Quality Improvement Program 28 TAC §10.22 Workers’ Compensation Health Care Networks

Quality Improvement Program A network must develop and maintain an ongoing quality improvement program designed to: Objectively and systematically monitor and evaluate the quality and appropriateness of care and services Pursue opportunities for improvement

Quality Improvement Program The quality improvement program must include: –Medical case management program –Return-to-work program

The network’s governing body is ultimately responsible for the quality improvement program. The governing body must: Appoint a quality improvement committee that includes network providers Approve the quality improvement program Approve an annual quality improvement plan Meet at least annually to receive and review reports of the quality improvement committee and take action as appropriate Review the annual written report on the quality improvement program

Quality Improvement Program The quality improvement program must be continuous and comprehensive and must address: –The quality of clinical care and –The quality of services The network must dedicate adequate resources to the quality improvement program, including: –Personnel –Information systems

Quality Improvement Program The network must develop a written description of the quality improvement program that outlines: –The organizational structure of the program –The functional responsibilities of the program –The frequency of committee meetings

The network must develop an annual quality improvement work plan designed to reflect the type of services and the populations served by the network in terms of: –Age groups –Disease or injury categories –Special risk status, such as type of industry

Quality Improvement Program The work plan must include: –Objective and measurable goals –Planned activities to accomplish the goals –Time frames for implementation –Individuals responsible –Evaluation methodology

The work plan must include evaluation of each program, including: Network adequacy which encompasses: availability and accessibility of care and assessment of providers who are and are not accepting new patients Continuity of health care and related services Clinical studies Adoption and periodic updating of: treatment guidelines, return-to-work guidelines, individual treatment protocols, and the list of services requiring preauthorization

–Employee satisfaction –Provider satisfaction –Complaint and appeal processes –Complaint data –Identification and removal of communication barriers which may impede employees and providers from effectively making complaints against the network –Provider billing processes, if applicable

–Contract monitoring, including delegation oversight, if applicable, and compliance with filing requirements –Utilization review and retrospective review processes, if applicable –Credentialing –Employee services, including after-hours telephone access logs –Return-to-work processes and outcomes –Medical case management outcomes

The network must prepare an annual written report to the department on the quality improvement program, which includes: –Completed activities –Trending of clinical and services goals –Analysis of program performance, and –Conclusions regarding the effectiveness of the program

The network must implement a documented process for the selection and retention of contracted providers. The network’s procedures must ensure that selection and retention criteria do not discriminate against doctors or health care practitioners who: –Serve high-risk populations or –Specialize in the treatment of costly conditions

The quality improvement program must provide for a peer review action procedure for providers as described by the Medical Practice Act Section (7) Occupations Code, which states: "Medical peer review" or "professional review action" means the evaluation of medical and health care services, including evaluation of the qualifications and professional conduct of professional health care practitioners and of patient care provided by those practitioners. The term includes evaluation of the: (A) merits of a complaint relating to a health care practitioner and a determination or recommendation regarding the complaint; (B) accuracy of a diagnosis; (C) quality of the care provided by a health care practitioner; (D) report made to a medical peer review committee concerning activities under the committee's review authority; (E) report made by a medical peer review committee to another committee or to the board as permitted or required by law; and (F) implementation of the duties of a medical peer review committee by a member, agent, or employee of the committee. “

The network must have a medical case management program with certified case managers, whose certifying organization must be accredited by an established accrediting organization, including: –The National Commission for Certifying Agencies (NCCA) –The American Board of Nursing Specialties, or –Another national accrediting agency with similar standards Case managers must be certified in one or more of the following areas: Case management Case management administration Rehabilitation case management Continuity of care Disability management Occupational health

Examples of Case Manager Certifications: CertificationSponsoring OrganizationWebsite CCM Certified Case Manager Commission for Case Manager Certification ccmcertification.org CRC Certified Rehabilitation Counselor Commission on Rehabilitation Counselor Certification crccertification.com CDMS Certified Disability Management Specialist Certification of Disability Management Specialists Commission cdms.org RN,C or RN,BC Registered Nurse Case Manager American Nurses Credentialing Center nursingworld.org

Examples of Case Manager Certifications that may follow the NCCA standards, but have not yet achieved NCCA accreditation: CertificationSponsoring Organization Website A-CCC Advanced Certification in Continuity of Care National Board for Certification in Continuity of Care CMAC Case Management Administrator, Certified The Center for Case Management CRRN Certified Registered Rehabilitation Nurse Association of Rehabilitation Nurses

Case managers must work with: treating doctors referral providers employers and employees to facilitate cost-effective health care and the employee’s return-to-work

Until January 1, 2007, non-certified case managers may assist in providing the required medical case management services. The non- certified case managers must have prior experience in one of the areas delineated previously and may not serve as claim adjusters. The non-certified case managers must be under the direct supervision of a certified case manager at all times.