Quality Assessment and Performance Improvement. The HMO must provide for the delivery of quality care with the primary goal of improving the health status of Members and, where the Member’s condition is not amenable to improvement, maintain the Member’s current health status by implementing measures to prevent any further decline in condition or deterioration of health status. The HMO must work in collaboration with Providers to actively improve the quality of care provided to Members, consistent with the Quality Improvement Goals and all other requirements of the Contract. The HMO must provide mechanisms for Members and Providers to offer input into the HMO’s quality improvement activities.
Quality Assessment and Performance Improvement. The MCO must provide for the delivery of quality care with the primary goal of improving the health status of Members and, where the Member’s condition is not amenable to improvement, maintain the Member’s current health status by implementing measures to prevent any further decline in condition or deterioration of health status. The MCO must work in collaboration with Providers to actively improve the quality of care provided to Members, consistent with the Quality Improvement Goals and all other requirements of the Contract. The MCO must provide mechanisms for Members and Providers to offer input into the MCO’s quality improvement activities.
Quality Assessment and Performance Improvement. A. The Contractor shall implement an ongoing comprehensive Quality Assessment and Performance Improvement (QAPI) Program for the services it furnishes to beneficiaries. (42 C.F.R. § 438.330 (a).)
B. The Contractor’s QAPI Program shall improve the Contractor’s established outcomes through structural and operational processes and activities that are consistent with current standards of practice.
C. The Contractor shall have a written description of the QAPI Program that clearly defines the QAPI Program’s structure and elements, assigns responsibility to appropriate individuals, and adopts or establishes quantitative measures to assess performance and to identify and prioritize area(s) for improvement. The Contractor shall evaluate the impact and effectiveness of its QAPI Program annually and update the Program as necessary per Cal. Code Regs., tit. 9, § 1810.440(a)(6). (42 C.F.R. § 438.330(e)(2).)
D. The QAPI Program shall include collection and submission of performance measurement data required by the Department, which may include performance measures specified by CMS. The Contractor shall measure and annually report to the Department its performance, using the standard measures identified by the Department. (42 C.F.R. § 438.330 (a)(2), (b)(2), (c)(2).)
E. The Contractor shall conduct performance monitoring activities throughout the Contractor’s operations. These activities shall include, but not be limited to, beneficiary and system outcomes, utilization management, utilization review, provider appeals, credentialing and monitoring, and resolution of beneficiary grievances.
F. The Contractor shall have mechanisms to detect both underutilization of services and overutilization of services. (42 C.F.R. § 438.330(b)(3).)
Quality Assessment and Performance Improvement. A. The Contractor shall implement an ongoing comprehensive Quality Assessment and Performance Improvement (QAPI) Program for the services it furnishes to beneficiaries. (42 C.F.R. § 438.330 (a).)
B. The Contractor’s QAPI Program shall improve Contractor’s established outcomes through structural and operational processes and activities that are consistent with current standards of practice.
C. The Contractor shall have a written description of the QAPI Program that clearly defines the QAPI Program’s structure and elements, assigns responsibility to appropriate individuals, and adopts or establishes quantitative measures to assess performance and to identify and prioritize area(s) for improvement. Contractor shall evaluate the impact and effectiveness of its QAPI Program annually and update the Program as necessary per Cal. Code Regs., tit. 9, § 1810.440(a)(6). (42 C.F.R. § 438.330(e)(2).)
D. The QAPI Program shall include collection and submission of performance measurement data required by the Department, which may include performance measures specified by CMS. The Contractor shall measure and annually report to the Department its performance, using the standard measures identified by the Department. (42 C.F.R. § 438.330 (a)(2), (b)(2), (c)(2).)
Quality Assessment and Performance Improvement. The Contractor will establish and implement a system of Quality Assessment and Performance Improvement (QAPI) as required by 42 CFR 438.200-438.242 and a Utilization Management (UM) program as required by 42CFR 456 and stated within the MCO Policy and Procedure Guide. The Contractor will have an ongoing Continuous Quality Improvement (CQI) program for the services furnished to its members that meets the requirements of 42CFR 438.200. The Contractors Medical Director will be responsible for managing the CQI program. The Contractor will submit, annually by December 15, its QAPI Quality Assessment Workplan, UM Workplan and Program Integrity Plan to SCDHHS for review and approval. Any subsequent changes or revisions must be submitted to SCDHHS for approval prior to implementation. The full scope of QAPI, and UM requirements are outlined in the MCO Policy and Procedure Guide, Quality Assessment and Utilization Management Requirements. The Contractor is required to conduct performance improvement projects as specified in the MCO Policy and Procedure Guide. The Contractor will agree to an External Quality Review, review of QAPI / CQI / UM Quality Assessment Committee meeting minutes and annual medical audits to ensure that it provides quality and accessible health care to Medicaid MCO program members, in accordance with standards contained in the MCO Policy and Procedure Guide and under the terms of this Contract. Such audits shall allow SCDHHS or its duly authorized representative to review individual medical records, identify and collect management data, including but not limited to survey and other information concerning the use of services and the reasons for disenrollment. It is agreed that the standards by which the Contractor will be surveyed and evaluated will be at the sole discretion and approval of SCDHHS. If deficiencies are identified, the Contractor must formulate a Plan of Correction (POC) incorporating a timetable within which it will correct deficiencies identified by such evaluations and audits. SCDHHS must prior approve the POC and will monitor the Contractor's progress in correcting the deficiencies. See MCO Policy and Procedure Guide. The Contractor must attain accreditation by a nationally recognized organization such as the National Committee for Quality Assurance (NCQA) or the Utilization Review Accreditation Commission (URAC) within a reasonable time period, not to exceed four years from the initial county network approval date. SCDHHS wi...
Quality Assessment and Performance Improvement. The Contractor will submit reports of Quality Assessment and Performance Improvement (QAPI) activities, including, a QA Workplan, Plan of Correction (POC), Utilization Management (UM) activities and Workplan, Program Integrity Workplan and Quality Measures documentation in accordance with the periodicity contained in §11 of this Contract and the Policy and Procedure Guide. The Contractor shall collect information to report all HEDIS measures designated by SCDHHS in this Contract and the MCO Policy and Procedure Guide. The Contractor should collect HEDIS measures in calendar years 2010 and submit this information to SCDHHS. However, the Contractor is not required to submit audited HEDIS results to SCDHHS until June 15, 2012 for the 2011 calendar year. This requirement may be adjusted if the Contractor is in the process of obtaining NCQA certification but has not completed the entire process.
Quality Assessment and Performance Improvement. [§460.32(a)(9), (a)(10), (a)(11)]; [§460.130, §460.134(c), §460.136, §460. 140]; [§460.202(b)]
(1). A description of the PACE Organization's quality assessment and performance improvement program is contained in Appendix K.
(2). The PACE organization shall meet or exceed minimum levels of performance on standardized quality measures as established by CMS and the SAA. The minimum level of performance is: The organization will achieve an immunization rate for both influenza and pneumococcal vaccinations of 80% for the participant population that is appropriate. (Rate will exclude those participants who have had prior immunization or the vaccine is medically contraindicated).
(3). The PACE Organization shall furnish data and information on participant care activities, as established by CMS and the SAA. These data are contained in Appendix L.
Quality Assessment and Performance Improvement. The Contractor will submit reports of Quality Assessment and Performance Improvement (QAPI) activities, including, QAPI Work Plan, Plan of Correction (POC), Case Management (CM) activities and Work Plan, and Quality Measures documentation in accordance with the periodicity contained in §11 of this Contract and the MHN Policy and Procedure Guide .
Quality Assessment and Performance Improvement. The CCN will submit reports of Quality Assessment and Performance Improvement (QAPI) activities in accordance with the reporting section and periodicity contained in § 4.7 of this Provider Agreement and the CCN-
Quality Assessment and Performance Improvement. The Medical Staff is responsible for ensuring that the professional care furnished to patients of the Local Hospital by members of the Medical Staff is of high quality, safe, efficient, and effective and meets the professional standards of the community, the Local Hospital, the Corporation, and the Parent Corporation. The Medical Staff shall discharge this responsibility by meeting regularly to review, analyze, and appraise its clinical experience and the quality of care rendered by members of the Medical Staff, in conformance with its Medical Staff Bylaws and Local Hospital policies and procedures. The review and analysis shall be based on patient medical records and such other documents and patient information as may be reasonably necessary. The Medical Staff shall identify and implement an appropriate response to findings. Such quality assessment and performance improvement activities shall be regularly reported to this Hospital Community Board and the Parent Corporation Quality Committee and the Executive Vice President – Chief Medical Officer of the Parent Corporation, or his/her designee, in accordance with applicable policies and procedures.
