15_Attachment_J-5_Study_Examples.doc

Attachment J-5 Study Examples

Focused Study Examples:

1. Study the relationships of identified quality issues and exceptional quality of care delivery to groups of doctors in practice, organizational provider groups, or provider institutions. (Historically, quality of care delivery has been associated with individual physicians for quality measurement and study.)

2. Study areas of commonly recurring processes and/or procedures, or types of care that entail risk. These include those that generate, or have the potential to generate a substantial fraction of the quality of care concerns, or involve transitions of patients from one provider to another. This would include studies examining issues related to patients that move between Military Treatment Facilities and the MCSC and/or DP care systems.

3. Study the relationship between “world class” quality care delivery systems (and their associated good clinical outcomes) to establish methods for identifying superior providers or provider organizations. Find best quality practice models.

4. Provide focused studies when significant quality issues are identified by Regional Directors. These studies may include review of specific groups of patients, provider institutions, or provider groups to access the quality and appropriateness of care delivery.

5. Patient focused studies may also include Data Validation review. (Each year, the Medicaid Managed Care Plans submit 100 medical records for abstraction. The abstracted elements are then compared to the encounter data that have been submitted by those same health plans to the Medicaid Managed Care Encounter Database. This allows a comparison between medical record data and the electronic encounter data being used for patient focused work. Areas that lack congruence can then be identified and addressed with the managed care plans, enhancing the quality of the encounter data and providers directly in order to be successful.)

6. Focused Study reviews may also include:

a. Evaluation of:

i. high volume case types (OB, cardiovascular care)

ii. high cost case types (neonatal, special procedures)

iii. high potential for patient safety compromise (provider institutions, nursing homes, outpatient procedures)

iv. “high” diagnostic groups findings

v. non-network provider cases (might examine what types of care most frequently provided by non-network providers and look for quality markers in these areas)

7. Focused Study evaluating the association between identified Fraud and Abuse cases and poor clinical outcomes or standard of care not met.

TQMC HT9402-15-R-0005, Section J, Attachment J-5