Quality Management Program

The Quality Management (QM) Program supports many of the activities of the Utilization Management, Provider Relations, Member Services, and Health Education Departments at Valley Health Plan. QM performs a number of ongoing and ad hoc quality and care review studies throughout the year. VHP’s goal is to conform to regulatory standards set by the DMHC, the California Department of Health Services and all other regulatory agencies. The program closely monitors and promptly incorporates relevant statutory and regulatory changes. All providers must participate in the VHP QM program as part of the contractual agreement with VHP. QM monitors and/or performs activities which may include the following: HEDIS (Health Plan Employer Data and Information Set) VHP also selects other clinical areas not covered by the HEDIS studies. Access Survey, Audit, Dashboard Audit of Primary Care Provider Sites and Medical Records Audit Behavioral Health Provider Sites and Medical Records Provider and Member Satisfaction Surveys Potential Quality Issues (PQIs) Provider Groups Contracted Hospitals

a) Design and maintain a QM structure and process that supports continuous quality improvement, including measurement, analysis, intervention, and reassessment. b) Pursue opportunities for improvements in the health status of the enrolled population through preventive care services, health education, and disease management. c) Establish clinical and service indicators (with appropriate performance goals and benchmarks) reflecting the demographic characteristics of the Membership. d) Annually measure Member satisfaction with providers and Plan through trending and analysis of the Member grievance process. e) Annually measure provider satisfaction and address sources of dissatisfaction. f) Develop priorities of focused studies, emphasizing high volume services and providers, high-risk populations, and other quality improvement areas. g) Ensure timeliness of Credentialing/ Re-credentialing of providers. h) Coordinate QM with performance monitoring activities throughout VHP. i) Develop an annual Work Plan that includes a schedule of activities with measurable objectives and monitoring of previously identified issues. j) Evaluate annually the effectiveness of the previous year’s QM activities and interventions. Trend clinical and service indicators from year to year. k) Ensure provider performance in quality of care and service areas, medical record keeping, preventive health, accessibility of medical and behavioral healthcare, environmental safety, and health safety. l) Maintain and enforce a Conflict of Interest and Confidentiality policy for the protection of Peer Review activities and confidential Member and provider information. m) Ensure that the Health Plan does not exert undue economic pressure that might delay or withhold medically necessary services.

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n) Ensure Members’ rights, dignity, and the total needs of each individual regardless of race, ethnicity, gender, religion, socioeconomic levels or sexual orientation. o) Ensure non-discriminatory evaluation of Member grievances or provider disputes. p) Promotes a setting in which all services are provided in a culturally linguistically appropriate manner. QM attachments pertaining to the Quality Management Program, see Section 15.

Governing Board: Health and Hospital Committee (HHC) is a subcommittee of the Santa Clara County Board of Supervisors formally empowered by the Board to serve as the governing board for VHP.

The committee meets monthly or a minimum of four times per year to approve and oversee the implementation of the health plan’s quality efforts and formalized program. The Medical Director or QMC Chairperson may call additional meetings if the need arises.

The QM Committee provides an annual summary and evaluation of the effectiveness of the QM Program to the HHC. The HHC may approve the report and make recommendations and/or may make independent recommendations for action.

All providers shall maintain medical records in accordance with standards established by VHP and regulatory agencies. Records must be maintained in a manner that is current, detailed, organized, permits effective patient care and quality review, and maintains confidentiality. a) The medical record is kept in a lockable file cabinet within the provider office and not accessible to patients. b) A system of medical record retrieval allows for prompt and accurate retrieval and availability to the provider at each patient encounter.

c)

d)

e) f) g) h)

i)

j) k) l) The medical record system tracks the record when it is out of the filing system. There must be a system for the incorporation of information in the chart between visits as well as a system for the archiving of purged data. Medical records are inaccessible to patients and other unauthorized persons and are maintained to guard against unauthorized disclosure of confidential information and to protect confidentiality. There is a medical record for each Member seen. All pages in the record are securely anchored and all pages are filed chronologically. Each page in the record contains the patient's name or patient ID number for patient identification. Personal/biographical and demographic data include age, sex, address, telephone number, marital status, and are updated as appropriate. A copy of a “consent to treat” form is maintained in the medical record and other consents as required by current legislation. The medical record documents all aspects of patient care, including use of ancillary services. All entries are dated. The author of all entries is identified, including title.

m) n) o) p) q) r)

s) t)

u) The records are legible, documented accurately, and in a timely manner. The reason for the visit is noted, i.e., the chief complaint(s). Diagnostic information and a plan of treatment for each visit are documented. Treatments, procedures, and tests, including results, are documented and consistent with treatment. There is a specific follow-up date for a return visit or other follow-up plan for each encounter. There is evidence of continuity and coordination of care between the primary and specialty physicians, including continuity of care and coordination between primary care and behavioral health providers. There is evidence that failed appointments are followed-up. As required by the Patient's Right to Self-Determination Act, documentation is present that the patient has executed an Advance Directive (a written instruction such as a living will or durable power of attorney for health care) or that information was offered /given to the patient. There is evidence of member health education, preventive care, and other health safety activities.

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