プロバイダーマニュアル

品質管理活動

総合的な品質管理と継続的な品質改善は、さまざまな計画された活動の中で行われます。これらの活動には以下が含まれますが、これらに限定されません。

  1. 危機管理

    The Quality Management / Utilization Management Committee (QM/UMC) monitors:

    1. 大量のサービスと治療
    2. ハイリスクメンバーと治療
    3. Intensive Behavioral Health Services (IBHS) for Children and Adolescents
    4. Reportable Events
    5. Quality of Care Activities
  2. サービスの効果の評価

    The QM/UMC evaluates the effectiveness of services provided to consumers and families. The following domains are included:

    1. サービスへのアクセス
    2. サービス認可の適正性（認可制度監査）
    3. 承認および苦情に関するデータ
    4. サービス品質管理計画
    5. 治療結果
      1. 公共福祉省が要求するすべてのデータ収集および報告活動への参加
      2. Population-based studies and surveys as approved by the QM/UMC
  3. 内部プロセスの品質と有効性の評価

    The QM/UMC evaluates the effectiveness of internal processes and overall performance. The following domains and methodologies are included:

    1. 電話アクセスの標準と応答性
    2. メンバーおよびプロバイダー サービスの応答性と正確性
    3. 再発率と再犯率
    4. 全体的な使用パターンと傾向
    5. 他のサービス機関や学校との調整
    6. 苦情および苦情の追跡プロセス
    7. プロバイダ システムの十分なキャパシティ
  4. プロバイダー ネットワークの品質とパフォーマンスの評価

    The QM/UMC uses data to focus on the assessment of health care delivery and patterns and trends in care, rather than on individual occurrences of care. The system includes the following components:

    1. 利用パターン
    2. 苦情および苦情データ
    3. 個別化されたサービス計画と治療計画の質
    4. Reportable Events
    5. 消費者満足度チーム (CST) データ
    6. 行政コンプライアンス
    7. プロバイダーのプロファイルとレポート カード
    8. 年次電話満足度調査データ
    9. 臨床文書記録のレビュー
  5. Monitoring of Significant Member Incidents (Reportable Events)

    Quality Management prepares quarterly reports showing the frequency and type of reportable events by population category (e.g., age, gender, etc.) and by service type. Clinical records may be requested, in some cases, for review by the Carelon Risk Management Analyst. Other avenues are explored as well, in order to complete a thorough investigation. The Medical Director has final authority to close reportable event cases.

  6. 疑わしい/立証された詐欺および虐待の報告

    Fraud and Abuse Coordinator は四半期ごとに書面によるレポートを作成します。これには、イベントの種類ごとに、機密性を保護するためにサニタイズされたすべての詐欺および/または虐待の申し立て、および調査の結果が含まれます。

  7. 臨床記録の内容、保持および保管

    Carelon has established policies and procedures for clinical records content, retention and storage, which encompass physical security, information systems security and staff training. This is monitored in the recredentialing process.

  8. 会員満足度の評価

    In order to determine if behavioral health services are meeting the needs and expectations of consumers, family members, including parents of children and adolescents, and persons in recovery, the HealthChoices Program has established systems and procedures to routinely assess member and family satisfaction. These systems and procedures include the use of ongoing consumer/family satisfaction team (CFST) providing for face-to-face discussions with consumer and family members as a means for early identification and resolution of problems related to service access, delivery and outcome. Providers are expected to cooperate fully with all CFST activities. An annual statistically valid telephonic survey is also conducted by Carelon. Findings and resulting recommendations from the survey and CFST activities are incorporated into the HealthChoices Program ongoing quality management and improvement program.

  9. プロバイダー満足度の評価

    An annual telephonic provider satisfaction survey is conducted by Carelon. Data is reviewed by the QM/UMC and areas for quality improvements are developed and monitored.