Manwal ng Tagabigay

MGA GAWAIN SA PANGANGASIWA NG KALIDAD

Ang kabuuang pamamahala ng kalidad at patuloy na pagpapabuti ng kalidad ay nangyayari sa loob ng konteksto ng iba't ibang nakaplanong aktibidad. Kasama sa mga aktibidad na ito, ngunit hindi limitado sa, ang mga sumusunod:

1. Pamamahala ng Panganib

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

   1. Serbisyo at Paggamot ng High Volume
   2. Mga Miyembro at Paggamot na Mataas ang Panganib
   3. Intensive Behavioral Health Services (IBHS) for Children and Adolescents
   4. Reportable Events
   5. Quality of Care Activities
2. Pagsusuri ng Bisa ng Mga Serbisyo

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

   1. Pag-access sa Mga Serbisyo
   2. Kaangkupan ng Mga Awtorisasyon ng Serbisyo (Mga pag-audit ng system ng awtorisasyon)
   3. Data ng Awtorisasyon at Karaingan
   4. Kalidad ng Pagpaplano ng Pamamahala ng Serbisyo
   5. Mga Resulta ng Paggamot
      1. Pakikilahok sa lahat ng aktibidad sa pangongolekta at pag-uulat ng datos na kinakailangan ng Department of Public Welfare
      2. Population-based studies and surveys as approved by the QM/UMC
3. Pagsusuri ng Kalidad at Pagkabisa ng mga Panloob na Proseso

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

   1. Mga Pamantayan sa Pag-access sa Telepono at Pagtugon
   2. Pagkatugon at Katumpakan ng Mga Serbisyo ng Miyembro at Provider
   3. Mga Rate ng Relapse at Recidivism
   4. Pangkalahatang Mga Pattern at Trend ng Paggamit
   5. Koordinasyon sa Iba Pang Mga Serbisyong Ahensya at Paaralan
   6. Proseso ng Pagsubaybay sa Reklamo at Karaingan
   7. Sapat na Kapasidad sa Provider System
4. Pagsusuri ng Kalidad at Pagganap ng Network ng Provider

   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. Mga Pattern ng Paggamit
   2. Data ng Reklamo at Karaingan
   3. Kalidad ng Mga Indibidwal na Plano ng Serbisyo at Pagpaplano ng Paggamot
   4. Reportable Events
   5. Data ng Consumer Satisfaction Team (CST).
   6. Administrative Compliance
   7. Mga Profile ng Provider at Report Card
   8. Data ng Taunang Telephonic Satisfaction Survey
   9. Mga Pagsusuri sa Talaan ng Dokumentasyon ng Klinikal
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. Pag-uulat ng Pinaghihinalaang/Substantiated Fraud at Pang-aabuso

   Ang Coordinator ng Panloloko at Pang-aabuso ay naghahanda ng nakasulat na ulat sa bawat quarter, na kinabibilangan ng lahat ng mga paratang ng pandaraya at/o pang-aabuso, ayon sa uri ng kaganapan, nilinis upang protektahan ang pagiging kumpidensyal, at ang resulta ng pagsisiyasat.

7. Nilalaman, Pagpapanatili at Pag-iimbak ng mga Clinical Records

   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. Pagtatasa ng Kasiyahan ng Miyembro

   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. Pagtatasa ng Kasiyahan ng Provider

   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.