TRICARE Operations Manual 6010.62-M, April 2021
Clinical Operations
Chapter 7
Section 6
ClinicalQuality Management Program (CQMP)
Revision:
1.0The contractor shall operatea CQMP which results in demonstrable quality improvement in thequality and value of health care provided to beneficiaries, andin the process and services delivered by the contractor. This CQMPshall be designed to achieve the efficient and effective provisionof timely access to high quality, high value health care. The CQMPshall be a fundamental contractor function.
2.0CQMP PLAN
2.1The contractorshall develop and submit a written CQMP plan which includes a detaileddescription of the purpose, methods, proposed goals and objectivesdesigned to meet the intent of the program. For plan submissionrequirements, see DD Form 1423, Contract Data Requirements List(CDRL), located in Section J of the applicable contract.
2.2The contractor shall includeclinical quality metrics in their network provider steerage model,including but not limited to, current indicators outlined by theorganizations including:
•National Perinatal InformationCenter (NPIC) (as available)
•National Surgical Quality ImprovementProgram (NSQIP) (as available)
•The Joint Commission ORYX (asavailable)
•Leapfrog® Hospital Safety Grades(as available)
•Leapfrog® Hospital Survey (asavailable)
•Healthcare Effectiveness Dataand Information Set (HEDIS)
•Centers for Medicare and MedicaidServices (CMS) Care Compare
3.0CLINICAL QUALITY OUTCOMES DASHBOARDAND DATA REPORTS
3.1The contractor shall collect,monitor, analyze and report clinical quality data, quarterly, semiannually,and annually. For reporting requirements, see DD Form 1423, CDRL,located in Section J of the applicable contract.
3.2The contractor shall partnerwith network facilities and providers and recommend performance improvementstrategies and work with them to achieve measureable improvementsin outcomes when unfavorable data trends greater than (>) threemonths (as compared with national and Defense Health Agency (DHA)benchmarks and goals) are identified. The Government reserves theright to identify changes in benchmarks 60 days prior to the exerciseof each option year. For reporting requirements, see DD Form 1423,CDRL, located in Section J of the applicable contract.
3.2.1The contractorshall collect, monitor, analyze, identify, address and report clinicalquality and value data via submission of an electronic ClinicalQuality and Value Data Dashboard. A core set of measures with goalswill be provided annually by the Government Designated Authority(GDA), 60 days prior to the start of the option year that shallbe included in the dashboard; the contractor may also propose additionalmeasures for the dashboard.
3.2.2The contractorshall ensure that the dashboard is accessible to Government staff24/7 except for periods of maintenance.
3.2.3The contractorshall collaborate with the GDA prior to the start of health caredelivery (SHCD) and annually thereafter to determine clinical qualityand value improvement outcome measures to be reported on the ClinicalQuality and Value Data dashboard. Topic areas for the measures include,but are not limited to, health outcomes, patient experience, andhealth value care. In addition to measures proposed by the contractor,the Government will strive to align Private Sector Care (PSC) andDirect Care (DC) measures.
3.2.4The contractorshall utilize clinical data to determine clinical quality outcomes.
3.2.5For dashboard reporting requirements,see DD Form 1423, CDRL, located in Section J of the applicable contract.
3.3The contractor shall developand submit a minimum of four Quality and Value Improvement Initiatives (QVIIs).
3.4The contractor shall developQVII topics in consultation with the Government and QVIIs shallbe designed to test new and innovative strategies to improve clinicaloutcomes and beneficiary quality of life. Topics may address administrativeprocesses, beneficiary health, error reduction, patient safety improvement,beneficiary functional status, beneficiary or provider satisfaction/experience,high-value, and high-risk issues. Appropriate scientific methodologyand rigor shall be applied in written research questions and statisticallysignificant analysis, as applicable. For reporting requirements,see DD Form 1423, CDRL, located in Section J of the applicable contract.
4.0CQMP STRUCTURAL AND FUNCTIONALREQUIREMENTS
4.1The contractor shall allowthe appropriate GDA active participation in their CQMP and non-voting membershipin their regional level Quality Management Committees, including,but not limited to, Peer Review Committees both medical-surgicaland Behavioral Health (BH), Clinical Quality Management Committees,and Credentialing Committees.
4.1.1The contractorshall provide DHA with all meeting materials at least three businessdays prior to all scheduled meetings via eCommerce. If the threefull business day standard is not met, DHA reserves the right to requirethe contractor to reschedule the meeting.
4.1.2The contractorshall schedule committee meetings on dates and times mutually agreeableto the contractor and Government representatives.
4.2The contractor shall developand implement written policies and procedures to identify PotentialQuality Issues (PQIs), steps to resolve identified problems, suggestinterventions to resolve problems, and provide ongoing monitoringof all components of the contractor’s operations and the care andtreatment of TRICARE beneficiaries.
4.3The contractorshall provide and maintain a Health Insurance Portability and AccountabilityAct (HIPAA)-complaint electronic-based PQI submission, trackingand trending tool for collecting all quality of care concerns regardlessof source.
4.3.1The contractorshall identify, track, trend, and report interventions to resolvethe PQIs and Quality Issues (QIs), using the most current indicatorsfrom:
•National Quality Forum (NQF)Serious Reportable Events (SREs)
•CMS Hospital Acquired Conditions(HACs)
•Agency for Healthcare Researchand Quality (AHRQ) Patient Safety Indicators (PSIs)
•Any other DHA required indicatoror event
4.3.1.1For reporting requirements,see DD Form 1423, CDRL, located in Section J of the applicable contract.
4.3.1.2The contractor shall processto completion 95% of all PQIs within 90 calendar days from the identificationand 99% within 180 calendar days of identification.The contractorshall see approval from the GDA if they identify another categoryof an indicator/event to add to the required reports.
4.3.2The contractor’s electronicPQI tool shall allow for any member of the healthcare team, including beneficiaries,to submit a PQI. The tool shall be easily located on the portaland intuitive.
4.3.3The contractorshall provide the GDA and their designees with training and realtime access to the PQI tracking and trending tool.
4.3.4The contractor shall make PQIinvestigation, provider Corrective Action Plans (CAPs), provider responsesto CAPs and contractor follow-up plans readily accessible withinthe PQI tool.
4.4The contractorshall report, by a secure means, potential SREs to the GDA withintwo business days from when the contractor becomes aware of theevent. For reporting requirements, see DD Form 1423, CDRL, locatedin Section J of the applicable contract.
4.5The contractorshall submit attestation to the GDA when the notification was receivedverbally, identifying the source, with time and date of receipt.
4.6The contractor shall report,by a secure means, closure of the reported SRE to the GDA withintwo business days. For reporting requirements, see DD Form 1423,CDRL, located in Section J of the applicable contract.
4.6.1The Government may requirethe contractor to reopen any SRE case in which the Government expressesconcern.
4.6.2The contractor shall completetheir investigation addressing the Government’s concerns and submit theirreport to the Government not later than 60 calendar days after theGovernment requests for a SRE case to be reopened.
4.6.3The Government will approvecase closure or request additional investigations within five business daysof receiving the contractor’s report for SRE cases that have beenreopened.
5.0PATIENT SAFETY OR QI IDENTIFICATION
5.1The contractor shall identify,evaluate and report all PQIs and confirmed QIs.
5.2The contractor shall assessevery medical record reviewed for any purpose, including, but notlimited to, every medical record reviewed for any care managed,observed, or monitored on an ongoing basis for quality of care andappropriate utilization.
5.3The contractorshall process to completion 95% of all PQIs within 90 calendar daysfrom date of identification and 99% within 180 calendar days ofidentification. For reporting requirements, see DD Form 1423, CDRL,located in Section J of the applicable contract.
5.4The contractor who receivesor identifies a cross-region PQI shall conduct an initial clinicalassessment based upon the information on hand, and if a PQI exists,forward the case and all supporting information to the contractorwith geographic jurisdiction for the case review, investigation,and intervention(s), consistent with TRICARE Operations Manual (TOM)requirements. The contractor with geographic jurisdiction has theability to have meaningful “quality interventions,” and has thebest opportunity to demonstrate improved quality by providers withinits jurisdiction.
5.5The contractorshall implement appropriate quality interventions to reduce thenumber of QIs and improve patient safety. When the contractor confirmsa QI or determines there is deviation in the standard of practiceor care, the determination shall include assignment of an appropriateseverity level and sentinel event, when applicable, and describethe actions taken to resolve the quality problem. For reportingrequirements, see DD Form 1423, CDRL, located in Section J of theapplicable contract.
5.6Referto https://manuals.health.mil/pages/DownloadManualFile.ashx?Filename=Definitions.pdf for commonlyused quality terms and definitions including, but not limited to,QVII, PQI, and QI to include severity levels.
6.0PEER REVIEW
6.1The contractorshall operate a Peer Review Organization (PRO) in accordance with 32CFR 199.15; all claims submitted for health services aresubject to review for quality of care and appropriate utilization.
6.2The contractor shall ensureall QIs, regardless of the source, are reviewed and confirmed bya Peer Review Committee composed, at a minimum, of qualified peerreviewers to determine deviations from standards of care, severitylevels, recommending interventions to include CAPs, reporting tolicensure boards, and follow-up monitoring through resolution. Allstandard of care determinations shall be approved by the Peer Review Committee(s).
6.3The contractor shall send casesfor external peer review regardless of severity level when the contractor doesnot have an actively participating like-specialist (peer) on theircommittee. A like specialty peer reviewer should have comparableeducation, training, experience, licensure, certification, clinicalprivileges and scope of practice as the practitioner under review.The GDA reserves the right to determine appropriateness of like-peer reviewer.All standard of care determinations shall be approved by the PeerReview Committee(s).
6.4The PeerReview Committee shall assure all identified clinical quality issuesare tracked, trended, patterns identified, reported to committeeand appropriately addressed until resolution is achieved.
6.5The GDA may perform the followingfunctions:
6.5.1When the Government identifieda patient safety issue where TRICARE beneficiaries are, or couldbe at risk, the GDA may require the contractor to take the necessarysteps to safeguard the safety of TRICARE beneficiaries.
6.5.2When the Government identifiesclinical quality concerns regarding the care rendered to a TRICARE beneficiaryor group of beneficiaries, the GDA may request the contractor toconduct a clinical quality review and case investigation and reporttheir findings to the Government.
7.0AHRQ PSIs
7.1The contractor shall utilizethe current provider-level PSI software, available from the AHRQ,to evaluate the safety of care delivered in the network. The softwareis designed for use with administrative data sets and will not requiremanual chart abstraction.
7.2The contractorshall run the appropriate data for all PSIs and use the analysisof the results to identify PQIs and patient safety issues for individualproviders, groups, or facilities. Analysis will also be used toprovide focus for specific patient safety interventions and/or studyactivity that will be implemented at the direction of the contractor.
7.3The contractor shall reporttheir findings, interventions, and outcomes on 100% of the casesthat meet the AHRQ PSI criteria. For reporting requirements, seeDD Form 1423, CDRL, located in Section J of the applicable contract.
8.0BH STANDARDIZED MEASURES
8.1The contractor shall conducta semi-annual statistically valid sample size audit of network providers documentationfor the following standardized measures, Post-Traumatic Stress Disorder(PTSD), anxiety disorders, and depressive disorders; when age appropriate,across all BH settings (outpatient mental health (MH) and SUD, OpioidTreatment Programs (OTPs), Intensive Outpatient Programs (IOPs),partial hospitalization, psychiatric RTCs, and inpatient/residentialSubstance Use Disorder Rehabilitation Facilities (SUDRFs).
8.1.1The contractorshall collaborate with the Government to determine a statisticallyvalid sample size no later than 14 calendar days prior to the audit.
8.1.2The contractor shall requireproviders to document in the medical record total score resultsat treatment baseline, every 60-day intervals, and at dischargefor the following:
| If diagnosed with: | ||
| PTSD | PTSD Checklist (PCL-5) | |
| Anxiety Disorders | Seven-item Generalized AnxietyDisorder (GAD-7) | |
| Depressive Disorders | Patient Health Questionnaire(PHQ-9 or A for ages 11-17) | |
Note:Consistent with National DefenseAuthorization Act (NDAA) for Fiscal Year (FY) 2016, Section 729and Veterans Health Administration (VHA)/Department of Defense (DoD)Clinical Practice Guidelines.
8.1.3The contractorshall educate providers and beneficiaries on the optimal treatmentdosage or frequency for best clinical outcomes for diagnosis ofPTSD, anxiety disorders, and depressive disorders.
8.1.3.1The contractor shall educateproviders that administration of standardized measures shall be validatedfor the age of the patient. The most current edition of the standardizedmeasures shall be used. The provider may use clinical discretionto administer additional instruments as clinically indicated.
8.1.3.2The contractor shall encourageuse of evidence based treatment and educate provider and beneficiarieson current VHA/DoD Clinical Practice Guidelines.
8.2The contractorshall report audit results of the standardized behavioral healthmeasures to the Government. For reporting requirements, see DD Form1423, CDRL, located in Section J of the applicable contract.
9.0Centers For Medicare And MedicaidServices (CMS) Care COMPARE
9.1The contractorshall utilize the CMS Care Compare website (measures, readmission,mortality and other reported data) to evaluate and analyze institutionalperformance for each network facility in the respective region andprovide a report of the analysis. The results of the analysis areto be used for identification of facility or specific patient safetyperformance improvement, network credentialing activities and/orstudy activity that will be implemented at the direction of thecontractor and included in the report. For reporting requirements,see DD Form 1423, CDRL, located in Section J of the applicable contract.
9.2The contractor shall partnerwith network facilities and recommend performance improvement strategiesand work with them to achieve measurable improvements in outcomeswhen unfavorable trends are shown within all CQM data monitoredin the applicable contract.
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