W. Va. Code R. § 114-53-5

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 114-53-5 - Quality Management & Improvement

5.1. Organizational arrangements and responsibilities for quality management and improvement processes shall be clearly defined and assigned to appropriate individuals.

a. There shall be a detailed written description of the program which shall be reviewed annually and updated as necessary.

b. A senior executive shall be responsible for program implementation.

c. A medical director shall be employed by the health maintenance organization and have substantial involvement in quality improvement activities.

1. Upon application to and approval by the commissioner, a health maintenance organization may employ a medical director on a part-time basis during the first two years of the HMO's operation.

2. All health maintenance organizations are required to employ a full-time medical director no later than the first day of the third year of the HMO's operation.

d. A committee shall be created to oversee quality improvement and shall include HMO providers as active participants. The committee shall keep contemporaneous written records reflecting all of its actions.

e. The role, structure and function, including frequency of meetings, of the quality improvement committee shall be specified in the program description.

f. Adequate resources including, but not limited to, personnel, analytic capabilities and data resources shall be dedicated to meet program needs.

g. A written quality improvement work plan shall be prepared annually and shall include: the objectives, scope and planned projects or activities for the year; planned monitoring of previously identified issues, including tracking of issues over time; and planned evaluation of the quality improvement program.

5.2. The quality improvement committee shall be accountable to the governing body of a health maintenance organization. The governing body shall consist of the board of directors or a committee of senior management in instances where the board's participation with quality improvement is indirect. There must be documented evidence of a formally designated structure, accountability at the highest levels of the organization and ongoing and/or continuous oversight of quality assurance.

a. The governing body shall formally designate a subcommittee to provide oversight of quality improvement or formally decide to provide such oversight as a committee of the whole.

b. There must be written documentation that the governing body has reviewed and approved the written overall quality improvement program and the annual quality improvement work plan.

c. The governing body or designated committee shall regularly receive written reports from the quality improvement program delineating actions taken and improvements made.

d. All quality assurance information shall be considered in recredentialing, recontracting and/or annual performance evaluations.

5.3. All findings, conclusions, recommendations, actions taken, and results of actions taken as a result of the quality improvement process shall be documented and reported to the appropriate individuals and committees in the health maintenance organization and through established quality improvement standards.

a. Quality improvement activities shall be coordinated with other performance monitoring activities, including but not limited to utilization management, risk management and resolution, monitoring of member complaints and grievances, assessment of member satisfaction and medical records review.

b. Quality improvement shall be coordinated with other management functions of the health maintenance organization such as network changes, benefits redesign, medical management systems, practice feedback to providers and patient education.

5.4. Requirements to participate in quality improvement activities shall be incorporated into all provider contracts and employment agreements. Contracts shall specify that hospitals and other contractors will allow the health maintenance organization access to members' medical records. Contracts shall also specify that the health maintenance organization allows open provider-patient communication regarding appropriate treatment alternatives and that it does not penalize the provider for discussing medically necessary or appropriate care for the patient.

5.5. The quality improvement program must be ongoing and designed to objectively and systematically monitor and evaluate the quality and appropriateness of care and service provided members and to pursue opportunities for improvements.

a. The scope of the program shall be comprehensive and shall include quality of clinical care and quality of service.

b. Members shall be afforded opportunities to participate in and offer suggestions on quality improvement.

c. A health maintenance organization shall monitor and evaluate clinical issues in institutional and non-institutional settings, primary care and major specialty services including mental health, high volume high-risk services, preventive care services, and the care of acute and chronic conditions. Such monitoring and evaluation shall reflect the population served in terms of age groups, disease categories and special risk status.

5.6. A health maintenance organization shall adopt and use practice guidelines or explicit criteria that are based on reasonable scientific evidence.

a. The guidelines shall be reviewed and updated as needed.

b. The guidelines and any updates shall be communicated in writing to all providers.

5.7. An HMO shall develop and implement mechanisms for:

a. Assessing plan and provider performance against practice guidelines;

b. Evaluating member continuity and coordination of care;

c. Detecting under- and over-utilization; and

d. Assessing patient outcomes.

5.8. A health maintenance organization shall establish standards for the availability of primary care providers and access which shall include but not be limited to routine, urgent and emergency care; identification of members with chronic/high-risk illnesses and the appropriate programmatic responses; telephone appointments, advice and member service lines. The availability and access standards shall conform to the minimum requirements set by the commissioner.

5.9. A health maintenance organization shall develop indicators, a data collection system and data analysis capabilities to track quality improvement.

a. Indicators shall be objective, measurable and based on current knowledge and clinical experience and shall be used to monitor and evaluate all aspects of care and services identified.

b. An HMO shall have performance goals and/or a bench marking process for each indicator.

c. Appropriate methods and frequency of data collection shall be used for each indicator.

d. Appropriate clinicians shall be used to evaluate data on the clinical performance of practitioners.

e. Multidisciplinary teams shall be used, where indicated, to analyze and address systems issues.

5.10. If a health maintenance organization receives ten or more complaints from members or enrollees within a six-month period that relate to the same or similar subject matter, the health maintenance organization shall develop a specific written plan of action as to the resolution of the complaints and file a report with the commissioner on how the complaints were successfully resolved.

W. Va. Code R. § 114-53-5