36C26318R0695-004.pdf

QUALITY ASSURANCE SURVEILLANCE PROGRAM (QASP)

FOR HEALTH CARE RESOURCES (HCR)

Date: June 25, 2018 From: Service Chief, Primary & Specialty Medicine Service Line Subj: Quality Assurance Surveillance Program for Primary Care Services To: Network Contracting Office (NCO)

Thru: Medical Center Chief of Staff Medical Center Director VISN Network Director

1. This QASP adheres to the same quality standards and bench marks as set forth for St. Cloud VA Health Care System staff.

2. Contracted staff will be held to these same performance standards.

Ongoing Professional Practice Evaluation (OPPE) OPPE Dates: FY 2018

Provider:

Service: PSM

Designated Women's Health Provider:

No/Yes

MEASURE

Sample/Data

Source Target QTR 1 QTR

2 QTR 3 QTR

ADMINISTRATIVE

Panel Size PCMM Coord NA Encounters Face-to-Face PCMM Coord NA Number of ACE Exams PCMM Coord NA

PATIENT CARE AND PROCEDURAL SKILLS

Source Target QTR 1 QTR

2 QTR 3 QTR

Medical Records: % of Progress notes signed w/in 7 days

PSM Quality Coord 95%

Encounter Closure: % of encounters closed w/in 7 days

PCMM

Coordinator 99%

3rd Next available: Avg 3rd next available date per quarter PCMM Coord NA

C&P: Inadequate exams returned from VBA (adjusted total)

PSM Quality Coord/C&P Clerks

≤2%

Procedures (# cases reviewed)

Coord NA

Colposcopies

Endometrial Biopsies

IUD Insertions

IUD Removal

Procedures: Complication Rate

Coord < 1%

Informed consent completed

Coord

90%

Participation in time out

Correct site surgery marking or Provider remains with patient from consent to procedure performed

Coord 90%

Blood Transfusions (# of episodes)

Blood Utilization: Complication Rate

Coord 0%

Pre-transfusion labs

Appropriate indication documented

Transfusion order present

Informed consent completed

Reassignments: Total # of Primary Care Provider Reassignment Requests

# of Pt Neg Reassign Requests/ # of Neg Reassign Req Approved

# of Provider Reassign. Requests

# of Other Reassign. Requests (distance, different gender, saw PCP in Community, etc.)

MEDICAL KNOWLEDGE

Source Target QTR 1 QTR

2 QTR 3 QTR

DM BP<140/90

Clin Rem Rpt by Stop Code 77%

DM FOOT EXAM

Stop Code 90%

HGB A1C >/= 9

Stop Code ≤ 19%

HTN BP<140/90 Ages 18-59

Stop Code 80%

HTN BP<150/90 Ages 60-85

Stop Code 80%

% of + Alcohol screens completed within 14 days

Coord 80%

% of + Depression screens completed within 24 hours

% of + PTSD screens completed within 24 hours

Evidence of chief complaint or reason for evaluation

Clinical Pertinence Review by Peer

Evidence of examination appropriate to chief complaint

Clinical Pertinence

Impression/diagnosis accurate

Clinical Pertinence

Evidence plan is appropriate

Clinical Pertinence

Evidence that evaluation addressed reason for visit

Clinical Pertinence

Appropriate orders and consults were placed as described in the plan

Clinical Pertinence Review by Peer

90% Started Q2-18

Documentation patient was notified of test results within 7 calendar days of available for actionable tests

Clinical Pertinence

Documentation patient was notified of test results within 14 calendar days of available for non-actionable tests

Clinical Pertinence

Med list reconciled/updated and documented in the medical record

ECG Overeader / Do you agree with the Interpretation (MD/DO Only)

Clinical Review by Peer 90%

CERVICAL CYTOLOGY MONITORS

(WH Providers only)

Sample/Data Source Target QTR 1 QTR

2 QTR 3 QTR

Appropriate recommendation for follow-up of abnormal cervical cytology according to ASCCP criteria.

PSM Quality

100%

Unsatisfactory Pap Obtained

Coord ≤ 1

PRACTICE-BASED LEARNING AND

IMPROVEMENT

Sample/Data Source Target QTR 1 QTR

2 QTR 3 QTR

Med Staff Meeting attendance (For Full Time MD/ DO only)

COS Admin Asst. 50%

Clinical Pertinence Reviews: # completed / # given

PSM Admin Staff NA

% of Clinical Pertinence Reviews returned within 30 days of being sent to staff

PSM Admin Staff/ PSM QC 90%

INTERPERSONAL AND COMMUNICATION

SKILLS

Sample/Data Source Target QTR 1 QTR

2 QTR 3 QTR

Patient complaints

Report of Contact, Communications to Pt Advocate Office, Survey Comments, PSM

Administration, or COS office

≤ 3 complaints in a quarter

Colleague or other staff complaints

PSM

Administration, or COS office

≤ 3 complaints in a quarter

Patient compliments

Report of Contact, Comm to Pt Advocate Office, Survey Comments, PSM Admin COS office

NA

Colleague or other staff compliments

PSM

Administration, or COS office

NA

PROFESSIONALISM

Source Target QTR 1 QTR

2 QTR 3 QTR

Validated disruptive or unprofessional behavior with patients

PSM SLD or PSM Nurse Administrator

Validated disruptive or unprofessional behavior with staff

PSM SLD or PSM Nurse Administrator

SYSTEMS-BASED PRACTICE

Source Target QTR 1 QTR

2 QTR 3 QTR

Interfacility Transfers % have the consulting MD co-sign note when Inter-Facility Transfer Form 10-2649Ais completed by a non-MD

PSM Quality

Intra-facility Transfers Provider to provider verbal hand-off communication

Acceptance of patient documentation

C&P QUALITY REVIEW

Source Target QTR 1 QTR

2 QTR 3 QTR

Does the report address the exam/DBQ worksheet criteria for the condition(s) at issue?

Clinical Pertinence

Does the examiner reconcile/explain any internal discrepancies, inconsistencies or contradictions?

Clinical Pertinence

Does the report provide a precise diagnosis or explain why a precise diagnosis was not provided for each condition at issue?

Clinical Pertinence

If there is a change in the diagnosis of a service connected condition, did the examiner provide an explanation or rationale for the change?

Clinical Pertinence

If the examiner documented the presence of a noted or suspicious condition requiring immediate medical care or further evaluation, was there documentation that the Veteran/Service Member was notified?

Clinical Pertinence

If a medical opinion was requested, was the claim file, VBMS, and/or Virtual VA were reviewed in conjunction with any other records?

Clinical Pertinence

If a medical opinion was requested, was the requested medical opinion provided?

Clinical Pertinence

If a medical opinion was requested, was a rationale provided for the requested medical opinion?

Clinical Pertinence

Note: All provider profile measures/data are customized to reflect provider-specific practice and are defined at the time of credentialing and privileging.