Section 732-2.3 - Quality assurance and improvement

732-2.3 Quality assurance and improvement.

(a) A PPO shall develop and implement on a continuous basis a quality assurance and improvement program that includes organizational arrangements and ongoing procedures for the identification, evaluation and resolution of potential and actual problems in health care administration and delivery to claimants. These organizational arrangements and ongoing procedures shall be fully described in written form, provided to all members of the governing authority, providers and staff, and made available to eligible employees of an affected employer.

(b) The organizational arrangements for the quality assurance and improvement program must be clearly defined and should include, but need not be limited to, the following:

(1) a quality assurance and improvement committee, responsible for quality assurance activities, consisting of the medical director, the administrator, at least one member of the governing body and provider representatives including physicians;

(2) accountability of the committee to the governing body, with requirements for periodic written and oral reports to the governing body;

(3) participation from an appropriate base of providers and support staff;

(4) supervision by the medical director;

(5) regularly scheduled meetings at appropriate intervals but at least quarterly; and

(6) written minutes of the meetings of the quality assurance and improvement committee describing in detail the actions taken by the committee, the medical charts reviewed, problems discussed, recommendations made, and any other pertinent discussions and activities.

(c) The content of the quality assurance and improvement program shall reflect the scope of services provided and address all of the following:

(1) high risk procedures;

(2) sentinel events or occurrences; screens to identify potential failures in quality of care;

(3) development of explicit criteria and protocols for evaluating the quality of care;

(4) review and documentation of all claimant complaints and written evaluations described in paragraph (12) of subdivision (e) of section 732-2.6 of this Subpart and reasons given by those who opt out. Such written evaluations from claimants and any data extracted from such forms shall be made available to the commissioner and chair upon request;

(5) review and assessment of the continuity of care;

(6) review and assessment of the appropriateness and timeliness of referrals;

(7) review of the education and training of all primary treating physicians to ensure their knowledge and training in occupational medicine and Workers' Compensation Law requirements, including but not limited to:

(i) regulatory and reporting requirements under the workers' compensation program; and

(ii) familiarity with workplace hazard causes, restrictions, disability evaluation and rehabilitation; and

(8) review of the adequacy of access to care as demonstrated by records of complaints pertaining to waiting periods for appointments and telephone access.

(d) A PPO shall document the manner by which it examines actual and potential problems in health care administration and delivery to eligible employees. While a variety of methods may be utilized, the following components shall be addressed:

(1) the establishment of procedures for the analysis, monitoring and assessment of the quality of care provided, including review criteria developed in accordance with generally accepted standards of medical practice;

(2) the acquisition of sufficient data to perform a meaningful analysis; for example, through a statistically valid sample size for medical chart review; and

(3) involvement of appropriate clinical personnel, including physicians and other providers, in peer review activities.

(e) The quality assurance and improvement program shall include the development and documentation of timely and appropriate recommendations for addressing problems that are identified in health care administration and delivery to claimants. The PPO shall demonstrate operational mechanisms for responding to those problems.

(f) The PPO shall document the steps taken to follow-up on recommendations made by the quality assurance and improvement committee. The PPO shall be able to demonstrate that recommendations of the committee responsible for quality assurance activities are reviewed and acted upon in a timely manner, in order to:

(1) assure the implementation of appropriate action relative to the recommendations;

(2) assess the results of such action; and

(3) provide for revision of recommendations or actions and continued monitoring when necessary.
 

Effective Date: 
Wednesday, July 16, 1997
Doc Status: 
Complete