| (a) Basic, single service, and limited service HMOs
must develop and maintain an ongoing QI program designed to objectively
and systematically monitor and evaluate the quality and appropriateness
of care and services and to pursue opportunities for improvement.
Unless the HMO has no enrollees, the QI program should include the
active involvement of one or more enrollee(s) who are not employees
of the HMO.
(b) The HMO governing body is ultimately responsible
for the QI program. The governing body must:
(1) appoint a quality improvement committee (QIC) that
must include practicing physicians and individual providers, and may
include one or more enrollee(s) from throughout the HMO's service
area, none of whom may be employees of the HMO;
(2) approve the QI program;
(3) approve an annual QI plan;
(4) meet at least annually to receive and review reports
of the QIC or group of committees and take action when appropriate;
and
(5) review the annual written report on the QI program.
(c) The QIC must evaluate the overall effectiveness
of the QI program.
(1) The QIC may delegate QI activities to other committees
that may, if applicable, include practicing physicians, individual
providers, and enrollees from the service area.
(A) All committees must collaborate and coordinate
efforts to improve the quality, availability, and accessibility of
health care services.
(B) All committees must meet regularly and report the
findings of each meeting, including any recommendations, in writing
to the QIC.
(C) If the QIC delegates any QI activity to any subcommittee,
then the QIC must establish a method to oversee each subcommittee.
(2) The QIC must use multidisciplinary teams, when
indicated, to accomplish QI program goals.
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