
management. The Quality Management Unit will provide oversight of the UM
function for OHS Partners.
1. The Quality Management Unit will monitor, evaluate and assure
CCHP Quality Management Program and Structure - January , 1997 Page 13
continuity of care, coordination of care, appropriate level of care and
services, access, appeals and their oversight by the OHS Partners to assure
that provision and utilization of service meets professionally recognized
standards of practice.
2. Activities will include data collection, analysis of trends and pertinent
reports and recommendation for corrective action.
3. The UM Program will develop and report useful feedback to the OHS
Partners as part of a Continuous Quality Improvement Process. The
Department will also report to the Board through the Medical Director, as
well as through the Quality Council.
G. The Quality Management Unit manages the communications between the Contra
Costa Health Plan and the CCHP Health Partners regarding quality issues.
Provider grievances, communication of policy and procedure changes, and
member-provider issues, are responsibilities of the Quality Management Unit..
The Quality Management Unit is responsible for the oversight of the
communications and interfaces with the OHS Partners and Community Partners
and will act as an information conduit between Contra Costa Health Plan, its
CCHP Health Partners and their contracted providers. The functions are further
detailed in the QM Plan.
H. Each and every aspect of the quality management program and the Quality
Management Unit is integrated into the overall administration of Contra Costa
Health Plan through senior management and Board activities.
CCHP Quality Management Program and Structure - January , 1997 Page 14
ccs
oma
CL
as
41
caw
G a
++s
7.o 1
111 ,t
istoo d
E�`
to
1
3 sio
w• L � 1 � 1
co
ro
a.
O �
3 O
O O O ++ 1 = 1
a o
R
C
o -
y
s
a
J:j
y a
3wN a oVa
q >
Um
Q � a � _ g1 1
W2 . . . . . . o . . . ._ LL§ . . . . . . .
ba
Q
0 aa
O N C
U V �
m � w
> a a
-68 88
Ot
s
CTw CONTRA COSTA
Center Avenue, Suite 100
HEALTH PLAN Martinez,California 94553-3-
4639
A division of Contra Costa Health Services
QUALITY MANAGEMENT PLAN
PURPOSE
The CCHP Quality Management Program will improve the health status of its members through an
effective system of planning,monitoring, assessing and improving the quality of care and access to
services members receive within all Organized Health System Partners and Community Partners.
CCHP Quality Management Plan will assess the degree that CCHP's mission of "providing
affordable, high quality, accessible health care with integrity and compassion to all who use our
programs" is reached.
GOALS
The goal of improving CCHP performance is to improve member health outcomes throughout the
network by improving performance of clinical,governance and support,processes. The performance
of the "important functions" as defined by JCAHO significantly affects its member outcomes, the
costs to achieve those outcomes and the perceptions of its members and their families about the
quality of its services.
The Quality Management Program will improve the performance through continuous monitoring
and evaluation and improvement of-
Management
£Management of Human Resources
• Management of Information
• Leadership
• Health Promotion and Disease Prevention
• Continuum of Care
• Education and Communication
• Rights, Responsibilities and Ethics
The performance improvement program will monitor and assess all aspects of clinical care including:
the direct delivery of health care provided by individual practitioners (physicians, nurses,
psychologists,etc.), Community Partners(acute care facilities,long-term care facilities,home health
agencies,pharmacies, etc.) and Health Partners (Merrithew Memorial Hospital and Health Centers
and Kaiser).
AFFORDABLE CAREW S SERVICE
Monitoring, assessing and improving the quality of services includes a review of.
• The efficacy of the procedure or treatment
• The appropriateness of a specific test, procedure or service
• The availability of needed test,procedure or treatment
• The timeliness with which needed services are provided
• The effectiveness of services provided
• The continuity of services provided ensuring horizontal and vertical integration of
services
• The safety with which service are provided
• The efficiency with which services are provided
• The respect and caring with which services are provided
All improvement happens through systematic, organization wide process improvement which
involves the following elements:
• Planning
• Process design
• Performance measurement
• Performance assessment
• Performance improvement
Using these basic tenets of quality improvement, CCHP is responsible for coordinating, integrating
and implementing system wide improvement activities which include both Organized Health System
and Community Partners.
OBJECTIVES
1. Maintain current compliance with Department of Corporations.
2. Comply with recognized industry standards for Improving Network Performance set forth
in JCAHO,NCQA, and Title 22.
3. Become NCQA accredited.
4. Confirm at all times that all CCHP Health Partners' Quality Assessment and Improvement
Program and Utilization Management structure staff and processes are in compliance with
all provisions of CCHP QM Plan and meet professionally recognized standards.
5. Identify opportunities for improvement and implement change in the whole range of health
care services provided by CCHP to it's members. The objective of ongoing systematic
improvement will be implemented by careful attention to the following five aspects of
performance improvement:
a. Planning Performance Improvement
CCHP Quality Management Plan - January, 1997 Page 2
- 0 New and existing network activities are integrated into a systematic,network wide approach.
• The process is collaborative and involves all appropriate CCHP, Community and OHS
Partner personnel, clinical staff and licensed independent practitioners.
• CCHP will establish priorities for ongoing .monitors and focused-review studies with
emphasis on access,preventive services,high volume providers or services, and high risk or
problem-prone services.
• CCHP will evaluate the program annually and plan the following year's activities based on
input from Joint Conference of CCHP, CCHP Medical Director, CCHP Quality Council,
Health Partners, and Plan members and the Managed Care Commission and accreditation
agencies.
• Establish and maintain policies,procedures and criteria for credentialing,recredentialing and
reappointment of Health Partners.
• Assure that members can achieve resolution to problems or perceived problems relating to
access to care or other quality issues through Member Services, grievance and appeal .
procedures
• Protect against undue economic pressure to cause OHS or Community Partners to grant
privileges to providers that would otherwise not be granted or to pressure providers to render
care beyond the scope of their training
b. Design
• When designing new processes,components or services,CCHP will consider how the design
will help fulfill it's mission, vision and plans.
• Successful design will incorporate information from a variety of sources including but not
limited to:
• CCHP mission and plans
• Information about the needs and expectations of members, Health Partners,
personnel, clinical staff, licensed independent practitioners and others
• Scientific and professional sources such as practice guidelines, clinical standards or
business guidelines.
• Industry benchmarked data about similar processes and their outcomes from other
networks, Health Partners or reference data bases.
C. Measuring Plan Performance
CCHP Quality Management Plan-January, 1997 Page 3
• CCHP measurements will focus on processes, outcomes and comprehensive performance
measures over time and will include:
• The needs, expectation, and feedback of members and others
• The results of ongoing infection control activities
• The safety of the environment
• Findings from utilization review and risk management activities
• CCHP will measure the performance of functions,processes and outcomes which effect the
health of its'members.
• CCHP will identify opportunities for improvement through a system of monitoring which
includes the following activities: monitoring where appropriate the performance of OHS and
Community Partners in providing quality of care and access to care, through the use of
indicators, member satisfaction surveys, complaints, focused studies, facility inspections,
medical record audits and analysisof administrative data.
• Monitor processes related to the movement of members along and among service and
provider sites to ensure continuity of care that meets the members needs.
• Establishing current benchmarks and future expectations embodies in the CCHP Quality
Management Plan.
• Monitor known or suspected quality of care problems or trends or adverse clinical events
that impact the health care of members.
• Monitor the preventive services and health-promotion programs to evaluate their
effectiveness.
• Monitor the use of clinical resources from three perspectives: over utilization, under
utilization and inefficient or inappropriate utilization
• Aggregate other important data elements and sources of information available to CCHP that
bear on Health Partner quality of care review performance including membership service,
pharmacy and CHDP data.
• Monitor compliance with regulatory requirements of appropriate state and federal agencies.
• Monitor Health Partners oversight of delegated activities to assure that each subcontractor,
medical group,and independent practitioner has a mechanism to fulfill those responsibilities
including adequate administrative capacity, technical expertise, reporting capacity and
financial resources.
CCHP Quality Management Plan- January, 1997 Page 4
• CCHP will measure important functions as defined by JCAHO under the planning section
of CCHP Quality Management Plan.
d. Performance Assessment
• Results of all ongoing monitors and focused review studies will be assessed on a regular
basis. The frequency of data assessment will be based on CCHP priorities and the process
being measured. The data will be assessed to determine:
• The stability or constancy of the outcome over time
• The degree of conformance to outcome objectives
• Whether design specifications for new processes or procedures were met
• Priorities for improvement of existing processes
• If corrective actions successfully,improved performance
• Performance improvement will be compared to benchmarked data whenever such data exist.
using:
• State-of-the-art standards
• Best practice
• Practice guidelines
• Internal performance over time
• Performance of other networks or Health Partners
• The CCHP Quality Management Unit will present data using appropriate statistical control
techniques. The results of all ongoing monitoring and focused studies will be trended over
time using adequate sample size.
e. Performance Improvement
• When results of ongoing monitoring reveals an undesirable pattern of performance or an
important sentinel event occurs,the Health Plan will initiate an intensive review to determine
the possible cause of unacceptable performance.
• All results of ongoing monitoring and special studies will be considered at the time of
physician reappointment.
• Each significant issue identified in the focused review or other quality of care studies
requires a corrective plan which includes clearly stated objectives and time frames for
completion. These action plans are communicated to the OHS Partners and Community
Partners involved.
• Corrective action plans will use a systematic approach to improvement:
• Planning the improvement action
• Testing the action by either making system-wide changes or on a test-pilot basis.
CCHP Quality Management Plan - January, 1997 Page 5
• Studying the effect of the corrective action
• Fully implementing the successful measures
• The cycle of"Plan, Do, Study, Act" will continue until the desired goal is reached.
• These corrective action plans may include but are not limited to:
• System-wide improvements of significant processes
• Using Quality Improvement Teams trained in CQI tools
• Changes to administrative policies and procedures
• Written or verbal provider education
• Required provider training or educational courses
• Provider re-certification procedures
• Prospective or retrospective monitoring of the provider's practice patterns
• In service training of provider's staff
• Member education
• Required submission by the provider of a corrective action plan with subsequent re-
monitoring or confirm compliance with and success of the action plan
• Intensified review of the network provider or Health Partner's care including but not
limited to a requirement for second opinions for surgical procedures, retrospective
or prospective claims analysis
• Modification, suspension restriction or termination of Health Partner or network
provider participation privileges
• Corrective action plans will be incorporated into the annual Quality Improvement
Plan
ACTIVITIES AND STRUCTURE OF THE CCHP OM PROGRAM
I. Scope of Activities
The scope of the Contra Costa Health Plan QM Plan includes monitoring of Community and
OHS Partners, review of quality and appropriateness of care and of service planned or
rendered to Contra Costa Health Plan members, including:
A. Inpatient and outpatient care, other institutional care, ancillary and supportive care
and other levels, types and places of service as utilized by the Contra Costa Health
Plan patient population for acute and chronic conditions.
B. All aspects of care and service, including at least: accessibility, continuity,
availability, level of care, appropriateness, timeliness, preventive services, and
effectiveness of care provided within the purview of the Contra Costa Health Plan.
C. All members' health needs, whether covered by Contra Costa Health Plan benefits
plans or requiring coordination with outside agencies.
D. All Community and OHS Partners and their affiliated providers including at least,
credentialing/recredentialing/reappointment, overall performance and clinical
CCHP Quality Management Plan- January, 1997 Page 6
competence.
Il. Committee Reporting and Structure
A. The Quality Management Unit will help support and maintain the QM committees
and subcommittees and the entire CCHP review process. The Quality Management
Unit will receive multiple sources of data as described in the Quality Management
Plan. The CCHP Quality Management Unit will organize and disseminate the
information to all appropriate committees and personnel.
B. COMMUNITY PARTNER PEER REVIEW COMMITTEE
1. Duties and responsibilities
The Community Partner Peer Review Committee will be the forum where
individual community Primary Care Physicians and other CCHP Health
Partners not affiliated with any other quality management program will carry
out their QA/QI and Utilization Management functions.
a. Report to the Quality Council as a quality review,peer review and a
utilization management committee for the CCHP Health Partners who
are not otherwise represented at the Quality Council. The
Chairperson of the Network Peer Review Committee will present
quality review, peer review and a utilization management report to
the Quality Council.
b. Duties and responsibilities of the Network Peer Review Committee:
1) Receives, reviews, evaluates reports of represented CCHP
Health Partners prepared by Quality Management Unit staff.
2) Receives potential quality issues and recommends action
regarding quality of care issues from represented CCHP
Health Partners.
3) Receives and reviews quarterly or more frequent aggregated
QI reports from CCHP Quality Management Unit.
4) Receives, analyzes and reviews quarterly utilization
management reports and recommends action and follow up,
where indicated.
5) Develops and submits (via the Community Peer Review
Committee Chairperson) quarterly, or more frequently,
QA/QI reports, including utilization management reports,to
the Quality Council and receives and appropriately
CCHP Quality Management Plan - January, 1997 Page 7
communicates Quality Council feedback to represented
CCHP Health Partners.
6) Acts as a first level appeal for grievances and quality of care
unresolved at CCHP Health Partners level.
7) Develop annual QI plan and QI reports for Quality Council
approval.
8) Reports to Quality Council.
C. The Community Partner Peer Review Committee reports will be
disseminated to all members and other represented CCHP Health
Partners by the Community Peer Review Committee Chairperson. In
addition, providers will receive update letters, reports, and other
publications directly from the CCHP Health Partners.
d. The Community Partner Peer Review Committee reports will be
distributed to all divisions of the represented CCHP Health Partner
administration.
2. Reporting of minutes
a. Community Partner Peer Review Committee minutes and annual plan
will be disseminated to all committee_members
b. Community Partner Peer Review Committee minutes and annual plan
will be submitted to the CCHP Quality Council
C. Minutes are confidential.
C. CREDENTIALS COMMITTEE
1. The committee will receive reports from the Quality Management Units of
the CCHP Health Partners to whom the credentialing function has been
delegated; it will review the credentialing activities and policies of the CCHP
Health Partners and recommend approval to the Board of Supervisors; .
arbitrate credentialing disputes, report issues to other subcommittees and
make recommendations regarding potential providers and report to the
Quality Council.
2. Reporting of minutes
a) Credentials minutes, actions and recommendations of corrective
action will be forwarded to the Quality Council, PAC of CCHP and
eventually the Board of Supervisors.
CCHP Quality Management Plan- January, 1997 Page 8
- b) Minutes are confidential
D. QUALITY COUNCIL
1. Duties and Responsibilities
a. Receives, reviews, evaluates reports of subcommittees
b. Receives potential quality issues and recommends action regarding
quality of care issues from the Quality Management Unit
C. Receives and reviews quarterly or more frequent aggregated QI
reports from CCHP Quality Management'Unit.
d. Receives, analyzes, and reviews quarterly, or more frequently,
Utilization Management reports and recommends action and follow
up, where indicated
e. Develops and submits (via the Medical Director) quarterly, or more
frequently,QA/QI reports,including Utilization Management reports,
to the Board of Supervisors and receives and appropriately
communicates Board feedback and Board.policy to CCHP Health
Partners.
f. Acts as a second level appeal for grievances, credentialing issues, and
quality of care unresolved at CCHP Health Partners level.
g. Receives Health Partner reports. Analyzes success of corrective
actions.
h. Credentialing.
2. Reporting of minutes and annual plan
a. Quality Council minutes will be disseminated to all committee
members, Health Partners, Quality.Management Unit.
b. Quality Council minutes and annual plan will be submitted for review
and PAC of CCHP quarterly.
C. Minutes are confidential
E. JOINT CONFERENCE COMMITTEE
1. Duties and responsibilities
CCHP Quality Management Plan-January, 1997 Page 9
a. The Joint Conference Committee of the Board of Supervisors serves
as a closed forum for discussion between the Governing Body and the
physician members of the CCHP to discuss issues relating to Quality
Assurance, Risk Management, Credentials and related topics.
b. The Joint Conference Committee will serve as the final level for
specified appeals.
C. The Joint Conference Committee will transmit written reports of its
activities to the Board of Supervisors and the Quality Council.
2. Reporting of minutes
a. Minutes of the Joint Conference Committee will be reported quarterly
to the Board of Supervisors and to the Quality Council.
PLANNING
Systematic improvement in performance is achieved by long range planning and continual
reassessment of the effectiveness of current programs.
In order to plan future refinements of the Quality Management program, Contra Costa Health Plan
will perform the following functions:
A. Review the effectiveness of the Program in improving the quality of care delivered
to members.
B. Monitor and evaluate Contra Costa Health Plan's for the Community Partners and
the OHS Partners administration of the Quality Management Program for the its
Health Partners and their contracted community providers.
C. Assess the adequacy of Quality Management information to review overall Program
effectiveness, and to assess variation among all Health Partners.
D. Assess the OHS Partners' Quality Management Plan, as well as their administrative
and financial capacity and technical expertise to implement their respective Quality
Management plans. The number and extent of delegated functions will be
determined by these assessments, which will be performed by Contra Costa Health
Plan Quality Management Unit and the Quality Council. CCHP will evaluate the
performance of delegated quality management activities by OHS Partners through:
1. Review of the minutes of the Quality Management Committee of the Health
Partner.
2. Review and analysis data input from OHS Health Partners.
CCHP Quality Management Plan- January, 1997 Page 10
- 3. Review reports submitted by the OHS Partners regarding quality
management activities, including the results of their reviews of potential
quality issues as well as focused review studies and audits.
4. Analyze quality of care studies and other reports, including analysis of the
review methodology, timetables and frequencies of reviews and studies,
criteria used in the studies,and study findings and conclusions.
5. Specifically, address barriers to access, patterns of under-utilization and
timeliness of care.
6. Review and recommend corrective action to address quality of care issues.
7. Review the resolution and follow up of potential quality issues corrective
actions for timeliness and appropriateness of actions.
8. Assure that OHS Partners QA/QI Committee structure and process
significantly involves providers.
9. Confirm that at all times the OHS Partners Quality Assurance and Utilization
Management structure, staff and process are in compliance with all
provisions of the Contra Costa Health Plan Quality Management program
and professionally accepted standards.
E. ANNUAL QA/QI PROGRAM EVALUATION
1. At least annually Contra Costa Health Plan will review data and reports of
Program activities and findings to assess the effectiveness of the Program.
2. This evaluation includes a review of completed and continuing program
activities, trends of clinical and service indicators, focused review studies,
medical record audits, quality of care issue tracking and utilization of
management data, effectiveness of the Program's monitoring and review
activities, and,effectiveness of the Program identifying and acting upon
Quality of Care Issues.
3. Contra Costa Health Plan will review its clinical practice guidelines and
medical policies and procedures to recommend enhancements in the
guidelines to Community and OHS Partners.
4. The annual QM Evaluation represents an important overall component of the
overall CCHP annual report. This report will measure the successes and
- challenges of the Program in improving patient care and network provider
performance, assessed in relation to the previous year's QM work plan.
5. This report is developed by the Contra Costa Health Plan Quality
CCHP Quality Management Plan - January, 1997 Page 11
Management Unit and the Quality Council.
6. The annual reports are made to the Contra Costa Health Plan Joint
Conference Committee and will be communicated to all Health Partners.
7. Each year an Annual QM Work Plan is prepared by the Quality Management
Unit based on the results of the Annual Program Evaluation. The Work Plan
is approved by the Quality Council and the Board of Supervisors. The Work
Plan includes a description of-
The
£The Quality Management objectives, scope and planned activities to
be undertaken in the coming year.
• Monitoring of previously identified issues, including tracking of
issues during the next year and time lines.
• Criteria for evaluation of the accomplishments of the Quality
Management Program.
• The Work Plan will be communicated to all Health Partners.
F. ANNUAL QUALITY MANAGEMENT WORK PLAN
The CCHP expects to develop and implement the following quality improvement
activities in the 1997 calendar year:
1. A review of all contracting hospital clinical certifications and results of
quality reviews performed by national and regional review entities as well as
those performed by hospital peer review committees.
2. Implementation of uniform criteria to assess access to and continuity of
services.
3. Implementation and monitoring of criteria for adverse events.
4. Evaluate and change as necessary quality of service and care instrument to
evaluate utilization management and quality management performance.
5. Perform DDA focused review studies to obtain baseline data to be compared
to national and state norms.
6. Track and report grievance and appeal procedures
7. Develop guidelines for risk management.
8. Develop,review and endorse standards of practice for indicator and focus
CCHP Quality Management Plan - January, 1997 Page 12
review studies.
9. Develop reporting format for the Contra Costa Health Plan Board of
Supervisors Joint Conference Committee.
DESIGN
When new processes, services, or information systems are designed, input from the Quality
Management Unit will be sought through consultation with the Medical Director. Other important
sources of information include:
• The network's mission and plans
• Health Partners' mission, vision and plans
• Members and providers needs
• Community resources
• Scientific and professional knowledge about the intended design
The Quality Management Unit may be involved in:
• Pre-design evaluation of services
• Member or provider survey
• Focus groups
• Research into scientific and professional sources such as practice guidelines or
clinical standards
• Facilitating network design teams
MEASURING: AREAS OF FOCUS
Appropriate monitoring of the delivery of care is critical to network improvement. The monitoring
and evaluation of clinical care will reflect the individual components of care (providers), the full
range of services and how they interrelate continuum and coordination.
Measurement systems will focus on:
• High volume, high risk or problem prone processes
• Outcomes
• Comprehensive performance measures over time
• Known areas of concern of California
CCHP Quality Management Plan- January, 1997 Page 13
• Medi-Cal CHDP recipients
• Needs,expectations and feedback of members and providers
A. QUALITY AND UTILIZATION MEASURES
Through an extensive system of monitoring, Contra Costa Health Plan will evaluate covered health
care services at both a systemic and individual member level.
The input will derive from administrative data and chart audits performed by Contra Costa Health
Plan Quality Management Unit and OHS Partners. Data will be aggregated into activity reports,
logs, focused review studies, Utilization Management data trending, provider quality profiles and
site visit reports. These monitors include, but are not limited to:
1. Focused review studies of medical services mandated by the State Department of Health
Services:
a) Pediatric Preventive Services: Immunizations
Description of the measure: The percentage of Medicaid enrollees who turn two
years old during the reporting year, who were enrolled continuously for 12 months
prior to their second birthday (allowing one break in service, not to exceed 30 days,
or one month), and who received the following immunizations:
• Four DTP (or an initial DTP followed by any combination of at least three
DTP, DtaP and/or DT)by the child's second birthday;
• Three polio (IPV or OPV) vaccinations by the child's second birthday;
• One MMR falling between the child's first and second birthdays;
• AT least, one H influenza type b between the child's first and second
birthdays;
• Three Hepatitis B by the child's second birthday; and
• A combination of four DTP (or an initial DTP followed by any combination
of at least three DTP,DtaP and/or DT)by the child's second birthday, AND
three polio vaccinations by the child's second birthday, AND one MMR
between the child's first and second birthdays AND at least one H influenza
type b between the child's first and second birthdays, and (starting in 1997,
for the 1996 reporting year) three hepatitis B by the child's second birthday.
b) Pediatric Preventive Services: Health Screen
Description of the measure: The percentage of Medicaid-enrolled children who turn
age 15 months during the reporting year who were continuously enrolled in the plan
from 31 days of age, and who received either zero, one, two,three, four, five or six
well-child visits with a primary care physician during their first year of life. Health
CCHP Quality Management Plan - January, 1997 Page 14
plans calculate seven rates;the denominator is the same for all seven rates. A child
should be included in only one numerator(i.e. a child receiving six well-child visits
will not be included in the rate for five, four or fewer well-child visits).
C) Adult Preventive Services: Breast Cancer Screen
Description of the measure: The percentage of Medicaid enrolled women between
the ages of 50 and 64 years of age who had a mammogram during the previous two
calendar years.
d) Adult Preventive Services: Cervical Cancer Screen
Description of the measure: This measure calculates the percentage of Medicaid
enrolled women aged 16-64 years who were continuously enrolled during the
reporting year (allowing for one break in service, not,to exceed 30 days or one
month) and who have received one or more Pap tests-within the past three years.
e) Pregnant Women: Initiating of Prenatal Care
Description of the measure The percentage of Medicaid enrolled pregnant women
with a live birth who had their first prenatal care visit 26 to 44 weeks prior to
delivery OR within four weeks of enrollment. Women enrolled in the plan for four
weeks (28 days) or less prior to delivery should not be included in this measure.
f) Pregnant Women: Prenatal Care Utilization
Description of the measure: The percentage of pregnant Medicaid enrolled.women
who received 0 to 20, 21 to 40, 41 to 60, 61 to 80 or z 81 percent of the expected
number of prenatal care visits, adjusted for gestational age and the month prenatal
care began.
g) Pregnant Women: Low Birth Weight
Description of the measure: Two birthweight measures are to be calculated: 1)the
percentage of infants whose birthweight is less than 1,500 grams; and 2) the
percentage of infants whose birthweight is less than 2,500 grams. Babies in the very
low birthweight category are a subset of babies in the low birthweight category.
h) Utilization Measures
Quality indicators: The total number, and a rate per 1,000 member months, of
cholecystectomies, hysterectomies, dilation and curettage procedures,
tonsillectomies/adenoidectomies,and myringotomies performed during the reporting
period.
i) Emergency Services
Quality Indicators: Medicaid NEDIS: Each visit to an Emergency Room that does
not result in an inpatient stay should be counted once, regardless of the intensity of
care required during the stay or the length of time spent. Patients admitted to the
hospital from the Emergency Room should not be included in counts of visits. Only
visits to Emergency Rooms should be counted; visits to urgent care centers should
not be counted in this measure.
CCHP Quality Management Plan- January, 1997 Page 15
j) Access (Utilization of Preventive/Ambulatory Services by Adults and Children)
Quality. Indicators: Medicaid HEDIS: Unduplicated. counts of Medi-Cal
beneficiaries, 12 to 24 months, 25 months to six years old, seven to ten years old,
ages 21 - 39 and ages 40-64,respectively, as of December 31 of the reporting year,
who were members of the plan as of December 31 of the reporting year, and who
were continuously enrolled in the plan during the reporting year (allowing for one
break in service not to exceed 30 days or one month) who had an ambulatory care
encounter as specified by Medicaid HEDIS.
k) Continuity of Care
Quality Indicators: Percent of visits for primary care which were made with the
member's own assigned Primary Care Physician.
1) Coordination of Care: Tuberculosis
Quality Indicators: Each case will be followed for one year from the time the initial
report is made. The medical record will be audited at the end of a one year period in
order to determine if adequate treatment was given, whether family members and
close contacts were tested, and whether appropriate education was done.
m) Adolescent-Comprehensive Well Care Visit: Health Education
Description of the Measure: The percentage of Medicaid-enrolled adolescents aged
12 to 21 during the reporting year who had one or.more comprehensive well-care
visits with a primary care provider during that year which included anticipatory
guidance regarding tobacco use, high risk sexual behavior, contraception, sexually
transmitted diseases.
n) Family Planning
Quality Indicators: Medical records of teenagers will be reviewed to determine
whether the member was asked if she was sexually active and whether appropriate
referral or care for contraception was given. Charts will be audited using an audit
tool to be developed in conjunction with the CCHP Health Partners.
o) Substance Counseling for Adolescents
Description of the measure: The percentage of Medicaid-enrolled adolescents aged
12 to 21 during the reporting year who received substance counseling during the
reporting year.
2. Availability and access to appointments and services
a) Access to appointments
1) Emergent Care: Immediate access 24 hours a day; 7 days per
week
2) Urgent Care: Within 24 hours
CCHP Quality Management Plan- January, 1997 Page 16
3) Routine Care: Preventive Exams -within 60 calendar days
• Initial Health Assessment-within 120
calendar days
• Non-Urgent (Patient Symptomatic) -
within 21 calendar days
4) First Prenatal Visit: Within 7 calendar days upon request
5) CHDP Periodic
Health Screens Within 30 calendar days upon request
` 6) Specialist appts.: Routine Specialty Referral - within 30
calendar days
Urgent Speciality Referral -within 24 hours
b) Service Waiting Times
1) Provider Office
Waiting Time 0 to 45 minutes
2) Telephone
Waiting Time 0 to 60 seconds
3) %of prenatal members with prenatal care in the first trimester
3. Respect, caring and acceptability of services including:
• Member satisfaction surveys
• Review of member grievances and concerns
• Telephone waiting time
• Office waiting room time
• Maximum time or distance a patient must travel
• Shopper surveys
• Disenrollment questionnaire
4. Appropriateness and utilization of services including:
• Review of pattern of authorization denials, appeals, complaints and grievances
• Pattern of referral authorization requests, approvals, denials, appeals and outcome of
appeals
• Timeliness of decisions
• Utilization of Emergency Room
• % of visits that occur with Primary Care Physician
CCHP Quality Management Plan- January, 1997 Page 17
• Hospital admissions/10,000
• Utilization of ambulatory and inpatient services
• % of funds for health care spent on catastrophic illnesses
• Authorization for costly procedures
• Out of plan claims
5. Environment of care and safety of the member to whom the care is provided:
• On site facility audits/reviews
• Member complaints and grievances
• Review of disenrollment questionnaire survey results
6. Adequacy of the medical record including organization, documentation, legibility,
continuity, specialty referral and utilization.
The following are minimum documentation requirements:
a) Demographic Information
1) Name (first and last name)
2) Sex
3) Date of birth
The actual month, day and year the patient was born.
4) Home address
The home address of the patient's primary residence, e.g., street and town.
Home or work telephone number.
5) Occupation (Pediatric excluded)
6) Employer
A description of the patient's employer
7) Marital status
8) Primary language spoken
b) Clinical Documentation
1) All pages in medical record contain patient identification
• Patient name is on all pages with entries.
• Laboratory request/reports have patient name and ordering.physician.
2) Individual medical record for each individual receiving care
3) Medical record organized
• Chart is in reverse chronological order or chronological order but is
consistent by facility site and content is in a consistent format.
Consistent format means reports are in respective sections of the
CCHP Quality Management Plan- January, 1997 Page 18
medical record,e.g.,laboratory information is in the lab section of the
medical record.
• All reports are filed in the correct order following the chart sequence.
Reports should be filed under the appropriate sections. Each type of
report, when there is more than one, should be filed in reverse
chronological order or chronological order as consistent with the rest
of the chart and charting policies at that facility.
4) Each entry dated
5) Each entry contains the author's name and profession
The author signs (in ink or electronically)his/her own entry
6) Legible
The record should be legible to someone other than the writer. If handwriting
cannot be interpreted by one reviewer, it should be evaluated by another.
7) Reason for visit or chief complaint
For each visit,the reason for the visit or chief complaint is noted. The review
of systems exam coincides with the reason for the visit or the chief
complaint. Each stated complaint must be addressed.
8) Past medical history
For patients seen 3 or more times a past history should be easily identified
and should include history of immediate family members,or a note indicating
there are no family members history of problems, serious accidents,
operations or illnesses. History may include: marital history; job
(occupation); military service; recreation, including foreign travel, sports,
hobbies, special interests and lifestyles that could affect health status.
9) Complete problem list or summary
An updated completed problem list summarizes significant illnesses,medical
conditions, past surgical procedures, or chronic-health problems which is
updated as new problems are encountered,as evidenced in the progress notes.
• Chronic problem list or permanent data base (or list of chronic
problems) has appropriate entries, made by a clinician who has
reviewed the record.
CCHP Quality Management Plan- January, 1997 Page 19
• All patients receiving ongoing medications should have an entry on
the Chronic Problem List or on a separate medication list.
10) Allergies/adverse reactions
The patient's medication allergies and adverse reactions to medications must
be conspicuously listed or, if allergies and adverse reactions to medications
are absent, "no known allergies" (NKA), "no known drug allergies(NKDA)",
or "NA", or "none" is documented.
11) Medication documented in progress note
Prescriptions are documented in the progress note with the corresponding
treatment plan. This would include medications prescribed during the visitor
being renewed over the phone. Documentation will include:
• Drug name
• Strength/dosage
• Quantity/refills
• Directions for use
12) Immunizations are documented in the record
13) Preventive screening
Preventive screening and preventive services are documented in accordance
with the Medi-Cal Preventive services requirement and the organization's
practice guidelines(e.g.,baseline history and physical exam within 120 days
or enrollment for adults).
14) Prior problems addressed as subsequent visits
Each encounter with a provider should include notion of any unresolved
problems from a previous visit.
15) Recommended follow up documentation
Each provider encounter has a notation regarding follow-up care, treatment,
or visit, indicating instructions regarding current problem, chronic disease,
and/or periodic health appraisal. The specific time of return is noted in days,
weeks, months, or PRN.
16) All referrals shall be noted in the chart.
17) All emergency care provided, inpatient discharge and consult report notes
reviewed.
CCHP Quality Management Plan - January, 1997 Page 20
• 18) Reviewed means the emergency notes, discharge summary, or consultant
-report has.been initialed or signed and dated by.the,provider. The turnaround
time should be no longer than 60 days.
• Emergency room,discharge summary,or consultation report in chart;
or
• Progress note documents patient failed to appear for the appointment
with consultant; or
• The routine practice of sending a separate (not chart) copy to the
Primary Care Physician will satisfy this requirement.
19) Laboratory studies/other diagnostic studies reviewed
Reviewed means the lab and other diagnostic studies have been signed or
initialed and dated by the provider.
• Laboratory results,radiologic results and other diagnostic reports are
signed or initialed and dated by the ordering provider documenting
knowledge of result.
• Patients are notified of adverse results and notification is documented
in progress notes.
• The routine practice of sending a separate (not chart) copy to the
Primary Care Physician will satisfy this requirement.
20) Smoking history, alcohol/substance abuse.
For patients 12 and older having three visits or more, smoking habits, alcohol
use, and substance abuse are noted in the history and physician or progress
notes.
21) Orders must be noted on the progress notes
Laboratory, X-Rays, and other tests must be ordered by a Physician,Nurse
Practitioner, or Physician Assistant.
22) Physical exam-the basic components of an office visit physical exam must
include are at a minimum documentation of:
• Vital signs
Periodic weight
Periodic blood pressure
• Height(once)
• Results of findings from actual physician exam limited or
comprehensive as appropriate (e.g., enlarged lymph nodes and
CCHP Quality Management Plan - January, 1997 Page 21
• location, discovery of herniation and location, mass by palpation,
etc.).
23) Progress notes
• The use of SOAP charting is preferred for each patient visit.
• If the back side of a progress note is utilized, the identifying
information, including name, must be documented on both sides.
24) If applicable, documentation of request or refusal of language interpretation
services should be documented in the progress notes.
B. STANDARDS OF PRACTICE
1. The standards of practice used as criteria, measures, indicators, protocols, practice
guidelines, review standards or benchmarks in the Contra Costa Health Plan Quality
Management process are based on professionally recognized standards. They are obtained
from national and local medical professional associations, local professionally recognized
practices,review of applicable medical literature,available medical knowledge,and state and
federal requirements. These polices will be reviewed and endorsed annually by the Quality
Council.
2. Standards are communicated to providers through the Health Partners in a systematic manner
and may include but not be limited to: conferences and committee meetings, newsletters,
bulletins, forums, etc.
3. Standards are incorporated into Health Partners review policies. Those policies must be
written. Medical policies must be reviewed annually,revised as appropriate, and authorized
by Board of Supervisors, subject to guidelines endorsed by the Contra Costa Health Plan
Quality Council and approved by the Board of Supervisors.
4. Standards are used to evaluate quality of care of providers.
5. Standards apply to:
a. Clinical services provided by network practitioners,including primary care, specialty
care and preventive care service in the hospital, inpatient and outpatient settings.
b. Availability of providers and accessibility of primary and specialty care including
geography, timeliness, culture and linguistics.
C. Health promotion and health management services and activities of providers.
d. Adequacy of facilities, environmental health and safety, emergency care and
infection control practices.
CCHP Quality Management Plan- January, 1997 Page 22
. e. Medical record-keeping practices of providers.
f. Medical policies and medical necessity determination, resulting in utilization
management policies.
g. Appropriateness and timeliness of care and referrals / level of care /and access to
care.
h. Any of the aspects of care specified in prior sections of this Plan.
6. Standards,Norms and Guidelines are derived from the following sources:
a) Standards for Quality of Care
1) Department of Corporations Standards
2) NCQA standards for quality, utilization management, and credentialing
3) JCAHO standards for network performance
4) HEDIS Medicaid performance standards
5) Other independent credentialing,certification and accreditation organizations,
including CMRI, The Quality Commission, AAAHC and URAC
6) United States Preventive Services Task Force (USPSTF) Guidelines (1996)
7) Child Health and Disability Prevention(CHDP)program guidelines
8) Professional speciality service guidelines, including American Academy of
Family Practice, American College of Physicians, American Academy of
Pediatrics, American College of Obstetrics and Gynecology, and the
American Medical Association
9) Federal agencies' guidelines including Office of Technology Assessment
(OTA), Agency for Healthcare Policy and Research (AHCPR), National
Institute of Health (NIH), Department of Health and Human Services
(DHHS), Center for Disease Control (CDC), United States Public Health
Services (USPHS)
10) Professional community standards, as determined by Contra Costa Health
Plan Medical Policy Subcommittee
11) National consensus organization guidelines for clinical practice
12) Milliman and Robertson guidelines
CCHP Quality Management Plan -January, 1997 Page 23
13) The English language peer reviewed medical literature
14) The Technology Evaluation Committee of the Blue Cross-Blue Shield
Association
15) Pharmacology Guidelines extracted from Practice Standards of the American
Society of Hospital Pharmacists and the PDR
16) Expert opinion
17) HMO standards for access to ambulatory care
b) Standards and norms for Utilization Management section of Quality Management
Program include:
1) Milliman and Robertson
2) Interqual Severity of Illness/Intensity of Service (ISSI)
3) Commission for Professional Activity Studies (PAS) length of stay norms
7. These standards are embodied in the Medical Policies and Quality Management plans of the
respective Community Partners. The Contra Costa Health Plan Quality Council reviews the
standards annually to assure that medical policies have been implemented, updated, and .
reauthorized by the Governing Body of each Health Partner.
8. Thresholds and targets derived from these standards and norms and accepted for use must
be:
a) Measurable
b) Achievable
C) Consistent with national norms and goals
d) Consistent with requirements of regulatory agencies and legal guidelines
e) Consistent with the vision of Contra Costa Health Plan
f) Valuable to the assessment of quality or the potential improvement of quality for our
member population
C. MONITORING METHODOLOGIES
Contra Costa Health Plan Quality Management Unit is responsible for collecting, collating and
reporting the monitors on a regular basis as outlined in the Quality Management Program. The
CCHP Quality Management Plan - January, 1997 Page 24
Quality Management Unit will be responsible for reporting both non-delegated community provider
auditing and monitoring, as well as oversight of delegated.OHS.Partners..Methods of monitoring
include, but are not limited to:
1. FOCUS REVIEW STUDIES
A. SCOPE
Focused Review studies are performed by Quality Management Unit staff of the
Health Partners under the general oversight of the Contra Costa Health Plan Quality
Management Unit. The State Department of Health Services specific studies to be
reported back to the State Department of Health Services. An emphasis of review
will be the eleven areas of concern outlined by the State.
B. STUDY DESIGN
Focused Review Studies include the following design elements:
a. Objective and reason for topic selection
b. Sampling framework and sampling methodology as outlined in HEDIS
C. Data collection and analysis methodology as outlined in HEDIS
d. Report of data and/or findings
e. Analysis and conclusions
f. Action plans as appropriate
g. Reassessment as appropriate
C. DATA COLLECTION METHODOLOGIES
Data for Focused Review Studies may be collected through:
a. Member surveys
b. Provider surveys
C. Telephone surveys
d. Focused medical.record audits
e. On site provider facility inspections
f. Analysis of encounter/claims data
g. Analysis of prior authorization data
h. Analysis of member complaints and grievances
i. Other methodologies as determined by the Contra Costa Health Plan
D. POTENTIAL QUALITY ISSUE IDENTIFIED THROUGH FOCUSED REVIEW
1. Potential Quality Issues identified through Focused Review are referred,
prioritized,reviewed, acted upon, documented and reported to Contra Costa
Health Plan on a quarterly basis
CCHP Quality Management Plan - January, 1997 Page 25
- 2. All QCI incidents will be logged and tracked to ensure appropriate, timely
actions.
r
3. Significant QCI sentinel events may lead to system-wide Quality
Improvements
E. OVERSIGHT OF DELEGATED FOCUSED REVIEW STUDIES
1. The results of Focused Review Studies will be reviewed and compiled by
Quality Management staff and the Medical Director to determine if any
specific opportunities to improve the delivery of care,accessibility or service.
Opportunities to improve quality will be addressed.
2. Results of all focused review studies will be reported to the Quality Council,
Community Partner and OHS Partners QA Committees
F. NON-DELEGATED COMMUNITY PARTNER FOCUSED REVIEW STUDIES
1. Data will be collected through:
a. Chart review
b. Administrative data review
C. Analysis of encounter/claims data
d. Analysis of prior authorization data
e. Claims data
f. Member grievance or adverse outcome data
2. The frequency of data collection will be specified for each indicator to
achieve consistency of data collection.
3. Results will be tabulated and trended with comparative data of providers and
OHS partners.
G. ROLE OF HEALTH PROFESSIONALS IN THE REVIEW PROCESS
1. Findings are reviewed by the Quality Council and Medical Director.
2. Non-delegated Community Partners findings are reviewed in the Community
Partner Peer Review Committee
3. Findings of focus review studies are used to determine opportunities for
improvement
4. Variation is OHS and Community Partners are assessed and corrective
actions are planned whenever deemed necessary
H. METHODOLOGY FOR PROVIDING FEEDBACK TO PROVIDERS
CCHP Quality Management Plan - January, 1997 Page 26
• 1. Focus Review studies Health Partner variation will be distributed to all OHS
affiliated providers and Community Partners
2. Results of Indicator Monitoring including corrective actions will be discussed
and reviewed at CCHP Quality Council, CCHP Community Partner Peer
Review Committee and OHS Partners Quality Improvement Department
and/or Committee and with respective Medical Directors
3. OHS or Community Partners will be alerted earlier if a noted which might
require urgent attention.
1. SPECIFIC ACTIONS OR INTERVENTIONS TO IMPROVE THE OUTCOMES
1. Member interventions including member outreach and education
(a). Assign members to care managers for specialized attention
(b). Re-engineer organizational processes and structures
(c). Design provider/member educational:and incentive programs.
(d). Introduce new technology
2. Provider interventions
(a). Develop employee training programs
(b). Quantify and compare Health Partner performance and utilize best
practice techniques.
(c). Disseminate provider performance data on where providers stand
relative to peers on various measures
(d). Design provider-specific studies to further investigate causes of
variation.
(e). Develop clinical practice guidelines with participation of OHS and
Community Partners for dissemination to all providers
(f). Ultimately, providers may be terminated for quality problems after
appropriate appeals processes.
2. INDICATOR MONITORING
CCHP Quality Management Plan - January, 1997 Page 27
A. SCOPE
The Contra Costa Health Plan Quality Council will specify a core of indicators common to
all Health Partners. Each Health Partner's Quality Management Plan will have a written list
of clinical indicators. Indicators will cover important high risk, high volume or problem
prone services or procedures. Both quality and utilization will be monitored. A major
component of the Quality Management Program is the use of.indicators to monitor important
aspects of care, accessibility and service. Examples of these indicators include:
1. Hospital bed days/1,000 members per year
2. Compliance statistics for preventive services, including CHDP
3. Ambulatory visits/member/year
4. Referrals (requested, authorized, approved,denied/year)
5. Encounters/1,000 children/year for asthma, developmental disorders, mental
or behavioral disorder and anemia)
6. Out of plan visits
7. Emergency Room visits
8. Telephone surveys and disenrollment surveys
B. STUDY DESIGN
1. Results of indicator studies will be reported on a regular basis to the Contra
Costa Health Plan Quality Management Unit and promptly in the event of a
major finding. Contra Costa Health Plan Quality Council will develop a list
of core indicators which will represent the minimum expectation for
monitoring and reporting for each Health Partner.
2. Community partners will provide annual lists of Contra Costa Health Plan
Indicators to be reviewed by the CCHP Quality Council.
3. Benchmarks or targets are established for indicators, bases on reasonable
scientific evidence; public policies, benchmarks and guidelines adopted by
national,federal or state agencies, such as the US Public Health Service; state
-and federal requirements; and internally adopted service standards
4. Each OHS Partner will incorporate written criteria in their QI plans consistent
with those established by the Contra Costa Health Plan.
C. DATA COLLECTION
1. The methods and frequency of data collection will be specified for each
indicator,to achieve consistency of data collection.
2. Wherever feasible,data are reported as population-based rates,the numerator
of which is the number of specific events being studied, and the denominator
of which is the number of members at risk for the event or observation.
CCHP Quality Management Plan- January, 1997 Page 28
F. NONDELEGATED COMMINITY FOCUSED REVIEW STUDIES
1. Data will be collected through:
a. Chart review
b. Administrative data review
C. Analysis of encounter/claims data
d. Analysis of prior authorizarion data
e. Claims data
f. Member grienance or adverse outcome data
2. The frequency of data collection will be specified for each indicator to
achieve consistency of data collection.
3. Results will be tabulated and trended with comparative data of providers and
OHS partners.
G. ROLE OF THE HEALTH PROFESSIONAL IN THE REVIEW PROCESS
1. Findings are reviewed by the Quality Council and Medical Director.
2. Non-delegated Community Partners findings are reviewed in the Community
Partner Peer Review Committee
3. Findings of indicator monitoring are used to determine opportunities for
improvement
4. Variation is OHS and Community Partners are assessed and corrective
actions are planned whenever deemed necessary
H. METHODOLOGY FOR PROVIDING FEEDBACK TO PROVIDERS
1. Trended indicators monitoring along with Health Partner variation tables will
be distributed annually to all providers.
2. Results of Indicator Monitoring including corrective actions will be discussed
and reviewed at CCHP Quality Council, CCHP Community Partner.Peer
Review Committee and OHS Partners Quality Improvement Department
and/or Committee and with respective Medical Directors
3. OHS or Community Partners will be alerted earlier if aventions including
member outreach and education
I. METHODOLOGY FOR MAKING IMPROVEMENTS IN CCHHP
PERFORMANCE
CCHP Quality Management Plan - January, 1997 Page 29
• 1. Member Interventions
(a). Assign in mbers to care managers for specialized attention
(b). Re-engineer organizzaional processes and structures
(c). Design provider/member educational and incentive programs.
(d). Introduce new technology
2. Provider interventions
(a). Develop employee training programs
(b). Qualtify and compare Health Partner performance and utilize best
practice techniques.
(c). Disseminate provider performance data on where providers stand
relative to peers on various measures
(d). Design provider-specific studies to further investigate causes of
variation.
(e). Develop clinical practice guidelines with participation of OHS and
Community Partners for dissemination to.all providers
(f). Ultimately, providers may be terminated for quality problems after
appropriate appeals processes.
3. MEDICAL RECORD AUDITS
A major component of the Quality Management Program is the review of Community and OHS
Partner medical records to confirm medical record keeping practices and to examine directly the care
that is delivered to patients.
A. SCOPE
1. Contra Costa Health Plan will review OHS and Community Partners to
confirm that the Medical Record includes:
a) Assessing the quality of practitioners' medical record keeping
practices to confirm that providers maintain reliable, readily usable
records of health care.
b) Assessing the quality of care delivered by providers as documented
in their medical records, with specific emphasis on:
CCHP Quality Management Plan- January, 1997 Page 30
_ (1) Services
(2) Health promotion
(3) Health management
(4) Continuity of care
(5) Appropriateness of referrals for specialty care
(6) Under utilization
B. STANDARDS FOR MEDICAL RECORDS
1. Contra Costa Health Plan will review Community and OHS Partners to
confirm that:
a) Medical records are maintained in a manner that is current, detailed,
organized and permits effective patient care and review of quality of
care.
b) Medical records reflect all aspects of patient care, including:
(1) Inpatient and ambulatory care
(2) Continuity of care
(3) Preventive services
(4) Health promotion
(5) Health management
(6) Referrals for specialty care
(7) Use of ancillary services
2. Standards for medical records of Medi-Cal services comply with the
requirements of the State Department of Health Services and include the
medical record documentation requirements of the Child Health and
Disabilities Prevention Program (CHDP)
3. The standards for medical records are communicated to providers in provider
bulletins and the OHS Partners'Provider Manuals and during Quality Council
and Community Partner Peer Review.
D. DELEGATED REVIEW OF MEDICAL RECORDS BY OHS PARTNERS
1. Contra Costa Health Plan will review OHS Partners QA/QI Plan and QA/QI
reports to confirm that:
a) The focus, number and frequency of medical record audits are stated
in the OHS Partner Annual Work Plan.
b) An approved checklist, consistent with the requirements of the
National Committee for Quality Assurance (NCQA), Department of
Corporations and JCAHO is used to audit medical records. Contra
'CCHP Quality Management Plan- January, 1997 Page 31
Costa Health Plan may,with the approval of the Quality Council and
OHS Partner QA/QI Committee,recommend additional criteria to the
checklist as needed.
C) In cases where medical records audits have been delegated to a
subcontractor, medical group or IPA, the subcontractor, medical
group or IPA either uses the Contra Costa Health Plan criteria or
submits its own criteria to the Contra Costa Health Plan Quality
Council for approval prior to use.
2. Contra Costa Health Plan Quality Management Unit will perform selected
audits of provider medical records to validate OHS Partner oversight and
when necessary to comply with oversight requirement of regulatory agencies
(State Department of Health Services, Department of Corporations, etc.)
E. NON-DELEGATED MEDICAL RECORD AUDIT REVIEW
1. Requirements for medical records will be distributed to all Community
providers initially in the provider manual and on an annual basis thereafter.
2. Quality Management Unit Coordinators will visit network providers offices
on a yearly basis and inspect records with the goal.of assessing the quality of
care documented in their records with similar criteria as utilized in the
delegated model.
3. Compliance percentages will be compiled as both aggregated and individual
providers.
4. Reports of individual and aggregated data will be made available to:
individual providers, Contra Costa Health Plan Quality Council, CCHP Plan
Community Peer Review Committee and Contra Costa Health Plan
credentials to be considered at reappointment.
F. POTENTIAL QUALITY ISSUES
Potential Quality Issues identified through Medical Record Audits of Health Partners
are referred,prioritized, reviewed, and improved
G. ROLE OF HEALTH PROFESSIONAL IN THE REVIEW PROCESS
1. Results of Medical Record Audits are reviewed by Quality Management
staff, the Medical Director and the appropriate Quality Management
Committee, to determine if any PQI exist and to identify specific
opportunities to improve the delivery of care, accessibility or service.
2. Opportunities to improve quality are addressed.
CCHP Quality Management Plan- January, 1997 Page 32
• 3. Contra Costa Health Plan requires that Health Partners maintain
confidentiality of all medical records examined during audits in accordance
with all legal requirements concerning policy on confidentiality for medical
information
H. METHODOLOGY FOR PROVIDING FEEDBACK TO PROVIDERS
1. Trended indicators monitoring along with Health Partner variation tables will
be distributed annually to all providers.
2. Results of Indicator Monitoring including corrective actions will be discussed
and reviewed at CCHP Quality Council, CCHP Community Partner Peer
Review Committee and OHS Partners Quality Improvement Department
and/or Committee and with respective Medical Directors
3. OHS or Community Partners will be alerted earlier if a significant trend is
noted by CCHP which might re urgent attention.
I. METHODOLOGY FOR MAKING IMPROVEMENTS IN CCHP PERFORMANCE
1. Member Interventions.
(a). Assign members to care managers for specialized attention
(b). Re-engineer organizzaional processes and structures
(c). Design provider/member educational and incentive programs.
(d). Introduce new technology
2. Provider interventions
(a). Develop employee training programs
(b). Qualtify and compare Health Partner performance and utilize best
practice techniques.
(c). Disseminate provider performance data on where providers stand
relative to peers on various measures
(d). Design provider-specific studies to further investigate causes of
variation.
(e). Develop clinical practice guidelines with participation of OHS and
Community Partners for dissemination to all providers
CCHP Quality Management Plan- January, 1997 Page 33
- (f). Ultimately, providers may be terminated for quality problems after
appropriate appeals processes.
4. PEER REVIEW OF QUALITY ISSUES
A. SCOPE
Ultimately the assessment of the quality of care delivered by practitioners and health
plans must be accomplished by his/her professional peers. This process assures the
judicious application of professional standards, and also creates the basis for
separating administrative and financial concerns from decisions affecting the quality
of care and service.
-Contra-Costa Health Plan defines a Potential Quality Issue (PQI) as a deviation or
suspected deviation from expected provider performance, clinical care or outcome
of care which cannot be determined to be justified without additional review. Such
issues must be referred to Quality Management personnel for incorporation into the
Quality Management peer review process. Not all PQI are found to be quality of care
problems.
A (Quality of Care Issue) QCI is a deviation from expected provider performance,
clinical care or outcome of care which has been determined through the CCHP peer.
review process to be unjustifiably inconsistent with professionally recognized
standards of practice. A QCI is a quality of care problem.
A major component of the Quality Management Program is the identification and
review of Potential Quality Issues and the implementation of appropriate corrective
action to address confirmed quality of care issues. Contra Costa Health Plan Quality.
Management Unit, utilizing QA processes, will monitor Potential Quality Issues
management by Community and OHS Partners and within Contra Costa Health Plan
Member Services.
B. OHS PARTNER DELEGATED PQI AND CQI REVIEW
1. Identification of PQI
a) OHS Partners will be reviewed at least annually to Confirm that each
partner has established and maintains a set of quality screens..or
indicators which are used by Quality Management/Utilization
Management/Risk Management concurrent review nurses and
utilization management staff to identify PQI through systematic
review. The quality screens or indicators must be consistent with the
Contra Costa Health Plan Quality Management Plan.
b) The oversight will include the following: OHS Partner aggregated
reports of PQI Review Process, OHS Partner Risk Management
CCHP Quality Management Plan- January, 1997 Page 34
_ minutes, OHS Partner Quality Management minutes, audits and
identification by other means, including but not limited to:
• Medical record quality and utilization audits
• Facility inspections
• Surveys
• Studies
• Profiles
• Grievances and complaints
• Credentials reviews
• Information from network providers or their quality assurance
committees and staff
+ c) PQI may be reported within the Health Partner by members, staff and
Medical Director(s), network providers, physician advisors or peer
reviewers, QA Committee members, hospital staff and regulatory or
licensing agencies.
2) Review of PQI and QCI by the Contra Costa Health Plan
a) Each OHS Partner must have written procedures regarding PQI
reviews. Reviews must be performed.by an appropriate licensed
professional(s). All PQI's will be reported to Contra Costa Health
Plan Quality Management Unit generally in summary format.
b) QCIs are reported to the Contra Costa Health .Plan Quality
Management Unit. Each QCI,including a summary in Health Partner
reports, reports of Quality Management Committees, activities,
grievances, disenrollments will be audited to assure that a summary
of the concern, information source, conclusions, recommendations,
actions and follow up actions is documented by the Health Partner in
an appropriately maintained case file.
c) All PQI and QCI activity reports will be reviewed by the Contra
Costa Health Plan Medical Director. Also,a summary log of PQI and
QCI activity will be reported to the Quality Council Joint Conference
of CCHP.
d) The nurses will refer QCI cases to the Medical Director for review.
e) The severity of QCI is evaluated based on the nature of the care
provided, the management of care, diagnoses made, outcomes and
their inter-relationships.
f) Resolution of Confirmed PQI by Health Partners. Each confirmed
QCI requires a corrective plan. All QCI, their review findings,
CCHP Quality Management Plan- January, 1997 Page 35
_ corrective actions and follow up actions will be demonstrated to be
documented in appropriately maintained OHS Partner case files.
C. COMMUNITY PARTNER NON-DELEGATED PQI AND QCI REVIEW
1. PQI of network providers may be discovered in a variety of ways including,
but not limited to:
• Chart audits
• Member grievances
• Network hospital clinical indicator and PQI monitoring
• Risk Management referrals
• Referrals from other providers
• Claims filed
2. The quality of care and documentation will be initially reviewed by a Contra
Costa Health Plan QA/QI coordinator using the appropriate screening tool .
Cases which fall out of initial review will be referred to the network provider
Peer Review Committee for review. The Committee will determine whether
a QCI exists and the severity of the QCI, the nature of care provided,
management of care and outcome.
3. The Provider Network Peer Review Committee will forward their
recommendations for corrective action to the Quality Council.
4. The provider will be sent a confidential letter by the Medical Director noting
the circumstances of the QCI, recommendation of whether a QCI exists and
the Peer Review Committee and the corrective actions taken.
5. Copies of QCI provider letters and case review will be placed in provider's
quality profiles to be reviewed at the time of recredentialing.
5. GRIEVANCES
The purpose of an Appeals Process is to allow members and Health Partner an opportunity
to appeal rejections for care or reimbursement for services.
Clinical and provider appeals are reviewed by the Quality Management Unit of the.CCHP.
Reimbursement issues are also reviewed by the Quality Management Unit after
administrative internal review results in a denial. The Appeals Process is addressed in Policy
#MS 111 (Section 6.5.6.2G).
A. SCOPE
1. Goal
The goal of Grievance Review is to provide members a means by which they
CCHP Quality Management Plan- January, 1997 Page 36
can report and seek resolution of perceived failures by CCHP Health Partner
providers or the CCHP Health Partner to provide appropriate health care
services, access to care, or quality of care, or quality of service.
2. Clinical and Provider Grievances
a. A Clinical and Provider Grievance is defined as a written or verbal
complaint or concern from a CCHP member but also includes
complaints and concerns regarding:
1) The quality of health care received or delivered, including
such aspects of care as:
(a) accessibility
(b) acceptability
(c) appropriateness
(d) level
(e) continuity
(f) timeliness
(g) effectiveness
(h) outcome
2) The professional demeanor,quality of service and behavior of
providers or their staff.
3) The performance of any part of the Health Partner health care
delivery system, its network providers and the CCHP, as it
relates to quality of care.
B. OVERSIGHT OF DELEGATED OHS PARTNER
Grievance Handling Process
1. Members are given written and oral infomation by the Health Partners with
which they are enrolled describing the grievance process. Members will not
be prohibited from using the grievance process. The CCHP will review these
communications and audit their implementation.
2. Clinical and Provider grievances are submitted to the appropriate Health
Partner Department and are reviewed at the levels and within the time frames
outlined in the program's administrative procedures.
3. Clinical and Provider grievances are reviewed and resolved in the same
manner as PQI and QCI. Grievances must be reviewed by a Medical Director
and may not be closed by a nurse reviewer.
CCHP Quality Management Plan- January, 1997 Page 37
• 4. All CCHP OHS Partner Grievances will be reported to the CCHP Quality
Management Unit monthly.with documentation or resolution of any.
5. Unresolved cases will be referred to Quality Management Unit and the
Medical Director for second level of action.
6. Summary reports of all CCHP grievance activity as well as aggregate reports
from OHS Partners will be made to the Medical Director.
7. Upon resolution of each clinical or provider grievance,the member who filed
the grievance is informed.
C. NON-DELEGATED COMMUNITY PARTNER GRIEVANCES
1. Clinical and provider grievances are submitted to the Member Services Unit
of CCHP.
2. Grievances are reviewed at this level, and time frames and appeals processes
are outlined (Policy#MS111).
3. Grievances are reviewed by the Medical Director.
4. Aggregate grievance reports are presented to CCHP Quality Council, CCHP
Community Peer Review Committee annually.
D. TRACKING AND MONITOR OF QUALITY OF CARE ISSUES
1. All quality of care issues are reviewed by the Medical Director and
appropriate action taken.
2. Community Partner quality of care issues are referred to the Community Peer
Review Committee for review and then the Quality Council.
3. OHS Partner quality-of care issues are referred to the Quality Council and
OHS Partner Quality Management Unit.
E. ROLE OF HEALTH PARTNER IN REVIEW
1. All PQI grievances are reviewed by the Quality Management Unit to
determine if a QCI exists or if significant trends are arising that might affect
quality in the future.
2. QCI will be reviewed through the Peer Review process .
3. Copies of all QCI grievances will be placed in the appropriate provider's
quality profile.
CCHP Quality Management Plan - January, 1997 Page 38
F. METHODOLOGY FOR PROVIDING FEEDBACK TO STAFF
1. All member grievances regarding providers will be communicated in writing
to the provider with the corrective action planned or undertaken.
2. Provider grievance procedures and appeals process is outlined in Policy
MS 111, Appeals Process.
6. SATISFACTION SURVEYS
A. SCOPE
1. Satisfaction surveys allow the CCHP QMU and Quality COUNCIL to gain
valuable information about-member's perception of CCHP"S service and
quality of care.
2. Survey questions will reflect:
Coordination and Continuity of care
Access to services
Quality of care
Waiting times
Health information and Education
B. STUDY DESIGN
1. Surveys have been designed to address the scope of care as well as special
areas of interest such as linguistic needs, special clinics or members with
special needs.
2 Surveys will be distributed in a variety of mechanisms including:
Hand distributed
Mailed surveys
Interviewswith members and/or their families
Focus group of members
Phone Surveys
3. Survey questions will be determined based on:
Professional literature
Benchmarking with other managed care systems
Regulatory requirements
4. An adequate number of surveys will be distributed to allow statistical
significance of the results.
CCHP Quality Management Plan- January, 1997 Page 39
C. DATA COLLECTION
1. Survey instruments will be tabulated allowing comparative data where
indicated.
2. Phone surveys and interviews will be summarized in and administrative
report.
3 Focus groups will be professionally videotaped and summarized in
administrative reports.
D. OVERSIGHT OF DELEGATED OHS SATISFACTION SURVEYS
1. Survey results used by OHS Partners which include results from
CCHP members will be reported to CCHP QMU>
2. OHS Partner patients may be randomly surveyed by CCHP and would be
included in the overall database.
E. NON-DELEGATED COMMUNITY PARTNER SATISFACTION SURVEY
1. Members of Community Partners will be randomly selected to be surveyed,
taking care to have all Partners surveys over the specified time period.
2. Data will be both aggregated and/or separated by individual provider where
statistically significant data is available.
F. ROLE OF THE HEALTH PROFESSIONAL IN SATISFACTION SURVEYS
1. All results will be discussed at QC and CPPRC. Survey results will be assess
to see if corrective actions are necessary either on an individual basis or
system-wide.
2. Results will be distributed to all CCHP member service units as well as the
Joint Conference Committee of CCHP.
3. Copies of individual variation histograms will be placed in Quality Profiles
for review at the Time of Recredentialing.
G. METHODOLOGY FOR PROVIDING FEEDBACK TO PROVIDERS
1. All OHS and Community Partners will receive copies of the trended
aggregate data as well as individual variation histograms were applicable
2. Newsletters will discuss survey results and improvements
CCHP Quality Management Plan - January, 1997 Page 40
• 3. Results will be discussed at QC and the Community Partner Peer Review
Committee.
4. The results will be sent to respective OHS Partner QMD and QA committees
for review.
5. Results will also be sent to the Manage Care Commission.
H. METHODOLOGY FOR MAKING IMPROVEMENTS IN CCHP PERFORMANCE
1. Member Interventions.
(a) Assign members to care managers for specialized attention
(b) Re-engineer organizzaional processes and structures
(c) Design provider/member educational and incentive programs.
(d) Introduce new technology
2. Provider interventions
(a) Develop employee training programs
(b) Qualtify and compare Health Partner performance and utilize best
practice techniques.
(c) Disseminate provider performance data on where providers stand
relative to peers on various measures
(d) Design provider-specific studies to further investigate causes of
variation.
(e) Develop clinical practice guidelines with participation of OHS and
Community Partners for dissemination to all providers
(f) Ultimately, providers may be terminated for quality problems after
appropriate appeals processes.
7. PROVIDER FACILITY INSPECTIONS
A. SCOPE OF INSPECTIONS
Contra Costa Health Plan will require that:
1. The scope of provider facilities which are inspected includes, but is not
CCHP Quality Management Plan - January, 1997 Page 41
limited to,physicians' offices and other network providers' offices.
2. The scope of provider inspections also includes any provider facility for
which inspection may be required by a state or federal regulatory agency.
3. Provider facility inspections may include, but are not limited to, inspection
of:
(a) Adequacy and cleanliness of physical facilities
(b) Environmental health and safety
(c) Infection control
(d) Storage, handling and expiration date of pharmaceuticals
(e) Patient access and handicapped access
(f) Administrative policies and procedures
(g) Medical record keeping practices
(h) Scheduling and waiting times
(i) Sterilization,packaging, and expiration date for reusable instruments
(j) Emergency procedures
4. Provider facility inspections will be performed at least every two years.
5. Contra Costa Health Plan will perform selected audits of provider facilities
to validate OHS Partner oversight and when necessary to comply with
oversight requirement of regulatory agencies (State Department of Health
Services, Department of Corporations, etc.).
6. OHS Partners will submit reports of their facility inspections every two years
to the Medical Director.
B. STANDARDS
1. Standards for Medi-Cal provider facilities comply with the requirements of
the State Department of Health Services and include the requirements of the
Child Health and Disabilities Prevention(CHDP) Program and comply with
applicable federal regulations.
2. Standards for non Medi-Cal provider facilities comply with professionally
recognized standards and state and federal regulations. The QI/UM
Coordinator maintains appropriate facility inspection checklists and criteria.
C. DEFICIENCIES IDENTIFIED THROUGH FACILITY INSPECTIONS
1. Deficiencies identified through facility inspections are referred,prioritized,
reviewed,handled and documented in accordance with Qualtiy Management
Program DDA Section 6.5.5.3.
CCHP Quality Management Plan- January, 1997 Page 42
• 2. Contra Costa Health Plan will monitor corrective actions by review of audit
records, and also by Contra Costa Health Plan provider site reviews.
D. ROLE OF THE HEALTH PROFESSIONAL
1. The Health Partner reports of facility inspections are reviewed by Contra
Costa Health Plan Quality Management staff, the Medical Director and the
Quality Council to identify specific opportunities to improve the delivery of
care, accessibility or service.
2. Opportunities to improve quality are addressed in accordance with Section
VII of this exhibit.
E. NON-DELEGATED REVIEW OF PROVIDER FACILITIES
1) Scope of facility inspections
a) The scope includes:
• Physician's offices
• Network acute care facilities
• Subacute care facilities
• Ambulatory surgery centers
b) Provider facility inspection includes, but is not limited to:
• Adequacy and cleanliness of physical facilities
• Environmental health and safety
• Infection control
• Storage, handling and expiration date of pharmaceuticals
• Patient access and handicapped access
Administrative policies and procedures
• Medical record keeping practices
• Scheduling and waiting times
• Sterilization, packaging, and expiration date for reusable
instruments
• Emergency procedures
C) Provider facility inspection will occur at time of contracting and at
least every two (2) years or earlier if member quality of care is
thought to be in jeopardy.
ASSESSING HEALTH PARTNER PERFORMANCE
A. CCHP Quality Management Unit will asses the results of all monitoring activities from both
Health Partners and Community Partners.
CCHP Quality Management Plan - January, 1997 Page 43
B. Results will be assessed to determine:
1) Validity of results
2) Stability of performance over time
3) Degree of conformance to outcome objectives
4) Whether corrective actions were effective
5) How CCHP's performance compares to benchmarked standards
C. CCHP Quality Management Unit will present data using appropriate statistical tools
including, but not limited to:
1) Bar charts with confidence limits
2) Run charts
3) Control charts
4) Scatter diagrams
5) Tabular data
D. Quality Management Unit will report their findings to CCHP Quality Council and Joint
Conference of CCHP and Board of Supervisors on a regular basis (defined for each
individual monitor).
IMPROVING HEALTH PARTNER PERFORMANCE
A. SYSTEMIC QUALITY OF CARE ISSUES
1. When results of ongoing monitor reveals an undesirable pattern or an important
sentinel event occurs the CCHP Quality Management Unit will assist Community
and Health Partners to implement changes in process,policy or procedure to improve
the delivery of care through the design and implementation of quality improvement
interventions.
2. Corrective action plans will use a systematic approach to improvement:
• ' Planning the improvement action
• Testing the action by either making system wide changes or on a test-pilot
basis
• Studying the effect of the corrective action
• Fully implementing the successful measures.
The cycle of"Plan, Do, Study, Act" will continue until the desired goal is reached.
3. These corrective action plans may include, but are not limited to:
• System-wide improvements of significant processes using Quality
Improvement Teams trained in CQI tools
• Changes to administrative policies and procedures
CCHP Quality Management Plan- January, 1997 Page 44
. Written or verbal provider education
• Required provider training or educational courses
• Provider re-certification procedures
• Prospective or retrospective monitoring of the provider's practice patterns
• In service training of provider's staff
• Member education
• Required submission by the provider of a corrective action plan with
subsequent remonitoring or confirm compliance with and success of the
action plan
• Intensified review of the network provider or Health Partners care including,
but not limited to, a requirement for second opinions for surgical procedures,
retrospective or prospective claims analysis
• Modification, suspension, restriction or termination of Health Partner or
network provider participation privileges
• Corrective action plans will be incorporated into the annual Quality
Improvement Plan
4. Monitoring and Reassessment
• To prevent recurrence of corrected quality of care issues,the subject provider
is monitored by the CCHP Health Partner and/or reassessed to confirm that
the corrective action has resolved the issues
• Quality of care issues remain open until resolved
• Improvements in patient care resulting from corrective action are documented
appropriately
• CCHP Quality Management Unit, in conjunction with Quality Council of
Contra Costa Health Plan will monitor these processes in CCHP Health
Partner's operation by review of quarterly CCHP Health Partner reports
• In all categories outlined in the Contra Costa Health Plan QI process. The
CCHP Quality Management Unit will implement its own QI process with
respect to CCHP Health Partner deficiency when necessary.
B. CORRECTIVE ACTION INTERVENTION AT THE PROVIDER LEVEL
1. Peer review takes place at the Health Partner Peer Review Committee level through
the Quality Council and Community Peer Review Committee. However, upon
appeal,the CCHP Quality Management Unit may conduct case specific peer review.
In cases where the CCHP Health Partner's Medical Director or the CCHP's Medical
Director determines that additional review is needed,he or she may refer the case to
a specialty peer review consultant or to an ad hoc peer review committee. In the
delegated setting, the CCHP Health Partner Medical Director is responsible for
authorizing the referral of the case for additional review.
2. All CCHP peer review consultants (including members of ad hoc peer review
committees) are duly licensed professionals in active practice, with the same or
similar specialty training as the provider whose care is being reviewed.
CCHP Quality Management Plan- January, 1997 Page 45
_ 3. The peer review consultants must be board certified in the specialty of the provider
whose care is being reviewed, except in those cases where there is no applicable
board certification for the specialty.
4. The peer review consultants must meet CCHP's credentials requirements.
5. All CCHP peer review consultants are approved by the Medical Director, who
confirms that the peer review consultant has the necessary experience and
qualifications for the review at hand.
6. The Contra Costa Health Plan's Quality Management Review Process
a) Review of clinical quality of care issues includes, but is not limited to,
consideration of compliance with professionally recognized standards as set
forth in the section on standards in this Quality Management Plan.
b) Review of clinical quality of care issues is based on relevant information
obtained from: CCHP reports, facility medical records, the involved
providers,inpatient and outpatient institutional settings,Quality Management
studies, audits and other sources. If information is not sufficient to make a
review determination, the reviewer requests additional information and/or
investigates all related provider cases to determine if a pattern of deficiency
exists.
C) CCHP Quality Management Unit will be responsible for oversight of PQI
management by CCHP Health Partners including their-documentation of
corrective action plans and implementation of such plans.
d) In cases where opportunities for systemic or procedural improvements
affecting large numbers of members,providers or services are identified, the
CCHP Quality Management Unit recommends interventions to pursue such
opportunities .
f) All member grievances are reviewed by the Medical Director.
7. Corrective Actions
Contra Costa Health Plan will monitor the process by which Community and Health
Partners implement corrective action. Each quality of care issue identified or breach
of quality of care standards requires a corrective plan which includes clearly stated
objectives and time frames for completion. Community and Health Partners
implemented action plans are communicated to the providers involved and may
include, but are not limited to:
a) Provider education, by oral or written contract or through required further
training
CCHP Quality Management Plan- January, 1997 Page 46
b) Provider re-certification for procedures or services which require certification
C) Required submission by the provider of a corrective action plan, with
subsequent monitoring or re-auditing to confirm provider compliance with
said action plan.
d) Prospective or retrospective trend analysis of the provider's practice patterns
e) In service training for providers or their staff
f) Member education
g)' Modification,suspension,restriction or termination of participation privileges
h) Intensified review of the Provider's care, including, but not limited to,
proctoring a requirement for second opinions for surgical procedures,
retrospective or prospective administrative encounter/claims reviews and
intensified review of requests for prior authorization
i) Changes to administrative policies and procedures, as appropriate
j) Imposition of sanctions including, but not limited to, enrollment freezing,
monetary sanctions and termination
C. REPORTING OF DELEGATED CORRECTIVE ACTIONS
1. At least quarterly each CCHP Health Partner will prepare a written summary report
of all quality of care problems including those requiring follow up. Each item will
include a corrective action plan, including proposed follow up and time lines.
2. This report is presented to the Quality Management Unit to confirm that appropriate
corrective action is taken on quality of care issues which need follow up and will be
summarized to the Quality Council and the Joint Conference Committee .
D. REPORTING OF COMMUNITY PARTNER PROVIDER CORRECTIVE ACTIONS
1. CCHP Quality Management Unit will keep a log of all ongoing network provider
corrective actions and progress toward implementation. Quarterly reports will be
forwarded to the Community Partner Peer Review Committee as well as the CCHP
Quality Council. The corrective action plan will include planned remedies, time
lines and proposed follow up and/or monitoring.
2. If serious quality concerns are raised, the Community Partner Peer Review
Committee or Quality Council can recommend consideration of a fair hearing
process. This may result in limitations or loss of credentialing by CCHP.
CCHP Quality Management Plan- January, 1997 Page 47
PROVIDER CREDENTIALS REVIEW
A. GOALS AND OBJECTIVES
1. Contra Costa Health Plan has written procedures for the purpose of provider
credentials review to confirm that all contracted providers possess the practice
experience, licenses, certifications, privileges, professional liability coverage,
education, and professional and other qualifications to provide a level of quality of
care consistent with professionally recognized standards, and that network providers
meet the credential requirements of applicable state and federal agencies.
2. Contra Costa Health Plan Quality Management Plan contains a uniform data format
for Community and OHS Partner credentialing information as follows:
• License
• Board Certification or status in certification process
• Residency
• Medical School
• Malpractice Claims History
• Medicare/Medi-Cal sanction history
• Work history/CV
• Physical/mental health statement
• Chemical dependency/substance abuse statement
• Loss of licensure or felony conviction
• Attestation
• DEA (or CDS)
• Signed contract on file
• Current malpractice policy
• Hospital privileges
• Site visit
• Medical record review
• Linguistic capabilities
• Arrangements for phone call reception when office closed
• Practice coverage arrangements (specifics)when provider not on call
• If no hospital privileges, coverage arrangements (hospitals will not be
required to provide hospital privileges to physicians who do not meet
credential requirements)
• Certified Nurse Practitioner (CNP), Physician Assistant(PA), Registered
Nurse(RN)/Licensed Vocational Nurse (LVN), Midwife staff
• Certification
• Protocols
• Certification for Physician who supervises
• Office lab, if so, CC/Q certificate (waiver and tax identification number)
• Qualified Medical Examiner(QME) status
• Comprehensive Perinatal Services Program (CPSP) status
• Child Health Disability Prevention(CHDP) + 100% sanction status
CCHP Quality Management Plan- January, 1997 Page 48
• Medi-Cal provider status
• Gender
• Facility ownership
• Peer references for providers not previously in network
• Signature page
• Ethnicity
3. The Contra Costa Health Plan will review Health Partner credentialing plans to
confirm that they are consistent with number 1) and 2).
4. The credentialing process, activity and decision results will be reviewed by the
Contra Costa Health Plan Credentialing Subcommittee.
5. The Contra Costa Board of Supervisors will exercise final approval of
credentialing/recredentialing/reappointment decisions for the Contra Costa Health
Plan Community and OHS Partners.
B. SCOPE
1. The credentials of the following types of providers are reviewed by the Quality
Management/Credentialing Unit for both delegated OHS Partners and non-delegated
Community Partners.
a) Individual practitioners as follows:
(1) Doctors of Medicine (M.D.)
(2) Doctors of Osteopathy(D.O.)
(3) Clinical Psychologists
(4) Doctors of Podiatry (DPM)
(5) Certified Clinical Social Workers
(6) Licensed Registered Physical Therapists
(7) Audiologists
(8) Speech Therapists (Speech Pathologists)
(9) Marriage and Family Counselors (MFC)
(10) Chiropractors (DC)
(11) Midwives
(12) Dietitian
(13) CRNA's
b) Institutional Providers as follows:
(1) Acute Care Hospitals
(2) Psychiatric Hospitals
(3) Skilled Nursing Facilities
(4) Surgery Centers or Ambulatory Surgery Facilities
(5) Long-Term Care Facilities
CCHP Quality Management Plan- January, 1997 Page 49
(6) Urgent Care Facilities
(7) Durable Medical Equipment companies
(8) Home Health Agencies
C. GENERAL REQUIREMENTS
The Contra Costa Health Plan review of OHS Partners credentialing processes will confirm
that:
1. The credentials and qualifications of providers are reviewed prior to granting them
participation privileges.
2. Review of each provider's credentials is repeated every two years to confirm that the
' credentials information is current and that the provider's qualifications continue to
meet criteria. Relevant information resulting from Quality Management reviews,
customer services complaints, Utilization Management reviews and member
satisfaction studies are to be considered during subsequent credentials review.
3. All Community and Health Partners and affliated providers possess applicable
licenses, certifications and/or accreditations required by the state in which they
practice.
4. All Medi-Cal providers meet all credential requirements of the California State
Department of Health Services.
5. The specific credential's criteria for each type of provider are consistent with those
adopted by the Credentialing Subcommittee of Contra Costa Health Plan.
6. Final right to deny provider participation in the plan rests with the Joint Conference
of Contra Costa Health Plan.
7. The Contra Costa Health Plan Credentialing Subcommittee affords providers due
process in accordance with the Policies and Procedures established by the Contra
Costa Health Plan Quality Improvement program.
D. STATE DEPARTMENT OF HEALTH SERVICES REQUIREMENTS
1. The Contra Costa Health Plan will perform or oversee functions required by State
Department of Health Services including, but not limited to:
• Medical chart audits including, but not limited to, audits in accordance with
CHDP Program requirements.
• Audits related to sterilization protocols.
• Audits of specialty referrals.
• Facility inspections.
• Studies of childhood immunizations and prenatal care.
CCHP Quality Management Plan- January, 1997 Page 50
2. Reporting
Contra Costa Health Plan Quality Management staff will provide the Director of
QA/QI with quarterly reports regarding the performance of Quality Management
functions required by State Department of Health Services.
E. DELEGATED STRUCTURE AND AUTHORITY FOR OHS PARTNER
CREDENTIALING
1. OHS Partners will report to Contra Costa Health Plan to confirm that:
a) Credentials review staff and/or the OHS Partner Medical Director/Medical
Staff President conducts the initial reviews regarding acceptance or denial of
network privileges, and the required follow up reviews.
b) Authority for final reviews of credentials is delegated by Contra Costa Health
Plan to the Credentialing Committee or Medical Executive Committees in the
case of acute care facilities which reports to the Contra Costa Health Plan
Quality Council and CCHP Joint Conference.
C) OHS Partner will have due process protection for credentialing and
termination issues.
F. NON-DELEGATED COMUNITY PARTNER CREDENTIALING
CCHP requires a thorough and rigorous credentialling/recredentialling process to certify all
Community Partners as CCHP providers.
1. Scope
All MDs, DOs, DDSs, DPMs, DCs, and psychologists wishing to care for CCHP
members are required to apply for credentials.
2. Applicant applications shall include information regarding:.
a) Education
b) State, professional and DEA licensure
C) Board certification
d) Health impairments
e) Professional liability coverage and information
f) Pending or completed limitation of licensure
g) Staff membership status
h) Location of offices
i) Requests for specific privileges
j) Criminal charges
k) Acknowledgement of current illigal drug use
CCHP Quality Management Plan- January, 1997 Page 51
1) References
3. Application Processing
a) The application is submitted to CCHP Credentials Subcommittee where the
above information is verified. This will include primary source verification
from MBC and NPDB and federal and state agencies regarding Medicare and
Medicaid status. Information regarding competence for clinical privileges
will be sought from recent affiliations.
b) A site visit shall occur for all OB/GYN,primary care practioners as specified
under Section V.C.7 of the CCHP QMP.
4. Role of the Health Professional in Credentialling
a) The Credentials Committee shall review the application, supporting material
and facility site review and submit their written recommendations to the
Medical Director/designee.
b) At the time of reappointment QM\UM data including but not limited to focus
study review, indicator monitoring,grievances,member satisfaction surveys,
medical record audits, sitie visits shall be ;considered in the decision for
reappointment.
C) The Medical Director shall review the application,supporting documentation,
the reports and recommendations form the CCHP Credentials Committee and
prepare a written report to the CEO.
d) The CEO is responsible for the reporting of favorable and unfavorable
decisions to the Governing Board through Joint Confference Committee who
shall make the final decision.
CCHP UTILIZATION MANAGEMENT
The Contra Costa Health Plan(CCHP)Utilization Management program is an important component
of CCHP's overall Quality Management program. The Utilization Management program is designed
to actively manage the use of Health care resources to promote efficient and high quality professional
care for its members. The Utilization Management program is carried out by the CCHP Quality
Management Unit under the direction of the Medical Director by authority of the Board of
Supervisors. The Utilization Management program as an integral part of CCHP operations
contributes to administrative and management processes, and member services programs and
departments such as Credentialing Committee, Provider Affairs, Authorization Unit, Member
Services and Quality Council. The Utilization Management functions and activities interface with
other CCHP departments, committees and programs by communication at meetings and by report
distribution.
CCHP Quality Management Plan - January, 1997 Page 52
- A. GOAL
The goal of the CCHP Utilization Management program is to ensure that the care and
services received by CCHP members are cost effective, appropriate,timely, of high quality,
consistent with community standards of care, and are coordinated and continuous across the
health care spectrum.
B. OBJECTIVES
The objectives of the Utilization Management program are to:
• Facilitate accessible, appropriate, and cost effective care and setting to CCHP
members.
• Establish a process for collaboration and communication between Health Partners,
delegated and non-delegated, to work with CCHP to enhance the utilization of
appropriate health care services.
• Oversee, assess, monitor, and implement appropriate utilization processes for the
enhancement of health care services rendered to the members.
• Evaluate compiled information pertinent to member-preventive health care behavior
and awareness, and implement necessary process modifications.
• Act as an intermediary between necessary disciplines.for continuity of member care.
• Work in conjunction with Health Partners in assessing and identifying long term
care, catastrophic illness, and the treatment and resources necessary for positive
member outcomes.
• Continually strive for, and support, interdepartmental collaboration and dialogue for
quality improvement focus within utilization management.
C. .SCOPE
The CCHP Utilization Management program includes both the oversight of important
Utilization Management functions delegated to Organized Health System (OHS) Partners,
and provision of direct Utilization Management functions for the Community Partner. The
important functions which are assessed for both the OHS and Community Partners are:
• Monitoring and oversight
• Developing and implementing corrective action plans
• Assessing outcomes
CCHP Quality Management Plan - January, 1997 Page 53
• Contributions to quality improvement
D. RESPONSIBILITY. ACCOUNTABILITY AND REPORTING
1. Organizational Structure
The ultimate responsibility and accountability for Utilization Management functions
rests with the Board of Supervisors. Utilization Management program
implementation, oversight, monitoring, evaluation, fiscal administrative and
management decisions that do not compromise quality of care and service are
delegated by the Board of Supervisors to the CCHP Medical Director.
The CCHP Quality Management Unit, under the direction of the Medical Director,
oversees and monitors Utilization Management activities, conducts facility on-site
Utilization Management audits,collects and aggregates the Utilization Management
outcomes and service information, and prepares Utilization Management reports
which are presented to the Quality Council on a quarterly basis by the Medical
Director.
The CCHP Quality Council provides medical oversight of Utilization Management
program activities and outcomes. The CCHP Medical Director chairs the Quality
Council where s/he presents Utilization Management-data and reports to the members
for review,discussion,recommendation and approval on a quarterly basis. Quarterly
summaries of Utilization Management activities are forwarded to the CCHP Joint
Conference Committee and thence to the Board of Supervisors.
2. Delegation
The Utilization Management functions are delegated to the Organized Health System
(OHS) Partners. Delegation of the Utilization Management functions to an OHS
Partner is granted after successful completion of an initial audit by the CCHP Quality
Management Unit for the Health Partner's ability to meet CCHP and Department of
Health Services Utilization Management requirements and standards. The Health
Partner must have an active Utilization Management program and plan, directed and
approved by the Medical staff, which addresses all the elements enumerated under
"Utilization Management Plan" below. Delegation status is recertified annually by .
the CCHP Quality Management Unit by on-sight audit. OHS Partner Utilization
Management reports are aggregated and reported quarterly to the CCHP Quality
Management Unit and Quality Council.
3. Non-Delegation
The CCHP Quality Management Unit conducts direct assessment of Utilization
Management functions for the CCHP Community Partners (i.e. office providers,
specialists and referral providers). The Quality Management Unit staff collects and
aggregates required Utilization Management data from Community Partners, which
CCHP Quality Management Plan- January, 1997 Page 54
are reported to the CCHP Quality Council on a quarterly basis.
.4. Oversight
The CCHP Quality Management Unit under the direction of the Medical Director,
oversees both the delegated and non-delegated Health Partner Utilization
Management activities.
The goal of CCHP oversight is to monitor the Utilization Management processes of
Health Partners to assure that the health services delivered to CCHP members is of
high quality,appropriate,timely,cost effective,and access assured;that member care
and services are monitored on a regular basis, correction actions are carried out,
processes to identify opportunities for improvement to care and service are in
operation.
The Quality Management Unit reviews the OSH Partners Utilization Management
program and plan for compliance to CCHP requirements prior to the assignment of
members to the Health Partner. Thereafter, the OSH Partner is audited annually to
reaffirm that Utilization Management processes continue to meet CCHP
requirements. The following delegated Utilization Management functions are
assessed:
• Oversight of Utilization Management delegated to affiliated providers
• Documentation of standards for Utilization Management decisions
• Compliance with the standards
• Timeliness
• Grievance and appeal provisions and compliance
• Appropriateness of utilization, with particular attention to under utilization
The oversight objectives are to:
a. To assure that the OHS Partner has a written, approved Utilization
Management plan and program which meets the CCHP Utilization
Management requirements delineated in the CCHP Utilization Management
Plan presented in Section 6.5.9.1.
b. To ensure that the Health Partner's Utilization Management program is
adequate in meeting the following responsibilities and processes:
1) Oversight of Utilization Management delegated to affiliated providers
2) Documentation of standards for Utilization Management decisions
3) Compliance with the standards
4) Timeliness
5) Grievance and appeal provisions and compliance
6) Appropriateness of utilization, with particular attention to under
utilization
CCHP Quality Management Plan- January, 1997 Page 55
C. To assess if the Health Partner's Utilization Management processes
effectively,perform the followingimportant functions:
1) Utilization issues are identified, documented and reviewed
2) Timely and appropriate action plans for improvement are initiated to
address utilization management problems
3) The monitoring and improvement processes are carried out in an
ongoing and consistent manner.
E. UM FUNCTIONS AND RESPONSIBILITIES
• Medically approved UM policy and program
• UM Goals and Objectives
• UM Authority and Responsibilities
• UM Functions
• UM Reports and Reporting Structure
• UM Plan update and approval process
• Review process that includes timelines
• Operational requirements,policies and procedures
• Confidentiality and conflict of interest policies and procedures
• Criteria for review and authorization of inpatient hospital admissions, continued
hospital stay, discharge screens, outpatient services,planned medical procedures and
services, out of plan care, high cost services; mechanism for criteria updating and
approval
• Authorization procedures for planned, urgent and emergency services and care;
referrals to specialty and out of plan services
• Referral process for specialty services, inpatient services, outpatient services and
second opinions
• Tracking mechanisms for approved, denied, or modified referrals
• Procedures for the denial of services and care
•. Member notification system with timelines
CCHP Quality Management Plan- January, 1997 Page 56
• Appeal procedure for denied services/care with timelines
• Delegation of Utilization Management functions to, and requirements and
responsibilities of affiliated providers
• Processes for assessing under-and over utilization review,readmissions,. Emergency
Department use
• Mechanism to evaluate provider utilization of services, e.g. admissions, ancillary
services use, out of plan services
• Processes and evaluate member utilization of services, e.g. provider visits/year,
hospitalization per 1,000 members, Emergency Department use, out-of-plan use
• Procedures to link members to fee for service program (CCS, family planning,
mental health, school based services)
• Mechanism to promote smooth access to services not requiring authorization e.g.
services for STD's, emergency care, pregnancy
• Utilization Management Committee composition, structure, authority, duties,
meeting requirements
• Roles,duties and qualification of Utilization Management Medical Director or Chair,
Primary Care Physician, Utilization Management Nurse Reviewer
• Oversight of delegated Utilization Management activities
• Utilization Management records, reports, meeting minutes, guidelines,
confidentiality, accessibility and storage rules
F. STAFFING
The CCHP Medical Director is responsible for the oversight and direction of the Utilization
Management program, including monitoring to assure that administrative and management
decisions do not compromise the quality of care and service provided to CCHP members.
The UM Program activities are carried out by the Quality Management Unit as part of the
Quality Management plan. The staff are licensed health care professionals, nurses, who
provide direct audit oversight, analysis of Utilization Management functions, assure that
Utilization Management communication lines between CCHP and its Health Partners are
maintained in a consistent manner. The Quality Management Unit Director and nurses act
as resources for the OHS Health Partner's Utilization Management Departments and to the
Community Partners to facilitate linkages for excluded services and transfers to fee-for-
service health programs (CCS, mental health, family planning and school based services).
CCHP Quality Management Plan -January, 1997 Page 57
G. ANNUAL UTILIZATION MANAGEMENT PROGRAM EVALUATION
Contra Costa Health Plan's Quality Council evaluates Utilization Management data and
program reports and findings annually to assess the effectiveness of the Utilization
Management program. The review of Utilization Management is part of CCHP's annual
review of their QA/QI program. This evaluation includes a review of completed and
continuing program activities, trends of clinical and service indicators audits, utilization
audits, effectiveness of Utilization Management monitoring and review activities, and
effectiveness of the Utilization Management program in identifying and acting upon
Utilization Management issues.
Feedback to the Health Partners is accomplished through the Health Partners' participation
on the Quality Council,distribution of Utilization Management reports, audit findings, and
analyses and Quality Council evaluations and recommendations for improvement to the
Health Partners in the form of reports, newsletters, conferences and meetings.
The outcome of the Annual Review,recommendations for improvements and related action
plans are submitted by the Quality Council to the CCHP Joint Conference Committee for
review, recommendation and approval. The Annual Review is forwarded to the Board of
Supervisors for review and approval.
QUALITY MANAGEMENT PROGRAM OVERSIGHT OF DELEGATED
FUNCTIONS
A. Authority and Responsibility of the Contra Costa Health Plan
1. The Board of Supervisors delegated to the CEO authority and responsibility to
establish and manage a Knox-Keene licensed health service plan.
2. The Executive Director of Contra Costa Health Plan in turn delegates to the Medical
Director, a physician duly licensed by the State of California, the administrative
authority and responsibility to establish and maintain the Quality Management Unit
of Contra Costa Health Plan Administration.
3. The Board of Supervisors directly delegates responsibility for the quality of care
review program to the Medical Director, assuring that the consideration of quality
issues is separated from administrative and financial issues.
4. The Medical Director in turn delegates responsibility for the day-to-day
administration of the QM Program to the Administrative Director of Nursing and
Quality Management and the QI/UM Coordinators.
5. The Administrative Director of Nursing and Quality Management and the QI/UM
Coordinators have the responsibility for interfacing with the Quality Management
Units and UM Departments of each of the OHS Plan Partners. This interface must
assure the bi-directional flow of required information evaluation, and actions.
CCHP Quality Management Plan- January, 1997 Page 58
6. Quality Management and UM functions are delegated to OHS Plan Partners with
Contra Costa Health Plan oversight,monitoring and involvement. Prior to delegation
of each function, the Contra Costa Health Plan Quality Management Unit, in
conjunction with the Joint Conference Committee, will determine the capability of
each OHS Partner to perform each potential delegated function. Participation as an
OHS Partner, actual enrollment numbers, and number and extent of delegated
functions will be based on this determination. This process has commenced with a
due diligence evaluation and contract negotiations.
B. Each OHS Partner must have a written QM Plan and a QM Program operated continuously
and designed to identify and pursue opportunities for improving care and service, including
detecting and correcting under-utilization and access. The delegated organization's
governing body must approve its QM Plan (including the credentialing plan) and receive
regular reports of QM activities. The plan must document goals and objectives and describe
the organizational structure, staffing and resources for performing QM. Each OHS Partner
must maintain an appropriate quality of care committee structure, and staff. Quality of care
activities will be conducted by a duly constituted committee which includes network
providers and meets on a regular basis. The committee will have written reports which
ascend through the committee structure of the OHS Partner governance process with reports
to the Contra Costa Health Plan(through the Quality Management Unit)to ensure the Contra
Costa Health Plan fulfills its monitoring and oversight functions. As indicated above, the
Contra Costa Health Plan quality of care review activities are reported to the Board of
Supervisors through the Joint Conference Committee which retains ultimate responsibility
for oversight of quality of care.
Each OHS Partner will have a medical administration with a sufficient number of qualified
medical directors. The medical directors in conjunction with a sufficient number of qualified
quality management.professionals, will staff the Quality Management Unit of the OHS
Partner. The Quality Management Unit will be responsible for oversight and implementation
of corrective actions regarding all quality functions. The Quality Management Unit will
report its activities to the appropriate Quality Improvement Committee of the OHS Partner.
C. Contra Costa Health Plan requires OHS Partners to have quality management programs in
place to monitor and oversee contracted providers and provider groups. The programs must
be consistent with the Contra Costa Health Plan's QM program. OHS Partners will assure
that such providers have the administrative and financial capacity and technical expertise to
meet the Quality Management requirements of Contra Costa Health Plan and its regulators,
including hospitals. The OHS Partner must communicate its QM plan to the providers.
Contra Costa Health Plan also monitors the quality management activities of such providers
to detect and correct both deficiencies in quality management program performed and
deficiencies in quality of care and service.
D. Inpatient care will be provided by Contra Costa Health Plan acute care hospital providers that
are accredited by the Joint Commission Accreditation of Health Care Organizations
(JCAHO). In their delegation status role, the OHS Partners continuously monitor the
utilization of hospital services for appropriateness, usage of equipment, facilities and service
CCHP Quality Management Plan- January, 1997 Page 59
through their Utilization Management Program. The OHS Partners may delegate inpatient
quality functions to their contracting provider hospitals. In such instances after ascertaining
that the hospital's Quality Assessment Improvement program is in place and appropriate,the
OHS Partners will regularly monitor the hospital providers activities to assure the services
provided by OHS licensed independent practitioners are consistent with accepted practice
standards. Provider hospital agreements with the OHS Partners include expectation that on-
going quality assessment and improvement programs ensure that the hospital conforms with
accepted hospital practices within the community. Hospitals must cooperate with the Contra
Costa Health Plan by allowing access to minutes or on site access when deemed necessary
by the Contra Costa Health Plan Medical Director.
E. OHS Partners and their contracted medical groups or IPAs must have established Quality
Management Committees that meet at least quarterly and which review quality of care issues,
formulate actions for improvement, implement the actions and monitor the performance of
the program. Reports regarding these Quality Management Committee activities must be
made available to Contra Costa Health Plan by OHS Partners, with minutes of each
subcommittee meeting available for inspection by the Contra Costa Health Plan. These
reports are protected from outside disclosure under the peer review confidentiality codes.
F. The OHS Partners must develop an annual QI Plan, and work plan consistent with that of
Contra Costa Health Plan and must maintain records of its QA activities and actions. In
some instances the Contra Costa Health Plan Quality Council,may make recommendations
to OHS Partners for improvement or corrective action activities which would be included in
the OHS Partner Annual QI work plan.
G. Contra Costa Health Plan Quality Management staff must be permitted reasonable access to
the quality management files,minutes and records of the provider entity, for the purpose of
auditing quality management activities.
H. Each OHS Partner must submit a Quality Report to the Contra Costa Health Plan Quality
Management Unit for presentation to the Quality Council on a regularly scheduled basis (at
least quarterly.) The report shall be sufficiently detailed to include findings and actions
taken as a result of the Health Partner's QM Program.
I. OHS Partners will take appropriate action in areas where problems are identified. They are
responsible for providing feedback to Contra Costa Health Plan Quality Management Unit
regarding the conclusions,recommendations, actions and follow-up to all studies and cases
where input has been requested.
J. The above notwithstanding, Contra Costa Health Plan retains the ultimate responsibility for
implementing and maintaining an effective Quality Management Program and for conducting
effective review of overall quality of care delivered to its enrollees.
CCHP Quality Management Plan- January, 1997 Page 60
CONTRA COSTA
. � 595 Center Avenue,Suite 100
HEALTH PLAN Martinez,California 94553-4639
A division of Contra Costa Health Services
ANNUAL QUALITY MANAGEMENT WORK PLAN
The CCHP expects to develop and implement the following quality improvement
activities in the 1997 calendar year:
1. A review of all contracting hospital clinical certifications and results of
quality reviews performed by national and regional review entities as well
as those performed by hospital peer review committees.
2. Implementation of uniform criteria to assess access to and continuity of
services.
3. Implementation and monitoring of criteria for adverse events.
4. Evaluate and change as necessary quality of service and care instrument to
evaluate utilization management and quality management performance.
5. Perform DDA focused review studies to obtain baseline data to be
compared to national and state norms.
6. Track and report grievance and appeal procedures
7. Develop guidelines for risk management.
8. Develop, review and endorse standards of practice for indicator and focus
review studies.
9. Develop reporting format for the Contra Costa Health Plan Board of
Supervisors Joint Conference Committee.
AFFORDABLE CAREwP.EUSm SERVICE