Quality Improvement Accountability

 

Organizational Structure Supporting Quality Improvement: Accountability

The Board of Directors

Molina Healthcare of Michigan's Board has ultimate authority and responsibility for the quality of care and service delivered by MHM. The Board is responsible for the direction and oversight of the QI Program and delegates authority to the Quality Improvement Committee (QIC) under the leadership of the Chief Medical Officer. The President/CEO also serves as a member of the Molina Healthcare of Michigan Board of Directors.

The Quality Improvement Committee (QIC)

The QIC is responsible for the implementation and ongoing monitoring of the Quality Improvement program. Through the Quality Improvement Sub-committees, the QIC recommends policy decisions, analyzes and evaluates the progress, results and outcomes of all quality improvement activities, institutes needed actions and ensures follow-up.

The QIC sets the strategic direction for all quality activities at Molina Healthcare. The QIC receives reports from all QI sub-committees, advises and directs the committees on the focus and implementation of the QI program and work plan. The QIC reviews data from QI activities to ensure that performance meets standards and makes recommendations for improvements to be carried out by sub-committees or by specific departments.

The QIC is chaired by the Chief Medical Officer, and is composed of management of key health plan functions and network practitioners. The QIC confirms and reports to the Board that plan activities comply with all state, federal, regulatory and NCQA standards. The QIC reports to the Board any variance from quality performance goals and the plan to correct the variance. The QIC submits to the Board approved, signed, minutes reflecting committee decisions and actions of each meeting. In addition it presents an annual QI program, work plan and prior year evaluation, as well as quarterly summaries of important activities to the Board.

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Quality Leadership

  • The Chief Medical Officer and Director of QI are responsible to plan, design, implement and coordinate QI activities. Their combined responsibilities include but are not limited to:
  • Reporting to the Board at the quarterly meetings.
  • Demonstration and promotion of the QI Program through communication, practice, and resource allocation.
  • Achievement of organizational goals.
  • Direct involvement in QI activities to include:
      Analysis of UM and QI data
      Serve as chair of QI committees
      Ensure effectiveness of quality activities and allocate resources
      Ensure practitioner participation
  • The Chief Medical Officer is the designated physician who has substantial involvement in the QI Program. This individual is responsible for:
  • Supervision of all of Healthcare Services including operational oversight responsibility for the Quality Improvement, Utilization Management, Credentialing, and Pharmacy departments. Additionally the Chief Medical Officer will evaluate the link between Behavioral Health and MHM on a regular basis.
  • Chairing the Quality Improvement Committee (QIC), and co-chairing the Pharmacy and Therapeutics Committee (P&TC), the Peer Review/Credentialing Committee (PRC), and the Utilization Management Committee (UMC).
  • Oversight of development, dissemination, implementation and evaluation of clinical practice guidelines, preventive health guidelines and benefit interpretation guidelines.
  • Communication of information and decisions to network practitioners and providers, and follow-up on corrective action plans implemented for issues regarding quality of care, patient safety, or service.
  • Directs the provision of medical management for health care services, including behavioral health services, in conjunction with the Medical Director, the Clinical Behavioral Health Director and the Pharmacy Director.
  • The Director, QI under the direction of the Chief Medical Officer, leads the QI function and has the following responsibilities:
  • Promote and maintain quality as a priority and guiding principle throughout the organization.
  • With the Chief Medical Officer, implements the MHM Safety Strategy.
  • Make available administrative support for planning, oversight, and allocation of resources to establish and maintain an organization-wide system of QI.
  • Serve as a resource for planning, implementation, and evaluation of the QI Program.
  • Provide operational oversight of the QI Program and annual work plan, Health Education, HEDIS, Health Management, Delegation Oversight, and other clinical measurement processes.
  • Coordinate health service activities to provide for measurement and analysis, obtaining needed expertise as needed.
  • Coordinate the organization's ongoing NCQA Accreditation activities.
     
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    Standing Quality Improvement Sub-Committees

The QIC delegates QI functions to specific sub-committees. Each of these sub-committees is guided by a description that outlines its composition, meeting frequency, standards and responsibilities. All MHM Quality Sub-committees meet at a minimum quarterly and all keep contemporaneous minutes using a standard format.

The activities of all quality committees are treated in a confidential manner, as outlined in their policies. (Please refer to attached 2005 Committee Purpose and Meeting Dates, APPENDIX B for a full description of sub-committee membership and responsibilities)
  • The Quality Improvement Committee (QIC). Information from the QIC is reported to the Board of Directors on a quarterly basis or more often as appropriate.
  • The Peer Review/Credentialing Committee (PRC). The PRC reports to the QIC.
  • The Member and Provider Satisfaction Committee. Reports to the QIC.
  • The Pharmacy and Therapeutics Committee (P&TC). The P&TC reports to the QIC.
  • The Utilization Management Committee (UMC). The UMC reports to the QIC.
  • The Compliance Committee (CC). The CC reports to the QIC.

QI Department Roles and Responsibility

The QI Department is comprised of appropriately credentialed registered nurses, health professionals, and ancillary personnel who are responsible for coordination of the QIP and planned QI activities. These include, but are not limited to:
  • Coordination of a health plan wide annual evaluation and planning cycle, resulting in an annual QI work plan that outlines organizational QI objectives with action plans, goals, responsibilities, timeframes and reporting requirements.
  • Coordination of clinical and service quality measurement and quarterly reporting to the QIC.
  • Management of QI projects, studies and interventions, preparation and submission of QI documents and reports, and recommendations to appropriate quality sub-committees.
  • Identification of opportunities for improvement through monitoring and analysis of clinical and satisfaction data.
  • Ensuring compliance with MHM and regulatory standards for timely response or resolution of complaints and appeals, in conjunction with UM and Member Services staff.
  • Monitoring QI preparations for compliance with regulatory requirements and for future accreditation. Coordinates the preparation of the formal study documentation, including Quality Improvement Activities (QIAs) and Performance Improvement Projects (PIPs).
  • Development, adoption, and implementation of relevant health education programs.
  • Implementation of the clinical quality of care case review process
  • Membership on appropriate Quality Sub-committees.
  • Maintenance of accountability and oversight of delegated administrative functions to include credentialing, utilization management, and claims to contracted provider groups.
  • Development, maintenance and implementation of QI policies and procedures.
  • Maintenance of necessary QI resources including, but not limited to written materials, software, specialty consultation, analyst and statistical support.
  • Identification and interventions for disparities for racially and ethnically diverse populations

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Other Departmental Roles and Responsibilities for QI

All departments have a key role in quality improvement. Departments participate in interdepartmental activities but also focus on intradepartmental opportunities to improve effectiveness or efficiency. All departments participate in one or more of the Quality Improvement Committees.

The UM staff is responsible for:
  • Development and maintenance of the UM Program, policies and procedures, annual UM work plan and program evaluation in compliance with NCQA, MHM and other regulatory and accrediting standards.
  • Monitoring over and under-utilization, coordination and continuity of care, including access to a nurse advice line.
  • Documentation of all potential quality of care, risk management, and member safety issues identified during UM review. The Chief Medical Officer determines the severity of each case and determines if peer review is required.
  • Oversight of the coordination of care with healthcare delivery organizations (i.e., facilities) and contracted entities, and with groups delegated for UM functions
  • Implementation of a case management program in collaboration with health management and prevention programs.

The Provider Services staff is responsible for:
  • Monitoring practitioner, provider and health delivery organization access and availability, including behavioral health, and implementing improvement plans.
  • Review of practitioner satisfaction surveys, practitioner complaints and other forms of practitioner feedback and implementation of improvement plans.
  • Dissemination of provider education materials as identified including statements of members' rights and responsibilities.
  • Administration of the provider inquiry process for payment issues related to post-service claims and/or authorization denials.
  • Monitoring the trends of member concerns, complaints, appeals and disenrollment related to dissatisfaction with provider and provider inaccessibility and identifying opportunities for improvement, in conjunction with Member Services staff and QI.

The Member Services staff is responsible for:
  • Administration of the members' rights and responsibilities.
  • Monitoring member access to Molina Healthcare and compliance with contractual and regulatory standards for timely response or resolution of all issues, in conjunction with Provider Services.
  • Monitoring trends of member complaints, appeals and disenrollment and identification of opportunities for improvement.
  • Review of member satisfaction surveys and other forms of member feedback, identification of opportunities for improvement, and implementation of improvement activities.
  • Reporting all potential quality of care and risk management issues that are reported by members following policy and procedure.
  • Administration of the member complaint and appeal policy, ensuring timelines met per policy.

Compliance Manager is responsible for:
  • Coordination of compliance audits.
  • Oversight of compliance with all applicable statutory, regulatory and contractual requirements.
  • Review of draft and final regulations and statutes.
  • Education and training for Molina Healthcare staff regarding contract provisions and new law/regulation.
  • Liaison with the state of Michigan.
  • Coordination of contract renewal activities.
  • Implementation and monitoring of the Compliance Plan.
  • Maintenance of approved policies and procedures, ensuring annual review and approval.
  • Preparation and review of member communications and submission to the state for approval as required, including member handbook and mailings.
  • Management and review of confidentiality issues and provision of training as needed.
  • Coordinate organizational compliance for HIPAA (Health Insurance Portability and Accountability Act).

The Credentialing staff is responsible for:
  • Implementation of a credentialing and recredentialing program that includes completion of office site visits to ensure a safe environment for members and appropriate practices, development and maintenance of provider profiles including available data from health plan functions and staffing the PRC.
  • Implementation of the medical record-keeping audit program.
  • Delegation Oversight

The Pharmacy staff is responsible for:
  • Identification of key processes to evaluate pharmacy safety and effectiveness.
  • Maintenance of notification system for drug alerts.
  • Development and maintenance of operational policy and procedures for effective formulary management, authorizations processes and safe practices.
  • Oversight of Pharmacy Benefit Manager to ensure practices meets MHM's standards.

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Role of Participating Providers

Participating practitioners serve on all clinical committees including, QIC, UMC, P&TC and PRC. Through this committee activity, participating providers may:
  • Review and provide feedback on proposed practice guidelines, preventive health standards, clinical protocols, health management programs, quality and HEDIS results, new technology and any other clinical issues regarding policies and procedures.
  • Review proposed QI study designs.
  • Participate in the development of action plans and interventions to improve levels of care and service.

In cases where specific specialty feedback or assistance is needed, community specialists are used to review cases and to provide feedback on proposed interventions or programs. As needed, focus groups of practitioners may be used for assisting with the design or evaluation of specific programs.

 
Confidentiality

Molina Healthcare of Michigan is authorized by specific regulatory agencies and by members to obtain and review medical records, including member and practitioner identities. Authorization is subject to all state and federal laws and regulations, including Title 42 Code of Federal Regulations, Molina Corporate Employee Handbook, Section B, Security and Confidentiality. Use of Protected Health Information (PHI) is outlined in a privacy notice distributed to all members.

All Molina Healthcare personnel sign a Confidentiality Agreement and a Code of Conduct and Employee Handbook Acknowledgment form. Signed documents are on file in the Human Resources Department. In addition, non-Molina Healthcare members of QI committees sign a confidentiality statement when attending committee meetings and are protected from being required, with some exceptions, to testify in civil actions related to specific committee activities and actions.

As an approved Coordinated QI Program by MDCH, information and documents created specifically for, and collected and maintained by an approved program receive protections from public disclosure. Molina Healthcare's QI documents are maintained in compliance with all legal requirements and include, but are not limited to, internal reviews, including patient care review studies, QI studies and reports, minutes of QI committees and administrative (i.e., non-clinical) processes having a direct impact on the provision of care or service. The findings of all Molina Healthcare QI committees are part of the QI Program. Such findings will not be released to any outside agency without the express permission of the originating agency and assurance that confidentiality will be maintained.

The Board assigns the responsibility of managing and reviewing confidentiality issues to the Government Contracts and Compliance Department. A Compliance Committee has been formed as directed by the Compliance Plan. This committee addresses issues of confidentiality.


Conflict of Interest

No reviewing physician may perform a review on one of his/her patients, the patients of his/her partners, or cases in which the reviewing physician has a proprietary financial interest in the site providing care.

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