| (a) A network must develop and maintain a continuous
and comprehensive quality improvement program designed to monitor
and evaluate objectively and systematically the quality and appropriateness
of health care and network services, and to pursue opportunities for
improvement. The quality improvement program must include return-to-work
and medical case management programs. The network must dedicate adequate
resources, including personnel and information systems, to the quality
improvement program.
(b) Required documentation of the quality improvement
program, at a minimum, includes:
(1) Written description. The network must develop a
written description of the quality improvement program that outlines
the program's organizational structure, functional responsibilities,
and committee meeting frequency;
(2) Work plan. The network must develop an annual quality
improvement work plan designed to reflect the type of services and
the population served by the network in terms of age groups, disease
or injury categories, and special risk status, such as type of industry.
The work plan must include:
(A) objective and measurable goals, planned activities
to accomplish the goals, time frames for implementation, individuals
responsible, and evaluation methodology;
(B) evaluation of each program, including:
(i) network adequacy, which encompasses availability
and accessibility of care and assessment of providers who are and
are not accepting new patients;
(ii) continuity of health care and related services;
(iii) clinical studies;
(iv) the adoption and periodic updating of treatment
guidelines, return-to-work guidelines, individual treatment protocols,
and the list of services requiring preauthorization;
(v) employee and provider satisfaction;
(vi) the complaint-and-appeal process, complaint data,
and identification and removal of communication barriers that may
impede employees and providers from effectively making complaints
against the network;
(vii) provider billing and provider payment processes,
if applicable;
(viii) contract monitoring, including delegation oversight,
if applicable, and compliance with filing requirements;
(ix) utilization review processes, if applicable;
(x) credentialing;
(xi) employee services, including after-hours telephone
access logs;
(xii) return-to-work processes and outcomes; and
(xiii) medical case management outcomes.
(3) Annual evaluation. The network must prepare an
annual written report on the quality improvement program that includes:
(A) completed activities;
(B) trending of clinical and service goals;
(C) analysis of program performance; and
(D) conclusions regarding the effectiveness of the
program.
(c) The network is presumed to be in compliance with
statutory and regulatory requirements regarding quality improvement
requirements, including credentialing, if:
(1) the network has received nonconditional accreditation
or certification by the National Committee for Quality Assurance,
The Joint Commission, URAC, or the Accreditation Association for Ambulatory
Health Care;
(2) the accreditation includes all quality improvement
requirements set forth in this section;
(3) the certification for a function, including credentialing,
includes all requirements set forth in this section;
(4) the national accreditation organization's requirements
are the same as, substantially similar to, or more stringent than
the department's quality improvement requirements; and
(5) the network has and will maintain documentation
demonstrating that doctors who provide certifications of maximum medical
improvement or assign impairment ratings to injured employees are
authorized under §130.1 of this title (relating to Certification
of Maximum Medical Improvement and Evaluation of Permanent Impairment).
(d) The network governing body is ultimately responsible
for the quality improvement program and must:
(1) appoint a quality improvement committee that includes
network providers;
(2) approve the quality improvement program;
(3) approve an annual quality improvement work plan;
(4) meet no less than annually to receive and review
reports of the quality improvement committee or group of committees,
and take action when appropriate; and
(5) review the annual evaluation of the quality improvement
program.
(e) The quality improvement committee must evaluate
the overall effectiveness of the quality improvement program. The
committee may delegate and oversee quality improvement activities
to subcommittees that may, if applicable, include practicing doctors
and employees from the service area. All subcommittees must:
(1) collaborate and coordinate efforts to improve the
quality, availability, and accessibility of health care services;
and
(2) meet regularly and routinely report findings, recommendations,
and resolutions in writing to the quality improvement committee for
the network.
(f) The network must have a medical case management
program with certified case managers whose certifying organization
must be accredited by an established accrediting organization, including
the National Commission for Certifying Agencies, the American Board
of Nursing Specialties, or another national accrediting agency with
similar standards. In accordance with Labor Code §413.021(a),
concerning Return-to-Work Coordination Services, a claims adjuster
may not serve as a case manager. The case manager must work with providers,
employees, doctors, and employers to facilitate cost-effective health
care and the employee's return to work, and must be certified in one
or more of the following areas:
(1) case management;
(2) case management administration;
(3) rehabilitation case management;
(4) continuity of care;
(5) disability management; or
(6) occupational health.
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