§ 9.674. Quality assurance standards.

 (a)  A plan shall have an ongoing quality assurance program that includes review, analysis and assessment of the access, availability and provision of health care services. The quality assurance program shall provide for a mechanism allowing feedback to be reviewed and used for continuous quality improvement programs and initiatives by the plan.

 (b)  The quality assurance program shall meet the following standards:

   (1)  The plan shall maintain a written description of its quality assurance program outlining its structure and content.

   (2)  The plan shall document all quality assurance activities and quality improvement accomplishments.

   (3)  The activities of the plan’s quality assurance program shall be overseen by a quality assurance committee that includes plan participating health care providers in active clinical practice.

   (4)  The plan’s quality assurance structures and processes shall be clearly defined, with responsibility assigned to appropriate individuals.

   (5)  The plan shall demonstrate dedication of adequate resources, in terms of appropriately trained and experienced personnel, analytic capabilities and data resources for the operation of the quality assurance program.

   (6)  The plan shall ensure that all participating health care providers maintain current and comprehensive medical records which conform to standard medical practice.

   (7)  The plan’s review of quality shall include consideration of clinical aspects of care, access, availability and continuity of care.

   (8)  The plan’s quality assurance program shall have mechanisms that provide for the sharing of results with health care providers in an educational format to solicit input and promote continuous improvement.

   (9)  The plan shall provide to the Department a description of the annual quality assurance work plan, or schedule of activities, which includes the objectives, scope and planned projects or activities for the year.

   (10)  The plan shall present a report of the plan’s quality assurance activities documenting studies undertaken, evaluation of results, subsequent actions recommended and implemented, and aggregate data annually to the plan’s board of directors, and shall provide a copy of the report to the Department.

 (c)  In administering a quality assurance plan, the plan shall do the following:

   (1)  Include in its quality assurance plan regularly updated standards for the following:

     (i)   Health promotion.

     (ii)   Early detection and prevention of disease.

     (iii)   Injury prevention for all ages.

     (iv)   Systems to identify special chronic and acute care needs at the earliest possible time.

     (v)   Access to routine, urgent and emergent appointments that shall be approved by the plan’s quality assurance committee. The plan shall conduct annual studies of access and availability, the results of which shall be incorporated into the report referenced in subsection (b)(10).

   (2)  Notify health care providers and enrollees of these standards.

   (3)  Involve health care providers and enrollees in the updating of its quality assurance plan.

Cross References

   This section cited in 28 Pa. Code §  9.631 (relating to content of an application for an HMO certificate of authority); 28 Pa. Code §  9.654 (relating to HMO external quality assurance assessment); and 28 Pa. Code §  9.675 (relating to delegation of medical management).



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