HomeMy WebLinkAboutMINUTES - 03262002 - C92 TO BOARD OF SUPERVISORS • ontr
FROM: WILLIAM B. WALKER, M.D.
Health Services Director Costa
DATE: February 8, 2002 .��-�-
County
SUBJECT: Approval of Contra Costa Health Plan's Quality Management 20 Annual Work
Plan
SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION
RECOMMENDATION:
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.
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 every year to involve the Board of Supervisors, as the governing body, more
directly in the Quality Management process.
The Quality Management Plan describes the goals, objectives,:and activities of the Quality
Management Program. It also contains the 2002 Annual Quality Management Work Plan which
describes the quality improvement activities CCHP expects to develop and:implement.in 2002. As part'
of the 2002 Work plan, CCHP will perform focused review studies required by the State Department Of
'Health Services as part of the Local Initiative program.
The Quality Management Program and 2002 Annual Work Pian has been reviewed and approved by:
- The Contra Costa Health Plan Quality Council, August 2001
The Joint Conference Committee, September 24, 2001
- The Contra Costa Managed'Care Commission, January 16, 2002
FINANCIAL IMPACT None
ATTACHMENTS Quality Management Program and Annual Work Plan
CONTINUED ON ATTACHMENT: ✓ YES SIGNATURE rvf
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e✓'RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD:COMMITTEE
_APPROVE OTHER
SIGNATURE(S):
ACTION OF BO ON OVE AS RECOMMENDED— OTHER
VOTE(OF SUPERVISORS
/4UNANIMOUS(ABSENT ) HEREBY CERTIFY THAT THIS IS A TRUE
AYES: NOES: ANIS CORRECT COPY OF AN ACTION TAKEN
ABSENT: ABSTAIN: AND ENTERED ON THE MNUTES OF THE BOARD
OF SUPERVISORS ON THE DATE SHOWN.
CONTACT: Patti Landrum,CCHP 313-6498 ATTESTED � � 9 , 04
JOHN SWEETEN,CLERK OF THEAARRD OF
SUPERVISORS AND COUNTY ADMINISTRATOR
CC: Mitt Camhi,CCHP
Patti Landrum,'CCHP
BY DEPUTY
Contra Costa Health Flan'
ua .it Management Program Description 2002
--Table of Contents --
Topic Page No.
I. INTRODUCTION. .................................. ..................... ..... ............................... .....1
1I. MISSION.......... ...................................... .. ....» ... . ...... . ..l
III. PURPOSE................................. ............................ . . .............. ...... ..1
IV. SCOPE............................................................................................... ..................„..1
V. OBJECTIVES......................................................................................................... ...1
VI. AUTHORITY AND RESPONSIBILITY... ........... .., , . . .. .2-4
A. Assistant Medical Director........ . ........ .... . . . .. .3
B. Medical Director.................................................. ...................................................3
C. Quality Management Unit........................................... ..............................................3
1. Director of Quality Management, . ... ..3`
2. Quality Management Nurse(s).... ............. ... .4
3. Manager of Health Education. .. .... .....» .... ............4'
VII. ASPECTS OF CARE AND SERVICE...............................................................................5
VIII. CCHP's QMP',COMMITTEE STRUCTURE....................................................... .....,........5
A. Board of Supervisors............................. ........................................................ .........5
1. Activities ....... ......... ... ......... .... ...... .5
2. Membership. ......... .......» . ....... ... .. .5
3. Chair. ........................ .......... .... .5
4. Meetings.......................... ........................................ ........................ .........6
B. Joint Conference Committee. . ...... .. . ....... .. .. ... ..6:
C. Quality Council.. . ........... . ... .7-9
D. Quality Council Subcommittees...... . . . . ., .. ... ..... ..9-14
1. Clinical Leadership. ................... ..... ...., .9- 10
2. Credentialing Committee............................................., .................,.........10-12
3. Grievance Committee.......................... ...................................................12-13'
4. Pharmacy and Therapeutics Committee......... .............................................13-14
E. Public Advisory&'Other Coordinating''Committees...................................................14-15
IX. QM DELEGATION. . . . ..» .... .. ..16
X. QUALITY MANAGEMENT.
AND INITIATIVES.. » .. . .... . .16-19
A. Process................................... ........ ...................................,... .............................17
1. Study Topic. ...... ... ... . .. ........ .. . ..17
2. Study Planning. ..... .» .. .17
3. Practice Guidelines.. ...................... .............................................. ..............17
4. Quality Indicators. . .. .... ... ,17'
5. Data Analysis Plan...... ........................................ .......................................17
6. Measurement Tool(s)..........................................................> ........................17
7. Validation of Collected Data.......................................... .................................17
8. Data Analysis. .... .. ....... 18
9. Interpretation of Findings. .... ..18
10. Communication of Findings. . . . ... .18
11. Improvement Plan. .. ..18
Contra Costa Health Plan
Ouality Management Program Description 2002
-Table of Contents --
Topic Page No.
B. Quality Improvement Initiatives. . ........... . ................ , ... . ..... ... . ..1 8-19
1. Preventive. ............................... ........... . ..18
2. Clinical-Chronic..................... .................................. .................. .........18-19
3. Non-Clinical. .19
XI. COORDINATION OF QM PROGRAM WITH OTHER MANAGEMENT FUNCTIONS............24
A. Credentialing. ...... .. ....... ... ..20'
B. Member Grievance�Process.......................................................................................20
C. Utilization Management.... ..................................................... ................................21
D. Telephone Triage Program. ... ...... ... ....., ........ .21
E. Cooperative Care Management Program ........... ....., .... . . ....21
XII. DISCIPLINARY ACTION.. ... ...... ..... .... ... . . 21
XIII. CONFIDENTIALITY.. ................. ............... . .... .... . ...... ..21
XIV. CONFLICT OF INTEREST........................ .......................... ...... ........,............,........21
QualityManagement Program Description 2002
I'. INTRODUCTION
Contra Costa Health Plan (CCHP) is the Contra Costa County operated Health Maintenance
Organization (HMO), the first 'Federally-qualified HMO in the country operated by, local
government. CCHPcontracts with individual providers, Contra Costa Regional Medical Center
and Health Centers (CCRVIC&HC) and Kaiser Permanente to arrange comprehensive health
care services.
CCHP provides health care for public and private employee groups, private>individuals, Medi-
Cal and Medicare beneficiaries, and low-income county residents. CCHP's overall commitment'`
is serving the County's most vulnerable populations,
II. MISSION
The goal of CCHP's Quality Management Program (QMP) is to 'ensure that quality, appropriate'
health care and related services provided meet or exceed members' and other customers`
expectations. The QMP mission is carried out in accordance with CCHP's organizational
mission to provide affordable, high quality, accessible health care with integrity and compassion
to all that use our programs;
III. PURPOSE
The CCHP QMP description will inform internal and external customers about how CCHP will
promote, manage, and document improvement in the quality of health care and other related
services provided to its members, through a continuous system of planning, monitoring,
assessing, and improving.
IV. SCOPE
The scope of CCHP's QMP activities include the quality of clinical care and the quality of
service for all services including; but not limited to, preventive, primary, specialty; emergency,
and ancillary care services. The scope of activities reflect CCHP's population in terms of age
groups, disease categories and special risk status, and include, but are not limited to, services
provided in institutional settings,ambulatory care,home care and mental health.
V. OBJECTIVES
Identify opportunities for improvement through a system of monitoring,which includes Member
and Physician, surveys, complaints, focused studies, facility inspections, medical-record'audits
and analysis of HEDIS and administrative data. Implement change, as appropriate, in the range
of health-care services provided by CCHP to its members,
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Establish priorities for ongoing monitoring and focused-review studies with emphasis on access,
preventive services,high volume,high risk, or problem-prone care or services.
Confirmthat 'CCHP delegated `,providers' Quality Assessment and Improvement Program
structure, staff, and processes are in compliance with all provisions of CCHP's QM Plan, QM'
policies and procedures, and meet'professionally recognized standards.
Comply``with internal and external standards and requirements related to duality improvement
activities.
Assure that members can achieve resolution to problems or perceived problems relating to'access
to care or other quality issues through Member Services and QM grievance procedures.
Monitor processes related to the movement of members along the continuum of care and ensure'
continuity of care that meets the members'needs and expectations.
Maintain policies and procedures'for QM, and the facility and medical record review portion of
the credentialing process.
Assure that contracted physicians can achieve resolution to problems or perceived problems
rotating to member's access to care or relating to physician membership in CCHP through QM
procedures.
VI. AUTHORITY AND RESPONSIBILITY
Though CCHP retains ultimate accountability for quality oversight, :quality management is a
shared responsibility`between CCHP and its delegated contracted providers. CCHP's primary
delegated providers are CCRMC &HC and Kaiser Permanente.
The Contra Costa Counly Board of Supervisors has the ultimate responsibility for
development and implementation of the QMP. The Board of Supervisors is responsible for
reviewing and approving the QMP on at least an annual basis. The Board of Supervisors is the
ultimate decision-making body for all contract approvals and terminations,physician:disciplinary
action, and approval of action taken with regard to member or physician grievances.
To ensure that action necessary to implement the QMP is taken in a timely manner, the Board of
Supervisors delegates responsibility for day-to-day operations of CCHP to the CCHP Chief
Executive Officer,who, in turn,has empowered the Joint Conference Committee and QC to
periodically review and take action, as may be required,with regard to contracting,physician
disciplinary actions,and member and physician grievances, subject to the Board of Supervisors'
approval.
The Quality Council(QC 1 has the primary responsibility for implementing and directing the
QMP. It is responsible for developing and making recommendations to the Board of Supervisors'
or the JCC regarding',quality management standards,criteria by which care will be measured, and
priorities for which aspects of care will be monitored.
The QC analyzes quality of care studies,indicators, utilization reports, grievances, and survey
data and makes recommendations to the Board of Supervisors or the JCC regarding changes to
be made to the QMP'.
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The QC is also responsible for receiving,handling, and making recommendations to the Board of
Supervisors or the JCC regarding quality of care issues and member and physician grievances.
The QC is administratively supported by The CCHP Quality Management Unit(QMU). This
unit has responsibility for managing the day-to-day quality activities for the non-delegated
Community Providers as well as providing oversight of quality management activities for
contracted delegated providers.
The QMU receives and investigates any potential quality of care incident and directs information
to the appropriate committee or unit for further action.
In addition.,the QMU is responsible for compiling reports and summaries of recommendations of
specific committees(as is set forth in detail below)for presentation to the QC, the JCC, and to
the Board of Supervisors.
The staff in the QMU are currently licensed registered nurses,supervised by a:
licensed/credentialed physician who acts as the CCHP Medical Director.
A. Assistant'Medical Director
Reports to the CCHP Medical Director. The Assistant Medical Director is responsible
for oversight of the Utilization Management and Credenti ling Programs. He/she is
accountable for all utilization review decisions and perforins all deniat reviews where the
denial is based on medical necessity. The Assistant'Medical Director coordinates with
the Nursing Director and Authorization/Utilization Manager to conduct Utilization
Management Unit staff meetings.
B. Medical Director
Reports to the CCHP CEO. The Medical Director is responsible for the administration
and coordination of quality and medical management of CCHP. The Medical Director
oversees the activities of the QMU, the Utilization Management Unit and the Cooperative
Care Management Unit. He/she oversees the development of medical policy as well as
the medical component of the credentialing process. CCHP's Medical Director devotes a
minimum of 50%of his/her time to quality-related activities.
C . Quality Management Unit
1. Director of Quality Management
A currently licensed registered nurse who reports to the CCHP Medical Director.
He/she is responsible for development and implementation of the annual Q
Program. He/she oversees the day-to-.day activities of the QM Unit including but
not limited to:
a. Compliance with all regulatory and accreditation requirements for QM
activities.
b. Development and administration of DHS required Internal Quality
Improvement Projects. (IQIPs).
c. Oversight of the QM review of grievances and;occurrences.
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d. Oversight of the facility review and corrective action component of the
Credentialing Program.
e. Development and annual review and revision of QM policies and procedures.
f. Coordination of vendor audit and production of NEDIS measures.
g. Development and oversight of QM delegation audit activities.
h. Development and oversight of CCHP Health Education Program.
2. Quality Management QM Nurse(s)
One, or more,currently licensed;registered nurse who report to the Director of QM., The
QM Nurse(s)is/are responsible for:
a. Coordination ofHEDIS hybrid measure production.
b. Design of quality studies and chart abstractiontools:
c. Production of reports.
d. Assistance with data analysis,
e. Review of medical occurrences and grievances and development of response
letters.
f. Credentialing facility review and medical record review. Development and
monitoring of corrective action plans
g. Oversight of QM delegation audits.
3. Manager of Health Education
A Masters prepared Health Educator who reports to the Quality Management Director
Responsibilities include,but are not limited to:
a. Pursue use of consistent educational curricula throughout the CCHP provider
network
b. Collaborate with all provider networks to develop and implement new adult
and pediatric educational curricula for specific disease entities.
c. Provide health education support to CCHP disease management teams.
d. Identify'resources for translator services for all relevant languages.
e. Coordinate translation of member materials to all relevant languages.
f. Develop and implement methods to assess and meet the cultural and
linguistic needs of CCHP members.
g. Develop educational resources for CCHP CPN network.
h. Devise,implement and communicate member referral process for educational
services.
i. Participate with CCRMC Health Educator meetings
j. Document the CCHP'Health Education Program Description and assure the
program is updated and evaluated annually.
k. Assure compliance with all Health Education requirements'of regulators and
purchasers.
1. Collaborate with CCHP Marketing Department to produce the Health Sense
Newsletter in English and Spanish.
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Vii. ASPECTS OF CARE AND SERVICE
CCHP's Quality Management Unit, in coordination with other CCHP units, monitors specific
aspects of care and service. These aspects or activities of care and service include,but are not
limited to:
a. Accessibility/Availability of care
b. Continuity/Coordination of care
c. Under/Over Utilization
d. Mental Health Care
e. Chronic/Acute Care
f. High Risk/High VolumeServices
g. Preventive Health Care
h. Member and Physician/Dissatisfaction
i. Medical Quality of Care Grievance Resolution
VTI. CCHP's QMP COMMITTEE STRUCTURE
Committees:
A. Board of Supervisors
Contra Costa County Board of Supervisors,which is elected through general elections, is the
governing ''body of the CCHP. The Board of Supervisors is ultimately responsible for
development and implementation of the QMP, for contracting, physician disciplinary action,;
and action taken with regard to physician and member grievances.
1. Activities'
a. Develops policy in consultation and with the recommendation of the JCC.
b. Reviews,evaluates,and acts upon the annual QMP and Work Plan.
c. Reviews,evaluates,and acts upon QM reports that are submitted at least quarterly
and more frequently as may be required.
d. Receives, evaluates and acts upon recommendations of the CCHP Credentialing
Committee.
e. Appoints JCC membership.
f. Reviews, evaluates,and acts upon findings of the JCC.
2. Megmbershlp
There are five(5)members of the Board of Supervisors.:Each is elected through general
elections in one of the five districts of Centra Costa County for a terra of four(4)years.
3. Chair
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The chairmanship of the Board of Supervisors rotates among the five beard members
annually.
4. Meetiows
The Board of Supervisors holds weekly public meetings in accordance with the Brown
Act. To preserve the confidentiality of some discussion and reports,the Board of
Supervisors has the authority to meet in executive session{without any members of the
public present}.
B. Joint Conference Committee
The mechanism by which the Board of Supervisors implements the QMP and exercises
oversight of the CCHP'is the JCC of the Board of Supervisors and the CCHP. All meetings
of the SCC are open to the public because of the public nature of the Board of supervisors.
As with the Board of Supervisors,the JCC has the authority to discuss confidential matters
in executive session,when members of the public will be excused.
1. Activities
a. Promotes communication between the Board of Supervisors, QC, and CCHP
administration,
b. Assesses and.monitors the overall performance of CCHP and its contracted
providers including,but not limited to, the quality of care and service
provided'to members.
c. Receives, evaluates,and makes recommendations to the Board regarding the
reports and recommendations of the QC. Such reports include reports
regarding the current and on-going activities of the QMU and are made on a
quarterly basis or more frequently;as may be required.
d. At least annually, reviews, evaluates, and makes recommendations to the
Board regarding modification of the QMP and Work Plan and implementation
of the QMP and Work Plan. Receives, evaluates, and takes action with regard
to reports from CCHP's QM Director and Medical Director regarding the
current and on-going activities of the QMU on a quarterly basis or more
frequently as may be required. Any action taken by the JCC is subject to
approval'by the Board.of Supervisors.
e. Reviews, modifies, approves, and implements provider sanctions and contract'
terminations. Any action taken by the JCC is subject to approval by the Board
of Supervisors.
f. Reviews, evaluates, and acts upon Medical Policy Guidelines, subject to the
Board of Supervisors' approval
g. Receives and reviews quarterly reports regarding Grievance Committee
activity. The JCC makes recommendations to the Board of Supervisors
regarding corrective action that may be necessary to improve reporting or
implementation of the QMP. The;JCC can,if necessary,take immediate
action to implement an immediate change to the QMP or haw the QMP is
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implemented. Such action is subject to review and approval of the Board of
Supervisors.
h. Oversees Protection of Confidentiality of Quality information as cited in
Evidence Code 1157 and Health and Safety Code 1370.
2. Membership
The JCC shall not exceed nine(9)total members:
a. Two(2)members'from the Board of Supervisors, appointed by the Board.
These two members have full voting privileges.
b. Two (2)physician members appointed by the Board from among any of
the providers of the CCHP delegated and non-delegated'provider
networks. To fill these positions,the CCHP Medical Director will solicit
nominations by announcing the vacancy to all providers. The CCHP'
Medical Director will select the candidates and present them to the Beard
for approval. These two'members each have a one-year term and have full
voting privileges..
c. One(1)member is the CCHP Medical Director. This member has ex-
officio status without voting privileges.
d. One(1)member is the Director of Health Services of Contra Costa
County. This member has ex-officio status without voting privileges.
e. One(1)member is the CCHP Executive Director.This member has ex-
officio status without voting privileges.
f£ One(1)member is the Health Services Chief Financial Officer. This
member has ex--officio status without voting privileges.
g. One(1)member is the chairperson of the Managed Care Commission.
This member has ex-officio status without voting'privileges.
3. Chair
The Chair of the JCC is'a member of the Board of Supervisors.' The Chair is
elected annually.
4. Meetings
Meetings of the JCC are held at least quarterly and are open to the public, except
for confidential matters that may be discussed and acted upon in executive
session.
C. The Quality Council'(QC)
The Quality Council(QC)is the principal committee for coordinating and directing
Quality Management activities for CCHP,including but not limited to: quality
management,member and provider grievances,peer review and'credentialing, and
utilization management.
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1. Activities
a. Receives, evaluates, and acts upon the reports of subcommittees.
b. Annually reviews, evaluates, and makes recommendations to the Board
of Supervisors or the SCC regarding the status of contracted providers to
whom quality management,utilization management,credentialing,
medical records and memberrightsand responsibilities activities have
been delegated.
c. Receives recommendations from the Credentialing Committee and':
evaluates the recommendations by integrating provider-specific quality
of care, utilization management, and other data made available by the
CCHP Credentialing Committee, The QC mages recommendations to
the Board of Supervisors or the JCC regarding the credentialing status of
providers.
d. Receives,at least quarterly and more frequently as may be required;
Quality Management occurrence and grievance reports regarding
potential member or provider quality issues. The QC investigates such
occurrence and grievances reports and makes recommendations to the
Board of Supervisors and the JCC regarding resolution of quality of care
issues or implementation of any corrective action that may be required.
Receives and reviews, at least quarterly and more frequently as may be
necessary,reports from the Director of QM regarding unit activities
including,but not limited to: Quality Improvement projects,Disease
Management team status,Health Education, occurrence and grievance
volume and trends,delegation audit scores and recommendations. The
Quality Committee evaluates these reports and makes recommendations
to the Board of Supervisors and the JCC regarding implementation of
any corrective action that may be required.
e. Receives,on at least a quarterly basis and more frequently as may be
required,UNI reports. The QC evaluates such reports and makes
recommendations to the Board of Supervisors and the JCC regarding
implementation of correctiveaction that may be required.
f. Receives,'on at least a monthly basis,reports regarding Grievance
Committee activity. The Quality Committee evaluates such reports and
makes recommendations to the Board of Supervisors and the JCC
regarding implementation of corrective action that may be required
g. At least annually,reviews and makes recommendations to the Board of
Supervisors and the JCC regarding modifications to be made to the
QMP,Work Plan, and other Quality Management reports.
h. Reviews and evaluates Quality Management reports pertaining to
medical,Pharmacy and.Therapeutics, and benefit interpretation policy
issues. The QC makes recommendations to the Board of Supervisors
and the JCC regarding'trends and modifications to be implemented.
i. Distributes Quality Management and other CCHP information to
individually contracted providers via the Medical Director through
letters,newsletters,policies and procedures,provider manuals, and other
appropriate methods.
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j. Reports to CCHP senior administration for the purpose of planning and
designing services for and administering CCHP.
k. Physician committee members may be asked to provide additional
medical review of appeals/reconsiderations.
1. Periodically reviews and approves clinical practice guidelines.
2. Membership
Members of the QC will include:
a. The CCHP Medical Director with full voting privileges.°
b. The CCHP Assistant Medical Director with full voting privileges.
c The Quality Chair or designee from each of CCHP's delegated provider
networks with full voting privileges.'.
d. Director of CCRMC &HC QM Department with full voting privileges.
e. The CCHP QM Director with full voting privileges.
f. At least two(2)independent physicians from any of the CCHP contracted
provider networks, at least one of whom will be from the individually
contracted physician network. To fill these positions,the CCHP Medical
Director will solicit nominations by announcing the vacancy to all
providers. The physician members will be appointed and annually re-
appointed by the CCHP Medical Director. Interested physicians will be
solicited when vacancies occur. Both members serve one-year terms and
have full voting privileges.
g.: The CCHP Authorizations/Utilization Manager with full voting privileges.'
h: The CCHP Clinical Programs Liaison with fall voting privileges.
i. The CCHP Patient Services Director with full voting privileges.
j:. The CCHP Nursing Director and/or designee with full voting privileges.
k. Note: For peer review issues, only medical providers may vote.
3. Chair
The QC is chaired by the CCHP Medical Director,'or in his/her absence,the
Assistant Medical Director.
4.Meetings
The QC meets monthly, a minimum of nine(9)times yearly.
D. QC Subcommittees
1. Clinical Leadership
The Clinical Leadership Committee provides direction to CCHP with regard to
quality and medical management programs including,but not limited to:
utilization management, ease management,quality management,health education,
credentialin , peer review,clinical guidelines development and implementation,
and appeals and grievance policy. The Clinical Leadership Committee reports to
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the QC at least quarterly and more frequently as the need arises with
recommendations for foots study and disease management topics.
Activities
a. Annually reviews the QMP and Work Plan and makes recommendations
to the QC to improve the QMPand Work Plan.
b." Annually reviews the QM,Health Education,UM CCM, and Telephone
Triage policies and procedures and makes recommendations to the QC to
improve these policies and procedures.
c.' Recommends to the QC the direction and policy for clinical projects and
programs.
d. Reviews and evaluates clinical benefit interpretations and authorization
criteria. Clinical Leadership may suggest modifications existing benefit
interpretations and authorization criteria.
e. Reviews process and results of the annual HEDIS'effort'and recommends
action on results to the appropriate committees.
Membership
a. CCHP Medical Director with full voting privileges
b. CCHP Assistant Medical Director with full voting privileges
c. CCHP QM Director with fall Voting privileges
d. CCHP Health and Resource Management Director with'full voting
privileges
Chair
The CCHP Medical Director, or Assistant Medical'Director chairs the Clinical
Leadership Committee.
Meetings
The Clinical'Leadership Committee meets bi-monthly, a minimum of six times
per year.
2. Cre+dentiating Committee
The Credentialing Committee conducts the process ofcredentialing CCHP contracted
providers. It makes recommendations to the QC regarding credentialing and re-
credentialing of CCHP providers;handles primary-level appeals regarding credentialing
disputes and,if necessary,'makes recommendations regarding such disputes to the QC,
and reports quality-related issues to other subcommittees for investigation and action:
The Credentiling Committee reports to the QC on a monthly basis or more frequently as
may be required,with its recommendations for credentialing and other disciplinary,action
involving providers' credentials.
Activities
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a.s Receives reports regarding credentialing actions and policies from the
Quality Management Units of the contracted delegated providers.
b. Conducts primaryappeals of credentialing disputes and makes
recommendations to the JCC regarding such.appeals. (See, Credentialing
Policy CRI 1.006.A)
c. Reports issues that potentially implicate quality of care issues to other
subcommittees for investigation and action,
d. Makes recommendations regarding applicants for credentials or re-
credentialing to the QC.'
e. Reviews information from the facility site review process and makes
recommendations to the QC regarding corrective action necessitated by
the facility site review.
f£ Considers pertinent grievance and occurrence information as part of the
re-credentialing process and where appropriate notifies the QC or the
Medical Director of potential duality;issues that may require immediate
intervention.
g. On at least an annual basis,reviews, and makes recommendations to the
QC for modifications to the Credentialing policies and procedures.
Membership
a.' The CCHP Assistant Medical Director with full voting privileges.
b.' The CCRMC&HC Credentialing Committee Chairperson or his/her
representative. This member has full voting privileges.
c. The CCHP'Director of Provider Affairs.
d The CCHP Provider Affairs Liaison.
e. Two(2) independent physicians from any of the CCHP contracted
providers, at least'one of whom will be from the individually contracted
physician network. One of these shall be a primary care'physician; the
other shall be a specialty care physician. To fill these positions,the QMU
will solicit nominations by announcing the vacancy to all providers. The
Medical Director will select and appoint the most qualified candidates.
Both members serve one=-year terms and have full voting privileges.
f. The QMU staff who support the committee without voting privileges.
g. The Credentialing Unit staff who supports the committee without voting
privileges.
Chair
The CCHP Assistant Medical Director chairs the Credentialing Committee.
Me_ _..et&pj
The Credentialing Committee meets monthly, at a minimum'of nine times a year.
3. 'Grievance Committee
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The Grievance Committee provides the first level of appeal for all non-urgent
requests for reconsideration of denied,modified or deferred services,payment for
denied claims, and unsatisfactory resolution of formal grievances and acts as an
avenue of member representation within the CCHP Health Plan, The Committee also
reviews complaints against CCHP members for appropriate action. Requests for
reconsideration may be received from members or their legalrepresentative. The
voting quorum for this committee is at least three Committee'members,with at least
one Committee member from clinical staff. The Authorizations/Utilization
Management Coordinator shall review the case in advance, and determine if medical
specialist or additional'administrative staff opinions are warranted.
CCHP members and/or their appointed designees are informed of their right to attend
this meeting to present their ease in advance of the meeting. In cases where there is a
potential of risk or injury to CCHP employees,the CCHP member will not be
allowed to present their case in person but may designate someone to participate,on
their behalf.
The Grievance Committee reports to the QC, on<a monthly basis or more frequently
as may be required, with summary reports of its activities,including trending of
grievance and appeal data, and reports on specific cases that require review by the
QC''
Activities
a. Reviews and makes determinations, subject to the QC and the Board of
Supervisors' approval, on all Requests for Reconsideration of denied claims
and/or denied,modified or deferred services.
b. Reviews and makes determinations, subject to the QC and the Board of
Supervisors' approval,on all appeals of grievances not resolved to a member's
satisfaction.
c. Reviews'all case review requests submitted by a third party, including Fair
Hearings, and coordinates CCHP's response, as appropriate.
d. Reviews and makes determinations, subject to the Quality Council and the
Board of Supervisors' approval, of complaints against CCHP members
e. Handles all investigative, administrative matters associated with member and
provider;grievance reviews.
f. Files are confidentially maintained by the Member Services Unit for 5 years.
g. Acts as avenue of patient advocacy within CCHP.
Scope of Authority
a. Refers issues regarding benefits of contract changes to the UM Committee.
b. Makes contract change recommendations for member materials.
c. Makes recommendations for quality improvement.
d. Can approve or deny grievance appeals based on majority vote, subject to the
approval of the QC and the Board of Supervisors.
e. Can uphold or overturn the denial of service or claim based on majority vote,
subject to the approval of the QC and the Board of Supervisors.
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f. Can recommend action against a member,which may;include plan-initiated
di -enrollment, to the QC. .'
g. Can recommend to the QC that suspicious activities be reported to the Fraud
Unit for investigation.
Membership
a. Non.-Clinical:
Director of Patient Services or Patient Services Supervisor,full voting
privileges
Business Services Manager or Claims Supervisor, with full voting
privileges.
b. Clinical'
Medical Director or Assistant Medical Director
AuthorizationsiMilization Manager or UM Nurse
In the specialized case that a medical specialist opinion is warranted, the specialist;
will have full voting privileges.
Meetings
The Grievance Committee meets ad hoc as needed and generally once each
month.
Resolution of urgent or expedited appeals of denied services is described in policy
MS 8.031.A
4. Pharmacy And Therapeutics Committee
The Pharmacy and Therapeutics Committee is responsible for the oversight of
drug utilization trends, maintenance of the pharmacy management program,;and
ongoing development and oversight of the C'CHP drug list. The Pharmacy and
Therapeutics Committeereports to the QC semi-annually or more frequently as
may be required. ,
Activities
a. Review drag utilization'patterns and''establish guidelines and protocols
that help ensure high quality, cost-effective drug therapy.
b. Analyze new drugs and determine their status for inclusion to the CCHP
drug list.
c. Review the drug list and make additions and deletions as necessary based
on objective pharmacoeconomie evaluation of their relative therapeutic
efficacy,safety, and cost.
d. Make decisions about pharmacy prior authorization policies.
e. Report potential clinic issues to the QC for further investigation and
action.
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Membership
Voting members.
CCHP Medical`Director
CCHP Nurse
CCHP Pharmacist
CCRMC Physician-Internal Medicine
CCRMC Physician-Family Practice
CCRMC Pharmacist
CPN Physician'
Mental Health Pharmacist
Practicing physician(s), representing a medical specialty as needed in
accordance with the agenda
Practicing community pharmacist(s) contractedwith CCHP
Non-voting members
CCHP Pharmacy Benefit Management Company representative pharmacists)
CCHP Director of Provider Relations
Designated CCHP Provider Relations Representative
Designated personnel(physician,pharmacist,nurse, etc.) representing Quality
Assurance
Chair:
The Chair of the Pharmacy and Therapeutics Committee is the CCHP Medical
Director:
Meetings;
Meetings are held quarterly,the third Friday of every month.
E. Public Advisory&Other Coordinating Committees
2. Managed Care'Commission
The Managed Care Commission is a public advisory commission that reports
directly to the Board of Supervisors at least annually and more frequently as may
be required. This commission replaced the CCHP Advisory Board.
Activities
a. Advises the Board.and CCHP on policy decisions and provides input from
the community and members about the financial plan,rate setting,
marketing and provider relations surveys.
b. Receives appropriate plan level QMU reports from.the CCHP Executive
Director.
c.' Advises the Executive Director regarding its concerns related to the
quality of care and services provided to CCHP members.
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d. The Chairperson of the Managed Care Commission provides feedback to
the CCHP senior management and MedicalDirector by participating in the
Joint Conference Committee.
Membershi
There are fifteen(15)members,'appointed by the Board of Supervisors. Six(6)
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(9)
seats are at large. The Health Services Director, CCHP Executive Director, and
the Board of Supervisors are ex officio members without voting privileges.
The Commission has three(3) standing subcommittees and three(3)special
subcommittees:
a. Standing Subcommittees'
1) Health Care
2) Finance
3) Marketing and Health Promotion:
b. Special Subcommittees
1) Governance
2) Cultural and Linguistic Advisory Committee
3) Public Policy.
Chair
The chair of the Managed Care Commission is elected from among the
Commission members and serves a one-year term.`
!Meetirts
The Managed Care Commission meets monthly.
For more details, see the Managed Care Commission bylaws in section 6.2 of the
DDA.
2. Cultural& Linguistic Advisory Committee(proposed)
The Cultural and Linguistic Advisory Committee(CLA )advises the Board.of
Supervisors and the Senior Management of CCHP on the specific needs and
concerns of CCHP members who have a different ethnic or cultural background
or who speak a different language. The committee reports to the Board of
Supervisors'once a year or more frequently as may be required.
Activities
a Receives appropriate aggregate QM reports without confidential provider
or member-specific information from the CCHP Medical Director.
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b. Advises the Medical Director regarding its concerns related to the quality
of care and services provided to CCHP members.
Membership
The CCHP's Manager of Health Education staffs the CLAC. The members of the
CLAC will include advisory members from the Managed Care Commission'
(MCC) as well as professionals, advocates and Medi-Cal members of the public,
representing the different language and ethnic groups served by CCHP.
Nominations will be sought from all members of CCHP through mail and
personal contacts with community leaders. CCHP'contracted providers may
assist in the search for candidates for this committee. C+CHP's Health'Educator
will select.the Committee'members and present them to the CCHP Director of
Marketing and Communications for approval.
Chair
The chair of the Cultural and Linguistic Advisory Committee will be appointed by
the Managed Care Commission from among the members of the Cultural and
Linguistic Advisory Committee'.
Meetings
The Cultural and Linguistic Advisory Committee meets at least semi-annually.
IX. QM DELEGATION
CCHP may delegate all, or any portion,of the QM program to a contracted provider group.'
Delegated quality monitoring status is granted upon successful demonstration by contracted
delegated providers that the required scope of quality monitoring activities is taking place. Prior
to delegation, the contracted provider group's QMP will be evaluated to assess its ability to carry
out required activities.
If CCHP delegates all or a portion of the QMP, CCHP will develop a written description of the
delegated activities, the delegates'accountability for these activities,the frequency of reporting
to the plan and'the process by which oversight will be accomplished.
An annual delegation oversight audit is performed on each of CCHP's delegates using the
National IPA Coalition(NIPAC) Standardized'Delegated Audit Tool. Delegation audits are
performed in accordance with Quality Policy QM14.301.
X QUALITY MANAGEMENT PROCESS AND INITIATIVES
A. Process
1. Study Topic
The QMI T will assess potential study topics to determine their relevance to CCHP
papulation. In addition,the QMU will determine CCHP's ability to:make and/or
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direct improvements in care and/or services related to the selected study topic.
Each topic or measure selected will have an established goal and/or benchmark.
2. Study Planning,
The Q U will consider the following:issueswhen planning a quality study:
a. Feasibility.
b. Establishment of timelines.
c. Assessment of appropriate dates of service and/or outcome data..
d Adequacy of sample size.
3. Practice Guidelines
Where indicated, clinical practice guidelines will be developed based on
reasonable medical'evidence and nationally recognized guidelines. The
guidelines will be submitted to CCHP QC for review and approval. CCHP will
measure its performance against selected guidelines. The guidelines Will be
updated or reviewed periodically and communicated to health plan providers and
appropriate staff.
4. Quality Indicators
CCHP will develop quality indicators appropriate to the study question. The
indicators will be objective and''measurable, and based on the most current
HEDIS version if appropriate.
5.Hata Analysis Plan
CCHP will develop a data analysis plan prior to data collection. It will be clear
and non-contradictory,include potential data collection problems,and detail the
method for determining whether to review the wrote at-risk population or a
sample of the population.
6, Measurement Tool(s)
CCHP will use measurement tool(s) appropriate for obtaining the information
pertinent to the study topic and indicators, accompanied by sufficient written
instructions„and appropriate to the level of experience of the data collection staff.
7. Validation of Collected Data
CCHP will assess the approximate degree of correlation between the
administrative data entries and the corresponding medical record entries and the
accuracy of the medical record abstraction,if applicable.
8. Data Analysis
CCHP will correctly perforin the appropriate descriptive and statistical tests. The
meaningful key data and study results;will be presented clearly. Appropriate
personnel will evaluate the analyzed data to identify barriers to improvement.
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9. Interpretation of Findings
CCHP will appropriately interpret and analyze key findings, using a multi-
disciplinary approach that will include'bio-statistical consultation.
10. Communication of'Findings
CCHP'will present study results and follow-up actions to the appropriate health
plan staff, committee(s), members, and providers.
11. Improvement Plan
CCHP will develop and implement a detailed improvement plan based on the
study findings. Appropriate interventions will be selected'and implemented to
improve system and/or practitioner performance. The plan will be reviewed by the
Clinical Leadership Committee prior to implementation.
B. Quality Improvement initiatives
1. Preventive
a.` Pediatric Preventive Services:':Immunizations
In 2002, CCHP will continue to focus on improvement of childhood''
immunization rates. Specific objectives for 2002 include:
1) Evaluation of the Immunization Registry/RIMS/data warehouse
interface. Assure appropriate and desired data flow from
administrative and clinical systems to warehouse.
2) Fully implement WIC pilot program, which began in February 2000.
3) Monitor effectiveness of automated Immunization reminder cards.
4) Measure 2001'HBDIS rates.
S) Plan future interventions based on analysis of above initiatives.
6) Collaborate with CCA.IR to pilot web based registry application and
automated reminder cards in CPN offices.
b. Adult Preventive Services: Breast Screening
In 2002,CHP will implement an automated reminder system for
mammography.
2. Clinical-Chronic
Asthma Management Team
In 2002,the Asthma Management Team will continue its implementation of the
asthma disease management program. The FACCT survey will be re-administered
to measure impact of the program.
Phare'Ny Utilization
In 2000, the CCHP Pharmacy and Therapeutics Committee evaluated pharmacy
utilization and determined appropriate interventions. The committee additionally
developed a phannacyinanagement program to respond to escalating pharmacy
costs. This included developing and implementing a pharmacy prior
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authorization.process. For 2001,the committee will focus on developing a
program to educate',providers regarding drug;utilization.
3. Non-Clinical
a. Claims processing timeframe improvement
CCHP Will continue the claims processing time project as a service
initiative for 2002. Evaluation of reports to track and measure claims
payment timeframes and trends Will be used to determine appropriate
interventions.
b. Satisfaction with CCHP Member Services
CCHP will continue monitoring satisfaction with CCHP Member Services
as a quality'initiative for 2002. Results of the report card survey will be
analyzed and appropriate interventions will be selected and implemented.
Improvement will be monitored through on-going Member and Physician
surveys and report card surveys.
c. Respect, caring and acceptability of services including:
1) Member and Physician surveys
2) Review of member grievances;and concerns
3) Telephone waiting time.
4) Office waiting-room time.
d Appropriateness and utilization of services including: Pattern of referral
authorization requests, approvals, denials, appeals and outcome of appeal.
1) Timeliness of decisions
2) Utilization of Emergency Room
3) Percent of visits that occur with Primary Care Physician
4) Hospital admissions/1,000
5) Utilization of ambulatory and inpatient services
6)' Authorization for costly?,procedures.
7)' Out-of-plan claims.
8) Environment of care and safety of the member to whore
the care is provided:
9) On-site facility audits/reviews
10)Member complaints and grievances
11)Review of is-enrollment questionnaire survey results.
XI. COORDINATION OF QM PROGRAM WITH OTHER MANAGEMENT
FUNCTIONS
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QM activities may impact and require action on the part of other administrative divisions. These
activities include credentialing, member grievance process, utilization management(UM), and
advice nurse telephone triage program. Management functions with a significant bearing on
quality are linked through QC.
A. Credentialing
CCHP has written policies and 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 federalagencies. Site visits are conducted,if applicable, for both
credentialing and re-credentialing
The credentialing process, activity and decision results are reviewed by the CCHP
Credentialing Committee. The Credentialing Committee reports monthly to QC with
recommendations for accepting a provider's application, for disciplinary action to be
taken against a physician,or for termination of a physician's contract. The QC reviews
the recommendations of the Credentialing Committee and provides any additional
information that may be pertinent to the provider's membership to the Board of
Supervisors. The Contra Costa Board of Supervisors exercise final approval of
credentialing/recredentialing/reappointment decisions for the CCHP contracted
providers.
In cases where the any person or committee believes that a provider poses a threat to
himself,to a member, or to a third party, immediate disciplinary action may be taken to
restrict the provider's credentials with CCHP. Such action shall be taken in accordance
with Credentialing policy CRI 1.006.A.
B ' Member Grievance Process
Member grievances are received and logged in Member Services." Grievances that raise
clinical quality'...-related issues are referred directly to the QM Unit for review, tracking,
and resolution.' The QMU tracks quality of care grievances for the purpose of identifying
potential'trends. Where appropriate, corrective action is implemented. A QM grievance
report and recommendations for remedial action are submitted quarterly, and more
frequently as may be required, to QC.
Resolution of argent grievances is described'in policy MS 8.031.A.
C. Utilization Management
CCHP's Utilization Management(LTM)Program covers all aspects of care and services
provided to all members. It provides prospective, concurrent, and retrospective review of
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health care services requested and received by members. (Please refer to the UM
Program Description.)
D. Telephone Triage Program
CCHP's Telephone Triage program is staffed by licensed Registered Nurses and provides
health care advice and education to CCHP members,patients utilizing the hospital and
clinic system, and those county residents lacking health care coverage. Please refer to the
Telephone Triage Quality Management Program description and procedures.
E. Cooperative Care Management Program
CCHP's Cooperative Care Management program works with the PCP to coordinate care
of CCHP members and those patients utilizing the hospital and clinic system.
XII. DISCIPLINARY ACTION
When a quality issue or trend is identified and attributed to'a specific physician, and is severe
enough to warrant reportable disciplinary action, the QC will take''action in accordance with the
CCHP credentaling appeal process(CRI1.006A). In such cases,physicians are entitled to
Judicial Review. The CCHP Executive Director will arrange for this review according to the
Judicial Review Policy. Corrective action will be reported to the Contra Costa County legal
council for subsequent reporting to the Medical Board of California(MBC)and the National
Practitioners Data Bank(NPDB).''
XIII. CONFIDENTIALITY
All quality files and ether quality data or information are maintained in a manner that protects
patient and provider confidentiality. CCHP's QM information is not discoverable or admissible
in a court of law as specified,in Section 1157 of the California Evidence Code and Section 1370
of the Health and Safety Code. All CCHP employees sign a statement of confidentiality upon
employment. .Additionally,participants'in CCHP's QC, Credentialing,Peer Review and
Grievance committees sign an additional statement of confidentiality related to the review of
medical quality of care issues.
XIV. CONFLICT OF INTEREST
Any individual who has been professionally involved in an issue or case may not participate in
the review, evaluation,or final disposition of the case.
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Contra Cosh Health Plan
Quality Management Program Description 2002
Approved by the Clinical Leadership Committee:
—0 ra-)&.J-1�—
Kate ol°well, MD, Committee Chair Date
Approved by the QC:
Kate lColwell, MD, Council C air Date (�
Approved by the Joint Conference Committee
/,4 Date
Donna Gerber,Co79
tt e Chair
Page-22
Contra Costa Health Plan Quality Management Program Description 2002-