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

   质量管理委员会监督：

   1. 大量服务和治疗
   2. 高危会员及待遇
   3. 儿童和青少年行为健康康复服务
   4. 重大事件
   5. 护理质量
2. 服务成效评估

   质量管理委员会评估为消费者和家庭提供的服务的有效性。包括以下域：

   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. 经 QMC 批准的基于人群的研究和调查
3. 评估内部流程的质量和有效性

   质量管理委员会评估内部流程的有效性和整体绩效。包括以下领域和方法：

   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

   质量管理委员会使用数据专注于评估医疗保健服务以及护理模式和趋势，而不是关注个别护理事件。该系统包括以下组件：

   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. 累犯和复发率
   5. 重大事件
   6. 消费者满意度小组 (CST) 数据
   7. 行政合规
   8. 提供者简介和成绩单
   9. 年度电话满意度调查数据
   10. 临床文件记录审查
5. 重大会员事件监控

   Quality Management prepares monthly reports showing the frequency and type of critical incidents by population category (e.g., age, gender, diagnosis, 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 QMC has final authority to close critical incident 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 (CST) 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 CST activities. An annual statistically valid telephonic survey is conducted by Carelon. Findings and resulting recommendations from the survey and CST 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 QMC and areas for quality improvements are developed and monitored.