1 Quality Assurance at HMC 10/08 Learning & Development

2 Objectives By the end of this module, you will be able to:  State the purpose of the Complaint & Risk Reporting process  State the definition of “complaint” as defined by HMC  Identify the steps to take for non-HMC complaints  Complete and submit a complaint using the Complaint Entry form  Complete and submit a Risk Report form

3 HMC Complaint Reporting

4 Purpose To ensure the delivery of quality services to our customers To assure members and clients of HMC’s commitment to safeguarding Protected Health Information (PHI)

5 Policy Health Management Corporation supports the delivery of high quality services by providing a mechanism for recording, investigating, resolving and reporting complaints that pertain to HMC services and employees.

6 Definition HMC defines a complaint as: An unsolicited verbal or written expression of dissatisfaction involving HMC and services provided by HMC. It may be received from our program participants, an employee of a client, an involved provider, or an HMC employee.

7 Definition Any complaints received not related to HMC or services provided by HMC must be directed to the health plan as there are specific business and accreditation needs that are impacted by timeliness of complaint reporting to the health plan. The health plan Customer Service units responsible for logging and investigating these types of complaints vary by geography, product and client. Please do not delay the progress for complaints that need to be handled by the health plan in a timely manner by entering them in the HMC system; redirect to the health plan.

8 Process StepAction 1 Access the HMC Intranet through your desktop and select “Operations” on the left side of the screen 2 Click on the appropriate “Care Center” link 3 Click on “View Links”

9 Process StepAction 4 Click on the “Customer Feedback” link 5 Click on the “Complaint Entry Form” link 6 Complete each section of the complaint entry form and click the “Submit Form” button *You will receive a confirmation page to confirm your report has been sent for review.

10 Form Navigation After selecting the “Customer Feedback” link from the “Regional Care Center Links” page, the Report Services page displays. The user can make a selection from 3 links: User’s Manual, Complaint Report, & Risk Reports. The User’s Manual contains step by step instructions for the Complaint Entry Form and Risk Management Report completion To enter a complaint, click on the “Complaint Entry Form” link.

11 Form Navigation In the “Entrant Detail” section, complete Today’s Date, your First and Last Name, your Title, your Care Center Location, your Department, & the name of your Department Manager. 10/15/2008 Clyde Barrow Nurse Coach Nashville ConditionCare Bonnie Parker

12 Form Navigation In the “Complainant Detail” section, complete the Type of Complainant (client, member/participant, provider, or HMC employee), Complainant’s First & Last Name, Program, Case Number, Date of Birth, State of Residence, Insured ID# and the name of the Client. Participant Mary Bozell ConditionCare /29/1961 Tennessee PO23456 Anthem SE

13 Form Navigation In the Complaint Detail section, complete the Date the Issue was Identified, the Date the Issue Occurred and the Object of the Complaint (Access Issue, Clinical Issue, Operational Process, Service Issue, or Privacy/Security Issue) and a detailed description of the complaint. Participant Mary Bozell ConditionCare /29/1961 Tennessee PO23456 Anthem SE Include as much detail about the complaint in this space. Be specific without including personal opinions/judgments. Some examples include: Excessive hold time, Participant called program 3x without an answer, Participant requested calls only at night and has received 3 calls in the morning…

14 Form Navigation After you have completed the Complaint Entry form, click on the “Submit Form” button

15 Form Navigation The confirmation page is displayed after clicking on the “Submit Form” button.

16 Process IfThen You are not able to access the Complaint Entry Form Submit your complaint to the following box: Include the following details: *Your first and last name *Care Center location *First & last name of the complainant *Name of client *Insured ID number *Case Number *Detailed/specific description of the complaint Any of the required information is not available Include as much information as possible and submit the information via

17 Resolution The QI department resolves all complaints in writing within 30 business days The QI department is responsible for trending the data and reporting the findings to the Quality Improvement Committee (QIC) quarterly Complaint processing is mandated by our accrediting bodies and also ensures our participants receive their program benefits in an appropriate manner

18 HMC Risk Reporting

19 Purpose To ensure the appropriate documentation and investigation of any incidents for which HMC may be accountable

20 Policy Health Management Corporation (HMC) investigates any incident, which may result in potential harm or liability for the corporation or for any internal or external customers.

21 Definition A possibility of loss or injury. Situations requiring completion of a Risk Management Report may include, but are not limited to:  Caller refusing EMS activation  HMC associates implying a diagnosis for a participant  HMC associates recommending a specific medication  Breach of confidentiality/non-permitted use/disclosure of PHI  Security incidents regarding electronic PHI and/or overall security of company systems  HMC associates who document information in the data management system that is not congruent with information reported by the participant

22 Process StepAction 1 Access the HMC Intranet through your desktop and select “Operations” on the left side of the screen 2 Click on the appropriate “Care Center” link 3 Click on “View Links”

23 Process StepAction 4 Click on the “Customer Feedback” link 5 Click on the “Risk Management Report” link 6 Complete each section of the Risk Management Report and click the “Submit Form” button *You will receive a confirmation page to confirm your report has been sent for review.

24 Form Navigation After selecting the “Customer Feedback” link from the “Regional Care Center Links” page, the Report Services page displays. The user can make a selection from 3 links: User’s Manual, Complaint Report, & Risk Reports. The User’s Manual contains step by step instructions for the Complaint Entry Form and Risk Management Report completion To enter a risk report, click on the “Risk Management Report” link.

25 Form Navigation Complete the date the Incident occurred, the date you complete the report, your first and last name, your title, the HRS case number if it applies, checkmark the applicable box under: Report Initiated By, Program and the Incident Type 10/15/2008 X X Clyde Barrow Nurse Coach X X

26 Form Navigation Provide a detailed description of the incident that occurred. Click the “Submit Form” button. X Provide a detailed description of the incident that occurred in this space. Be specific without including personal opinions.

27 Form Navigation The confirmation page is displayed after clicking on the “Submit Form” button.

28 Process IfThen You are not able to access the Risk Management Report Form Submit your Risk Management Report to the following box: Include the following details: *Your first and last name *Care Center location *First & last name of the complainant *Name of client *Insured ID number *Case Number *Detailed/specific description of the complaint Any of the required information is not available Include as much information as possible and submit the information via

29 Process There are any transmission errorsContact the compliance line at: IfThen

30 Resolution HMC associates complete Risk Management Reports for any incident that may result in actual or potential liability for HMC The Quality Improvement department forwards privacy breaches to the Privacy Manager within 1 business day of receipt The Quality Improvement department immediately begins an investigation into Risk Reports Quality Assurance at HMC begins with you and we thank you for your commitment to our participants, clients and HMC.