提供者手册

质量管理活动

全面质量管理和持续质量改进发生在各种计划活动的范围内。这些活动包括但不限于以下内容：

1. 风险管理

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

   1. 大量服务和治疗
   2. 高危会员及待遇
   3. Intensive Behavioral Health Services (IBHS) for Children and Adolescents
   4. Reportable Events
   5. Quality of Care Activities
2. 服务成效评估

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

   1. 访问服务
   2. 服务授权的适当性（授权系统审计）
   3. 授权和申诉数据
   4. 服务质量管理规划
   5. 治疗结果
      1. 参与公共福利部要求的所有数据收集和报告活动
      2. Population-based studies and surveys as approved by the QM/UMC
3. 评估内部流程的质量和有效性

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

   1. 电话接入标准和响应
   2. 会员和提供商服务的响应性和准确性
   3. 复发和累犯率
   4. 总体利用模式和趋势
   5. 与其他服务机构和学校的协调
   6. 投诉和申诉跟踪流程
   7. 提供者系统的足够能力
4. 供应商网络的质量和性能评估

   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. 使用模式
   2. 投诉和申诉数据
   3. 个性化服务计划和治疗计划的质量
   4. Reportable Events
   5. 消费者满意度小组 (CST) 数据
   6. 行政合规
   7. 提供者简介和成绩单
   8. 年度电话满意度调查数据
   9. 临床文件记录审查
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. 报告疑似/已证实的欺诈和滥用行为

   欺诈和滥用协调员每季度准备一份书面报告，其中包括所有欺诈和/或滥用的指控，按事件类型分类，经过消毒以保护机密，以及调查结果。

7. 临床记录的内容、保留和存储

   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. 会员满意度评估

   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. 供应商满意度评估

   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.