N.J. Admin. Code § 11:24-7.1

Current through Register Vol. 56, No. 24, December 18, 2024

Section 11:24-7.1 - Continuous quality improvement program

(a) The HMO shall have a system-wide continuous quality improvement program to monitor the quality and appropriateness of care and services provided to members. This program shall be under the direction of the medical director or his or her designee, who shall be a physician, and shall be based on a written plan which is reviewed at least annually and revised as necessary. The plan shall describe at least:

1. The scope and purpose of the program;

2. The organizational structure of quality improvement activities;

3. Duties and responsibilities of the medical director and/or designated physician responsible for continuous quality improvement activities;

4. Contractual arrangements, where appropriate, for delegation of quality improvement activities;

5. Confidentiality policies and procedures;

6. Specification of standards of care, criteria and procedures for the assessment of the quality of services provided and the adequacy and appropriateness of health care resources utilized;

7. A system of ongoing evaluation activities, including individual case reviews as well as pattern analysis;

8. A system of focused evaluation activities, particularly for frequently performed and/or highly specialized procedures;

9. A system of monitoring member satisfaction and network providers' response and feedback on HMO operations;

10. The procedures for conducting peer review activities which shall include providers within the same discipline and area of clinical practice; and

11. A system for evaluation of the effectiveness of the continuous quality improvement program.

(b) The board of directors of the HMO shall be kept apprised of continuous quality improvement activities and shall be provided at least annually with regular written reports from the program delineating quality improvements, performance measures used and their results, and demonstrated improvements in clinical and service quality.

(c) There shall be a multidisciplinary continuous quality improvement committee responsible for the implementation and operations of the program. The structure of the committee shall include representation from the medical, nursing and administrative staff, with substantial involvement of the medical director of the HMO.

(d) The program shall monitor the availability, accessibility, continuity and quality of care on an ongoing basis. Indicators of quality care for evaluating the health care services provided by all participating providers shall be identified and established and shall include at least:

1. A mechanism for monitoring patient appointments and triage procedures, discharge planning services, linkage between all modes and levels of care and appropriateness of specific diagnostic and therapeutic procedures, as selected by the continuous quality improvement program;

2. A mechanism for evaluating all providers of care. The findings from a health care facility's internal quality assurance program may be used to supplement, but shall not fully constitute, the HMO's assessment of patient care; and

3. A system to monitor provider and member access to utilization management services including at least waiting times to respond to phone requests for service authorization, member urgent care inquiries, and other services required in N.J.A.C. 11:24-8.3.

(e) The HMO shall follow up on findings from the program to assure that effective corrective actions have been taken, including at least policy revisions, procedural changes and implementation of educational activities for members and providers.

(f) Continuous quality improvement activities shall be coordinated with other performance monitoring activities including utilization management, risk management, and monitoring of member and provider complaints.

(g) The HMO shall maintain documentation of the quality improvement program in a confidential manner. This documentation shall be available to the Commissioner or his or her designee and shall include:

1. Minutes of quality improvement committee meetings; and

2. Records of evaluation activities, performance measures, quality indicators and corrective plans and their results or outcomes.

N.J. Admin. Code § 11:24-7.1