QUALITY IMPROVEMENT PROGRAM AUTHORIZATION ......Matthew Fitzsimmons Chairman, Board of Trustees NEON...

QUALITY IMPROVEMENT PROGRAM AUTHORIZATION SIGNATURES QIC Code: QIC-S1

Associated Laws, Regulations or Standards: HRSA, FTCA requirements

Related QIC Policies: Tabulated below

AFFIRMATION:The NEON Quality Improvement Program (QIP) and associated Plans are presented to the Board of Trustees forapproval. The QIP encompasses the policies listed below.

POLICY NAME CODE BRIEF DESCRIPTIONQuality Improvement Program(QIP) Fundamentals

QIC-P1 Description of purpose, goals, principles, scope, forecast, andbroad procedures associated with QIP.

Quality ImprovementCommittee (QIC)

QIC-P2 Details pertaining to the structure and functionality of the QIC.

Minutes & Documents QIC-P3 Guidelines on how to create and maintain documentation ofQIC activities.

Conflict of Interest QIC-P4 Details on conflict of interest and an exhibit of the attestationform.

Confidentiality QIC-P5 Guidelines on confidentiality and an exhibit of the attestationform.

Chartering Quality Workgroups& Teams

QIC-P6 Prescribed mechanism for establishing sub-committees of theQIC

Quality Improvement Mechanics QIC-P7 Guidelines on QI methodologies espoused by the QICQIP Plan QIC-P8 Listing of specific performance measures that are performed

and reported periodically.

Quality Management Work Plan QIC-P9 Guidelines for carrying out the work details of the variousPlans associated with this QIP

Annual QIP Evaluation QIC-P10 The structure for the Annual QIP Evaluation that is presentedto the Board of Trustees.

Risk Management Plan QIC-P11 Details on how the risk management program is executed.Adverse & Near-Miss EventsManagement

QIC-P12 Guidelines on identifying and reporting adverse events orincidents or near miss incidents.

Peer Review Plan QIC-P13 Details on how the professional review is executed.

Credentialing and Privileges Plan QIC-P14 Details on the credentialing procedure and how privileges areawarded.

SIGNATURE ATTESTATIONS:

NAME TITLE SIGNATURE DATE

Walter J. Clark, MD Medical Director, QIC Chair

Willie F. Austin President & CEO

Matthew Fitzsimmons Chairman, Board of Trustees

NEON QIC Policies & ProceduresQIC-P1 QIP Fundamentals

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QIC Policy Name: Quality Improvement Program Fundamentals QIC Policy Code: QIC-P1

Effective Date: 6/8/11 Revision/Review Dates:


Related QIC Policies: QIC-P7 QIP Mechanics; QIC-P8 QIP Plan; QIC-P9 QIP Work Plan; QIC-P10 QIPAnnual QIP Evaluation

Attachments: Quality Management & Support Hierarchy Diagram

Authorization: Refer to QIC-S1 Authorization Signatures

AFFIRMATION:

The Board of Trustees has delegated to Senior Management the responsibility for overall QualityManagement of the organization. This quality management scheme is realized through a hierarchalstructure that is illustrated in Exhibit 1 of this policy. Quality matters related to Corporate Complianceand Financial Operations are managed directly by Senior Management under the leadership of the ChiefExecutive Officer. All other quality matters are delegated to the Quality Improvement Committee (QIC).The Medical Director serves as the chairperson of the QIC who is assisted by a QI Coordinator.

Senior Management and the QIC are responsible for development and implementation of a QualityImprovement Program (QIP) Plan, QIP Work Plan and QIP Annual Evaluation. The QIP Plan covers themajority of services and operations of this healthcare organization. These activities will be reviewed andapproved by Senior Management, the QIC and the Board of Trustees on an annual basis. The QIP isintended to meet regulatory and accreditation requirements.

PURPOSE:

The QIP establishes a formal process for continuously and systematically monitoring, evaluating andimproving the adequacy and appropriateness of clinical services and operations within the organization.Through the QIP’s aggregation of processes, the organization exerts a proactive mechanism by which toexamine the multifaceted components of healthcare delivery, to recommend changes whenopportunities to improve are identified, to incorporate recommended enhancements, and to re-examine the components to strive for improvements in processes and outcomes.

GOALS:

The QIP, through its aggregation of activities, is designed to support the healthcare mission and vision ofNEON by balancing four goals: Patient Experience; Patient Care; Patient Safety; and, NEONSustainability.

Patient Experience:

Strive to achieve and/or maintain high levels of patient satisfaction with care performed byNEON staff at all points of contact in order to sustain and grow our patient population.

Patient Care:

Continuously improve the quality and effectiveness of clinical care that patients receive throughthe provision of evidence-based clinical guidelines by qualified professionals in service toNEON’s mission of eradicating health disparities.


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Patient Safety:

Create and/or maintain a culture of patient safety and a collective awareness that serves tominimize and/or prevent the occurrence of clinical errors, adverse events, and systembreakdowns that might lead to patient harm and negatively impact risk management.

NEON Sustainability:

Sustain NEON’s financial and regulatory ability to operate as a going concern so as to preservethe organization’s capacity to serve our cherished and targeted patient population.

PRINCIPLES:

In principle, the QIP supports the organization’s philosophy that patient experience, patient care, andpatient safety are everyone’s responsibilities. The QIP relies on communication, collaboration,cooperation, coordination, and sometimes coercion that involve multiple departments with varyingorganizational functions and activities shepherded by the Quality Improvement Committee, which iscomprised of key staff and management.

NEON supports the maintenance of a just culture that emphasizes implementing evidence-based bestpractices, learning from error analysis, and providing constructive feedback, rather than blame andpunishment. In a just culture, unsafe conditions and hazards are readily and proactively identified,medical or patient care errors are reported and analyzed, mistakes are openly discussed, andsuggestions for systemic improvements are welcomed.

The QIP stimulates the development, review, and revision of the organization’s practices and protocolsin light of clinical deficiencies, identified risks, and select loss prevention and risk reduction strategies.The QIP provides the foundation for developing key processes and procedures for day-to-day qualityimprovement and quality assurance.

SCOPE:

The scope of this QIP includes the following:1. Clinical Services (medical, dental, and behavioral health) as reflected in the QIP Plan (refer to

policy QIC-P8).2. Risk Management as reflected in the Risk Management Plan (refer to policy QIC-P11)3. Peer Review as reflected in the Peer Review Plan (refer to policy QIC-P13)4. Credentialing and Privileges as reflected in the Credentialing and Privileges Plan (refer to policy

QIC-P14)

FORECAST:

To support of our QIP mission, we forecast the following major achievements:

1. Maintain continuous accreditation by the Joint Commission.

2. By January 2013, the health center will align completely with federal ‘meaningful use’ electronichealth record guidelines.

3. By January 2013, the health center will be recognized, certified, or accredited as a PatientCentered Medical Home (Joint Commission or NCQA)


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PROCEDURE:

A. Program Requirements1. The QIP is designed to meet regulatory, HRSA, and FTCA requirements.2. The Medical Director is a member of Senior Management and is responsible for oversight of the

QIP’s compliance with applicable regulatory, HRSA, and FTCA requirements.3. The Medical Director is assisted by other members of Senior Management along with the

Quality Coordinator in ensuring and maintaining said compliance.4. Where applicable, policies for various aspects of the quality program will be written in

accordance or alignment with regulatory and accreditation requirements and the relevantregulations or standards will be documented on said policies.

B. Programmatic Documents1. The QIP is developed using applicable accreditation body standards or other guidelines related

to program content and structure and designed and maintained to meet regulatory andaccreditation compliance.

2. The QIP encompasses a QIP Plan (specific performance measures), Risk Management Plan (riskmitigation activities), Peer Review Plan (peer review activities and sanctions), Credential andPrivileges Plan and all other supporting manuals, policies and procedures in support of theabove-stated GOALS.

3. All Plans related to the execution of this QIP are reviewed bi-annually, at a minimum.4. Senior Management, the Medical Director and the Quality Coordinator are responsible for

development of or revisions to the QIP Plan, development of the QIP Work Plan, and executionof the Annual QIP Evaluation.

5. The format used for the Work Plan and Annual Evaluation is found under QIC-P9 QIP Work Planand QIC -P10 Annual QIP Evaluation.

6. Once the QIP Plan (revision or otherwise), QIP Work Plan and Annual QIP Evaluation arecompleted, they are presented to the QIC for review and approval, which is documented in QICminutes.

7. The approved QIP Plan is then presented to the Board of Trustees for approval, which isdocumented in the Board minutes. This approval generally follows a review by members of theQuality Committee of the Board of Trustees.

8. Approved versions of the QIP Plan, QIP Work Plan and Annual QIP Evaluation are maintained bythe Quality Coordinator for a minimum of six years.

9. Reports on QIP activities are provided to the Board of Trustees by the Medical Director (ordesignee) at least every two months and no less than six times per year. These reports areinclusive of QIP updates and requests for Board action on various aspects of the QIP.

C. Quality Management & Support Hierarchy (refer to Exhibit 1)

1. The Board of Trustees has designated a Quality Committee that is tasked with the responsibilityof reviewing reports from the QIC and bringing quality action items to the Board for officialaction. The Board of Trustees Quality Committee specifically addresses the following:

a) Quality performance updates related to the current QIP Plan;b) Review of QIP Annual Evaluation;c) Credentialing and privileges;d) Peer/professional review reports and related proposed actions.


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2. The Chief Executive Officer leads a Senior Management team that is tasked by the Board ofTrustees to provide overall Quality Management for the organization. Senior Managementdirectly manages quality matters related to the following:

a) Corporate Compliance;b) Financial operations related to the current Business Plan.

3. The Medical Director leads the QIC that is tasked by Senior Management and the Board ofTrustees to develop and execute a QIP Plan that addresses the majority of services andoperations of this healthcare organization.

4. The Human Resources Director leads the HR Forum that is tasked by Senior Management toaddress employee growth and organization capacity by promoting a positive work environmentand maximizing employees’ capacity, abilities, and knowledge so that they are equipped andprepared to contribute efficiently and effectively to the organization’s strategically-alignedclinical and non-clinical operations. The HR Forum provides a strategic foundation for achievingour overall QIP goals and performance objectives. Specific functions include the following:

a) Continuing education (e.g., risk management, clinical guidance, QI tools);b) Management training (e.g., employee evaluations, process improvement);c) Customer service training (directed at improving patient satisfaction);d) Employee satisfaction (directed at the retention of qualified employees).

Exception Process: There are no current exceptions

Monitoring: Will be at the discretion of the CEO and the Quality Committee of the Board of Trustees


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Exhibit 1: Corporate Quality Management & Support Hierarchy Diagram

Board ofTrustees

BOT QualityCommittee

SeniorManagement

QualityImprovement

Committee

RiskManagementCommittee

Safety &InfectionControl

Committee

ClinicalServices

Committee

Clinical StaffCommittee

Accreditation Teams

Human Resources Forum

NEON QIC Policies & ProceduresQIC-P2 Quality Improvement Committee

1

QIC Policy Name: Quality Improvement Committee QIC Policy Code: QIC-P2



Related QIC Policies: QIC-P2 Quality Improvement Program Fundamentals; QIC-P3 Minutes &Documents; QIC-P6 Chartering Quality Workgroups

Attachments: Exhibit 1 - Quality Management & Support Hierarchy Diagram;Exhibit 2 – Accreditation Team JC Compliance Participation Matrix


AFFIRMATION:

The Quality Improvement Committee (QIC) is the committee responsible for executing the QualityImprovement Program (QIP). Medical Director serves as the QIC liaison to the Board of Trustees. TheQuality Coordinator facilitates the activities of the QIC and subsidiary quality workgroups.

PURPOSE:

The Board of Trustees is ultimately accountable for the proper management and improvement of thequality of clinical care and related services provided by the organization. However, the Board delegatesresponsibility for management and oversight to the Medical Director and the membership of the QualityImprovement Committee (QIC). The membership QIC has defined roles and responsibilities.

PROCEDURE:

A. Quality Improvement Committee Membership

1. In order to ensure the participation of a multidisciplinary QIC membership that is representativeof the organization and its various facilities, the Medical Director collaborates with othermembers of Senior Management to determine the appropriate composition of the QIC.

2. The QIC is composed of the following members: Medical Director (chair), Dental Director (vice-chair), QI Coordinator, Operations Director, Director of Enabling Services, Risk ManagementCoordinator, Human Resources Director, Laboratory Director, Radiology Supervisor, AssociateDirector of Nursing Affairs, Associate Director of Medical Affairs, Business Office Supervisor,Pharmacy Director, Behavioral Health Director, Safety Officer, Facilities Manager, SoutheastCenter Director, East Cleveland Center Director, Superior Center Director, PediatricsPractitioner, Obstetrics Practitioner, Adult Medicine Practitioner, Optometry Practitioner,Podiatry Practitioner, Information Technology Director, and the Health InformationManagement Services Director.

3. The Medical Director is Chair of the QIC and ad hoc member of all other subsidiary qualityworkgroups (aka, sub-committees).

4. The Chair works closely with the QI Coordinator and delegates the day-to-day responsibilities ofthe QIP to the QI Coordinator.

5. The QI Coordinator in conjunction with the Chair act in a facilitative and consultative manner toassist the QIC in the implementation of policies, plans and projects associated with the QIP thatare aimed at improving organization quality performance and mitigating risk.


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B. New Member Orientation

1. The QI Coordinator is responsible for orienting new members to the QIC.

2. Each new member is given a New Member Packet that includes:

Information on the roles and responsibilities of the member;

The current QIP Description, Work Plan and Summary of current initiatives & measures;

Training on Quality Management methodology and models used to develop clinical qualityprograms;

Meeting Schedule; and

Membership & staff contact information.

C. QIC Roles & Responsibilities

1. The QIC is responsible for assisting the Chair in providing oversight and direction to the QIP.

2. QIP priorities and projects are established through the QIC.

3. The QIC monitors progress with meeting QIP Description (QIC-P8) goals and performanceobjectives.

4. The QIC ensures that the effectiveness of the QIP is evaluated on an annual basis.

5. The QIC or its quality workgroups, at the discretion of the Medical Director, develops andimplements corrective action plans or process improvements for clinical and operational qualitydeficiencies.

6. The QIC may charter quality workgroup committees (aka, sub-committees) and ad hoc qualityworkgroups (e.g., for special projects) at any time.

D. Member Responsibilities

1. Each member will participate in at least one quality workgroup (see QIC-P6 Chartering QualityWorkgroups) or an accreditation team dedicated to the organization’s strategy for continuousquality accreditation, certification, or recognition by external quality agencies (e.g., JointCommission, NCQA, or AAAHC), whichever is applicable.

2. Each member will come to meetings prepared by having read the agendas, minutes, andassociated documents that are distributed.

3. Each member is expected to attend the majority QIC plenary meetings and at least seventy-five(75) percent of respective quality workgroup meetings.

E. Quality Workgroups and Accreditation Teams (refer to Exhibit 1)

1. Quality workgroup committees (aka, sub-committees of the QIC) are permanent qualityworkgroups and represent the QIC in all regards on behalf QIP. The charge of such workgroupsis generally fixed over time and integrated with the QIP effort as a whole.

2. Ad hoc quality workgroups are temporary quality workgroups will and not to be confused withquality workgroup committees. The charge of such workgroups is generally time-limited forspecial short-term projects with the goal of folding its remnants into a chartered qualityworkgroup committee. However, if the remnants of said charge are substantial in nature, thead hoc quality workgroup may be chartered as a permanent quality workgroup committee.


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3. Accreditation teams are small groupings of QIC members that are designated by the Chair toeither play leading roles or supporting roles in assuring organizational compliance withdesignated sets or groupings of accreditation standards (e.g., Joint Commission, AAAHC, orNCQA). Team assignment is generally presented in the form of a ‘participation matrix’. Thedefinition of the team charge is specified by the particular accreditation standards andrespective elements of performance. (Refer to Exhibit 2)

F. Meeting Schedule

1. Recognizing that the majority of the QIP Work Plan occurs within the context of individualchartered quality workgroups, the overall QIC schedule of meetings will include at least one QIC-related meeting per month. In order to maximize attendance, availability, and participation ofmembership, QIC meeting schedules are to be coordinated by the QI Coordinator.

2. The QIC plenary shall meet no less than on a quarterly basis.

3. QIC plenary meetings are limited to 60 minutes.

4. It is preferable that to quality workgroup meetings not exceed 90 minutes.

5. The Chair and QI Coordinator establishes the yearly schedule of QIC plenary meetings anddistributes the schedule to all QIC members by January of the New Year.

6. The QI Coordinator is responsible for developing and distributing schedules for qualityworkgroup meetings to applicable QIC members on a quarterly basis.

7. Meeting schedules are also posted on the Intranet by the QI Coordinator.

8. Meeting schedules may change based on extenuating circumstances. In these instances, the QICoordinator will distribute schedule revisions and updates.

G. Meeting Format

1. An agenda (refer to QIC-P3 Minutes & Documents) will be utilized as guide to run a QIC orquality workgroup meeting.

2. Corrections to minutes will be the first order of business.

3. Discussion of agenda items will be the second order of business.

4. Decisions on actionable items will be based on ‘consensus’ not ‘majority vote’.

H. Meeting Access

1. To accommodate QIC membership, QIC or quality workgroup attendance can be physical orvirtual (e.g., webinar or teleconference).

2. QIC plenary meetings will generally be held at times that

I. Reporting

1. Minutes will be captured for each QIC plenary and quality workgroup committee meeting inaccordance with QIC-P3 Minutes & Documents.

2. The Medical Director (Chair) is responsible for generating periodic reports of QIP activities forthe purpose of reporting to the Board of Trustees.


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J. Process for Implementing Policies and Procedures Devised by the QIC

1. Membership of the QIC includes the majority of Senior Staff. These individuals are empoweredto affect change and implement procedures and process changes of clinical and operationalnature that are not constrained by existing policies. During the process of designing and testingprocess improvements, designers are also counseled to maintain attentiveness to humanresource capacity issues.

2. Policies designed by the QIC that do not require Board-approval are reviewed with Senior Staffand signed off by the CEO upon approval.

3. Policies designed by the QIC that require Board-approval are first approved by the CEO and thensubmitted to the Quality Committee of the Board of Trustees for review and potential action bythe Board of Trustees.

4. Implementing an approved policy requires the development of plan of execution (e.g., RiskManagement Policy begets a Risk Management Plan; Quality Improvement Program Policybegets a Quality Improvement Program Plan). The plan of execution provides details on howthe organization will comply with the policy.

5. Some policies are in themselves generally procedural in nature (e.g., Credentialing & PrivilegesPolicy). These policies are generally crafted with an understanding of who will perform theprocedures and the extent to which the individual(s) has adequate resources.

K. Board Presentations and QIP Board Actions

1. The Medical Director (Chair) is responsible for presenting to the Board of Trustees periodicreports of QIP activities and the degree of progress made towards achieving qualityperformance objectives.

2. Reports to the Board of Trustees will generally occur on a bi-monthly basis and no less than six(6) updates per annum.

3. The Medical Director is responsible for presenting to the Quality Committee of the Board ofTrustees any potential QIP action items that need to be brought before the Board, based onrecommendations of the QIC or any of its quality workgroup committees.

4. The Board’s Quality Committee considers the proposed actions and recommendations of theQIC and if in agreement presents the action items to the Board with consultative assistance ofthe Medical Director. If a quorum if present, the Board votes. The decision on the proposedaction items rests in favor of the majority.




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Exhibit 1: Corporate Quality Management & Support Hierarchy Diagram

Board ofTrustees

BOT QualityCommittee

SeniorManagement

QualityImprovement

Committee

RiskManagementCommittee

Safety &InfectionControl

Committee

ClinicalServices

Committee

Clinical StaffCommittee

Accreditation Teams

Human Resources Forum


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Exhibit 2: Accreditation Team Joint Commission Compliance Participation Matrix: June 2011 RevisionSenior Management Operations Director Medical Director

Discipline COMPLIANCE OPERATIONS CLINICALSECTIONS APR LD HR EC EM IM RC RI PI MM IC PC WT NPSG

1. Alexander, F Enabling Services S L S2. Angwah-Doho, M Nursing Services S S S S3. Barker, A Info Technology S L S4. Carson, R Behavioral Health S S5. Clark, B Center Operations S S6. Clark, T Development/Outreach S S7. Clark, W Clinical Services L S S L L S S S S8. Fennessy, N Clinical Services S S9. Foster, B Dental Services S S S S S S L10. Hardimon, D QI Coordinator/Nursing S L S11. Johnson, L Center Operations S S S S L S12. McClain, P Center Operations S S13. Miller, M Health Information S14. Murdock, P Safety & Facilities L S15. Peck, D Human Resources L L16. Penny, C Dental Services S S17. Solomon, G Laboratory Services S L18. Sreshta, M Pharmacy Services L19. Watson, A Clinical Services S L20. Williamson, G Center Operations S S

KEY: L= Leading Role; S= Supporting Role

NEON QIC Policies & Procedures

QIC-P3 Minutes & Documents 1

QIC Policy Name: Minutes & Documents QIC Policy Code: QIC-P3



Related QIC Policies: QIC-P2 Quality Improvement Committee

Attachments: Agenda Format; Meeting Minutes Format (short & expanded)


AFFIRMATION:

For each Quality Improvement Committee (QIC) plenary and chartered quality workgroup committee meeting, minutes will be recorded and retained by the QI Coordinator, with the exception of meetings related specifically to the organization’s peer/professional review process.

PURPOSE:

To provide guidelines for the development of minutes for quality-related meetings and related documents that provide evidence of the organization’s quality improvement efforts and demonstrate, wherever applicable, compliance with regulatory and accreditation agencies.

PROCEDURE:

A. Agendas & Minutes

1. Agendas and Minutes will be generated for any QIC or quality workgroup meeting, in accordance with policy QIC-P3 Minutes.

2. Approved minutes will be retained by the QI Coordinator in accordance with policy QIC-P3 Minutes.

3. QIC and quality workgroup meeting agendas will be distributed to each applicable member at least one week before the next scheduled meeting, along with a meeting reminder notice.

4. If applicable, minutes will be approved by the QIC or respective quality workgroup at the next scheduled meeting; once approved they will be retained categorically for the record by the QI Coordinator.

5. All quality workgroup leaders will report back to the QIC at the next scheduled plenary meeting.

6. Minutes that are associated with NEON’s professional review (aka, peer review) process are protected materials and are exempt and are NOT distributed in accordance with policy QIC-P3 Minutes.

B. Agenda Format

1. Meeting agendas shall serve as the official announcement of a QIC-related meeting.

2. Meeting agendas will include as a header, the name of the QIC entity (e.g., Quality Improvement Committee, Safety & Infection Control Quality Workgroup Committee).

3. Meeting agendas will include to date, time, and place.

4. Meeting agendas will include call-in or webinar connectivity details when applicable.



5. Individual agenda items will note the amount of time that will be devoted to the topic.

6. Individual agenda items will note the identity of the person who will be facilitating or leading the discussion of respective items.

C. Minutes Format

1. Minutes will include as a header, the name of the QIC entity (e.g., Quality Improvement Committee, Safety & Infection Control Quality Workgroup Committee) and be noted as CONFIDENTIAL.

2. Minutes will include date, time, and place of meeting and the time the meeting was called to order.

3. Minutes will include only the identity of those who attended.

4. Minutes will include the identity of the recorder.

5. Minutes will include whether the minutes for the prior meeting (if applicable) were approved and a space for the Chair’s signature.

6. In a tabulated format, columns for input from left to right that include, at a minimum, should include the following:

Topic of discussion

Discussion of topic and recommendations

Actions, follow-up, outcomes, due dates, and responsible parties

7. For greater detail, an expanded minutes format may also be utilized in a tabulated format with columns for input from left to right that illustrate the following:

Topic: Findings/Analysis/Discussion/Conclusions

Recommendations/Actions

Follow-Up

Responsible Parties

Due Date

D. Quality Improvement Program (QIP) Documents

1. QIP documents include agendas, attachments, and minutes of QIC plenary meetings, quality workgroup meetings, QIP Plan, QIP Work Plan, QIP indicators and measures, QIP Annual Evaluation, and QIP activity documents.

2. The QI Coordinator retains QIP documents in the QM department in accordance with federal and state regulatory requirements.

3. Confidential or restricted QIP documents are stored in locked files by the QI Coordinator.

4. All QIP documents are retained for a minimum of 6-years in accordance.

5. Confidential documents are destroyed in accordance with HIPAA Privacy policies on document destruction.



E. QIC Binders/Folders

1. The QI Coordinator is responsible for maintaining secured access to all QIP-related documents in a categorical manner, which can be accomplished by the use of specifically labeled binders or computerized folders, if documents are maintained in a digital format.

2. For QIP documents that are stored in computerized folders, a secure data back-up methodology must be specified and maintained and approved by the Chair with consultation with the IT Director.

3. QIP-related binders and computerized folders include but are not limited to:

QIC Meetings – agendas, attachments & minutes for the past 6 years;

Quality workgroup meetings - agendas, attachments & minutes for the past 6 years;

Binders for the likes of HIPAA and accreditation organizations (e.g., Joint Commission, AAAHC, NCQA) must be maintained as defined by the respective agency;

Current QIP process improvement projects and activities;

Others as requested by the Chair or QIC membership.





QIC-P3 Exhibit 1: QIC Meeting Agenda Format

NEON Quality Improvement Committee Meeting Agenda

Workgroup/Committee Name:

Date: Time of Meeting: Meeting Location:

Call or Webinar Details (if applicable):

Time Allotted Agenda Item Discussion Leader

1.

2.

3.

4.

5.

6.

7.

8.



QIC-P3 Exhibit 2: QIC Meeting Minutes Format (Minimum, utilizing portrait page layout)

NEON Quality Improvement Committee Minutes (CONFIDENTIAL)


Date: Meeting Location:

Members Present:

Meeting Facilitator: Time Called to Order:

Prior Minutes Approved: Yes No N/A Chair’s Signature:

Topic Discussion Action/Outcome/Due Date/ Party

1.

2.

3.

4.

5.

6.

7.

8.



QIC-P3 Exhibit 3: QIC Meeting Minutes Format (Expanded Version utilizing landscape page layout)

NEON Quality Improvement Committee Minutes (CONFIDENTIAL)


Date: Meeting Location:

Members Present:

Meeting Facilitator: Time Called to Order:

Prior Minutes Approved: Yes No N/A Chair’s Signature:

Topic: Findings/Analysis/Discussion/

Conclusions

Recommendations/ Actions

Follow-Up Responsible

Parties Due Date

1.

2.

3.

4.

5.

6.

7.

8.


QIC-P4 Conflict of Interest 1

QIC Policy Name: Conflict of Interest QIC Policy Code: QIC-P4


Associated Laws, Regulations or Standards: Personnel Policy Handbook

Related QIC Policies:

Attachments: Exhibit of Conflict of Interest Attestation Form


AFFIRMATION:

Our organization takes very seriously conflict of interest for all quality improvement activities. All staff members participating in Quality Improvement Committee (QIC) activities are expected to discuss any questions or concerns about the potential for conflict of interest candidly with the Medical Director (Chair) or Director of Human Resources.

PURPOSE:

To provide definition for ‘Conflict of Interest’ and to state clearly the expectations of this organization in relation to any conflict of interest in regards to participation in quality improvement activities of the organizations.

DEFINITIONS:

A. Conflict of Interest is defined as any relationship or affiliation on the part of the staff or medical reviewers that could compromise the independence or objectivity of the quality process.

B. Conflict of Interest includes, but is not limited to:

1. An ownership interest of greater than 5% between any affected parties;

2. A material professional or business relationship;

3. A direct or indirect financial incentive for a particular determination;

4. Incentive to promote the use of a certain product or service;

5. A known familiar relationship; and

6. Any prior involvement in the specific case under review.

PROCEDURE:

1. Each employee at the time of employment is provided with immediate access to a current Employee Handbook which describes the expectation for employees.

2. Each member of the QIC is required to sign a Conflict of Interest attestation statement on an annual basis.

3. The QI Coordinator facilitates process.

4. All staff is expected to adhere to the organization’s policy for Conflict of Interest.

5. When a potential for Conflict of Interest staff are expected to notify the Medical Director or Director of Human Resources of the situation.



6. The Medical Director is responsible for:

a) Determining if a Conflict of Interest exists;

b) Advising the employee directly or the HR Director of actions to take; and

c) Advising or consulting with Senior Management members, as appropriate.

7. QIP workforce, including temporary staff, functioning in the QIP decision-making process are required to sign and annually review/attest to this organization’s Conflict of Interest Attestation. (Exhibit 1)

8. The attestation document is maintained in the individual’s personnel file.





QUALITY IMPROVEMENT COMMITTEE CONFLICT OF INTEREST ATTESTATION

The Quality Improvement Committee (QIC) and its members have been entrusted with direct participatory role in the Quality Improvement Program for this healthcare organization. The members of the QIC have a duty to act as reasonable, prudent persons. It is expected that members of the QIC will act in the best interest of the organization at all times.

As protection to the individual members of the QIC and this healthcare organization, each member of the QIC is required to sign the following statement acknowledging that he/she has read and is aware of the possible areas in which he/she could have a duality or conflict of interest.

A. I will not knowingly disclose any confidential or proprietary information that I become aware of as a result of my membership on the QIC unless such disclosure is authorized by the QIC.

B. Conflict of Interest is defined as any relationship or affiliation on the part of the staff or medical reviewers that could compromise the independence or objectivity of the utilization process. Conflict of Interest includes, but is not limited to:

1. An ownership interest of greater than 5% between any affected parties;

2. A material professional or business relationship;

3. A direct or indirect financial incentive for a particular determination;

4. Incentive to promote the use of a certain product or service;

5. A known familiar relationship; and

6. Any prior involvement in the specific case under review.

C. If I become an officer or director of, or assume a fiduciary position with any of the above organizations, I shall immediately disclose such fact to the Chair of the QIC and will resign from the QIC immediately.

D. I will not accept any gifts, favors, or hospitality of any substantial value from outside vendors if it might tend to influence my participation and decision making as a member of the QIC. This prohibition does not include accepting items of nominal value (meals, refreshments or entertainment) which are of such a nature as to indicate mere tokens of friendship, and not related to any particular transaction or organizational activity.

E. I will declare my involvement in any business activity or venture that may be construed as a conflict of interest in the operation, direction or management of this organization.

F. Furthermore, I list all possible areas of conflict of interest I am presently aware of:

1. 2.

3. 4.

I understand and agree that I will update this Conflict of Interest Attestation annually so long as I am a member of the QIC or participate in any capacity.

Print Name: Department:

Signature: Date of Signature:

Forward this completed attestation form to HR Department for inclusion in the Personnel File


QIC-P5 Confidentiality 1

QIC Policy Name: Confidentiality QIC Policy Code: QIC-P5


Associated Laws, Regulations or Standards: HIPAA §164.526

Related QIC Policies:

Attachments: Exhibit of Confidentiality Attestation Form


AFFIRMATION:

Records and information generated in the performance of the medical staff and other allied professional staff and the Quality Improvement Program (QIP) activities are confidential, protected, and privileged. Health care providers duly appointed and acting within the scope and functions of the QIP are protected under federal and state laws from liability and damages if they abide standards associated with this program. All copies of minutes, reports, worksheets and other data will be maintained in a manner assuring strict confidentiality, wherever applicable.

A written confidentiality attestation detailing procedures for maintenance and release of data and other Quality Improvement information will be utilized to ensure compliance with the confidentiality policy.

It is the expectation of this healthcare organization that all employees will demonstrate the highest regard for the privacy of each patient and will strictly observe the confidentiality of health records and any other patient health information (PHI). Staff participating in quality activities will not disclose any discussions, deliberations, records, and other information generated in the connection with these activities, and to make no disclosures of such information except to persons authorized to receive it in the conduction of quality improvement functions.

PURPOSE:

1. To define how confidentiality is maintained in QIP processes.

2. To defined the confidentiality responsibilities of the QI Coordinator.

3. To secure confidential protected quality data and information from public domain and discovery during litigation

PROCEDURE:

A. Quality Committees

1. All committee/ workgroup members participating in quality activities are required to sign the Confidentiality Attestation form (Exhibit 1).

2. This attestation for is signed on an annual basis.

B. Committee members & Quality Staff

1. QI data, audits tools, worksheets and reports will be maintained in the QI Coordinator’s office and locked when he/she is not in the office.

2. At no time will documents containing PHI be left open on the desktop unattended.

3. All Quality Improvement Committee reports will be aggregate reports only.



4. Quality Improvement Committee minutes and agendas will be maintained in a QIC binder/folder with the outside marked as CONFIDENTIAL.

5. No minutes will be taken of peer or professional review activities. All provider Peer Review documentation (forms) will be maintained in a locked file in the QI Coordinator’s office.

6. If possible, paper-based QI documents and records will be scanned into a secure digital format that is password protected and retained for 6 years. If scanning is not possible, paper-based documents will be retained securely for 6 years then shredded/destroyed prior to disposal.

7. If possible and to assure confidentiality all QI documents will be scanned and/or saved on CD (or another reliable storage device) annually and the hard copies shredded prior to disposal.

8. Any documents containing PHI or Peer Review information will not be saved on any PC without being in a folder titled QI Protected. The computer folder must be password secured with access limited to the QI Coordinator and Medical Director.

9. Any documents related to QIP activities shall be considered and marked CONFIDENTIAL unless otherwise determined by the Medical Director (Chair).

The QI Coordinator will obtain signed confidentiality attestation forms from QIC members on an annual basis. These forms will be included in the employee’s personnel file.





QUALITY IMPROVEMENT COMMITTEE CONFIDENTIALITY ATTESTATION

The Quality Improvement Committee (QIC) and its members have been entrusted with direct participatory role in the Quality Improvement Program for this healthcare organization. The members of the QIC have a duty to act as reasonable, prudent persons. It is expected that members of the QIC will act in the best interest of the organization at all times.

As protection to the individual members of the QIC and this healthcare organization, each member of the QIC is required to sign the following statement acknowledging that he/she has read and is aware of the possible areas in which he/she could have a duality or conflict of interest.

As a member of the healthcare organization’s quality improvement workforce who might be involved in the collection, review, and evaluation of patient care information to support the quality improvement, utilization management and risk management endeavors of the organization, I recognize that confidentiality is vital to the free and candid discussions necessary to effective organization-wide review activities.

Therefore, I agree to respect and maintain the confidentiality of all discussions, deliberations, records, and other information generated in the connection with these activities, and to make no disclosures of such information except to persons authorized to receive it in the conduction of Quality Improvement Program functions. I also acknowledge the obligation to maintain the confidentiality in accordance with HIPAA Privacy Rules & regulations and prevailing Ohio laws.

The Medical Director (Chair) and the QI Coordinator will endeavor to maintain all data relating to quality improvement activities in a confidential manner, wherever appropriate. It is understood that all such information shall be considered confidential until proven otherwise. Data information and audit reports will be maintained in the same manner.

All requests for information will be individually screened; only individuals directly involved in the monitoring or evaluation activities or individuals representing accreditation, certification, and other review and regulatory bodies will be permitted access to the documentation. The Chair must approve all exceptions, in consultation with members of the Senior Staff when applicable. By my signature below I attest that I have read, understood and agree to comply with this policy.

Print Name: Department:

Signature: Date of Signature:

Forward this completed attestation form to HR Department for inclusion in the Personnel File


QIC-P 6 Charting Quality Workgroups & Teams 1

QIC Policy Name: Chartering Quality Workgroups & Teams QIC Policy Code: QIC-P6



Related QIC Policies: QIC-P2 Quality Improvement Committee

Attachments: Quality Workgroup Charter template


AFFIRMATION:

The Quality Improvement Committee (QIC) may create permanent quality workgroups (aka, sub-committees) and ad hoc workgroups. Each workgroup will receive a charter from the QIC that defines the responsibilities and reporting obligations. The QIC will designate a leader/facilitator each quality workgroup and approve members at the discretion of the QIC Chair. The QIC may sanction temporary workgroups when the need is identified. The QIC will also devise specialized accreditation teams if it is deemed necessary to ensure continuous accreditation with external quality agencies.

The scope and length of project for an ad hoc quality workgroups will be defined by the QIC prior to chartering the workgroup. The charter will specify their charge, a timeframe for completion, and a projected expiration of the workgroup. Ad Hoc quality workgroups can become permanent quality workgroup committees when approved by the QIC at the discretion of the Chair.

PURPOSE: To define the scope and authority of quality workgroups committees (aka, sub-committees), ad hoc quality workgroups, and accreditation teams and their relationship to the QIC.

DEFINITIONS: A. Quality workgroup committees (aka, sub-committees of the QIC) are permanent quality

workgroups and represent the QIC in all regards on behalf QIP. The charge of such workgroups is generally fixed over time and integrated with the QIP effort as a whole.

B. Ad hoc quality workgroups are temporary quality workgroups will and not to be confused with quality workgroup committees. The charge of such workgroups is generally time-limited for special short-term projects with the goal of folding its remnants into a chartered quality workgroup committee. However, if the remnants of said charge are substantial in nature, the ad hoc quality workgroup may be chartered as a permanent quality workgroup committee.

C. Accreditation teams are small groupings of QIC members that are designated by the Chair to either play leading roles or supporting roles in assuring organizational compliance with designated sets or groupings of accreditation standards (e.g., Joint Commission, AAAHC, or NCQA). Team assignment is generally presented in the form of a ‘participation matrix’. The definition of the team charge is specified by the particular accreditation standards and respective elements of performance.



PROCEDURE:

Chartering

A. Quality workgroup committees

1. Permanent quality workgroup committees include the Risk Management Committee, Safety & Infection Control Committee, Clinical Staff Committee, and Clinical Services Committee.

2. A quality workgroup leader/facilitator is designated by the QIC or at the discretion of the Medical Director (Chair).

3. For all quality workgroups, the QI Coordinator in collaboration with the Chair completes and keeps current a Workgroup Charter (Exhibit 1) that defines the scope and deliverables of said workgroup.

B. Ad Hoc Quality Workgroups

1. Ad hoc quality workgroups are designed to be temporary in nature and have a limited scope of quality work. A temporary timeframe is defined as 12 months or less.

2. A workgroup leader/facilitator will be designated by the QIC at the discretion of the Chair.

3. Prior to convening an ad hoc quality workgroup the QI Coordinator in collaboration with the Chair completes a Workgroup Charter (Exhibit 1) that defines the scope, deliverables, and projected expiration of said workgroup.

C. Accreditation Teams

1. Accreditation teams are generally comprised of small groupings of QIC members (generally 3-4 individuals) who have continuous responsibility for a limited set of accreditation standards and respective elements of performance.

2. Designated team participants are either assigned a leading or supporting role.

3. A charter is not expressed by means of a formal document as with workgroups. The charter is inferred from the designated set of accreditation standards. The accreditation team has the responsibility of assuring compliance and continuous readiness for surveys.

D. The Charter will include:

1. Workgroup name and date of inception;

2. Purpose, background and importance;

3. Leader/facilitator that is accountable for the workgroup’s report to the QIC;

4. Scope of work and deliverables;

5. QIP Goal congruence reference;

e.g., QIP Goal #2 (To continuously improve the quality and effectiveness of clinical care that patients receive through the provision of evidence-based clinical guidelines by qualified professionals in service to NEON’s mission of eradicating health disparities.)

6. QIP Plan performance measures directly impacted by workgroup;

7. Meeting frequency (minimum requirement is every 3 months);



8. Anticipated date of expiration, if applicable;

9. Additional organizational resources needed up front and going forward that will enhance the workgroup’s chances for success.

E. Expectations

1. All quality workgroups – temporary or permanent – are required to maintain agendas, minutes, PDSA Worksheets and reports in accordance with the policies of the QIC.

2. All quality workgroups – temporary or permanent – are required to adhere to all confidentiality and conflict of interest attestations of the QIC.

3. All quality workgroups – temporary or permanent – are bound by all organizational policies for disclosure of information and quality program guidance.

4. Quality workgroups and/or team members may be dissolved at any time by authority of the QIC at the discretion of the Chair in consultation with other members of the Senior Staff.

5. Members of workgroups or accreditation teams failing to adhere to QIC-related policies may be subject to disciplinary action in accordance with the established personnel policies and based on the severity of the failure to adhere or lack of judgment of the individual.





Exhibit 1: Quality Workgroup Charter Template

QUALITY WORKGROUP CHARTER

Workgroup Name:

Date of Inception:

Leader/facilitator Name:

Purpose of Workgroup:

Background and Importance:

Scope of Work:

Deliverables:

QIP Goal congruence:

QIP Plan performance measures directly

impacted by workgroup:

Meeting frequency: (minimum of Q3 months)

Expiration date: (if applicable)

Additional Organizational Resources

Needed to enhance chances for success:

Revision Dates:


QIC-P7 QI Mechanics 1

QIC Policy Name: Quality Improvement Mechanics QIC Policy Code: QIC-P7


Associated Laws, Regulations or Standards: HRSA FTCA requirements

Related QIC Policies: QIC-P8 QIP Plan; QIC-P11 Risk Management Plan

Attachments: Exhibit 1 – Problematic Memorandum; Exhibits 2a, 2b – Medical & Dental Triggers for QI; Exhibit 3 – Failure Mode & Effect Analysis Procedure


AFFIRMATION:

This organization shall rely on proven mechanics (tools and methodologies) in the implementation and execution of the Quality Improvement Program.

PURPOSE:

The mechanics (e.g., tools and methodologies) involved in our quality improvement effort within the scope of our Quality Improvement Program (QIP) and in service to our QIP Plan is where the proverbial ‘rubber meets the road’ in assessing, on a continual basis, risk and the quality of clinical services. These mechanics entail the tools and methodologies for identifying potential problems, preventing adverse occurrences, and the systematic collection and analysis of data. The mechanics herein specified help the organization identify and document system and process breakdowns. Finally, these mechanics incorporate strategies for process improvement implementation, continuous monitoring, and measurement techniques.

PROCEDURE:

A. Process for Assessing Risk and Clinical Quality Issues on a Continuous Basis

1. Joint Commission Periodic Performance Review tool:

a) The organization is accredited by the Joint Commission (JC). Associated with accreditation is access to a JC web-based tool that affords this organization the opportunity to perform a Periodic Performance Review. This online tool allows this organization to perform self-assessments.

b) To maintain accreditation, this organization is required to submit this self-assessment on an annual basis. This requirement is concatenated with the knowledge that JC surveys can occur at anytime within the space of a 36-month period.

c) There are 14 chapters of Standards of Compliance and more than 400 individual Elements of Performance that are inventoried on a continuous basis. Action plans are generated for individual areas of deficiency. The web-based extranet tool allows this organization to monitor and document its own progress towards clearing the deficiency.

d) Within the scope of the Quality Improvement Committee (QIC), accreditation teams are designated and tasked to address specific JC Standards chapters.

e) The Medical Director (QIC Chair) monitors the work of accreditation teams by viewing directly, on a periodic basis, their documentation and evidence of compliance within the website extranet tool.



2. Risk Management Plan Execution and Monitoring:

a) A Risk Management Policy has been developed, authorized, and disseminated.

b) A Risk Management Plan has been developed in order to execute the Risk Management Policy. (refer to QIC-P11 Risk Management Plan) This Plan falls within the scope of the Risk Management Quality Workgroup Committee of the QIC.

c) The Risk Management Quality Workgroup Committee of the QIC has oversight with the organizational execution of the Risk Management Plan. This workgroup’s membership includes Senior Management staff members and key managers and is empowered to deliver resources to the risk management effort.

d) Periodic assessments are performed and action plans are developed and implemented.

e) Reports are provided periodically to the CEO and the Board of Trustees.

3. QIP Plan Execution and Monitoring:

a) A QIP Plan has been developed, authorized, and implemented.

b) The QIP Plan lists QIP Goal-oriented and Life Cycle-aligned clinical performance measures that are prescribed for the needs of this organization.

c) Based on an annual QIP Work Plan, the QIC collects data on these measures and compares the results with pre-determined benchmarks that are concatenated said measures.

d) As part of the QIP Plan, a Patient Perception/Satisfaction Survey is performed on an annual basis.

B. Methods for Identifying Potential Problems and Prevent Adverse Occurrences

1. Problematic Memorandum (refer to Exhibit 1)

a) We shall continue to rely on all employees to bring to our attention any potential quality or patient safety concerns to the attention of various levels of Management.

b) Employees are empowered to complete a Problematic Memorandum that allows a structured narrative for observations tabulated below:

This problem affects Patient Safety

This problem has a disturbing rate of recurrence and affects patient care or my ability to perform my job

This problem has a nagging persistence and affects patient care or my ability to perform my job.

This problem has a low rate of recurrence, however, when it occurs, it results in severe disruption in patient care or my ability to perform my job.

This is the first occurrence of this problem, to my knowledge, but it severely disrupted patient care or my ability to perform my job.

c) When submitted to various levels of management, these problematic memoranda constitute quality work orders. These memoranda can be submitted directly to members of Senior Staff if an employee does not get an adequate or timely response from lower levels of supervision. Senior Staff members have the same obligation to investigate and attempt to resolve the quality issue.

2. Triggers for Quality Improvement (refer to Exhibits 2a, 2b)

a) A trigger is an event that is used to launch an action or a series of actions for the purpose of quality and process improvement.



b) For our purposes, Near Misses and Misses that will serve as triggers shall fall into one of the 6 categories specified for Medical & Dental services.

c) Clinical staff at all levels will be educated on a periodic basis on how to recognize these triggers.

d) Trigger information will be posted in all clinical units.

3. Failure Mode & Effect Analysis (refer to Exhibit 3)

a) The Joint Commission popularized the FMEA process for health care organizations. The FMEA continues be an effective analytical tool for identifying potential problems with high risk processes that ultimately might lead to patient harm.

b) On an annual basis the QIC will commission the performance of at least one Failure Mode & Effect Analysis (FMEA) of an identified high-risk process as our means of performing vulnerability assessments.

c) Generally, the FMEA task will rest with either the Safely & Infection Control Quality Workgroup or the Clinical Services Quality Workgroup.

C. Strategies for Improvement Implementation, Continuous Monitoring, and Measurement

1. FOCUS-PDSA Methodology

P-D-S-A Cycle

This organization adopted the PDSA cycle as a primary tool for process improvement and implementation. To aid in focusing our efforts and to properly launch a PDSA cycle, we utilize the FOCUS-PDSA routine, which breaks out as follows:

F ind a process to improve.

Organize a team that knows the process.

C larify current knowledge of the process.

U nderstand the sources of variation in the process.

S elect the process improvement methodology.

Plan

Plan change by studying a process.

Decide what could improve it.

Identify data sources that will help.

Do

Do data collection.

Make improvement.

Do data analysis.

Check

Check the effects by studying the results.

Check data for process improvement.

Review lessons learned.

Modify the planned change, if necessary.

Act

Act to improve the process by implementing the proposed change.

Act to hold the gain in quality.

Act to continue improvement.

While planning any process change or improvement, quality workgroups must constantly factor in the resources and methodologies for implementation. Critical questions noted below must be addressed:

1. Should we pilot the process change first?

2. How will affected staff be trained?

3. How will training impact current operations?

4. How will patient service or patient access be impacted during the initial phases of implementation?



2. Robust Process Improvement Methodology

a) In pursuit of performance improvement strategies utilized by High Reliability organizations, robust process improvement (RPI) methodologies will also be employed when addressing process deficiencies or failures. These methods have been generated from the likes of Six Sigma, lean, and change management strategies.

b) The power of these tools lies in their systematic approach, which involves the following: STEP 1- reliably measuring the magnitude of a problem; STEP 2- identifying the root causes of the problem and measuring the importance of each cause; STEP 3- finding solutions for the most important causes (e.g., utilizing Pareto distribution prioritization); STEP 4- proving the effectiveness of those solutions; STEP 5- deploying programs to ensure sustained improvements over time.

D. Tools Used to Systematically Collect Data

1. The current Practice Management System and Electronic Health Record System feeds into a common database. This database is queried to identify patients who meet select criteria.

a) In the absence of a specific registry to meets the select criteria, randomization must be employed. After a list is generated from the database, the online Research Randomizer (www.randomizer.org/form.htm ) is utilized to create a randomized listing.

b) We utilize UDS AUDIT SAMPLING METHODOLOGY in determining appropriate sample sizes.

c) When registries are available that satisfy the select criteria, the entire eligible population for the time period in question is utilized to collect the data.

2. Patient Perception Survey

a) A survey instrument is relied on to perform our annual patient perception surveys.

b) The survey form is dispensed in a pre-determined manner to patients with pre-determined sampling sizes based on proportion on patient population served at the respective health centers.

c) Survey data is input into databases to aid in report generation.

3. Patient Feedback System

a) A continuous system of collecting patient feedback is relied on to collect positive and negative information about our health services.

b) Upon resolution of negative feedback, the feedback is categorized based on the Joint Commission’s historic 9 Dimensions of Quality: Appropriateness of Care; Availability of Care; Continuity of Care; Effectiveness of Care; Efficacy of Care; Efficiency of Care; Respect & Caring; Safety of Care; and, Timeliness of Care.

c) Feedback data is then aggregated and sorted by dimension of quality in order to aid analysis for opportunities for improvement.

4. Fishbone Diagram Cause and Effect Schematic

a) This tool is generally utilized to collect information in a structured format about categorical causes that might be contributing to a process problem.

http://www.randomizer.org/form.htm



b) This tool is utilized during the FOCUS aspect of the FOCUS-PDSA cycle described in the previous section.

c) The four branches of ‘contributing cause’ categories are generally PLACE, PROCEDURES, PEOPLE, and POLICIES.

d) Categorizing the brain-storming data goes a long way towards assisting with the analysis of root causes.

E. Tools Used to Analyze Data

1. Benchmarks are pre-determined for all established performance measures associated with the QIP Plan.

a) The benchmarks drive analysis and QI initiatives.

b) Analysis of data is aided by comparing current results to previous performance results.

2. Data that is collected that is time-oriented and is collected a specific time intervals (e.g., daily, weekly, monthly, etc.) are plotted.

a) Data is plotted with time period on X-axis and results on the Y-axis.

b) Trending is evaluated by utilizing Balestracci (“Data Sanity”) methodology employing data medians.

c) To distinguish Common Cause variation from Special Cause variation, X-MR (Individuals Chart) control charts are employed to determine Common Cause limits.

d) To analyze performance comparison between providers, clinical units, or health centers, Analysis of Means (ANOM) methodology is utilized in order to ensure fair and equitable comparisons based on so-called ‘windows of opportunity’ for occurrences of quality or performance deficiencies.





Exhibit 1: Problematic Memorandum

NORTHEAST OHIO NEIGHBORHOOD HEALTH SERVICES, INC.

PATIENT SAFETY & QUALITY IMPROVEMENT

PROBLEMATIC MEMORANDUM NEON is committed to Patient Safety and Continuous Quality Improvement as WE strive for Service Excellence in a

Caring Environment. Please complete this form when you identify a problem (opportunity for improvement) that

may require additional support remote from your department or health center for the purpose of developing a

solution and resolution.

Check Your Center: Hough Superior Collinwood SE E. Cleve Norwood SWC

A. DESCRIBE THE PROBLEM (Opportunity for Improvement):

B. WHICH AREAS OF THE COMPANY ARE LINKED TO THIS PROBLEM?

check check

Laboratory Services Dental Services

Radiology Services Pharmacy Services

Health Records (HIMS Department) Patient Accounts

Medical Services Other (specify: )

C. WHICH RESPONSE BELOW IS MOST APPLICABLE TO THE PROBLEM YOU HAVE IDENTIFIED? check

This problem affects Patient Safety

This problem has a disturbing rate of recurrence and affects patient care or my ability to perform my job.

This problem has a nagging persistence and affects patient care or my ability to perform my job.

This problem has a low rate of recurrence, however, when it occurs, it results in severe disruption in patient care or my ability to perform my job.

This is the first occurrence of this problem, to my knowledge, but it severely disrupted patient care or my ability to perform my job.

D. IF APPROPRIATE OR APPLICABLE, NAME THE INDIVIDUALS YOU HAVE DISCUSSED THIS PROBLEM WITH, THUS FAR? (i.e., supervisor, Center Director, doctor, etc.)

E. PLEASE INDICATE ANY SUGGESTIONS ON HOW WE MIGHT RESOLVE THIS PROBLEM:

Your Name: Date:

Please forward this form to Operations Director, Dental Director, or Medical Director. THANK YOU



Exhibit 2a: Medical Triggers for Quality Improvement

USING a NEAR MISS or a MISS as a TRIGGER for

QUALITY IMPROVEMENT & PATIENT SAFETY

NEAR MISS:

A ‘near miss’ is when a mistake was made; but thank God we caught it in time before it could

affect our patient. However, somebody still needs to know about the ‘near miss’ so we can

improve the process; because the next person might not be so fortunate.

MISS:

A ‘miss’ is when a mistake was made; but we did not catch it in time before it affected our patient.

Somebody needs to know about the ‘miss’ so we can improve the process that contributed to the

mistake; because we want to get it right the next time.

A trigger is an event that is used to launch an action or a series of actions for the purpose of quality and

process improvement. For our purposes, Near Misses and Misses that will serve as triggers shall fall into

one of the 6 categories noted below:

MEDICAL CATEGORIES Points of Emphasis

1. WRONG PATIENT Wrong identity? Wrong chart?

2. WRONG MEDICATION Wrong medication? Wrong dose? Allergy?

3. LAB Wrong lab? Delayed lab? No lab result? No action?

4. REPORT Wrong report? Delayed report? No report? No action?

5. CANCER DIAGNOSIS Could we have made the diagnosis sooner?

6. DEATH OF A PATIENT After review, is there anything we could have done better?



Exhibit 2b: Dental Triggers for Quality Improvement

USING a NEAR MISS or a MISS as a TRIGGER for


NEAR MISS:

A ‘near miss’ is when a mistake was made; but thank God we caught it in time before it could

affect our patient. However, somebody still needs to know about the ‘near miss’ so we can

improve the process; because the next person might not be so fortunate.

MISS:

A ‘miss’ is when a mistake was made; but we did not catch it in time before it affected our patient.

Somebody needs to know about the ‘miss’ so we can improve the process that contributed to the

mistake; because we want to get it right the next time.

A trigger is an event that is used to launch an action or a series of actions for the purpose of quality and

process improvement. For our purposes, Near Misses and Misses that will serve as triggers shall fall into

one of the 6 categories noted below:

DENTAL CATEGORIES Points of Emphasis



3. WRONG PROCEDURE Wrong treatment? Delayed treatment? No treatment?

4. DOCUMENTATION REPORT Wrong note? Delayed note? No note?

5. WRONG X-RAY Wrong tooth? Wrong Orientation? Missing pathology?

6. WRONG DIAGNOSIS Wrong diagnosis? Failure to Diagnose? Failure to Follow-Up?



Exhibit 3: Failure Mode & Effect Analysis Procedure

Utilize the Lean Six Sigma Academy EXEL spreadsheet to document the FMEA process.

After identifying a HIGH RISK process, the following 10 steps are to be followed:

1. List the key process steps in the first column.

2. List the potential failure mode for each process step. In other words, figure out how this process step or input could go wrong.

3. List the effects of this failure mode. If the failure mode occurs what does this mean to us and our patients… in short what is the effect?

4. Rate how severe this effect is with 1 being not severe at all and 10 being extremely severe. Ensure the team understands and agrees to the scale before you start. Also, make this ranking system “your own” and don’t bother trying to copy it out of a book.

5. Identify the causes of the failure mode/effect and rank it as you did the effects in the occurrence column. This time, as the name implies, we are scoring how likely this cause will occur. So, 1 means it is highly unlikely to ever occur and 10 means we expect it to happen all the time.

6. Identify the controls in place to detect the issue and rank its effectiveness in the detection column. Here a score of 1 would mean we have excellent controls and 10 would mean we have no controls or extremely weak controls.

7. Multiply the severity, occurrence, and detection numbers and store this value in the RPN (risk priority number) column. This is the key number that will be used to identify where the team should focus first. If, for example, we had a severity of 10 (very severe), occurrence of 10 (happens all the time), and detection of 10 (cannot detect it) our RPN is 1000. This means all hands on deck… we have a serious issue!

8. Sort by RPN number and identify most critical issues. The workgroup must decide where to focus first.

9. Assign specific actions with responsible persons. Also, be sure to include the date for when this action is expected to be complete.

10. Once actions have been completed, re-score the occurrence and detection. This should occur within 3-6 months and repeated at the discretion of the Quality Improvement Committee.

NEON QIC Policies & ProceduresQIC-P8 QIP Plan

1

QIC Policy Name: Quality Improvement Program Plan QIC Policy Code: QIC-P8



Related QIC Policies: QIC-P1 QIP Fundamentals; QIC-P7 QI Mechanics; QIC-P9 Work Plan

Attachments: Exhibit 1: Medication Error FormExhibit 2: Patient Perception/Satisfaction Survey ToolExhibit 3: Clinical Audit Sampling Methodology

Authorization: Refer to QIC-S1 AuthorizationSignatures

QIP Goal Congruency: Patient Experience;Patient Care; Patient Safety; NEONSustainability

AFFIRMATION:

The Quality Improvement Program (QIP) Plan shall reflect high priority performance measures that help thisorganization stay on track with achieving its health care mission. The QIP Plan works in concert with the RiskManagement Plan and Peer Review Plan in assuring that this organization is aligned with QIP GOALS.

PURPOSE:

The QIP Plan is designed to provide structure to measurements that are important to this organization forinternal and external reporting requirements. The results of measurements and structured feedback are to beused to identify opportunities for improvement or reassurances that we are on the right track. A QIP WorkPlan will be

PROCEDURE:

1. A Performance Measures Contents Guide and pagination will be included to facilitate look-up ofperformance measurement definitions.

2. For each performance measurement the following will be listed:

a) Category of performance measurement

b) Background and objective of performance measurement

c) Key action steps designed to enhance the chances of achieving success or benchmark

d) Indicator type (rate based, sentinel, effort-related, outcome)

e) Goal/performance threshold

f) Owner of performance measurement in terms of generating the report

g) Data source for measurement

h) Evaluation methodology

3. A Work Plan (refer to QIC-P9 Work Plan) is developed on an annual basis in order to ensure thatperformance measures are collected as prescribed in the QIP Plan.


2

QIP PLAN MEASURES CONTENTS GUIDEPERFORMANCE MEASURES Pages

GOAL: Patient Experience

1. Patient Perception (Outcome): Patient Satisfaction Survey 4

2. Patient Perception (Outcome): Patient Feedback System 5

GOAL: Patient Care

3. Perinatal Life Cycle (Effort): First Trimester Prenatal Care Initiation 6

4. Perinatal Life Cycle (Effort): Postpartum Care within Appropriate Interval 7

5. Perinatal Life Cycle (Effort): Newborn Follow-up within Appropriate Interval 8

6. Perinatal Life Cycle (Outcome): Newborn Birth Weight 9

7. Pediatric Life Cycle (Effort): Immunization Status of 2 year old Children 10

8. Pediatric Life Cycle (Effort): Lead Level Testing of 3 year old Children 11

9. Pediatric & Adolescent Life Cycle (Effort): Asthma (Persistent) Management 12

10. Pediatric & Adolescent Life Cycles (Effort): Weight Assessment & Counseling 13

11. Adolescent Life Cycle (Effort): Behavior Risk Assessment & Counseling 14

12. Adult Life Cycle (Effort: Asthma (Persistent) Management 15

13. Adult Life Cycle (Effort): Cervical Cancer Screening 16

14. Adult Life Cycle (Effort): Abnormal Pap Smear Follow-up 17

15. Adult Life Cycle (Effort): Breast Cancer Screening with Mammography 18

16. Adult Life Cycle (Effort): Colorectal Cancer Screening Follow-up 19

17. Adult Life Cycle (Outcome): Hypertension Management 20

18. Adult Life Cycle (Effort): Weight Assessment & Intervention 21

19. Adult Life Cycle (Outcome): Diabetes Control (Excellent, Good, & Not Poor) 22

20. Adult Life Cycle (Effort): Type 2 Diabetics with LDL < 100 or on a Statin 23

21. Adult Life Cycle (Effort): Tobacco Use Assessment & Intervention 24

22. Geriatric Life Cycle (Effort): Geriatric Immunization 25

23. Oral Health (Outcome): Phase One Oral Treatment Plan Completion 26

24. Pharmacy & Therapeutics (Outcome): Appropriateness of Antibiotic Use 27

GOAL: Patient Safety

25. Pharmacy & Therapeutics (Outcome): Medication Errors 28


3

GOAL: Health Center Sustainability

26. Grant Viability (Leading Indicator): Number of Users 29

27. Financial Viability (Leading Indicator): Provider Productivity 30

28. Financial Viability (Leading Indicator): Financial Mix 31

29. Financial Viability (Leading Indicator): Medicaid HMO Assignment 32

30. Financial Viability (Leading Indicator): Appointment Show Rate 33

EXHIBITS

Patient Perception: Patient Perception/Satisfaction Survey Tool 34

Pharmacy & Therapeutics: Medication Adverse Events Reporting Form 35

Clinical Audit Sampling Methodology 36


4

Patient Perception:Patient Satisfaction Survey

Background and Objective:1. The BPHC requires that CHCs periodically assess patient satisfaction.

2. The Joint Commission requires that organizations query their patient population for certain issues as well.

Key Action Steps:1. Patient feedback will be sought on an ongoing basis for the purpose of process improvement.

2. Patient complaints shall be handled swiftly and concerns shall be categorized and aggregated for analysis.

3. Employees will be given opportunities to share problems they are having by means of the ProblematicMemorandum.

4. ‘Customer Service’ training is provided for the majority of employees that have contact with patients.

Indicator (rate based & outcome related):A. Questions for each of categories A to I are based on a 5-point Likert scale (‘A’ to ‘F’) and rolled-up to each

individual category (A to I) and reported for each category (A to I).

Numerator: Total of respondents answering ‘A’ or ‘B’ for indicator categories A to I

Denominator: Total number of respondents

B. Question K is scored ‘Yes’, ‘Maybe’, or ‘No’

Numerator: Total of respondents answering ‘Yes’ to question K

Denominator: Total number of respondents

Goal/Performance Threshold:A. The performance threshold is 90% in aggregate across all Likert-scaled survey categories A-I (internal goal)

B. The performance threshold is 85% for survey question K (internal goal)

Owner, Data Source and Evaluation:Owner: QI CoordinatorData source:

1. Color-coded (to differentiate health centers) survey forms are distributed to health centers proportional topatient volume. At least 500 survey random responses distributed proportionately among health centersbased on visit volumes at respective health centers.

2. Survey staff designates distribution points (for distribution) at respective health centers. Designated surveystaff request that users complete survey questionnaire.

3. Survey staff completes Age Category, Gender, and Payment/Insurance Status on questionnaire.

4. Users are instructed to fold the complete survey questionnaire and place it in the envelope provided. (Theenvelope should indicate the name of the health center only, and should be, preferably, a self-sealing typeof envelope).

Evaluation:

1. Data is entered into a Q&A database which is utilized to generate report.

2. Information is summarized and put into tabulated form and reported in aggregated category fashion.

Reporting Frequency:Annually (at a minimum)


5

Patient Perception:Patient Feedback System

Background and Objective:1. The Patient Feedback System is in support of the current Patient Grievance Policy.

2. This system provides an opportunity for patients to provide feedback on a continuous basis at the point ofcare.

3. This feedback allows the organization to identify and categorize opportunities for process improvement andemployee attitude & skills improvement.

Key Action Steps:1. Patient feedback will be sought on an ongoing basis for the purpose of process improvement.

2. Patient complaints shall be handled swiftly and concerns shall be categorized and aggregated for analysis.

3. Employees will be given opportunities to share problems they are having by means of the ProblematicMemorandum.

4. ‘Customer Service’ training is provided for the majority of employees that have contact with patients.

5. Employees will be directly engaged with relationship management through self-directed issue mitigationand customer care.

Indicator (categorical, process related):Feedback is categorized based on the Joint Commission’s historic 9 Dimensions of Quality: Appropriateness ofCare; Availability of Care; Continuity of Care; Effectiveness of Care; Efficacy of Care; Efficiency of Care; Respect &Caring; Safety of Care; and, Timeliness of Care

Goal/Performance Threshold:n/a

Owner, Data Source and Evaluation:Owner: Operations Department and HR DepartmentData source:

1. Patient feedback forms are available widely at the health centers.

2. Upon resolution of patient complaints, they are categorized by Operations Department or HR Department

3. Data is captured on InfoPath database.

Evaluation:

Data is categorized and aggregated in order to detect patterns and trends to generate a report.

Report is reviewed by Quality Improvement Committee for opportunities for improvement.

Reporting Frequency:Quarterly


6

Perinatal Life Cycle:First Trimester Prenatal Care Initiation

Background and Objective:1. BPHC 2010 Health Plan performance measure and UDS clinical indicator

2. It is generally recognized that women who comply with early and continuous prenatal care andappropriately timed postpartum care experience fewer maternal health problems. This influence onhealth problems carries over to the newborns. It is similarly recognized that newborns that are providedappropriately timed neonatal care experience fewer health problems.

3. The degree of achievement is measured with respect to the degree of success NEON has in influencing itsexpectant users to access initial prenatal care during the First Trimester.

4. Supportive of Healthy People 2020 Goals and Objectives.

5. Performance benchmark for this clinical measure was decreased from 90% to 80% to align with HP2020target.

Key Action Steps:1. Patients are offered on-demand pregnancy testing. All positive results are reported to staff social workers

who contact the patients and provide them the opportunity and encourage them to enter into medical careand case management.

2. Upon pregnancy determination, primary care providers are directed to make OB appointmentsimmediately, and encourage patient adherence.

3. Maintain adequate OB provider capacity in order to assure adequate accessibility to prenatal appointments.

4. Maintain current staffing levels and distribution along with non-federal grant support for special programsthat contribute to comprehensive perinatal case management

5. Enhance working relationship with area secondary public schools promoting health education classes oncare prenatal care during the first trimester. Continue working with YAAP in promoting early prenatal care.

6. CPCP outreach and tracking efforts.

Indicator (rate based & effort-related): Numerator: The number of expectant users of the denominator seeking initial prenatal care at NEON

during the First Trimester

Denominator: The accumulated total number of expectant users first seeking prenatal care at NEON duringthe current calendar year

Goal/Performance Threshold:The performance benchmark is 80% (HP 2020 target of 77.9%)

Owner, Data Source and Evaluation:Owner

Enabling Services Director

Data source:

CPCP log/database of perinatal statistics.

Evaluation:

Data is categorized and aggregated in order to detect trends to generate a report.


Reporting Frequency:Every 6 months


7

Perinatal Life Cycle:Postpartum Care within Appropriate Interval

Background and Objective:1. It is generally recognized that women who comply with early and continuous prenatal care and

appropriately timed postpartum care experience fewer maternal health problems.

2. The degree of achievement is measured with respect to the degree of success NEON has in encouragingrecently delivered OB users to access postpartum care within 6 weeks of delivery.

Key Action Steps:1. Maintain adequate OB provider capacity in order to assure adequate accessibility to postpartum

appointments.

2. CPCP L&D outreach and tracking efforts.

3. Explore and possibly implement Patient Centering program.

Indicator (rate based & process-related):

Numerator: The number of OB users of the denominator who have delivered who had prenatal care atNEON and appeared within 42 days of delivery to a NEON OB provider or an alternate OB provider forpostpartum evaluation

Denominator: The accumulated total number of OB users who have delivered during the current calendaryear and had prenatal care at NEON

Goal/Performance Threshold:The performance threshold is greater than 70% (internal goal)



Data source:


Evaluation:





8

Perinatal Life Cycle:Newborn Follow-up within Appropriate Interval

Background and Objective:1. It is recognized that newborns that are provided appropriately timed neonatal care experience fewer health

problems.


Key Action Steps:1. Maintain adequate pediatrics provider capacity in order to assure accessibility to newborn visits within the

prescribed interval.

2. CPCP outreach and tracking efforts.

3. Explore and possibly implement Patient Centering program.


Numerator: The number of infants of the denominator who were presented within 4 weeks of delivery to aNEON pediatric provider for newborn care

Denominator: The total number of infants born to OB users who have delivered and had prenatal care atNEON during the current calendar year

Goal/Performance Threshold:The performance threshold is 90% (internal goal)



Data source:


Evaluation:





9

Perinatal Life Cycle:Newborn Birth Weight


2. The degree of achievement is measured with respect to NEON influencing the outcome of births relative tonewborn infants not weighing less than 2500 grams at the time of birth.

3. Performance threshold was decreased from 10% to 8% to align with Healthy People 2020 target and toreflect NEON’s recent and persistent with this measure.

Key Action Steps:1. Provide patients with pregnancy testing on a walk-in basis during routine health center hours.

2. Upon pregnancy determination, primary care providers are directed to make OB appointmentsimmediately, and encourage patient adherence.

3. Maintain adequate OB provider capacity in order to assure adequate accessibility to prenatal appointments.

4. Through cooperation and collaboration amongst staff ob/gyn providers (primarily nurse midwives) and staffsocial workers (primarily licensed social workers), continue to screen for potential substance abuse issuesand when identified, refer to local substance abuse resources for treatment.

5. Maintain heightened awareness for medical high-risk issues that may lead to prematurity or prematurelabor.

6. Maintain high level of CPCP staff support for referred patients through heightened outreach and trackingactivities, inclusive of mailings, phone calls, and face-to-face encounters.

Indicator (rate based & outcome-related):

Numerator: The number of newborns born of the denominator with LBW (<2500 grams) whose mothershad prenatal care by NEON

Denominator: The total number of newborns whose mothers were cared for by NEON during the currentcalendar year

Goal/Performance Threshold:The performance threshold is 8% (HP 2020 target of 7.8%)



Data source:


Evaluation:





10

Pediatric Life Cycle:Immunization Status of 2 year old Children

Objective:1. BPHC 2010 Health Plan performance measure and UDS clinical indicator

2. NEON’s healthcare mission is inextricably linked to providing pediatric users convenient access to early,periodic, screening, diagnostic, and testing services, which includes immunization programs and growth anddevelopment assessments.

3. The degree of achievement is measured with respect to provider staff vaccinating pediatric users inaccordance with AAP guidelines restricted to vaccines available through the Federal Vaccines for Children(VFC) program.


Key Action Steps:1. Providers are encouraged to provide basic immunization assessment and vaccination as a component of

each visit to the health center, when there are no contraindications, regardless to whether the child ispresented with an appointment or not.

2. Continue participation in Ohio’s immunization registry (IMPACT SIIS) that will facilitate documentation andtracking and provide provider decision support. Implement an interface between IMPACT and NEON’selectronic health record in order to reduce steps involved in documentation.

3. Increase education efforts to make certain that all parents and guardians are aware that if they lose theirhealth insurance or if they have health insurance that does not cover immunizations, that they can still getsuch care at NEON.

Indicator (rate based, effort-related): Numerator: Number of denominator sample who had completed 4 DTP/DTaP, 3 IPV, 1 MMR, 2 Hib, 3

HepB, 2 HepA, 2 Rotavirus, 1VZV (Varicella), 4 Pneumoccocal, and 2 Influenza.

Denominator: The cohort of children who had their 2nd birthday during the study year, who had been seenat least twice at NEON prior to their second birthday and seen at least once during the calendar year by aprimary care provider, who did not have a contraindication for a specific vaccine.

Goal/Performance Threshold:The performance threshold is 80% (internal) (UDS national 2009 roll-up mean of 68.8%)

Owner, Data Source and Evaluation:Owner:

QI Coordinator

Data source:

MIS Department provides a report of pediatric users who had their 2nd birthday recorded during thecalendar year and seen at least once at NEON during the calendar year. Immunization record information isretrieved from IMPACT SIIS.

Evaluation:

Under the supervision of the Medical Director and review by Lead Pediatrician, a report is generated by QICoordinator




11

Pediatric Life Cycle:Lead Level Testing of 3 year old Children

Objective:1. The rationale for this study is that there is a high prevalence of lead poisoning amongst children that live in

the communities served by NEON.


Key Action Steps:1. Pediatric medicine providers are provided specific community standard guidelines on the care,

management, and screening of lead poisoning.

2. The County Board of Health forwards lead test reports to NEON. These reports are scanned into ICS ofNextGen for provider review and potential action.

Indicator (rate based, effort-related):

Numerator: Member of denominator sample who had blood lead screening performed at least once atNEON

Denominator: The cohort of children who had their 3rd birthday during the calendar year, who had beenseen at least twice at NEON prior to their 3rd birthday and seen once during the calendar year by a primarycare provider



QI Coordinator

Data source:

1. MIS Department provides a report of pediatric users who had their 3rd birthday recorded during thecalendar year and seen at least once at NEON during the calendar year.

2. Users are selected randomly based on UDS Audit Sampling Methodology described in Appendix based onpopulation size greater than 500.

3. Electronic Chart review 1st pass: LabCorp eResults online for 2nd pass

Evaluation:

Under the supervision of the Medical Director, a report is generated by QI Coordinator




12

Pediatric & Adolescent Life Cycle:Asthma (Persistent) Management

Objective:1. New UDS clinical indicator for 2011.

2. Studies currently point to the need for medical providers to heighten their awareness of and use of NAEPguidelines on the proper care and management of asthma.

3. The degree of achievement is measured with respect to provider staff providing appropriate care andmanagement to pediatric users who have been diagnosed with the condition of asthma.


Key Action Steps:1. Through excellent publications developed and circulated by NIH’s/NHBLI’s National Asthma Education

Program, medical providers are provided specific guidelines on diagnosis, management, and patienteducation relative to asthma.

2. Providers are encouraged to be meticulous and consistent in the care of asthmatic patients.

3. Require providers to use asthma disease management module of electronic health record system in orderto provide decision support

Indicator (rate based, effort-related): Numerator: The number of patients in denominator population who have been documented to be on anti-

inflammatory medication (inhaled corticosteroids, mast cell stabilizers, leukotriene modifiers)

Denominator: The number of patients 5 - 17 years of age with documented persistent asthma and seen atleast once at the health center for any cause during the calendar year by a primary care provider

Goal/Performance Threshold:The performance threshold is 95% (internal)


QI Coordinator

Data source:

Users diagnosed with asthma and with clinical qualifier of ‘Persistent’ (mild, moderate, or severe) areselected randomly based on UDS Audit Sampling Methodology described in Appendix based on populationsize greater than 500.

Review chart to confirm patient has persistent asthma.

Determine whether sampled patients were on appropriate medication for inclusion in numerator of thisindicator.

Evaluation:





13

Pediatric & Adolescent Life Cycle:Weight Assessment & Counseling

Background and Objective:1. New UDS clinical indicator for 2011.

2. It is general knowledge that disparities in health status indicators and risk factors for diet-related diseaseare evident in many segments of the population based on gender, age, race and ethnicity, and income. Forexample, overweight and obesity are observed in all population groups, but obesity is particularly commonamong Hispanic, African American, Native American, and Pacific Islander women. Obesity in the targetpopulation served by NEON, which is largely African American, reflects what has been noted nationally.Childhood obesity appears to be at epidemic levels. If obesity is not thwarted, Type 2 Diabetes developsquite commonly.

3. Healthy People objectives emphasize that the reduction of BMI in children and adolescents should beachieved by emphasizing physical activity and a properly balanced diet so that healthy growth ismaintained.

Key Action Steps:1. Provide point of care dietary and physical activity counseling by primary care provider in collaboration and

with support of staff dietician.

2. Provide printed material to parent/guardian.

3. Collaborate with school-based programs in promoting good nutrition and physical activity


Numerator: Children in the denominator who also have weight assessment with BMI calculated andrecorded and with evidence in health record that diet and physical activity counseling were provided withinthe previous 12 months.

Denominator: All children ages 2 – 17 who have had been seen at least twice at NEON and at least onceduring the calendar year by a primary care provider.



QI Coordinator

Data source:

1. MIS Department provides a report of users (2 to 17 years of age).

2. Users are selected randomly based on UDS Audit Sampling Methodology described in Appendix based onpopulation size greater than 500

Electronic medical records are reviewed.

Evaluation:





14

Adolescent Life Cycle:Behavior Risk Assessment & Counseling

Background and Objective:1. BPHC 2010 Health Plan performance measure.

2. High-risk behavior in adolescents is linked to an increased incidence of sexually transmitted diseases, teenpregnancy, bodily injury, and death.

3. Supportive of Healthy People Goals and Objectives.

Key Action Steps:1. Providers are strongly encouraged to abide by HealthChek guidelines with respect to performing behavioral

health risk assessments and screening on all adolescents on an annual basis.

2. NEON primary care providers utilize structured approaches to screening/assessing behavioral risks ofadolescent patients. However, behavioral health counseling is restricted by the amount of time that typicalproviders have to spend with the patient. Therefore, stabilize and expand access to behavioral health staffthat can address through counseling behavioral risks identified by primary care providers.

3. Adolescent patients have a low rate of presentation for annual preventive health examinations, which isoften the best time to perform behavioral health risk assessments and screenings that ultimately.Therefore, increase education outreach to parents and directly with adolescents when they present withacute health issues.


Numerator: Patients in the denominator population who have documentation of behavioral riskassessment and counseling that involved any or all of the following issues: use of tobacco, alcohol, illicitdrugs, sexual behavior, family planning, abstinence, motor vehicle use, accidents/injuries, violence andintentional injuries, depression, suicidal ideation, or other risk behavior.

Denominator: All patients aged 13-19 who have been seen at least once at NEON during the calendar yearby a medical provider.



QI Coordinator

Data source:

1. PMS is queried for a report of adolescent users (13 to 19 years of age) as described in the denominator ofthe indicator description noted above.

2. Users are selected randomly from the report regardless to the health center origin using the UDS AuditSampling Methodology described in the Appendix based on population size greater than 500.

Evaluation:





15

Adult Life Cycle:Asthma (Persistent) Management

Objective:1. New UDS clinical indicator for 2011.

2. Studies currently point to the need for medical providers to heighten their awareness of and use of NAEPguidelines on the proper care and management of asthma.


Key Action Steps:1. Through excellent publications developed and circulated by NIH’s/NHBLI’s National Asthma Education

Program, medical providers are provided specific guidelines on diagnosis, management, and patienteducation relative to asthma.

2. Providers are required to use asthma disease management module of electronic health record system inorder to document asthma severity level and take advantage of decision support.


Numerator: The number of patients in denominator population who have been documented to be on anti-inflammatory medication (inhaled corticosteroids, mast cell stabilizers, leukotriene modifiers)

Denominator: Patients 18 - 40 years of age with documented persistent asthma and seen at least once atthe health center for any cause during the calendar year by a primary care provider



QI Coordinator

Data source:

1. Asthma Registry or

Users diagnosed with asthma and with clinical qualifier of ‘Persistent’ (mild, moderate, or severe)are selected randomly based on UDS Audit Sampling Methodology described in Appendix based onpopulation size greater than 500.

2. Review chart to confirm patient has persistent asthma.

3. Determine whether sampled patients were on appropriate medication for inclusion in numerator of thisindicator.

Evaluation:





16

Adult Life Cycle:Cervical Cancer Screening


2. Cancer is one of the two leading causes of death in adults in the United States. To a considerable degree,morbidity and mortality related to cancer can be mitigated by the proper application of preventive healthcare and early treatment relative to these conditions.

3. There is general agreement that cervical cancer screening intervals should be no greater than 3 years.However, in certain women the intervals should be no greater than 1 year in instances of history of cervicalneoplasia and infection with HPV.

Key Action Steps:1. Primary care providers are expected to perform Pap testing to adult female users no less frequently than

every 3 years or as frequently as necessary depending on their clinical circumstances or not at all if theyhave had a hysterectomy without residual cervical tissue.

2. NEON provides Pap smear testing to patients without regard to their income and at minimum cost to themif they are uninsured.

3. Increase efforts at identifying patients who are due pap testing according to clinical guidelines by exploitingthe electronic health record database. Upon identification, increase outreach efforts to these usersthrough mail and phone contacts.

Indicator (rate based & effort-related): Numerator: Women in the denominator who have received one or more Pap tests within the past 36

months

Denominator: Women 24-64 years of age who have been seen at least once during the calendar year by aprimary care provider, excluding those women who have had a hysterectomy without residual cervix

Goal/Performance Threshold:The performance threshold is 70% (Healthy People 2020 target of 93%, UDS 2009 national roll-up mean of58.2%, Ohio 45.8%)


QI Coordinator

Data source:

1. PMS is queried for a report of female users (24 to 64 years of age) as described in the denominator of theindicator description noted above with the exception of criteria related to hysterectomy; a report that alsoshows the last provider to serve the patient.

2. Users are selected randomly from the report regardless to the health center origin using the UDS AuditSampling Methodology described in the Appendix.

3. Electronic medical records are reviewed. Only medical records that do not demonstrate that the patienthad a hysterectomy will be included in the sample for evaluation.

Evaluation:





17

Adult Life Cycle:Abnormal Pap Smear Follow-up

Background and Objective:1. NEON’s system of care is required by BPHC to achieve GYN follow-up of all targeted Pap smears (AS-CUS,

AS-GUS, CIN I or higher grade aged 21 or older and HSIL or higher grade AS-GUS in females less than 21)within 6 weeks of performance of index Pap test.


Key Action Steps:1. Primary care providers are directed to refer females with CIN I or greater Pap smear results to a GYN

provider within 6 weeks of the date of the Pap test. However, the referral for such service is to occurimmediately. Generally, it takes less than 2 weeks for a patient to be seen by a GYN provider at NEON.

2. Providers are directed to be very aggressive in ensuring adherence with GYN follow-up.

3. NEON GYN providers place high priority on assisting with adherence with said GYN follow-up.

4. Our enabling service providers are joined with our Quality Coordinator in the Quality Care Assurance Teamthat provides case management follow-up on all patients with abnormal Pap test results. They makecertain that patients are notified by providers and follow-up on whether patients have responded and/orcomplied with recommended follow-up based on current guidelines. This process is facilitated by the useof the NextGen EMR system.

Indicator (rate based & effort-related): Numerator: Women in the denominator who were provided some form of follow-up assessment – such as

notification, referral, scheduling of follow-up appointment, treatment – has been documented/recordedand initiated within 30 days of test completion

Denominator: Women who received a Pap test at NEON within the previous 6 months and the Pap test hadabnormal cytological findings (AS-CUS, AS-GUS, CIN I or higher grade aged 21 or older and HSIL or highergrade AS-GUS in females less than 21)



QI Coordinator

Data source:

1. Laboratory Department LabCorp Pap test log is retrieved.

2. Users with non-CIN results are selected randomly from log regardless to the health center origin using theUDS Audit Sampling Methodology described in the Appendix based on a population size greater than 500.

3. Electronic medical records are reviewed.

Evaluation:





18

Adult Life Cycle:Breast Cancer Screening with Mammography

Background and Objective:1. Breast cancer is the most common cancer diagnosis among African American women, and among women

nationwide. Studies have shown that when African American women follow the same preventive measuresas white women, their death rates from breast cancer are very similar. However at present, AfricanAmerican women are more likely than white women to be diagnosed at later stages of the disease and aremore likely to die from it.

2. To screen for breast cancer, the U.S. Preventive Services Task Force recommends screening mammographyevery 2 years for women 50 – 74 years old.


4. UDS utilization measure

Key Action Steps:1. Primary care providers are encouraged to offer appropriate mammography screening to all female users

who are 50 – 74 years old.

2. Mammogram Registry was established to facilitate the performance of mammograms within 30 days eitherat the Hough facility or at external facilities. External referrals are coordinated by the registry manager.

Indicator (rate based & effort-related):

Numerator: Women in the denominator who received a mammogram screen within the previous 24months

Denominator: Women aged 50 – 74 years who have been seen at least twice at NEON and at least onceduring the calendar year by a primary care provider

Goal/Performance Threshold:The performance threshold is 70% (internal goal) (HP 2020 target of 81.1%)


QI Coordinator

Data source:

1. PMS is queried for report of female users (50 years of age and older) as described in the denominator of theindicator description noted above.

2. Users are selected randomly from the report regardless to the health center origin using the UDS AuditSampling Methodology described in the Appendix.

3. First pass: determine whether Mammogram Registry database shows that patient has received amammogram either by NEON or elsewhere in Greater Cleveland.

4. Second pass: electronic medical records are reviewed.

Evaluation:





19

Adult Life Cycle Category:Colorectal Cancer Screening Follow-up

Background and Objective:1. Colorectal cancer is the third most common cancer among both men and women in the United States. It is

the second leading cause of cancer deaths in the U.S. (behind lung cancer), accounting for about 10% of allcancer deaths. Over 56,000 deaths from colorectal cancer are expected to occur in the U.S. in 2005.Colorectal cancer develops slowly and is often asymptomatic in its early stages. In addition, less than one-fourth of colorectal cancer cases are associated with a family history of the disorder. These characteristicsof the disease make early detection particularly important and effective.

2. The U.S. Preventive Services Task Force recommends colorectal cancer screening utilizing Fecal OccultBlood Test (FOBT), flexible sigmoidoscopy, or colonoscopy. Annual FOBT offers reductions in mortalityrates for colon cancer and is a reasonable screening methodology.


Key Action Steps:1. Primary care providers are encouraged to offer appropriate colorectal screening to all users who are 50

years old and older.

2. FOBT cards are widely accessible to our primary care providers and testing is performed by our LaboratoryDepartment.

3. Our enabling service providers are joined with our Quality Coordinator in the Quality Care Assurance Teamthat provides case management follow-up on all patients with abnormal colorectal screening results. Theymake certain that patients are notified by providers and follow-up on whether patients have respondedand/or complied with recommended follow-up based on current guidelines. This process is facilitated bythe use of the NextGen EMR system.

Indicator (rate based & effort-related): Numerator: Patients in the denominator who had a positive FOBT performed at NEON within the calendar

year for whom follow-up referral and/or treatment was initiated within 30 days

Denominator: Patients aged 50 or older who have been found to have a positive FOBT within the previous6 months by NEON’s Laboratory Department



QI Coordinator

Data source:

1. Laboratory Information System report of patients as described in the denominator of the indicatordescription noted above.

2. All positive FOBT tested patients are included in sample during reporting period.


Evaluation:





20

Adult Life Cycle:Hypertension Management


2. A significant number of NEON users have essential hypertension.

3. The degree of achievement is measured with respect to provider staff providing appropriate care andmanagement to adult users who have been diagnosed with the condition of essential hypertension.

4. The reference adult user population consists of those who have been diagnosed with hypertension.

Key Action Steps:1. Continue an in-house campaign of educating providers on current JNC guidelines on managing

hypertension, making certain that guideline narratives are easily accessible, and continue periodic reportingof clinical performance to providers while at the same time integrating clinical performance with monetaryincentives.

2. Minimize barriers related to patient acquisition of drug therapy for hypertension.

3. Develop and implement a hypertension and exploit the registry for opportunities to provide performancefeedback to providers and communications to select hypertensive patients who are delinquent withmedical visits.

Indicator (rate based & outcome-related):

Numerator: Patients in the denominator for whom the last blood pressure recorded was less than 140/90and the blood pressure was recorded within the calendar year.

Denominator: Patients aged 18 to 85 years of age who have been diagnosed with hypertension and whohave been seen at least twice at NEON and at least once during the calendar year by a primary careprovider

Goal/Performance Threshold:The performance threshold is 62% (HP 2020 target of 61.2%)


QI Coordinator

Data source:

1. Hypertension Registry or

PMS is queried for report of users (18 to 85 years of age) as described in the denominator of theindicator description noted above utilizing ICD-9 codes of 401.1 and 401.0. Users are selectedrandomly from the report regardless to the health center origin using the UDS Audit SamplingMethodology described in the Appendix based on population size greater than 500.


Evaluation:





21

Adult Life Cycle:Weight Assessment & Intervention


2. It is general knowledge that disparities in health status indicators and risk factors for diet-related diseaseare evident in many segments of the population based on gender, age, race and ethnicity, and income. Forexample, overweight and obesity are observed in all population groups, but obesity is particularly commonamong Hispanic, African American, Native American, and Pacific Islander women. Obesity in the targetpopulation served by NEON, which is largely African American, reflects what has been noted nationally.


Key Action Steps:1. Provide point of care diet and physical activity counseling by primary care provider in collaboration and

with support of staff dietician.

2. Electronic health record will be utilized to facilitate the detailing of follow-up plan for weight managementintervention.

3. Pursue local opportunities and grants to add capacity to NEON in order to address weight issues (especiallyobesity) in our patient population.


Numerator: Users for whom a BMI was recorded and if <18 or >25 a follow-up plan for weightmanagement intervention was documented.

Denominator: Patients aged 18 and older who have been seen at least once during the calendar by aprimary care provider

Goal/Performance Threshold:The performance threshold is 50% (internal goal) (related to Healthy People 2020’s NWS-6.2 objective target of31.8%)


QI Coordinator

Data source:

1. PMS is queried for report of users (18 years of age and older) seen at least once during the calendar by aprimary care provider.



Evaluation:





22

Adult Life Cycle:Diabetes Mellitus Control (Excellent, Good, & Not Poor)

Background and Objective:1. BPHC 2010 Health Plan clinical performance measure (‘Not Poor’) and UDS clinical indicator.

2. ADA develops and circulates relevant clinical guidelines on diagnosis, management, and patient educationrelative to diabetes. These guidelines are summarized and redistributed to providers.

Key Action Steps:1. Develop and implement diabetes focus clinic for poorly controlled diabetics.

2. Incorporate behavioral health component in the care pathway for diabetics who have not achievedtargeted control levels.

3. Develop and implement a diabetes registry and exploit the registry for opportunities to provideperformance feedback to providers and communications to select diabetic patients who are delinquentwith medical visits.

Indicator (rate based & outcome-related):Excellent Control Numerator: Patients with at least one HbA1c reading documented in the calendar year and whose last recorded value

was less than 7% Denominator: Cohort of diabetic patients who were 18-75 y/o during the calendar year who were served in the

calendar year and had one encounter for any reason whatsoever by a primary care provider. Include in denominatoreven if did not have HbA1c done

Good Control Numerator: Patients with at least one HbA1c reading documented in the calendar year and whose last recorded value

was 7 to 7.9% Denominator: Same cohort above for denominatorNot Poor Control Numerator: Patients with at least one HbA1c reading documented in the calendar year and whose last recorded value

was less than 9%

Denominator: Same cohort above for denominator

Goal/Performance Threshold:Excellent Control The performance threshold is 43% (HP 2020 target of 58.9% and UDS 2009 national roll-up mean of 39.8%)Good Control The performance threshold is 70% (Better Health Greater Cleveland Region 2010 mean of 70%)Not Poor Control The performance threshold is 80% (HP 2020 target of greater than 85.4% and UDS 2009 national roll-up

mean of 70.7%, Ohio 74.7%)Owner, Data Source and Evaluation:

Owner: Associate Director of Medical AffairsData source: Diabetes Registry universe or sampling of PMS report of diabetic patients seen during the calendar year

that had one or more visits with a primary care provider. Users are selected randomly from PMS reportusing the UDS Audit Sampling (70 charts).

Evaluation: Under the supervision of the Medical Director, report is generated by ADMA Report is reviewed by Quality Improvement Committee for opportunities for improvement.



23

Adult Life Cycle:Type 2 Diabetics with LDL < 100 or on a Statin

Background and Objective:1. Patients with Type 2 Diabetes have an increased prevalence of lipid abnormalities that contributes to higher

rates of CVD. Lipid management aimed at lowering LDL cholesterol, raising HDL cholesterol, and loweringtriglycerides has been shown to reduce macrovascular disease and mortality in patients with type 2diabetes, particularly in those who have had prior cardiovascular events

2. Having diabetes is synonymous with having CHD and as such lipid management must be aggressive. LDLlevels of less than 100 mg/dL is recommended or patients should be on a Statin medication to modify risk.

3. This particular clinical measure is utilized by Better Health Greater Cleveland and reported to thecommunity.

Key Action Steps:1. The American Diabetes Association develops and circulates relevant clinical guidelines on diagnosis,

management, and patient education relative to diabetes. These guidelines are summarized andredistributed to NEON providers.

2. Providers are strongly encouraged to perform a lipid panel on all diabetics on an annual basis

3. Maintain current absence of barriers in receiving medication for hyperlipidemia

4. Maintain access to dietician services within NEON’s network of health centers


Numerator: Patients in the denominator for whom the last recorded LDL was less than 100 mg/dL andtesting was performed within the previous 12 months or patient is on a STATIN medication to controlhyperlipidemia or modify risk

Denominator: A cohort of patients 40 years of age or older who have been diagnosed with Type 2 Diabetesand who have been seen at least twice at NEON and at least once during the calendar year by a primarycare provider

Goal/Performance Threshold:The performance threshold is 84% (Better Health Greater Cleveland Regional 2010 mean of 84%)

Owner, Data Source and Evaluation:Owner: Associate Director of Medical AffairsData source:

1. Diabetes Registry or

a. PMS is queried for a report of users (40 years of age and older) as described in the denominator ofthe indicator description noted above utilizing ICD-9 codes of 250.00,

b. Users are selected randomly from the report regardless to the health center origin using the UDSAudit Sampling Methodology described in the Appendix based on population size greater than 500.

2. Health Record Lab table in electronic health record is searched for lab finding.Evaluation: Under the supervision of the Medical Director, report is generated by ADMA Report is reviewed by Quality Improvement Committee for opportunities for improvement.



24

Adult Life Cycle:Tobacco Use Assessment & Intervention


2. Supportive of Healthy People 2020 goals and objectives.

Key Action Steps:1. Nursing staff are responsible for inquiring about tobacco use as a component of intake and are responsible

for updating the Social History template in the electronic health record.

2. Patients are asked to complete a self-assessment questionnaire at least once during the calendar year priorto nurse intake activity. The questionnaire includes questions on smoking history.

3. Electronic health record will be utilized to facilitate the detailing of tobacco use and documentation ofcessation intervention.

Indicator (rate based & effort-related):A. Numerator: patients 18 years and older for whom tobacco use assessment (screening) was performed at

least once in the previous 24 months.

Denominator: A cohort of patients 18 years of age or older who have been seen at least once during thecalendar year by a primary care provider.

B. Numerator: patients 18 years and older with documentation of active tobacco use with documentation of“cessation intervention” (e.g., G0375 or G0376 procedure codes in Procedure Table of NextGen)

Denominator: patients 18 years of age or older with evidence of active tobacco use (Social History,Previous Assessment, or Chronic Problem list) who have been seen at least once during the calendar yearby a primary care provider.

Goal/Performance Threshold:A. The performance threshold is 60% (internal goal) (no UDS national roll-up for comparison)

B. The performance threshold is 60% (internal goal) (no UDS national roll-up for comparison)


QI Coordinator

Data source:

1. PMS is queried for a report of user 18 years of age.

2. For Part A and Part B measures, users are selected randomly from the report regardless to the health centerorigin using the UDS Audit Sampling Methodology described in the Appendix based on population sizegreater than 500.

3. Electronic medical records are reviewed.Evaluation: Under the supervision of the Medical Director, report is generated by QI Coordinator Report is reviewed by Quality Improvement Committee for opportunities for improvement.

Reporting Frequency:Annually


25

Geriatric Life Cycle:Geriatric Immunization

Background and Objective:1. Influenza and pneumococcal infections are common cause of illness and death in persons >65 years of age,

especially in those with underlying medical conditions.

2. UDS utilization measure.

Key Action Steps:1. Maintain adequate stores of pneumococcal vaccine at all health center locations

2. Maintain adequate seasonal supplies of influenza vaccine for all health center locations

3. Perform internal marketing to providers and nursing staff about the importance of pneumococcalvaccination and annual influenza vaccination.

4. Mail notices to patients who are 65 years and older informing them about need for Flu vaccine

Indicator (rate based & effort-related): Numerator: Patients in the denominator for whom documentation shows that both pneumococcal vaccine

and current season influenza vaccine have been administered by NEON or another medical provider.

Denominator: A cohort of patients 65 years of age or older who have been seen at least twice at NEON andat least once during the calendar year by a primary care provider

Goal/Performance Threshold:A. The performance threshold is 70% for Influenza vaccination (internal goal)

B. The performance threshold is 70% for Pneumococcal vaccination (internal goal)

Owner, Data Source and Evaluation:Owner: QI CoordinatorData source:

1. PMS is queried for a report of users (65 years of age and older) as described in the denominator of theindicator description noted above.


3. Electronic medical records are reviewed.Evaluation: Under the supervision of the Medical Director, report is generated by QI Coordinator Report is reviewed by Quality Improvement Committee for opportunities for improvement.

Reporting Frequency:Annually during the first quarter of the calendar year


26

Oral Medicine:Phase One Oral Treatment Plan Completion

Background and Objective:1. BPHC 2010 Health Plan clinical performance measure.

2. NEON seeks to increase access to oral health care for the underserved. This performance measureaddresses two fundamental areas: 1) the need to perform a comprehensive oral health exam thatculminates with an accompanying treatment plan and 2) assuring that quality care is incorporated in theprocess of completing needed treatment in a timely manner.

3. Our performance with this measure, if sub-optimal, prompts the identification of contributing andconstraining factors and practical low cost improvement options relevant to significant areas listed above.

Key Action Steps:1. Distribute NEON Dental Guidelines that espouse ADA consensus on the appropriate components of cost

effective dental care.

2. Strive to maintain adequate dental provider staffing and ancillary staffing, improve scheduling efficiencies,and improve show-rate by promoting activities directed at modifying patient cultural expectations.

Indicator (rate based & outcome related): Numerator: Number of patients that complete Phase 1* treatment within 12 months of initiating a

treatment plan.

*Phase 1 = Prevention, maintenance and/or elimination of oral pathology that results from dental caries orperiodontal disease. This includes: oral cancer prevention and early diagnosis; prevention education andservices; emergency treatment; diagnostic services and treatment planning; restorative treatment; basicperiodontal therapy (non surgical); basic oral surgery that includes simple extractions and biopsy; non-surgical endodontic therapy; and space maintenance and tooth eruption guidance for transitional dentition.

Note: if the patient chooses to discontinue Phase 1 therapy, then the treatment would be consideredcomplete.

Denominator: Number of patients that receive a comprehensive oral exam (ADA code 0110 or 0150) or aperiodic recall (ADA code 0120) oral exam within the previous 12-18 months


Owner, Data Source and Evaluation:Owner: Dental DirectorData source:

1. PMS is queried for a report of dental users as described in the denominator of the indicator descriptionnoted above.


3. Electronic dental records are reviewedEvaluation: Under the supervision of the Medical Director, report is generated by QI Coordinator Report is reviewed by Quality Improvement Committee for opportunities for improvement.

Reporting Frequency:Annually


27

Pharmacy & Therapeutics:Appropriateness of Antibiotic Use

Background and Objective:1. Antibiotic resistance patterns are becoming increasingly problematic.

2. NEON is a practice dedicated to public health. Therefore, it providers must contribute to the public’s healthby doing their part to mitigate the increase in antibiotic resistance.

Key Action Steps:1. Providers are encouraged to follow antibiotic prescribing guidelines.

2. A webpage at www.neonproviders.com (Competencies & Testing, Get Smart: Antibiotic Use) is dedicated toappropriateness of antibiotic use featuring the CDC’s Get Smart campaign.

3. Through survey analysis and the provision of feedback to providers, the objective is to impact theprescribing habits of NEON providers to mirror accepted evidence-based guidelines of care. Informationgleaned from analysis of the audit herein specified will be shared with providers.

Indicator (rate based, process-related):

Numerator: Patients in the denominator for whom the antibiotic was prescribed appropriately

Denominator: A cohort of patients who have been prescribed an antibiotic over the previous 90 days by aNEON medical or dental provider and the antibiotic was dispensed by a NEON pharmacy


Owner, Data Source and Evaluation:Owner: Medical DirectorData source:

1. Pharmacy Director determines top four antibiotics that are prescribed. Medical Director selects two ofthese antibiotics. Pharmacy Director provides a listing of patients as described in the denominator of theindicator description noted above who have been prescribed the targeted antibiotics.

2. Users are selected randomly from the report, regardless to the health center origin, using the UDS AuditSampling Methodology described in the Appendix based on population size greater than 500.

Evaluation:

Medical Director or a physician delegate performs health record reviews and determine ‘antibioticappropriateness’ based on accepted standards/guidelines of care.


www.neonproviders.com


28

Pharmacy & Therapeutics:Medication Errors

Background and Objective:1. This measure is a response to a Joint Commission Performance Indicator (medication errors and prohibited

abbreviations) and one means of supporting patient safety.

2. The old adage of ‘first do no harm’ will never become outdated.

Key Action Steps:1. Medical and dental providers are encouraged to be extremely careful in their prescriptions of medications

for patients. Nursing staff is encouraged to question a NEON provider on any prescription of medicationthat appears to be inappropriate for the user, in type or dose.

2. When generating a prescription from the electronic health record system, prescribing providers arerequired to indicate the diagnosis that is associated with the medication. This provides an additionalpatient safety opportunity for pharmacist filling the prescription. The pharmacist can question theindication for the medication given the associated diagnosis if it seems inappropriate.

3. Pharmacy providers are also encouraged to question a NEON provider on any prescription that appears tobe inappropriate for the user, in type or dose.

4. Medical and dental providers are encouraged to report all instances where it appears that a dispensingerror occurred.

5. Pharmacy providers are required to report all instances where it appears that a prescribing error occurred.A P&T “Medication Error” reporting form should be completed in either case by the responsible providerand submitted to the Pharmacy Director or Medical Director. The reporting form allows input on thefollowing errors: Incorrect patient; incorrect medication; use of ‘prohibited abbreviations’; incorrect dose ofmedication.

Indicator (rate based & outcome related): Numerator: Total of medical errors reported by Pharmacy or Provider, utilizing ‘Medication Error’ form

during the previous 6 months

Denominator: Total number of prescriptions filled by NEON pharmacies during the previous 6 months

Goal/Performance Threshold:The performance goal is less than 0.01% (less than 1 in 10,000 prescriptions written)

Owner, Data Source and Evaluation:Owner: Pharmacy DirectorData source:

Pharmacists and prescribing providers

“Medication Error” forms are submitted to the Pharmacy Director or the Medical Director

Evaluation:

1. Pooled reporting forms are reviewed and the Medical Director, summarizing the 6 months of the studyperiod in order to detect adverse trends and patterns of behavior, where applicable, generates a report.

2. The Pharmacy Director in conjunction with the Medical Director determines the appropriate action basedupon the findings relative to clinical providers.



29

BPHC Grant ViabilityNumber of Users

Background and Objective:1. In order to ensure that there is adequate access to health care, HRSA is becoming increasingly more

concerned about a health center’s number of users rather than simply the level of productivity.

2. Health care organizations are being prompted to begin identifying more efficient and effective means ofserving patients so as to ensure that there is adequate primary care capacity to address the needs ofcitizens that find themselves newly insured under the Affordable Care Act in the coming years. FQHCs willsurely be at the forefront of these strategies.

Key Action Steps:1. Ensuring adequate provider capacity.

2. Ensuring adequate access to health centers telephonically and in person.

3. Ensuring a presence in the communities we serve via marketing and outreach efforts.

4. Providers and management staff receive monthly reports illustrated in ‘scorecard’ format.

Indicator (cumulative, leading):

All Users quantified cumulative for the year

All Medical Users quantified cumulative for the year

All Dental Users quantified cumulative for the year

All Behavioral Health Users quantified cumulative for the year

Goal/Performance Threshold:2011 performance goal is: All Users 43,135; Medical Users 41,841; Dental Users 10,533; BH Users 516

Owner, Data Source and Evaluation:Owner: CFO and Medical DirectorData source:

PMS

Evaluation:

1. A PMS report is generated and provided to the Medical Director.

2. A report is developed noting positive or negative variances as compared to the respective cumulativetargets based on the proportion of the 12-month period remaining.



30

Financial ViabilityProvider Productivity

Background and Objective:1. Dependent on financial mix, provider productivity is a leading indicator of net patient revenues.

2. Health care organizations are being prompted to begin identifying more efficient and effective means ofserving patients so as to ensure that there is adequate primary care capacity to address the needs ofcitizens that find themselves newly insured under the Affordable Care Act in the coming years. FQHCs willsurely be at the forefront of these strategies.




4. Monthly reports of individual productivity are distributed to providers.

5. Monthly reports provide individual productivity targets for individual providers, based on their full timeequivalency.

Indicator (snapshot, leading):

All Visits quantified cumulative for the year

All Medical Visits quantified cumulative for the year

All Dental Visits quantified cumulative for the year

All Behavioral Health Visits quantified cumulative for the year

Goal/Performance Threshold:2011 performance goal is: All Visits 130,025; Medical Visits 105,496; Dental Visits 22,645; BH Visits 1,884


PMS

Evaluation:

3. A PMS report is generated and provided to the Medical Director.

4. A report is developed noting positive or negative variances as compared to the respective cumulativetargets based on the proportion of the 12-month period remaining.

Reporting Frequency:Monthly


31

Financial ViabilityFinancial Mix

Background and Objective:1. Financial mix along with provider productivity is a leading indicator of net patient revenues.

2. FQHC health centers must be mindful of financial mix; otherwise they will find themselves with costsoutstripping revenues.

3. BPHC stipulates that FQHCs must generate enough revenue to exceed that of federal grant support (>50%)




4. Address the needs of our senior citizens.

5. Sustaining and growing our Medicaid/Medicaid HMO enrollment by partnering with HMOs in their variousoutreach programs.

6. Sustaining and growing Medicaid HMO enrollees’ appropriate use of services via the use of registriesaligned with HEDIS performance measures, provided by respective HMOs.

Indicator (rate based & leading): Numerator A: Self Pay Visits quantified cumulative for the year

Numerator B: Medicaid FFS and Medical HMO FFS Visits quantified cumulative for the year

Numerator C: Medicare FQHC FFS Visits quantified cumulative for the year

Denominator for A, B, C: Total of All Visits quantified cumulative for the year

Goal/Performance Threshold:2011 performance goal is: 38% Self Pay; 50% Medicaid-related; 5% FQHC Medicare


PMS

Evaluation:

1. A preliminary report is generated by CFO and provided to the Medical Director.

2. A report is developed by the Medical Director that depicts positive or negative variances as compared tothe respective targets.



32

Financial ViabilityMedicaid HMO Assignment

Background and Objective:1. Medicaid HMO Assignment contributes to Financial Mix indicator along with provider productivity is a

leading indicator of net patient revenues.

2. FQHC health centers must be mindful of financial mix; otherwise they will find themselves with costsoutstripping revenues.

3. BPHC stipulates that FQHCs must generate enough revenue to exceed that of federal grant support (>50%)




4. Sustaining and growing our Medicaid/Medicaid HMO enrollment by partnering with HMOs in their variousoutreach programs.

Indicator (snapshot & leading): Total aggregated number of Medical HMO Enrollees across the HMOs

Goal/Performance Threshold:2011 performance goal is: 19,000

Owner, Data Source and Evaluation:Owner: Operations DirectorData source:

PMS

Evaluation:

3. A preliminary report is generated by Operations Director and provided to the Medical Director.

4. A report is developed by the Medical Director that depicts positive or negative variances as compared tothe target.



33

Financial ViabilityAppointment Show Rate

Background and Objective:1. Appointment Show Rate along with financial mix a leading indicator of net patient revenues.

2. Appointment Show Rate is also associated with advancing the health status of patients with chronicdiseases.

3. FQHC health centers must be mindful of show rates; otherwise they will find themselves depending onwalk-in traffic to remain viable.

Key Action Steps:1. Provide patient reminders.

2. Provide daily opportunities for Same-Day appointments

3. Send missed appointment notices to patients.

4. Provide patients with appointments that they want rather than what we have available.

Indicator (rate based cumulative & leading): Numerator: Total number of kept appointments quantified cumulative for the year

Denominator: Total number of made appointments quantified cumulative for the year

Goal/Performance Threshold:The performance goal is 80% (internal)


PMS

Evaluation:

5. A preliminary report is generated by CFO and provided to the Medical Director.

6. A report is developed by the Medical Director that depicts positive or negative variances as compared tothe target.



34

Exhibit 1: Medication Error Reporting Form

MEDICATION ERROR FORM

Patient Name: DOB: MR #:

Name of Medication: Date of Prescription:

Name of Prescriber: Name of Pharmacist:

Health Center: Hough Superior Collinwood Southeast E. Cleveland Norwood

ERROR DESCRIPTION (completed by Prescriber or Pharmacist, where applicable)

Type of Error: Incorrect patient Incorrect medication

Incorrect dose Prohibited Abbreviation

Source of Error: Prescribing Doctor Prescribing APN/PA Dispensing Pharmacist

When was Error Detected: Prior to dispensing medication After medication was dispensed

If medication was dispensed after detection of medication error, describe the details of patient notification.

If medication error was due to prescriber/dispenser error, described below the details of prescriber ordispenser notification.

Provide Explanation for Medication Error: (completed by individual represented above as the ‘source of error’)

Name of Staff Person Completing this Form: Date Completed:

Forward to Pharmacy Director or Medical Director upon Completion


35

Exhibit 2: Patient Perception/Satisfaction Survey Tool

Our Report CardNEON Health Centers are committed to serving you better. Our aim is to achieve the highest grades. However, weare always in school looking for and learning new and better ways to serve you. When you give us a grade, it lets usknow how we are doing. Please complete our report card by circling or checking your choices in the area provided tothe right. An “A” is the best grade. An “F” is the worst grade.

A. Give our Medical Providers a grade on how well they: Check or Circle Choices

1. Understand what you say; A B C D F

2. Explain things to you; A B C D F

3. Take enough time with you; A B C D F

4. Take care of your Medical needs or problems; A B C D F

5. Take care of your Pain. A B C D F

B. Give our Dentists a grade on how well they: Check or Circle Choices




4. Take care of your Medical needs or problems; A B C D F

5. Take care of your Pain. A B C D F

C. Give our Nurses a grade on how well they: Check or Circle Choices




4. Act kind and courteous with you. A B C D F

D. Give our Dental Assistants a grade on how well they: Check or Circle Choices





E. Give our Receptionists a grade on how well they: Check or Circle Choices






36

Exhibit 2: Patient Perception/Satisfaction Survey Tool (backside)

F. Give our Health Center facility a grade on: Check or Circle Choices

1. How easy it is to get an appointment; A B C D F

2. How clean the building and exams rooms are; A B C D F

3. Your comfort while waiting to see one of our doctors; A B C D F

4. How organized things are. A B C D F

G. Give our Health Center health care team a grade on: Check or Circle Choices

1. How well you think our people that work here care about yourfamily’s health and well-being;

A B C D F

2. If you or your child is very sick, your ability to see one of our doctorswithin 24 hours after you called; A B C D F

3. How easy it is for you to talk on the phone to one of our doctors ornurses on the day you called; A B C D F

4. Being seen by one of our nurses within 30 minutes of yourappointment; A B C D F

5. How well you like our clinic hours. A B C D F

H. Give our Health Center support staff a grade on: Check or Circle Choices

1. How long it takes our Lab people to serve you; A B C D F

2. How long it takes our X-ray people to serve you. A B C D F

I. Give our Pharmacy people a grade on: Check or Circle Choices

1. How long it takes to get your prescription filled; A B C D F

2. How they act kind and courteous with you. A B C D F

J. How did you get here today? Bus Friend Drove Myself I Walked

(check answers) Cab HMO Van NEON Van Other Means

K. Would you tell your friends and relatives to come toour Health Center? Yes No Maybe

Your Comments:

If you wish, you may sign your name here:

Please p lace your report in the envelope provided and seal i t .Give your report to the Survey Staf f .

Thank You for Your Time and Your Help.


37

Exhibit 3: Clinical Audit Sampling Methodology

UDS AUDIT SAMPLING METHODOLOGY

STEP 1: Identify the patient population to be sampled (the universe):

Define the universe for each condition. Create a list and count each member of the patient population.

STEP 2: Determine the sample size for manual chart review:

The number of charts selected for manual chart review will be based upon the universe. The sample size will be 70 orthe number of charts that qualify; whichever is less.

STEP 3: Calculate the sample interval

Divide the patient population universe by the sample size to obtain the sample interval.

Sample Interval Size = Population size (N)/ Sample size (n)

STEP 4: Conduct systematic sample

Random Start:

Randomly pick a patient from the first sampling interval. For example, if the sampling interval is 10, the first samplinginterval includes patients #1 through #10. Randomly select one patient from this interval (e.g., Research Randomizer atwww.randomizer.org/form.htm)

Then, select every nth patient based on the sampling interval until reaching the desired sample size. For example, if thefirst patient selected is #8, and the sampling interval is 10, then the remaining patients to be selected are #18, #28,#38, etc.

Reselection Criteria:

If a selected chart is one for a patient that is not a member of your patient panel or is a patient that should beexcluded from the sample then you will need to reselect another patient chart. Go to the next chart; continue selectingthe next chart until a chart for an eligible patient is selected. Resume selection using the normal sampling interval aftersuccessful reselection. (If we run out of charts, we should continue the count back at the beginning of the universe.)

NOTE: For each measure, we have the option of reporting on the entire patient population as a universe (e.g., for theperinatal measures). This is an optimal method if the data for the measure are collected electronically and can bereported without manual intervention or manipulation.

www.randomizer.org/form.htm


QIC-P9 QM Work Plan 1

QIC Policy Name: Quality Management Work Plan QIC Policy Code: QIC-P9



Related QIC Policies: QIC-P8 QIP Plan; QIC-P11 Risk Management Plan; QIC-P13 Peer Review Plan; QIC-P14 Credentialing & Privileges Plan

Attachments:


AFFIRMATION:

The Quality Management (QM) Work Plan will be developed annually and revised in accordance with programmatic changes. The QI Coordinator and the Medical Director are responsible for development and implementation of the annual QM Work Plan.

PURPOSE:

The policy establishes the guidelines for carrying out the work details of the various Plans associated with this Quality Improvement Program. The Work Plan provides the WHO, HOW, WHAT, and the WHEN with respect to the various components of each Plan. By establishing a written work plan, we are able to properly coordinate our efforts and thus generate timely quality assessments.

PROCEDURE:

A. QM Work Plan Development

1. QIP Plan

a) The QI Coordinator will review the QIP Plan’s individual performance measure descriptions and assign dates of report completion based on the periodicities assigned to each measure.

b) The ‘Owner’ of each performance measure will be identified.

c) For each performance measure, a Quality Work Group will be identified that should receive the report for analysis and eventual quality work.

d) A calendar of these activities will be generated and distributed to the QIC and posted at the Intranet.

e) The QI Coordinator is responsible for providing reminders to ‘Owners’ of imminent reporting requirements (i.e., due within 7 days).

2. Risk Management Plan

a) The Medical Director will facilitate the review by the Risk Management Committee of the Risk Management Plan for deliverables associated with the Plan on an annual basis

b) The responsible party for each performance objective will be identified and tabulated.

c) Compliance dates will be included in the tabulation and this tabulation (e.g., matrix) should be kept up-to-date.



3. Peer Review Plan

a) The QI Coordinator will review the provider staff roster to determine the number of individuals who will undergo the peer review process.

b) It is intended that the peer review process be staggered throughout any given 12-month period so that peer review be performed on a quarterly basis in order to achieve the annualized commitment for each affected provider.

c) The clinical staff person who will perform the peer review will be identified.

d) A calendar of peer review activities will be generated and distributed to the Clinical Staff Committee.

e) The QI Coordinator is responsible for providing a listing of patients for each index provider to the designated peer reviewer.

f) The QI Coordinator is responsible for providing reminders to peer reviewers of imminent reporting requirements (i.e., due within 7 days).

4. Credentialing & Privileges Plan

a) The Associate Director of Medical Affairs (ADMA) will review the provider staff roster to determine who is up for re-credentialing within 90 days of expiration of privileges.

b) It is intended that the credentialing process be staggered throughout any given 12-month period so that credentialing is be performed on a quarterly basis in order to satisfy our credentialing commitment and present our findings to the Board of Trustees on a timely basis.

c) A calendar of credentialing activities will be generated and distributed to the Clinical Staff Committee and this calendar should be kept up-to-date.

d) The ADMA is responsible for providing a listing of providers up for re-credentialing to the Clinical Staff Committee on a quarterly basis, when applicable.

B. QM Work Plan Reviews & Approvals

1. Timeframes

a) Annually the QM Work Plan is developed, usually during the fourth quarter of the year for the coming year.

b) Review and approvals should be completed by the end of the first quarter of the New Year, if not sooner.

2. Review

The QM Work Plan draft is submitted to the Medical Director (QIC Chair) for review and input.

The QM Work Plan is submitted to Quality Work Groups wherever applicable for review and input.

3. Approval

The final draft of the QM Work Plan is submitted to the Chair for approval.



C. Implementation of the QM Work Plan

It is the responsibility of the Medical Director and QI Coordinator to ensure the execution of the QM Work Plan and ensure that measures and data are reported and procedures performed in accordance with the four Plans referred to hereinabove.




QIC-P10 Annual QIP Evaluation 1

QIC Policy Name: Annual QIP Evaluation QIC Policy Code: QIC-P10



Related QIC Policies: QIC-P1 QIP Fundamentals; QIC-P8 QIP Plan; QIC-P11 Risk Management Plan; QIC-P13 Peer Review Plan; QIC-P14 Credentialing & Privileges Plan

Attachments: Evaluation Template


AFFIRMATION:

Annually the Quality Improvement Program (QIP) will be evaluated for effectiveness.

PURPOSE:

The policy establishes the structure for the Annual QIP Evaluation that is presented to the Quality Improvement Committee (QIC) and ultimately to the Board of Trustees. This structure provides for a systematic and consistent programmatic evaluation of the QIP and provides a method of communicating the evaluation and determining the ways in which the various Plans associated with this QIP might be modified, revised, or updated.

PROCEDURE:

A. Program Evaluation

1. Responsibility

a) It is the responsibility of the QI Coordinator and Medical Director to develop the Annual QIP Evaluation.

b) Once a draft is completed it will be submitted by the Medical Director (QIC Chair) to the QI Committee for review and input.

c) The final draft will be submitted to the Board of Trustees as the Annual QIP Evaluation by the Medical Director.

2. Timeline

a) The draft Annual QIP Evaluation will be presented to the QIC during the early part of the first quarter of the New Year for prior year QIP activities.

b) The final draft of the Annual QIP Evaluation will be submitted to the Quality Committee of the Board of Trustees during the first quarter of the New Year for prior year QIP activities.

3. Review & Approval

a) The QIC reviews the draft Annual QIP Evaluation.

b) The Board of Trustees’ Quality Committee reviews the QM Program Evaluation and provides input to Medical Director, as appropriate, prior to presentation to the full Board of Trustees.

c) Upon presentation of the Annual QIP Evaluation to the Board of Trustees, the Board approves the report.



B. Evaluation Content

1. Format of evaluation

a) The attachment to this policy displays the format and current content requirements of the Annual QIP Evaluation.

b) The Annual QIP Evaluation template will be revised as needed to reflect the full and proper scope of the Quality Improvement Program.

2. This QM Program Evaluation will be maintained, retained and secured in the same manner as all QM documents as defined in QM-101 QM Program.





Exhibit 1: Annual QIP Evaluation Template

This template is utilized to help build the narrative for the annual report.

Executive Summary

Achieved Improvements and Significant Accomplishments

Findings:

Opportunities for Improvement

Findings:

Short and Long Term Recommendations for Improvement

Findings:

Quality Improvement Program Development

Resources Supporting QIP

Findings:

Regulatory Requirements, Safety & Compliance

HRSA

Findings:

FTCA

Findings:

OSHA

Findings:

Other

Findings:

Clinical Staff

Peer Review

Findings:

Credentialing

Findings:



Clinical Monitoring & Process Improvement Initiatives

Chronic Disease Management

Findings:

Preventive Health

Findings:

Process Improvement Initiatives

Findings:

Satisfaction

Patient Satisfaction

Findings:

Employee Satisfaction

Findings:


QIC-P11 Risk Management Plan 1

QIC Policy Name: Risk Management Plan QIC Policy Code: QIC-P11



Related QIC Policies: QIC-P7 QI Mechanics; QIC-P8 QIP Plan; QIC-P10 QIP Annual Evaluation; QIC-P12 Adverse & Near-Miss Events

Attachments:

Authorization: Refer to QIC-S1 Authorization Signatures QIP Goal Congruency: Patient Safety

AFFIRMATION:

The Risk Management Quality Workgroup Committee of the Quality Improvement Committee has the responsibility for overseeing the organization’s compliance with the approved Risk Management Policy. This effort is articulated through the Risk Management Plan herein articulated. This risk management effort is an integral component of this organization’s Quality Improvement Program. Along with the QIP Plan, the Risk Management Plan is included in the Annual Evaluation (refer to QIC-P10 QIP Annual Evaluation).

PURPOSE:

The Risk Management Plan (herein referred to as Plan) is designed to support the mission and vision of NEON as it pertains to clinical risk and patient safety as well as visitor, third party, volunteer, and employee safety and potential business, operational, and property risks.

GOALS:

The goals of the Plan are to:

a) Continuously improve quality of care and patient safety and minimize and/or prevent the occurrence of errors, events, and system breakdowns leading to harm to patients, staff, volunteers, visitors, and others through proactive risk management and patient safety activities.

b) Minimize adverse effects of errors, events, and system breakdowns when they do occur.

c) Minimize losses to the organization overall by proactively identifying, analyzing, preventing, and controlling potential clinical, business, and operational risks.

d) Facilitate compliance with regulatory, legal, and accrediting agency requirements (e.g., Joint Commission).

e) Protect human and intangible resources (e.g., reputation).

1. PRINCIPLES AND OBJECTIVES

The Plan is an overarching, conceptual framework that guides the activities of a program for risk management and patient safety initiatives. The Plan supports the organization’s philosophy that patient safety and risk management is everyone’s responsibility. Teamwork and participation among management, providers, volunteers, and staff are essential for an efficient and effective patient safety and risk management program. The Plan is implemented through the coordination of multiple organizational functions and the activities of multiple departments.



NEON supports the maintenance of a just culture that emphasizes implementing evidence-based best practices, learning from error analysis, and providing constructive feedback, rather than blame and punishment. In a just culture, unsafe conditions and hazards are readily and proactively identified, medical or patient care errors are reported and analyzed, mistakes are openly discussed, and suggestions for systemic improvements are welcomed. Individuals are still held accountable for compliance with patient safety and risk management practices. As such, if evaluation and investigation of an error or event reveal reckless behavior or willful violation of policies, disciplinary actions should be taken.

The Plan stimulates the development, review, and revision of the organization’s practices and protocols in light of identified risks and chosen loss prevention and reduction strategies. The Plan provides the foundation for developing key processes and procedures for day-to-day risk management activities that are geared towards implementing the current NEON Risk Management Policy. The goals of the Plan drive the following objectives:

1. Periodic examination of all physical premises to identify and correct conditions that are potentially hazardous to patients, employees, providers, and others;

2. Periodic review of the performance of all providers and staff members to identify and correct any practices that deviate from established procedures, quality guidelines, or potentially place patients at risk of harm;

3. Periodic review of NEON’s policies and procedures with revision as necessary to reflect current accepted standards of practice and alignment with BPHC program requirements with regards to risk management;

4. Resolution of patient complaints in a timely and respectful manner and the systematic evaluation of patient complaints to identify adverse trends that might contribute to organizational risk;

5. Coordination of the management of malpractice claims against NEON and/or its providers or staff in a timely and organized manner and in accordance FTCA administrative rules;

6. Compliance with FTCA requirements for FQHC quality-risk programs inclusive of credentialing, quality improvement, risk management, and service arrangements

7. Continuous Joint Commission accreditation;

8. Provision of education programs to providers and staff members on risk management and patient safety to heighten awareness of risk management issues and increase compliance with patient safety practices;

9. Event reporting, Identification, investigation, and trending of hazardous conditions, near misses, adverse occurrences, and potentially compensable events to prevent recurrence of similar events and to mitigate losses;

10. Risk assessment and risk mitigation planning;

11. Compliance with legal and regulatory mandates.

2. Executive Sponsorship

The success of Plan activities requires top-level commitment and support. NEON’s Senior Staff is committed to promoting the safety of all patients and the quality of their care, as well as the safety of



visitors, employees, volunteers, and other individuals involved in NEON operations. The Plan is designed to reduce system-related errors and potentially unsafe conditions by implementing continuous improvement strategies to support an organizational culture of safety and high quality patient care. Organizational leadership and management teams are empowered with the responsibility for implementing performance improvement and risk management strategies.

3. DEFINITIONS

Adverse event or incident: An undesired outcome or occurrence, not expected within the normal course of care or treatment, disease process, condition of the patient, or delivery of services.

Failure mode and effects analysis: A proactive method for evaluating a process to identify where and how it might fail and for assessing the relative impact of different failures in order to identify the parts of the process that are most in need of improvement. (refer to QIC-P7 QI Mechanics)

Loss control/loss reduction: The minimization of the severity of losses through methods such as claims investigation and administration, early identification and management of events, and minimization of potential loss of reputation.

Loss prevention: The minimization of the likelihood (probability) of a loss through proactive methods such as risk assessment and identification; staff and volunteer education, credentialing, and development; policy and procedure implementation, review, and revision; preventive maintenance; quality/performance review and improvement; root-cause analysis; and others.

Near miss: An event or situation that could have resulted in an accident, injury, or illness but did not, either by chance or through timely intervention (e.g., a procedure almost performed on the wrong patient due to lapse in verification of patient identification but caught at the last minute by chance). Near misses are opportunities for learning and afford the chance to develop preventive strategies and actions. Near misses receive the same level of scrutiny as adverse events that result in actual injury.

Patient Safety Goals: National Patient Safety Goals (NPSGs) for ambulatory care, established by the Joint Commission. The purpose of NPSGs is to improve patient safety by focusing on problems in healthcare safety and how to solve them. Current Joint Commission goals include:

Identify patients correctly.

Use medicines safely by labeling them appropriately and taking precautions with anticoagulants.

Review patient medications; communicate and educate about current medication regimens.

Prevent infections.

Potentially compensable event (PCE): An unusual occurrence or serious injury for which there is neither an active claim nor institution of formal legal action but that, in the organization’s judgment, is reportable to the party (or parties) providing the medical malpractice insurance. Examples include a fall with injuries, delay or failure in diagnosing a patient’s condition, an adverse reaction to treatment, significant complaints from a patient or family regarding care or treatment, and an attorney request for medical records.

Risk analysis: Determination of the causes, potential probability, and potential harm of an identified risk and alternatives for dealing with the risk. Examples of risk analysis techniques



include failure mode and effects analysis, systems analysis, root-cause analysis, and tracking and trending of adverse events and near misses, among others.

Risk assessment: Activities undertaken in order to identify potential risks and unsafe conditions inherent in the organization or within targeted systems or processes.

Risk avoidance: Avoidance of engaging in practices or of hazards that expose the organization to liability.

Risk control: Treatment of risk using methods aimed at eliminating or lowering the probability of an adverse event (i.e., loss prevention) and eliminating, reducing, or minimizing harm to individuals and the financial severity of losses when they occur (i.e., loss reduction).

Risk financing: Analysis of the cost associated with quantifying risk and funding for it.

Risk identification: The process used to identify situations, policies, or practices that could result in the risk of patient harm and/or financial loss. Sources of information include proactive risk assessments, closed claims data, adverse event reports, past accreditation or licensing surveys, medical records, clinical and risk management research, walk-through inspections, safety and quality improvement committee reports, insurance company claim reports, risk analysis methods such as failure mode and effects analysis and systems analysis, and informal communication with healthcare providers.

Risk management: Clinical and administrative activities undertaken to identify, evaluate, prevent, and control the risk of injury to patients, staff, visitors, volunteers, and others and to reduce the risk of loss to the organization itself. Activities include the process of making and carrying out decisions that will prevent or minimize clinical, business, and operational risks.

Risk retention: Internally driven financing mechanisms (e.g., self-insured retentions) intended to pay for accidental and uninsurable losses.

Risk transfer: Techniques involving the process of shifting the financial burden of losses to an external party or parties (e.g., insurance, contracts).

Root-cause analysis: A process for identifying the basic or causal factor(s) that underlie the occurrence or possible occurrence of an adverse event. (refer to QIC-P7 QI Mechanics)

Sentinel event: Defined by the Joint Commission as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse event.

Unsafe and/or hazardous condition: Any set of circumstances (exclusive of a patient’s own disease process or condition) that significantly increases the likelihood of a serious adverse outcome for a patient or of a loss due to an accident or injury to a visitor, employee, volunteer, or other individual.

4. SCOPE AND FUNCTIONS OF THE PLAN

The Plan interfaces with many operational departments and services throughout NEON’s operation.

4.1 Functional Interfaces

Functional interfaces with the patient safety and risk management program include the following (in alphabetical order):

Buildings and grounds



Credentialing of providers

Disaster preparation and management

Event/incident/accident reporting and investigation

Human resources

Infection control

Information technology

Legal and contracts

Materials management

Medication management

Patient and family education

Patient satisfaction

Quality and performance assessment and improvement

Safety and security

Social service programs

Staff education

Volunteers

4.2 Risk Management Functions

Risk management functional responsibilities include:

a) Maintaining a system for and overseeing the reporting of adverse events, near misses, and potentially unsafe conditions. Reporting responsibilities include internal reporting as well as external reporting to regulatory, governmental, or voluntary agencies. This includes the development and implementation of event-reporting policies and procedures.

b) Ensuring the collection and analysis of data to monitor the performance of processes that involve risk or that may result in serious adverse events (e.g., preventive screening, diagnostic testing, medication use processes, perinatal care). Proactive risk assessment will include the use of failure mode and effects analysis, system analysis, and other tools.

c) Maintaining an information system for overseeing organizational data collection and processing, data analysis, and generation of statistical trend reports wherever possible for the identification and monitoring of adverse events, and effectiveness of risk management execution. This system draws from the following sources of information:

Attorney requests for medical records, x-rays, laboratory reports

Quality Improvement Committee reports and minutes

Criteria-based outcome studies

Event, incident, or near miss reports and root-cause analysis

Health record reviews

Monitoring systems based on objective criteria

Notice letters, lawsuits

Patient complaints

Provider and nursing input



Results of failure mode and effects analysis of high risk processes

Root-cause analyses of sentinel events

d) Analyzing data collected on adverse events, near misses, and potentially unsafe conditions; providing feedback to providers and staff; and using this data to facilitate systems improvements to reduce the probability of occurrence of future related events. Root-cause analysis and systems analysis will be used to identify causes and contributing factors in the occurrence of such events

e) Ensuring compliance with data collection and reporting requirements of governmental, regulatory, and accrediting agencies.

f) Facilitating and ensuring the implementation of patient safety initiatives such as improved tracking systems for preventive screenings and diagnostic tests, medication safety systems, and clinical quality of care programs.

g) Ensuring effective handoff processes for continuity of patient care.

h) Facilitating and ensuring provider and staff participation in educational programs on patient safety and risk management.

i) Facilitating a culture of safety in the organization that embodies an atmosphere of mutual trust in which all providers and staff members can talk freely about safety problems and potential solutions without fear of retribution. This ordinarily involves performing safety culture surveys and assessments via mechanisms established for annual assessment of employee satisfaction.

j) Proactively searching for opportunities and strategies to reduce unsafe situations and improve the overall environmental safety of patients, visitors, staff, and volunteers.

k) Reducing the probability of events that may result in losses to the physical plant and equipment (e.g., biomedical equipment maintenance, fire prevention).

l) Preventing and minimizing the risk of liability to the organization, and protecting the financial, human, and other tangible and intangible assets of the organization.

m) Decreasing the likelihood of claims and lawsuits by developing a patient and family communication and education plan. This includes communicating and disclosing errors and events that occur in the course of patient care with a plan to manage any adverse effects or complications.

n) Reporting claims and potentially compensable events to FTCA authorities in accordance with the requirements of the FTCA policies and procedures.

o) Supporting clinical quality assessment and improvement programs throughout the NEON.

p) Implementing programs that fulfill regulatory, legal, and accreditation requirements.

q) Establishing an ongoing patient safety/risk management committee (herein below referred to as the Risk Management Team) composed of representatives from key clinical and administrative departments and services.

r) Monitoring the effectiveness and performance of risk management and patient safety actions. Performance monitoring data may include:

Assessments for ‘culture of safety’ (e.g., surveys)

Ongoing risk assessment information

Patient’s and/or family’s perceptions of how well the organization meets their needs and expectations

Quality performance data



Trending of event data

s) Completing FTCA deeming applications on a timely basis.

5. ADMINISTRATION, STRUCTURE, & MECHANISMS FOR COORDINATION

The Plan is administered through the Risk Management Team (RMT). The RMT is comprised of the Medical Director, Dental Director, Operations Director, Safety Officer, and the Executive Assistant to the CEO. The RMT reports to the CEO. The RMT interfaces with administration, staff, medical providers, and other professionals and has the authority to cross operational lines in order to meet the goals of the program. The Medical Director directs the activities of the RMT. The RMT convenes meetings periodically (quarterly at a minimum); meetings that may include representatives from any clinical or operations department depending on the issues at hand. Members of the RMT are purposed to facilitate the sharing and dissemination of risk management knowledge and practices across multiple disciplines and to optimize the use of key findings from risk management activities that ultimately lead to the reduction of the overall likelihood of adverse events and to improve patient safety and quality of care.

The RMT is responsible for overseeing day-to-day monitoring of patient safety and risk management activities and for various related investigations. The Executive Assistant to the CEO oversee the reporting of non-clinical risk-related events to external organizations, per regulations and contracts, and communicates analysis and feedback of reported risk management and patient safety information back to the RMT for action. The Medical Director and the Executive Assistant to the CEO are responsible for reporting to the FTCA agent on a timely basis actual or potential clinical lawsuits arising out of the organization, as specified by FTCA. The Executive Assistant to the CEO and the Medical Director serve as the primary contacts between NEON and external parties on all matters relative to risk identification, prevention, and control, as well as risk retention and risk transfer.

6. MONITORING AND CONTINUOUS IMPROVEMENT

The Risk Management Team (RMT) reviews risk management activities regularly. Senior Staff members of the RMT report activities and outcomes (e.g., risk and safety assessment results, event report summaries and trends) periodically to the Board of Trustees (annually, at a minimum). This report informs the Board of efforts made to identify and reduce risks and the success of these activities and communicates outstanding issues that need input and/or support for action or resolution. Data reporting may include event trends, claims analysis, frequency and severity data, credentialing activity, relevant provider and staff education, and risk management and patient safety activities. Performance improvement goals are developed to remain consistent with the stated risk management and patient safety goals and objectives. Documentation related to monitoring and continuous improvement is in the form of periodic risk management reports to the CEO on risk management activities and outcomes.

7. CONFIDENTIALITY

Any and all documents and records that are part of NEON risk management program are intended to be privileged and confidential to the extent provided by state and federal law. Confidentiality protections include attorney client privilege, attorney work product, and peer review protections.



NEON QIC Policies & ProceduresQIC-P12 Adverse & Near-Miss Events

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QIC Policy Name: Adverse & Near-Miss Events Management QIC Policy Code: QIC-P12



Related QIC Policies: QIC-P7 QI Mechanics; QIC-P11 Risk Management Plan

Attachments: Exhibit 1- Event Report and Classification FormExhibits 2a, 2b – Medical & Dental Triggers for Quality Improvement

Authorization: Refer to QIC-S1 Authorization Signatures QIP Goal Congruency: Patient Safety

AFFIRMATION:This organization endorses and supports a culture of safety and views adverse-event reporting as ameans of improving systems and processes in providing healthcare services to all patients. In acontinuing effort to promote a safe environment for patients, the Quality Improvement Committee’sRisk Management Quality Workgroup Committee will conduct a systematic program of adverse-eventreporting. Reporting will be non-punitive (e.g., not shooting the messenger), and all providers,employees, and volunteers are encouraged to report all patient and visitor events.This organization encourages open and honest reporting of actual or potential injuries or hazards topatients, visitors, and employees at all sites and services and at all levels of care throughout its networkof health centers.This organization aims to limit disciplinary action to only those individuals that engage in willful ormalicious misconduct or exhibit continued noncompliance in following established policies andprocedures relating to patient care and/or safety or continued failure to follow recommendations toimprove skills.This organization strives to facilitate education and problem resolution through forthright disclosure ofprocess failure and/or human error.

PURPOSE:

The objective of this policy is to preserve the assets, reputation, and quality of care of NEON byidentifying and reporting adverse events or incidents or near miss incidents as soon as humanly possibleallowing NEON to either correct the underlying root cause and, if applicable, mitigate any harm that mayhave been caused to a patient or visitor.Examples of situations to be reported include, but are not limited to, the following:

1. Any happening that could have caused or did cause injury to a patient (e.g., a medication erroror adverse reaction, delay in delivery of needed care, unexpected death).

2. Any condition or situation that could or did result in an injury to a patient (e.g., misfilingdiagnostic test results, failure to follow up on abnormal test results, scheduling problem,equipment malfunction).

3. Failure to comply with established policy or protocol, with or without patient, provider,employee, or visitor injury.

4. Any injury, potential injury, or unusual occurrence involving a patient, visitor, or employee onthe facility grounds (e.g., due to a fall, falling object).

5. Any suggestion or threat of lawsuits, contacting legal counsel, or claims for restitution.


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6. Anything unusual or not in compliance with everyday activities (e.g., EMR system not doingwhat is expected).

DEFINITIONS:

An adverse event or incident is defined, consistent with the NEON’s risk management plan, as “anundesired outcome or occurrence, not expected within the normal course of care or treatment, diseaseprocess, condition of the patient, or delivery of services.”

A near miss is defined as “an event or situation that could have resulted in an accident, injury, or illnessbut did not, either by chance or through timely intervention (e.g., a procedure almost performed on thewrong patient due to lapse in verification of patient identification but caught at the last minute bychance).” Near misses are viewed by NEON as opportunities for learning and for developing preventivestrategies and actions.

STIPULATIONS:

This policy applies to medical and dental providers, practice administrators, managers, mid-levelproviders, and all clinical and non-clinical employees of NEON. Everyone at NEON has a role in riskmanagement and patient safety and is accountable to the departments and units in which he or sheworks. This policy includes guidelines for identifying risks, assessing alternative methods to reduce risks,selecting and implementing the selected methods, and monitoring the effectiveness of the actionstaken.

Related to this policy, providers, employees, and volunteers are not subject to disciplinary action EXCEPTas follows:

1. The event is not reported as soon as possible after discovering that the event has occurred andin accordance with event-reporting procedures noted herein.

2. Providers, employees, or volunteers are directly involved in sabotage; malicious behavior;patient mistreatment, abuse, or neglect; chemical impairment; or criminal activity.

3. False information is provided on the event report or in the follow-up investigation.

4. A provider, employee, or volunteer fails to respond to educational efforts and/or to participatein the education process or other preventive plans.

Providers, employees, or volunteers who meet any of the exceptions listed above will be subject todisciplinary action in accordance with NEON’s established Human Resource policies and procedures.

Event reporting is an essential component of the risk management program and is considered part ofthe performance and quality improvement process. Event reports may not be copied or otherwisedisseminated. While the circumstances surrounding an event, all information contained in the eventreport, and any follow-up reports are confidential, NEON fully supports that patients and familymembers or designated representatives be fully informed of errors that reach patients under one orboth of the following circumstances:

1. When some unintended act or substance reaches the patient and results in harm.

2. When there is potential clinical significance of the event to the patient.

In addition, consideration should be given to disclosing errors that reach patients and do not result inharm. The decision to disclose these errors will depend on the circumstances of the event and thepatient. Responsibility for disclosing the error ultimately rests with the provider who has overall


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responsibility for the patient’s care; however, any member of the Risk Management Team (MedicalDirector, Dental Director, Operations Director, Safety Officer, and the Executive Assistant to the CEO)should be consulted first regarding approaches for appropriate communication of the occurrence ofadverse events or errors to patients.

PROCEDURES:

Each provider, employee, or volunteer shall be responsible to report all adverse events, incidents, andnear misses at the time they are discovered to his or her immediate supervisor and/or the risk manager.Immediate evaluation and stabilization of the patient or other individuals involved in the event shouldbe carried out. After any needed intervention has been provided to the patient or other involvedindividuals, an Event Report should be completed. Persons knowledgeable about the event shouldcomplete the Event Report objectively, accurately, and without conclusions, criticisms, or placement ofblame. All Event Reports should be forwarded as soon as possible, but at most within 24 hours, to amember of the Risk Management Team for review. Serious injuries and deaths resulting from anadverse event should also be reported immediately by telephone to a risk team member. The MedicalDirector should be notified of any events in Category F (see herein below, i.e., requiring hospitalization)or higher within 24 hours.

The Event Report should contain the following information: Date and time of the report Date and time of the event Location of the event Identification of people affected (e.g., patient, visitor, employee) Names of people witnessing the event Name of the provider to whom the event was reported (if applicable) and the provider’s

response (e.g., orders given) Brief, factual description of the event Key observations of the event scene (e.g., if event was a fall, was there water on the floor or ice

on the sidewalk?) Manufacturer, model, and lot (or batch) number of any medical device involved Condition of the people affected (including any complaints of injury, observed injuries, and a

brief comment on any follow-up care).

Upon review and approval of the CEO, the Risk Manager (Executive Assistant to the CEO partnered withthe Medical Director) will notify external regulatory or accrediting agencies of the event as required inaccordance with state and federal statutes and regulations or accreditation standards (e.g., JointCommission). Examples of external reporting requirements may also include reporting to the U.S. Foodand Drug Administration under the Safe Medical Devices Act or to state agencies.

The Risk Manager will notify insurers (e.g., liability, property, Workers’ Compensation) in accordancewith established notification procedures. The Risk Management Team will make certain that applicablestaff members preserve, secure, and inspect before putting back into service all equipment (e.g., bloodglucose monitors, steam sterilizers), assistive or transport devices (e.g., wheelchairs), accessories (e.g.,electrocardiography electrodes), packaging, or any other items that may have been involved in theevent.


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SEVERITY CATEGORY:

The Risk Management Team will assign a severity category (A thru I) to all adverse events, includingnear-miss and no-harm events. All events will be entered into a risk management database. Thepurpose of this database is to track events and to trend and analyze patterns of events for a proactiveapproach to quality improvement and identifying opportunities for organization wide improvements inprocesses or systems.

One of the following severity categories will be assigned.1 Examples are for illustrative purposes onlyand are not all-inclusive:

Unsafe Conditions:

Category A: Potentially hazardous conditions, circumstances, or events that have the capacity tocause injury, accident, or healthcare error.

o Examples: Inconsistent protocol or policy for recording pediatric immunizationscontributes to the potential for missed or duplicate immuizations being given. Prenatalpatient’s glucose level is not checked when indicated.

Events, No Harm:

Category B: Near-miss event or error occurred but did not reach the patient (e.g., caught at thelast minute or because of active recovery efforts by caregivers).

o Examples: Specimens are mislabled but recognized and corrected before leaving thehealth center or before reports are completed. Penicillin is prescribed for a patient withpenicillin allergy, but the error is noticed by a pharmacist before medication isdispensed.

Category C: An event occurred and reached the patient or visitor, but there is no evidence ofinjury or harm.

o Examples: An adult patient has been missing medication doses due to lack ofunderstanding about how to take the drug, but his or her condition or outcome isunaffected. A pediatric patient is observed falling in the waiting area, but no injury isfound upon examination.

Category D: An event occurred that required monitoring to confirm that it resulted in no harmand/or required intervention to prevent harm to the patient or visitor. There were no changes invital signs or laboratory values (if applicable). Patient’s or visitor’s physical and/or mentalfunctioning is unchanged. Event does not result in any hospitalization or change in level of care.

o Example: A patient sustains a hematoma in his antecubital fosa during a phlebotomyprocedure to draw blood for outpatient laboratory testing. The patient returns to theclinic provider to have his arm checked. No treatment is needed.

Events, Harm:

Category E: An event occurred that may have contributed to or resulted in temporary harm,required treatment and/or intervention, or required the need for observation or monitoring ofchanges in vital signs, mental status, or laboratory values.

1 Excerpted and adapted from the National Coordinating Council for Medication Error Reporting Programs (NCCMERP) and PennsylvaniaAssociation for Healthcare Risk Management.


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o Examples: A patient fall results in a scalp laceration that requires suturing andassessment for brain injury. An incorrect dose of a medication causes toxicity.

Category F: An event occurred that may have contributed to or resulted in temporary harm to apatient or visitor and required hospitalization.

o Examples: During the flushing of a patient’s ear canal, the tympanic membrane isdamaged, requiring a visit to the emergency departement and subsequent treatment.Group B streptococcus status of mother is not documented, and infant does not receiveappropriate treatment.

Category G: An event occurred that may have contributed to or resulted in permanent injury orharm to a patient or visitor.

o Examples: Patient is given an injection with a contaminated needle and acquireshepatitis C.

Category H: An event occurred that resulted in near-death circumstances or requiredintervention necessary to sustain life.

o Examples: Patient has an anaphylactic reaction to medication requiring treatment andtransfer to a hospital.

Event, Death:

Category I: An event occurred that contributed to or resulted in patient or visitor death.

o Examples: Patient’s prescribed medication dose results in an overdose and the patient'sdeath.

EVENT INVESTIGATION:

The Risk Management Team is responsible for conducting event investigations. The investigation is aform of self-critical analysis to determine the cause of the incident, analyze the process, and makeimprovements. The individual conducting the investigation will complete an event investigation report.All event investigation report should be completed within ten (10) working days from the date of theinitial event report. Depending upon the type of event, the investigation and report should addresspatient- or visitor-specific factors (e.g., physical harm, immediate and ongoing treatment required),external factors (e.g., lighting, flooring, clutter, distractions), witnesses’ statements, staffing,communication flow, construction or design factors, human or ergonomic factors, signage, equipmentfactors, and any other factors or conditions believed to be relevant to the cause of the event.

An investigation will be conducted, at minimum, for any of the following:

1. Any incident or adverse event with a severity category of “E” or above (i.e., any event that mayhave contributed to or caused temporary or permanent patient or visitor harm, initial orprolonged hospitalization, or death).

2. Any serious patient or family written or verbal complaint or verbalization that a lawsuit will bebrought against the provider or the facility.

3. Any significant adverse drug reaction or significant medication error. A significant medicationerror is defined as unintended, undesirable, and unexpected effects of a prescribed medicationor medication error that requires discontinuing a medication or modifying the dose, initial orprolonged hospitalization, or treatment with a prescription medication; results in disability,


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cognitive deterioration or impairment, congenital anomalies, or death; or is life-threatening.

4. Any unplanned instance of a patient being hospitalized, or transferred to the emergencydepartment or other higher level of care, directly from the health center or clinic.

5. Any incident involving police contact or reporting to external agencies or accreditors.

6. Any near miss with the potential for a high-severity level (e.g., potential to have been an eventwith harm [category E] and above).

ROOT-CAUSE ANALYSIS & ACTION PLAN:

Root-cause analysis is a process for identifying the basic or causal factor(s) that underlie the occurrenceor possible occurrence of an adverse event or error. A root-cause analysis should be conducted for allevents or errors with a severity category of “E” or above, or near misses with the potential for an eventor error with a severity category of “E” or above.

In accordance to Joint Commission guidelines, an acceptable root cause analysis has the followingcharacteristics:

1. The analysis focuses primarily on systems and processes, not on individual performance

2. The analysis progresses from special causes in clinical processes to common causes inorganizational processes

3. The analysis repeatedly digs deeper by asking “Why?”; then, when answered, “Why?” again, andso on

4. The analysis identifies changes that could be made in systems and processes (either throughredesign or development of new systems or processes) which would reduce the risk of suchevents occurring in the future

5. The analysis is thorough and credible.To be thorough, the root cause analysis must include the following:

a) A determination of the human and other factors most directly associated with thesentinel event and the process and system related to its occurrence;

b) An analysis of the underlying systems and processes through a series of “Why?”questions to determine where redesign might reduce risk

c) An inquiry into all areas appropriate to the specific type of event as describedd) An identification of risk points and their potential contributions to this type of evente) A determination of potential improvement in processes or systems that would tend to

decrease the likelihood of such events in the future, or a determination, after analysis,that no such improvement opportunities exist.

To be credible, the root cause analysis must do the following:a) Include participation by the leadership by individuals most closely involved in the

processes and systems under reviewb) Be internally consistent (that is, not contradict itself or leave obvious questions

unanswered)c) Provide an explanation for all findings of “not applicable” or “no problem”d) Include consideration of any relevant literature.


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In accordance to Joint Commission guidelines, an acceptable Action Plan includes the following:

1. Identifies changes that can be implemented to reduce risk or formulates a rationale for notundertaking such changes.

2. Identifies, in situations where improvement actions are planned, who is responsible forimplementation, when the action will be implemented (including any pilot testing), and how theeffectiveness of the actions will be evaluated.

HEALTH RECORD DOCUMENTATION:

If applicable, documentation in the patient's chart or medical record shall include:

1. Date and time of the event

2. A factual account of what happened

3. Name of provider involved and time of notification (if applicable).

4. Patient’s condition after the event

5. Any treatment or diagnostic tests rendered to the patient

RETENTION OF EVENT REPORTS:

Event reports shall be retained for a minimum of six (6) years or for the usual and customary statute oflimitations. All reports of events involving minors shall be maintained until one year past the age ofmajority. Written summaries of analysis of root cause and action plans for applicable event should beretained with corresponding event reports.




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Exhibit 1: Event Report and Classification Form

SEX: N/A F M AGE: DATE OF EVENT: MENTATION: Oriented: Yes No N/ASELECT ONLY ONE CATEGORY: Treatment/Procedure Equipment/Product Environment

Falls Medication Patient Relations

CHECK APPROPRIATE BOX IN DESIGNATED CATEGORY THAT BEST DESCRIBES THE EVENTTREATMENT /

PROCEDUREEQUIPMENT/

PRODUCTFALLS MEDICATION

Application/Removal of Cast/Splint Body Fluid Exposure Cancellation of Procedure Communication Error Consent Problem Delay Deviation from Established Procedure Identification Pt/Site Injection Site Problem Misfiled Chart Missing Supplies Not Documented Omitted Patient Refusal-Non Medication Reporting of Test Results Security Problem Struck by Object Suture Removal Technique Test/Treatment w/o Order Theft Unlabeled/Missing Specimen Other:

Disconnected/Dislodged Electrical Problem Improper Use Malfunction Defect Mechanical Problem Needle/Sharp Stick No Maintenance Inspection Tampered With/By Wrong Equipment Other:ENVIRONMENT Defective Alarms Excess Snow/Ice Fire Heat/Cooling Problem Inadequate Lighting Insects/Rodents Intrusion Alarm Medical Waste Problem Non-compliance ADA Power Failure Unsafe Other Conditions Unsafe Parking Conditions Wheelchair Other:

Chair Exam Table Faint Fall/Slip Found on Floor Scales Other:Check one: Attended UnattendedSurfaceCondition: Carpet Damage DryOther Factors: Footwear Lighting Obstacles

Adverse Reaction Allergic Reaction Given Without Order IM Site Problem Improper Order Inappropriate Sample Incorrect Route Medication Missing Mislabeled Non-labeled Vial Not Available Not Documented Omitted Analgesic Antianxiety Antibiotic Anticholinergic Anticoagulant Anticonvulsant Antidepressant Antiemetic Antihistamine Antihypertensive Antipsychotic Bronchodilator Cardiovascular CNS Stimulants Contrast Media Corticosteroids Diuretic Hormones

Outdated Patient ID Problem Patient Refusal Phone Prescrp Problem Sample Drug Mislabeled Sample Drug Outdated Wasted Wrong Dosage Wrong Drug Wrong Time Written PrescrpProblemOther: Immunizations Insulin Laxative Narcotic Ophthalmic Oral Hypoglycemic Potassium Sedative/Tranquilizer Supplemented Nutrition Unidentified Vasodilator Vasopressor Vitamins Other :

PATIENT RELATIONSConfidentiality Problem:

Computer Fax Staff Telephone Waiting Area

Answering Service Problem Assault/Violence Collection Agency Problem Delay/Missed Consultation Dissatisfied Patient/Family Excessive Waiting Period Incomplete Records

Incorrect Bill Incorrect Release of Records Irate Patient Loss of Prescription Pad Managed Care Denial Missed Appointments Missing Chart

Patient Termination Property Missing or Damaged Scheduling problem Third Party Refusal/Denial Walk-In/Same-day Problem Other :

EVENT CATEGORY: Courtesy of ECRI Institute

Type of Medication

(ch e c k one (s ) re la te d t o Fa ll / M edE ven t)


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Exhibit 2a: Medical Triggers for Quality Improvement (used as an employee education tool)

USING a NEAR MISS or a MISS as a TRIGGERfor


NEAR MISS:

A ‘near miss’ is when a mistake was made; but thank God we caught it in time before it couldaffect our patient. However, somebody still needs to know about the ‘near miss’ so we canimprove the process; because the next person might not be so fortunate.

MISS:

A ‘miss’ is when a mistake was made; but we did not catch it in time before it affected our patient.Somebody needs to know about the ‘miss’ so we can improve the process that contributed to themistake; because we want to get it right the next time.

A trigger is an event that is used to launch an action or a series of actions for the purpose of quality andprocess improvement. For our purposes, Near Misses and Misses that will serve as triggers shall fall intoone of the 6 categories noted below:

MEDICALCATEGORIES Points of Emphasis



3. LAB Wrong lab? Delayed lab? No lab result? No action?

4. REPORT Wrong report? Delayed report? No report? No action?

5. CANCER DIAGNOSIS Could we have made the diagnosis sooner?

6. DEATH OF A PATIENT After review, is there anything we could have done better?


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Exhibit 2b: Dental Triggers for Quality Improvement (used as an employee education tool)

USING a NEAR MISS or a MISS as a TRIGGERfor


NEAR MISS:

A ‘near miss’ is when a mistake was made; but thank God we caught it in time before it couldaffect our patient. However, somebody still needs to know about the ‘near miss’ so we canimprove the process; because the next person might not be so fortunate.

MISS:

A ‘miss’ is when a mistake was made; but we did not catch it in time before it affected our patient.Somebody needs to know about the ‘miss’ so we can improve the process that contributed to themistake; because we want to get it right the next time.

A trigger is an event that is used to launch an action or a series of actions for the purpose of quality andprocess improvement. For our purposes, Near Misses and Misses that will serve as triggers shall fall intoone of the 6 categories noted below:

DENTALCATEGORIES Points of Emphasis



3. WRONG PROCEDURE Wrong treatment? Delayed treatment? No treatment?

4. DOCUMENTATION REPORT Wrong note? Delayed note? No note?

5. WRONG X-RAY Wrong tooth? Wrong Orientation? Missing pathology?

6. WRONG DIAGNOSIS Wrong diagnosis? Failure to Diagnose? Failure to Follow-Up?

NEON QIC Policies & ProceduresQIC-P13 Peer Review Plan

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QIC Policy Name: Peer Review Plan QIC Policy Code: QIC-P13

Effective Date: 6/9/2004 Revision/Review Dates: 11/12/2008; 12/16/2009; 6/6/2011


Related QIC Policies: QIC-P1 QIP Fundamentals; QIC-P11 Risk Management Plan

Attachments:

Authorization: Refer to QIC-S1 Authorization Signatures QIP Goal Congruency: Patient Care;Patient Safety

AFFIRMATION:

NEON’s Peer Review Plan shall be accomplished through objective, confidential, and privileged healthrecord review of health care services performed by independent licensed practitioners employed byNEON within its network of health centers.

PURPOSE:

The purpose of the NEON Professional Review Program is to exercise a traditional means of minimizingthe risk or actual occurrence of potentially adverse events that negatively impact the health or welfareof patients served by NEON. This is accomplished through objective, confidential, and privileged healthrecord review of health care services performed for registered patients of NEON by independentlicensed practitioners employed by NEON within its network of health centers.

BACKGROUND:

The Federal Tort Claims Act (FTCA) covers NEON for the acts or omissions of its clinical staff in theperformance of clinical services to patients that fall within its Scope of Practice and Scope of Service. Asa consequence of FTCA coverage, NEON has an obligation to maintain a formal professional reviewprogram (also referred to as ‘peer review program’) that is approved and periodically reviewed by itsBoard of Trustees. This obligation is linked with the federal government’s desire that the covered entityperform a measure of malpractice risk management aside from a usual and customary qualityimprovement program. Additionally, it is the desire of the federal government that findings of acovered entity’s professional review program be incorporated in and integrated with the entity’scredentialing and recredentialing decisions in furtherance of the entity’s continuous efforts atpromoting and sustaining high quality healthcare.

The Federal Health Care Quality Improvement Act (HCQIA) of 1986 requires monthly reporting by healthcare entities to the State licensing board of any adverse professional review actions taken againstlicensed practitioners. The Act defines “professional review action” as an action or recommendation ofa professional review process in conducting professional review activities that are based uponcompetence or professional conduct of said practitioner and affect or may affect adversely the clinicalprivileges, or membership in a professional organization of the respective practitioner. The Actmandates that health care entities request information, which has been reported about a practitioner,in connection with professional review activities.

A “professional review activity” is defined in HCQIA as an activity regarding a practitioner intended toaccomplish any of the following:

1. To determine whether or not the practitioner should be awarded staff membership orprivileges;


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2. To determine the scope or conditions of the practitioner’s staff membership or privileges;

3. To change or modify said staff privileges.

The Act (Section 11111(a)) provides immunity from damages under both state and federal laws if suchactivities meet certain specific standards set out in the Act. Failure to report an adverse professionalreview action may result in the health care entity’s loss of immunity.

For immunity to apply, the professional review activity must be consistent with the following:

1. There is reasonable belief that it is in the furtherance of high quality healthcare.

2. A reasonable effort has been made to obtain the facts in the matter.

3. Adequate notice and hearing procedures have been afforded to the involved practitioner (the“right to a fair hearing” should be addressed in the by-laws).

4. There is reasonable belief that such action is warranted by the facts then known.

5. Professional review activities are conducted by Professional Review Bodies.

A “Professional Review Body” is defined as any of the following:

A Hospital;

A Board of Directors;

A Peer Review Committee;

Any committee of the medical staff when assisting the Board of Directors in a professionalreview activity.

Immunity provisions do not prevent the Federal Trade Commission, Department of Justice or any stateattorney general from bringing a criminal action where otherwise authorized to do so and are noteffective as a defense for suits for damages under any Civil Rights statutes. Immunity provisions may bewaived inadvertently. Legal advice should be sought early in any contemplated non-routine peer reviewactions.

HCQIA mandates reporting certain peer review actions to state licensing boards. These actions include:

1. Denial of staff membership or privileges;

2. Reduction in privileges;

3. Denial of reappointment;

4. Termination of privileges;

5. Suspension of privileges or staff membership;

6. Summary suspension for more than 14 days;

7. Resignations from staff membership after notification of impending investigation.

HCQIA established the National Practitioner Data Bank, which collects a history relating to clinicalprivileges and professional liability claims against all licensed medical practitioners. Hospitals andorganizations like NEON are required to access information from the data bank during the process ofand deciding on the granting of initial privileges and biennial renewal thereafter.


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PEER REVIEW PLAN CONTENTS GUIDE

SUBJECTS Pages

Professional Review Body 4

Professional Review Process 4-7

Special Reviews 7

DUE PROCESS ASSOCIATED WITH REVIEW PROGRAM 7-11

Informal Meeting to Address Professional Probation 7

Formal Meeting to Address Professional Probation Determination 7-8

Status of Practitioner Pending Outcome of Severe Adverse Recommendation 8

Rights Associated with Constructive Professional Rehabilitation and ProfessionalAlert Determination

9

Right to a Hearing before the Quality Committee of the Board of Trustees 9

Actions Not Associated with the Right to a Hearing before the Professional ReviewBody

9

Hearing before the Professional Review Body 9-10

Waiving the Right to a Hearing by Failing to Request a Hearing 11

Deliberation Process of the Board of Trustees 11

SPECIFIC GUIDANCE FOR PROFESSIONAL REVIEWER 12-15

Confidentiality Agreement 12

Protections of the Law 12

Structured Implicit Review 12-13

Rating the Process, Not the Outcome 13

Integrating Different or Disparate Items of Information 13

Poor Documentation and the Quality of Care 14

Assumptions about the Appropriate Goals of Care 14

Avoiding Controversies 14

Rating Review Concerns of Structured Implicit Review 14-15

Review Process Flows Illustrated 16-17

Professional Probation Due Process Flow Illustrated 18-19

Medical Record Review Form 20

Confidentiality Agreement 21


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PROCEDURE: Herein noted below.

Professional Review Body

The Chairman of the Board of Trustees appoints the members and the Chair of the Quality Committee ofthe Board. The Quality Committee functions within the by-laws of the organization. Trustees belongingto the Quality Committee constitute the Professional Review Body for NEON. The Chief ExecutiveOfficer, Clinical Directors, Corporate Compliance Officer, the Director of Human Resources, and legalcounsel also serve as ex-officio members of the Professional Review Body.

The primary functions of the Quality Committee are to review the quality of care rendered bypractitioners and quality of practitioners’ (employed or contracted by NEON) credentials. Thiscommittee is charged with the responsibility of reviewing the Quality Improvement Program for NEON,reviewing credentials of practitioners, and making privileging recommendations to the Board. Theprimary functions of the Quality Committee carry-over into of the objectives of the Professional ReviewProgram and are supplemented by the review work of select professionals and the clinical directors whoperform structured implicit quality reviews to support this program. The primary functions of theProfessional Review Body are to address severe personnel actions that are deemed appropriate duringthe performance of various phases of the Professional Review Program herein described.

It is intended that the Quality Committee review on an annual basis or more often as necessary, peerreview activity, proposed policy changes, and make recommendations for action to the Board ofTrustees. With the input of the Quality Committee on behalf of the Professional Review Body, the Boardof Trustees has the ultimate authority to summarily suspend or terminate a practitioner’s clinicalprivileges, once the practitioner is afforded what is herein construed as ‘due process’. The QualityCommittee on behalf of the Professional Review Body has the responsibility of recommending to theBoard of Trustees whatever other adverse actions that are warranted; particularly, the extent of anysuspension or the timing of a proposed termination. However, prior to such recommendations beingmade to the Board, the practitioner shall be notified in writing of his/her right to a hearing before theProfessional Review Body.

Professional Review Process

It is intended that licensed practitioners directly employed by NEON undergo some form of formalprofessional review on an annual basis, at a minimum. Licensed practitioners shall be subjected toannual professional review activities as part of NEON’s Professional Review Program. The professionalreview shall consist of a two-tier review process (Level One Reviews & Level Two Reviews) in whichreviewers (also known as peer reviewers), selected by the Medical Director or Dental Director, shallperform Level One review activities in support of the program. However, at any time, the respectiveClinical Director may elect to perform an initial Level Two Review that would replace a Level OneReview. Level One & Two Reviews will be based on a process referred to as a ‘structured implicitreview’.

Licensed practitioners (i.e., specializing in podiatry, optometry, and dermatology), who are minimallyrepresented at NEON with two or fewer practitioners of like kind, will only be subjected to modifiedLevel Two reviews by the respective Clinical Director. These practitioners will be obligated tocollaborate with the Clinical Director in the development and/or modification of clinical guidelinesspecific to their practice that address the top ten (10) most frequent diagnoses that are relevant to thepractitioner’s specialty area in his/her clinical practice at NEON. These guidelines shall be reviewed andmodified, when appropriate, in collaboration with the minimally represented practitioner on an annual


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basis to ensure that the guidelines remain current and applicable to his/her clinical practice at NEON.This review will take place in collaboration with and in communication with index practitioner eitherface-to-face or virtually through electronic or telephonic means, to allow the practitioner todemonstrate how his/her practice, as illustrated in the randomly selected health records, reflectsadherence to the agreed upon clinical guidelines.

Professional Reviewers are selected based on their historic demonstration of high quality health careand are practitioners in good clinical standing at NEON. These reviewers shall also be subjected toannual professional reviews. Reviewers will maintain their qualification to perform these qualityreviews as long as they are devoid of quality findings on their own clinical work as illustrated by chartsaudited on patients cared for by them. Reviewers will only be subjected to modified Level Two reviewsby the respective Clinical Director as described above for ‘minimally represented’ practitioners, in orderto allow the practitioner to demonstrate how his/her practice as illustrated in the randomly selectedhealth records reflects adherence to clinical guidelines espoused by NEON.

Significant deficiencies noted in the annual review and confirmed by the respective Clinical Director willprompt a second tier review, if applicable. This two-tier review process shall also apply to interimreviews that are instigated by the routine review process. (Refer to current peer review forms designedto facilitate structure assessments)

An individual report of the outcome of a professional review along with written practitioner feedbackwill be included in the practitioner’s credentialing file and kept confidential. A report of practitionerreview findings, along with written individual practitioner feedback, if offered, shall be submitted to theQuality Committee of the Board on an annual basis for review.

The two-tier review process shall be applied to as many as three phases, where applicable:

1. Phase One Reviews refer to initial professional reviews of a practitioner during the annualassessment.

2. Phase Two Reviews refer to the first of subsequent special reviews of a practitioner that isplaced on Constructive Professional Rehabilitation (CPR) or Professional Alert (PA). This reviewtakes place in ninety (90) or forty-five (45) days based on whether the practitioner is designatedas CPR or PA, respectively.

3. Phase Three review refers to the final subsequent special review of a practitioner who wasplaced on CPR subsequent to a special Phase Two Review.

The operational components of the professional review process are listed below:

1. A representative of Clinical Administration reviews the Practice Management System (or EHRsystem) appointment lists for patients previously seen by an index provider. Patient charts shallbe selected at random from any given date of service within the designated time-frame andforwarded for review by an appropriate Professional Reviewer. Patient electronic charts eligiblefor review will be those of patients seen two or more times by the index practitioner within theprevious twelve (12) months; or with at least one of those two visits within ninety (90) days; orwith at least one of those two visits within forty-five (45) days depending upon the nature of thereview.

2. The Professional Reviewer performs a structured implicit review and completes the ClinicalRecord Review Form or completes database entry in accordance to the specified methodology.


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3. Level One Reviews that have preliminary assessments that are classified as “Not Acceptable” arereferred to the respective Clinical Director for Level Two Reviews. Only a Clinical Director canperform a Level Two Review.

4. Practitioners who receive reviews that are devoid of “Not Acceptable” marks for Level One orTwo Reviews will receive no feedback.

5. Practitioners who receive reviews that include “Not Acceptable” marks but the accumulatedtotal of Severity Level (SL) points do not exceed four (4) points will receive feedback thatcorresponds to said review.

6. Practitioners who receive reviews that include “Not Acceptable” marks and they are confirmedafter a Level Two Review and exceed four (4) SL points in aggregate are either given the statusof Constructive Professional Rehabilitation (CPR) or Professional Alert or Professional Probation.

7. Constructive Professional Rehabilitation designation is reserved for the reviewed practitionerwho had no more than five (5) SL points assessed. The respective Clinical Director shall providecounseling to the affected practitioner and a Performance Improvement Plan will be formulatedand documented on the Practitioner Counseling Form. The practitioner will also be advised ofthe fact that s/he will be subjected to a special review process to supplement the AnnualReview. The practitioner is also given an opportunity to challenge the quality designation.Subsequently, the practitioner will be subjected to a Phase Two chart review in ninety (90) days.Ten (10) charts of patients seen within that ninety (90) day period will be reviewed via the two-tier review process.

8. The Professional Alert designation is reserved for the reviewed practitioner who had six to ten(6-15) SL points assessed subsequent to a Level Two Review.

9. With a Professional Alert designation, the respective Clinical Director provides counseling to theaffected practitioner and a Performance Improvement Plan is formulated and documented onthe Practitioner Counseling Form. The practitioner will also be advised of the fact that s/he willbe subjected to a special review process to supplement the Annual Review. The practitioner isalso given an opportunity to challenge the quality designation. Subsequently, the practitionerwill be subjected to a Phase Two chart review in forty-five (45) days. Ten (10) charts of patientsseen within that thirty (30) day period will be reviewed via the two-tier review process.

10. The Professional Probation designation is reserved for the reviewed practitioner who had morethan fifteen (15) SL points assessed during a Phase One chart review. This designation is alsoplaced on a practitioner who fails to downgrade his/her Professional Alert designation after aPhase Two chart review.

11. The Professional Probation designation is reserved for a reviewed practitioner who fails todowngrade his/her CPR designation after a Phase Three chart review.

12. The Professional Probation designation is placed on a practitioner who fails to be assessed atless than a CPR designation after a Phase Three chart review.

13. With a Professional Probation designation, the respective Clinical Director provides counselingto the affected practitioner. The respective Clinical Director, in collaboration with thepractitioner, develops a Corrective Action Plan that is intended to be a draft of a recommendedcourse of action. Subsequent actions are dependent upon the findings and recommendationsof informal meetings, formal meetings, and/or hearings before the Professional Review Body, inaccordance to this Program.


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14. Subsequent to Phase One, Phase Two, or Phase Three Reviews, the practitioner who has afavorable review outcome (less than a CPR designation), will undergo his/her next annual review(Phase One) twelve (12) months from the date of most proximal Phase One review.

15. In the presence of personnel actions that are derived from the execution of this Program, copiesof reviews, notes, minutes, and reports will be stored in a confidential manner under theauspices of the Human Resources Department for a period not less than six years.

Special Reviews

A Clinical Director at any time can subject a practitioner to a ‘Special Review’ that is for the purpose ofuncovering a potential clinical quality deficiency expressed by concerned patients. As few as threepatients that express a moderate and similar clinical concern based on the review of formal patientcomplaints received by the Clinical Director can spark the justification for such a review. Such a reviewmay also be triggered based on the receipt by the Clinical Director of a serious and credible complaintfrom just one patient. A ‘Special Review’ shall comprise of five (5) charts (including the concernedpatients) and mimic a Phase One Review as described above. Additionally, if there is a particular area ofclinical concern that is perhaps disease-specific that can be distilled from the patient complaints, thisreview will be centered on that disease.

DUE PROCESS ASSOCIATED WITH REVIEW PROGRAM

A. Informal Meeting to Address Professional Probation

To facilitate the resolution of professional issues at an early stage, the practitioner, who is placed onProfessional Probation, is advised in writing of this status and the implications of this status. Therespective Clinical Director then arranges that an Informal Meeting take place whose attendance islimited to the Chief Executive Officer, the affected practitioner, and said Clinical Director. The InformalMeeting shall take place within fourteen (14) days of the practitioner receiving written notice of theProfessional Probation. The goal of the informal meeting is to devise a constructive course of actionand define and agree to the terms of a Professional Probation that fits the clinical circumstances. Anadditional goal of the informal meeting is to ensure that the Practitioner understands the professionalreview process.

B. Formal Meeting to Address Professional Probation Determination

If the affected practitioner does not concur with the terms of a Professional Probation, one that doesnot limit his/her privileges, s/he will be afforded the opportunity to a formal meeting.If it is determined that a reasonable course of action is to consider recommending that the practitioner’sprivileges should be either limited, suspended, or terminated, then the affected practitioner shall beadvised of his/her right to a formal meeting with the Professional Review Body.

A formal meeting shall be arranged to take place within fourteen (14) days of the date of the InformalMeeting. A formal meeting is one that is comprised of the Chief Executive Officer, the CorporateCompliance Officer, the respective Clinical Director, the affected practitioner, and NEON’s legal counsel.The practitioner may have in attendance in his/her support another member of NEON’s medical staff ingood standing, and/or an attorney. However, if the practitioner is to be accompanied by any otherperson at the formal meeting, the practitioner will notify the office of the CEO. The presence of NEON’slegal counsel in this formal meeting is to assure the following:

1. To protect the interests of NEON’s patients;


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2. To ensure that due process is afforded to the affected practitioner;

3. To mitigate corporate and medico legal liability;

4. To fortify NEON’s legal footing in the event that the outcome of the professional review processleads to a reportable adverse action against the practitioner.

The purpose of a formal meeting is to allow the practitioner to challenge the procedural and clinicalbasis of any recommended actions against him/her and to allow for an investigation to take place if it isdetermined from this meeting that there are sufficient grounds to justify such an investigation.Nonetheless, it hoped that the whole matter can be concluded at the initial formal meeting if all partiesare in agreement.

If such an investigation takes place, the affected practitioner is expected to approach the mattersensitively, privately, discretely, and consistent with professional codes of conduct. Such aninvestigation shall take no more than fourteen (14) days to complete from the time the initial formalmeeting took place. Objective evaluation by peers (internal or external to NEON) and documentation ofall aspects of the investigation are essential.

A second and final formal meeting is permitted, when applicable and no later than twenty-one (21) daysafter the initial meeting, in order to negotiate the findings of the investigation noted above. Withinseven (7) days from the second formal meeting, the practitioner shall be notified of the course of actiondecided upon by the Chief Executive Officer.

If the Chief Executive Officer decides that the course of action should be Professional Probation and theterms of such probation will not limit the scope of the practitioner’s privileges, then the practitioner willhave no recourse other than to accept those terms, voluntarily resign, or be terminated fromemployment ‘for cause’. The practitioner shall be given written notification of the proposedrecommendation.

If the Chief Executive Officer decides that the course of action should be Professional Probation and theterms of such probation are intended to limit the scope of the practitioner’s privileges or termination,then the practitioner will be informed that a recommendation will be made to the Quality Committee ofthe Board of Trustees. The practitioner shall be given written notification of the proposedrecommendation. The practitioner shall be advised of his/her right to a hearing before the ProfessionalReview Body.

The Director of Human Resources is responsible for keeping minutes of formal meetings and shallproduce written summaries of these meetings. A copy the summaries will be placed in the HR filemaintained for the affected practitioner.

C. Status of Practitioner Pending Outcome of Severe Adverse Recommendation

A severe adverse recommendation associated with this professional review program is considered anyaction that leads to a limitation of scope or termination of privileges.

If limitation of scope is recommended the CEO, then said limitation shall take effect immediately,pending the outcome of the proceedings of this course of action. If termination is recommended by theCEO, then said practitioner shall be placed on administrative leave pending the outcome of theproceedings related to this course of action.


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D. Rights Associated with Constructive Professional Rehabilitation and Professional AlertDetermination

When a practitioner’s assessment gives rise to Constructive Professional Rehabilitation or ProfessionalAlert designations, s/he is not afforded the right to informal or formal meetings as herein described.This is because these designations do not lead directly to the potential for a restriction or limitation in apractitioner’s medical practice nor do they infer a quality concern that must be reported to an externalbody.

E. Right to a Hearing before the Quality Committee of the Board of Trustees

Any practitioner who could be adversely affected by any recommendations or actions based uponfindings of NEON’s Professional Review Program (e.g., mandatory reporting to the respective statelicensing board), shall be entitled to a hearing in accordance with the procedures set forth in thisprogram. This hearing shall occur prior to the Quality Committee submitting a recommendation to theBoard of Trustees for action in regards to the affected practitioner. The following potential actionsafford the affected practitioner the right to a hearing before the Quality Committee:

1. Suspension or privileges;2. Reduction or limitation of privileges;3. Termination of privileges at NEON.

F. Actions Not Associated with the Right to a Hearing before the Professional Review Body

The right to a hearing is not afforded to practitioners for the following circumstances:

1. Suspension or Termination upon loss or suspension of license, DEA certificate;2. Probation imposed by NEON that does not limit the practitioner’s scope of practice at NEON;3. If the practitioner is placed on probation by a state professional licensing agency, for which the

terms of such probation are automatically imposed upon the scope of practice that thepractitioner can perform within the context of his/her employment with NEON;

4. If the practitioner is placed on probation by a state professional licensing agency, and it isdetermined by NEON that such probation causes a limitation of scope of practice that isincompatible with continued employment with NEON, for which cause the practitioner isterminated from employment.

5. If the practitioner is placed on Constructive Professional Rehabilitation or Professional Alertstatus.

G. Hearing before the Professional Review Body

When applicable, a hearing before the Professional Review Body must be requested in writing withinfourteen (14) days of receipt of notification that an adverse action is being proposed. This writtenrequest should be hand-delivered directly to the Administrative Assistant to the Chief Executive Officeror to the Chief Executive Officer. Upon requesting a hearing, the hearing shall take place within thirty(30) days of the request.

The purpose of the hearing is to allow the practitioner a final opportunity to challenge the procedural orclinical basis of such actions against him/her and to allow for discussion to take place in order to clarifywhether in fact the practitioner was given due process. In attendance at the hearing will be QualityCommittee members and, optionally, members of the Executive Committee of the Board. The presence


10

of at least three (3) members of the Board of Trustees will constitute a quorum for the purposes of thishearing. The Chief Executive Officer, Clinical Directors, Corporate Compliance Officer, the Director ofHuman Resources, and NEON’s legal counsel (ex-officio members of Quality Committee) shall beavailable during this hearing.

The availability of NEON’s legal counsel for this hearing is for the purpose of ensuring that the followingelements are addressed:

To protect the interests of NEON’s patients;

To ensure that due process is afforded to the affected practitioner;

To mitigate corporate liability;

To protect the interests of the organization;

To fortify NEON’s legal footing in the event that the outcome of the professional review processleads to a reportable adverse action against the practitioner.

The practitioner may have his/her attorney present at the hearing. The Chair of the Quality Committeeof the Board of Trustees, if present, shall serve as the presiding moderator of the hearing. If the Chair isabsent, a member of the Executive Committee of the Board of Trustees, if present, shall serve as themoderator.

The moderator shall act to maintain decorum and to assure that all participants in the hearing have areasonable opportunity to present relevant evidence. The moderator will be entitled to determine theorder of proceeding during the hearing, to promulgate rules and procedures not inconsistent with thisprocess, to exclude or remove any person who is disruptive to an orderly and professional hearing, andto refuse to admit evidence which is not relevant to the subject matter of the hearing. Functioning as amoderator by a member of the Board of Trustees shall not in any way prevent said member from fullyparticipating in the deliberations and actions of the Board of Trustees.

The rights of participants in such a hearing shall be as follows:

To testify on his or her own behalf and to call and examine witnesses (internal and external toNEON) who voluntarily agree to appear on the practitioner’s behalf or NEON’s behalf.

To introduce non-confidential and confidential exhibits and documents relevant to the outcomeof the professional review in question;

To rebut any findings of the professional review;

To present the results of an external review of the medical record by another peer who is board-certified (if applicable) and he or herself is respected in the medical community.

The affected practitioner has the burden of proving to the satisfaction of the Professional Review Bodythat the proposed adverse recommendation or action either lacks substantial factual basis or that theconclusions drawn are arbitrary or capricious.

The Professional Review Body may, with the guidance of legal counsel, recess and reconvene for theconvenience of the participants or for the purpose of obtaining new or additional evidence orconsultation. Upon conclusion of the presentation of oral and written evidence, the hearing will beconcluded and the record closed. The Professional Review Body will then conduct its deliberationsoutside the presence of the affected practitioner to draw its final conclusions and recommendations.The Quality Committee on behalf of the Professional Review Body will present to the Board of Trustees


11

the recommendation of the CEO, unless the practitioner who requested the hearing has satisfied theapplicable burden of proof as set forth above.

A record of the hearing will be made by the taking of minutes and by a tape recording of theproceedings. The practitioner will be entitled to a copy of the minutes and of the recording uponrequest. The practitioner will be permitted to, at his/her own expense, have a court reporter attend andtranscribe the hearing.

Within thirty (30) days following the conclusion of the hearing, the Quality Committee on behalf of theProfessional Review Body will then submit a final and formal recommendation to the Board of Trustees,if applicable, for action during the next upcoming meeting of the Board. The practitioner who isaffected by an adverse recommendation or action will have no right to an appellate review of thedecision of the Board of Trustees after such action and such decision is made; and the decision will befinal and binding upon all parties.

H. Waiving the Right to a Hearing by Failing to Request a Hearing

The failure of the practitioner to request a hearing in a timely manner, in accordance with the proceduredescribed herein to which s/he is entitled, will be interpreted as the waiving of the right to such ahearing to which s/he might otherwise be entitled. Nonetheless, the respective Clinical Director shallcontact the affected practitioner directly in order to confirm that s/he does not intend to request ahearing.

I. Deliberation Process of the Board of Trustees

The Board of Trustees shall act on the Quality Committee’s recommendation at its next regularlyscheduled board meeting following the finalization of the Committee’s recommendation or the ChiefExecutive Officer’s recommendation following a confirmed waiving of the right to a hearing. In itsdeliberations, the Board shall review all the information and material considered by the ProfessionalReview Body and may consider all other relevant information received from any source.

If the Board’s proposed action has the effect of changing the Quality Committee’s recommendation, andsuch effect is more severe than what was originally recommended by the Committee, then the matterwill be referred back to the respective Clinical Director to allow for written notification to practitionerand the right to ‘due process’ to respond or react to the proposed action. This ‘due process’ entails theright to a second and final hearing before the Professional Review Body as described above.

If the Board’s action has the effect of changing the Quality Committee’s recommendation, and sucheffect is less severe than what was originally recommended, the matter is finalized and closed. If theBoard’s action concurs with the recommendation of the Quality Committee, then the matter is finalizedand closed. The Chief Executive Officer shall promptly send the practitioner a written notice informinghim/her of any action taken by the Board pursuant to this Program.

Subsequent to final deliberations by the Board and practitioner notification, NEON shall comply with thereporting requirements of the State of Ohio and the Federal Healthcare Quality Improvement Actregarding adverse credentialing and professional review actions.


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SPECIFIC GUIDANCE FOR PROFESSIONAL REVIEWER

General Comments

The Professional Reviewer must be thoroughly familiar with the scope, intent, and content of the NEONProfessional Review Program as it is written for the period in question. The structure of this Programinsulates the Reviewer from harm’s way given the fact that no review finding that is consideredabnormal is left unchallenged by a Clinical Director. Therefore, the respective Clinical Director isultimately responsible for the final quality assessment prior to the potential transmittal of a proposedadverse action to a reviewed provider. Additionally, there are a number of safeguards that protect allparties, particularly having to do with the provision of ‘due process’ to affected providers.

Confidentiality Agreement

The Professional Reviewer must abide by the confidentiality standards of this process at all times,otherwise he/she places him/herself at risk for personal liability. As such, an Agreement must beexecuted prior to performing any work within this Program.

Protections of the Law

According to Ohio Revised Code and Federal Law, no person who provides information as part of his/herinvolvement in a confidentially maintained formal professional review program without malice and inthe reasonable belief that such information is warranted by the facts known to him/her shall be subjectto suit for civil damages as a result thereof. (ORC 2305.25 and Federal Health Quality Care QualityImprovement Act, Section 11111(a))

Structured Implicit Review

The review work of the Professional Reviewer surrounds a process referred to as an structured implicitreview. This structured implicit review is aided by the use of the NEON Professional Record Reviewformat plus or minus the aid of a specially-designed computer database. This format facilitates thecollection of the following information on the clinical chart in question:

1. Review Concerns (seven in number) rated as either “Acceptable” or “Not Acceptable”surrounding the seven areas highlighted on the form;

2. For each Review Concern rated as “Not Acceptable”, a determination of Severity Level Points;

3. Applicable remarks relating to each Review Concern rated as “Not Acceptable”.


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Review Concerns incorporated in this Program are patterned after Ohio Revised Code 4731 that isutilized as the basis for discerning whether a physician warrants disciplinary actions by the State MedicalBoard. Review Concern #6 has been customized to NEON relative to the notion of standard of care.The review concerns are tabulated below:

Review Concerns

1. Degree to which practitioner performed adequate clinical assessments on the patient.

2. Degree to which practitioner performed appropriate diagnostic tests.

3. Degree to which practitioner established patient diagnoses and developed appropriate treatmentplans.

4. Degree to which practitioner provided treatment in an appropriate and timely manner.

5. Degree to which practitioner’s health record documentation on this patient was complete, clear,and concise.

6. Degree to which practitioner demonstrated at least minimal adherence to standards of carepracticed by similar NEON practitioners under same or similar circumstances whether or not anegative outcome for the patient is established.

7. Degree to which there was use of reasonable care and discrimination in the administration of drugs,or employment of acceptable scientific methods in the selection of drugs or other modalities fortreatment of disease.

Rating the Process, Not the Outcome

Professional Reviewers should divorce themselves from each patient’s actual outcome (e.g., death,morbidity, resolution of morbidity), and try to review the care according to what is recorded about whatwas done for the patient, thus the ‘process of care’. The Reviewer should consider if the processevident during the period of review and thus under study maximized the likelihood of a good clinicaloutcome and maximized humaneness and respect for patients’ wishes, imagining a population ofpatients similar to the one selected.

Integrating Different or Disparate Items of Information

Oftentimes, it is necessary to integrate several pieces of information to arrive at the specific ratingformulated. In such cases, the Reviewer should weight each piece of information he/she is trying tointegrate according to how important it was to the patient’s care. For example, several practitionersmay have participated in the care of the patient during the period under review. The Reviewer shouldweigh most heavily the practitioners’ data gathering that most influenced what was done for thepatient. Similarly, sometimes nurses and physicians will both be involved in a given aspect of care, butone group will do it well and the other poorly. The Reviewer will integrate the information, trying toweigh each staff subset’s contribution according to how much it contributed to what was done for thepatient.


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Poor Documentation and the Quality of Care

The Reviewer is urged to use all clues available in the health record to assess quality. Take note of andassign credit for the many ways practitioners have of documenting. Nevertheless, if the Reviewerbelieves that the health record does not adequately document the process then he/she shoulddowngrade his/her rating in the relevant sections of the structured implicit review.

Assumptions about the Appropriate Goals of Care

Regardless of what the actual goals of therapy appear to be, the Reviewer is asked to assume that thegoal should have been maximal prolongation of life or decrease in morbidity or maintenance of normalhealth uncomplicated by known infirmity unless the following is clearly documented in the healthrecord:

There is explicit documentation that the patient wishes to limit therapy;

The patient has a very poor prognosis and it is believed by the Reviewer that clinical care couldnot alter the outcome (e.g., a terminal illness that is causing extreme suffering, or poor priorfunctional status and suffering with no hope of recovery).

There is explicit documentation of poor adherence to clinical care recommendations ofpractitioner (e.g., missed appointments, refusal of preventive health services).

Avoiding Controversies

The Reviewer is asked to avoid holding practitioners to standards idiosyncratic to himself or herself, toNEON, or to the region. Also avoid holding practitioners to standards that are controversial within theprofession. We ask that the Reviewer concentrate on problems he/she believes a group of his/herknowledgeable peers would agree with. Additionally, the Reviewer is asked to seek another clinicalopinion of a peer of the provider undergoing assessment. When this is done, the Reviewer must notdivulge the identity of the subjects of the review (patient nor clinician); rather, he/she should pose theinformal inquiry in general terms.

Rating Review Concerns of Structured Implicit Review

When assigning a rating to a particular Review Concern, the Reviewer is asked to consider averageconditions at NEON and to avoid adjusting his/her rating according to an environment external to NEON.

Excellent rating is the best the Reviewer can imagine in the average health center. Excellentcare minimizes the risk of complications, maximizes the likelihood of a good outcome, andmaximizes humane care and respect for patients’ wishes. The definition of “outcome” is broad,and integrates length of life and health-related quality of life (e.g., physical function,psychological well-being), as well as short-term and long-term effects.

Medium or Standard ratings is acceptable, but just minimally so.

Very poor care is often malpractice if associated with morbidity (reversible or nonreversible) ormortality. This care has egregious errors and is likely to result in more harm than benefit or lessbenefit than alternative approaches available within NEON’s network of health centers.


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Below is a tabulated representation of how the quality rating scale is used should coincide with theReviewer’s decision on the care as “Acceptable” or “Not Acceptable”:

Gradients of Quality Very Poor Poor Medium orStandard

Good Excellent

Corresponding Rating onNEON Chart Reviewformat

Not Acceptable

“NA”

Acceptable

“A”

If “NA” is selected for a specific Review Concern for a particular chart, a Severity Level and theappropriate Points must be determined based on the guidance on the following page.

Severity Level Identified Problem Points

Level 0 No deficiency or quality problem identified 0

Level 1 Mismanagement without potential for significant adverseeffect(s) on the patient (e.g., medical recorddocumentation, communication, minor deficiencies).

1

Level 2 A confirmed quality problem with actual mild tomoderate adverse impact or the potential of moderate tosevere adverse effect(s) on the patient.

Refer to 2A and 2B

Level 2A Those with actual mild adverse effect(s) on thepatient.

Those with potential for moderate adverseimpact on the patient.

5

Level 2B Those with actual moderate adverse effect(s) onthe patient.

Those with potential for serious adverse impacton the patient.

10

Level 3 A confirmed quality problem with significant adverseeffect(s) on the patient.

Refer to 3A, 3B, and3C

Level 3A Reversible morbidity. 15

Level 3B Non-reversible morbidity. 20

Level 3C Death 25


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5 patient charts from Electronic Health Record areselected based on the following criterium:

Two or more patients visits with practitioner within theprevious 12 months relative to index date of review.

NEON Professional Review Phase One Review Process Flow

List of Patients and time period isforwarded to an applicableProfessional Reviewer.

Professional Reviewerperforms review ofmedical recordsutilizing Chart ReviewFormat to documentfindings in Peer ReviewDatabase

Review Forms ordatabase file isforwarded toClinical ServicesDepartment.

Reviews that indicate"Not Acceptable"findings are submitted,inclusive of medicalrecords, to therespective ClinicalDirector for a Level TwoReview.

Subsequent reviewperformed by MedicalDirector shallsupercede Level Onereview when applicableto any 'ReviewConcern'.

Level One Reviewsand applicable LevelTwo reviews arecombined to completeProfessional ReviewSummary report (PRS)for individualpractitioner.

The Professional Review Summaryreport is placed in provider'sCredentialing File.

An Abnormal Review is established when thesum of Severity Level (SL) Points across the 5-chart review exceed 4 SL Points, that isconcluded from a on Level Two Review).Respective Clinical Director meets withPractitioner who has Abnormal Review.Electronic Health Record is utilized to supportand/or discuss the review findings.

If Total SL Points do not exceed 4 then: Practitioner only receives a notice of review findings and recommendations on a Practitioner Review

Summary report (completed by completed and generated by the respective Clinical Director);

Practitioner is reviewed again in 12 months as part of routine annual review process.

Constructive Professional Rehabilitation (CPR),Professional Alert, or Professional Probationprocesses are activated, congruent with natureand severity of Abnormal Review.


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Practitioner is placed on ConstructiveProfessional Rehabilitation (CPR).Practitioner counseling is performed byrespective Clinical Director.A Performance Improvement Plan (PIP) isdeveloped by Clinical Director for theindividual provider.Practitioner gets copy of PIP.

Practitioner on CPR gets PhaseTwo Review (10 charts) in 90 days.[patients at least once withinprevious 90-day span and at leasttwice in previous 12 months]

Constructive Professional Rehabilitation (CPR) & Professional AlertPhase Two & Three Review Process Flows

For Abnormal Review, no morethan 15 SL Points wereassessed?

For Abnormal Review,no more than 5 SLPoints are assessedacross 5-chart review?

Yes

No

Practitioner is placed on Professional Alert.Practitioner counseling is performed byClinical Director.A Performance Improvement Plan isdeveloped by respective Clinical Director forindividual provider. Practitioner gets copy ofPIP.

Practitioner isplaced on

ProfessionalProbation.

Yes

No

Practitioner on Professional Alert getsPhase Two review (10 charts) in 45 days.[patients at least once within previous 45-day span and at least twice in previous 12months]

Normal professional status isrestored to provider & he/sheundergoes standardProfessional Review in 12months from date of initialPhase One Review.

Practitioner on CPR getsPhase Three Review (10charts) in 90 days. [patients atleast once within previous 90-day span and at least twice inprevious 12 months]

Yes

Phase Two Review outcomewarrants CPR designation?

Phase Two Reviewoutcome warrants NOspecial designation (i.e.,PA, or PR)?

No

Yes

No

Outcome of Phase ThreeReview is that Providerwarrants NO specialdesignation (i.e., CPR,PA, or PR)?

Yes

No


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Professional Review Program 'Professional Probation' & 'Due Process' Flow

Practitioner is placed on ProfessionalProbation based on appropriatecriteria.

Practitioner is advised in writing ofthis status and its implications.

If the Affected Practitioner does not concurwith the recommended constructive courseof action then a formal meeting is arrangedand takes place within 14 days .Attendees of Formal Meeting are: CEO,Corporate Compliance Officer, ClinicalDirectors, Director of Human Resources,Legal Counsel, and affected practitioner.

An Informal Meeting takes places within 14 days of thiswritten notification.

The attendees include the CEO, respective Clinical Director,and the Affected Practitioner.

Purpose of Informal Meeting is to develop a constructivecourse of action and define and agree to the terms of theProfessional Probation that fits the clinical circumstances.

The purpose of the formal meeting is to allow thepractitioner to challenge the procedural and clinical basis ofany recommended actions against him/her and to allow foran investigation to take place if it is determined from thismeeting that there are sufficient grounds to justify such aninvestigation.

If such an investigation takes place, the affected practitioneris expected to approach the matter sensitively, privately, anddiscretely consistent with professional codes of conduct.

Such an investigation takes place within fourteen (14) daysto complete from the time the initial formal meeting tookplace.

A second and final formal meeting ispermitted, when applicable and no laterthan twenty-one (21) days after theinitial meeting, in order to negotiate thefindings of the investigation notedabove.

Within seven (7) days from the second formalmeeting, the practitioner will be notified of thecourse of action and proposed terms ofProfessional Probation by the CEO.

The practitioner is given writtennotification of the proposedrecommendation with 7 days.

Practitioner is afforded right toHearing before the ProfessionalReview Body

The practitioner is given written notification of the proposedrecommendation within 7 days.

The Affected Practitioner must accept the terms of theProfessional Probation, voluntarily resign, or be terminatedfrom employment 'for cause'.

No Yes

Professional Probationentails a limitation or restriction inscope of practitioner's practice at

NEON?


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Summary of Professional Review activities isreported to Board's QI Committee on semi-annualbasis.

Board's QI Committee proposes actions to Boardpursuant to recommendations of CEO and MedicalDirector.

Certain outcomes of Professional Revieware reported to applicable state licensingboards (HCQIA 1986 mandate).

GENERAL REPORTING OF REVIEW ACTIVIES & OUTCOMES

Hearing before Professional Review Body & Board of Trustees Action Process Flow

A practitioner who is afforded the right to ahearing before the Professional Review Bodymust request a hearing in writing withinfourteen (14) days of receipt of notification thatan adverse action is being proposed.

Upon requesting a hearing, the hearing takes placewithin thirty (30) days of the request.

The purpose of the hearing is to allow thepractitioner to challenge the procedural or clinicalbasis of such actions against him/her and to allowfor discussion to take place in order to clarifywhether in fact the practitioner was given dueprocess.

A representative of the Board of Trustees(Quality Committee or ExecutiveCommittee) serves as moderator of theProfessional Review Body.

Within thirty (30) days following the conclusion ofthe hearing, the Quality Committee (on behalf ofProfessional Review Body) submits a final andformal recommendation to the Board of Trusteesfor action during the next upcoming meeting ofthe Board.

The Board of Trustees considers the Quality Committee's recommendation at its next regularly scheduledmeeting following the finalization of the Committee's recommendation or the Chief Executive Officer'srecommendation following a confirmed waiving of the right to a hearing.

Practitioner is given written notice of action,which is final.

Practitioner is given written notice ofproposed action and the right to anotherhearing before the Professional ReviewBody

Practitioner is given written notice of action,which is final.

Yes

No

Yes

No

Board concurs withrecommended actions?

Board decides that recommendedactions should be more severe?

Board decides that recommendedactions should be less severeor none at all.


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NEON PROFESSIONAL REVIEW: MEDICAL RECORD REVIEW FORM

Provider Code: Type: IM Ped FM Ob/Gyn Pod Opt

Review Level: One Two 12-month time span of review: from [ ] to [ ]

MR#: Reviewer Code: Date of Review:

Brief Clinical Summary:

Review Concerns A NA SLP Remarks (if ‘NA’)

1. Degree to which practitionerperformed adequate assessments onthe patient.

2. Degree to which practitionerperformed appropriate diagnostictests.

3. Degree to which practitionerestablished patient diagnoses anddeveloped appropriate treatmentplans.

4. Degree to which practitionerprovided treatment in an appropriateand timely manner.

5. Degree to which the practitioner’smedical record documentation on thispatient was complete, clear, andconcise.

6. Degree to which practitionerdemonstrated at least minimaladherence to standards of carepracticed by similar NEONpractitioners under same or similarcircumstances whether or not anegative outcome for the patient isestablished.

7. Degree to which there was use ofreasonable care and discrimination inthe administration of drugs, oremployment of acceptable scientificmethods in the selection of drugs orother modalities for treatment ofdisease.


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NORTHEAST OHIO NEIGHBORHOOD HEALTH SERVICES, INC.PROFESSIONAL REVIEWER CONFIDENTIALITY AGREEMENT

I agree to respect and maintain the strict confidentiality of all discussions, deliberations, records, andother information generated in connection with the NEON Professional Review Program. I understandthat by signing this Agreement I am binding myself to maintain such confidentiality. I agree that I willnot make any voluntary disclosure of such confidential information except to persons authorized toreceive it.

If, as a Professional Reviewer of the NEON Professional Review Program, I have a conflict of interest withrespect to any matter being reviewed, I shall refrain from performing the clinical review. It shall bedeemed that I have a conflict of interest if there is any involvement on my part in the review case tosuch an extent that it might impair my objectivity in performing said review.

I understand and agree that any of the Beneficiaries (collectively referring to reviewed providers andindividuals involved in NEON Quality Improvement & Assurance activities) shall have the right to seekand obtain from a court of competent jurisdiction, in an action for that purpose, an order and/or ajudgment enjoining and prohibiting me from voluntarily disclosing confidential information in violationof this Agreement. I agree that it is impossible to measure in money the damages that may be causedthereby to the Beneficiaries and the NEON Professional Review Program. I hereby waive any claim ordefense that the Beneficiaries have been adequately remedied by law, and I consent to the impositionof injunction relief to prevent a breach of this Agreement. The Beneficiaries may, at the discretion ofthe Court, be entitled to recover attorney’s fees and court costs from me in any such action in whichthey are successful. I understand that if such action is unsuccessful, such attorney’s fees and courtcosts including those incurred by me shall be the responsibility of NEON.

I understand that I am indemnified and held harmless through and by NEON from any judgments thatare rendered and any award of any attorney’s fees and costs, which are made arising out of my goodfaith activities on behalf of NEON as a Professional Reviewer.

This obligation is of strictest confidence and shall survive the termination of my performance of clinicalreview activities within the context of the NEON Professional Review Program.

The Above is Accepted and Agreed to by the Undersigned:

Reviewer’s Printed Name:

Reviewer’s Signature: Date of Signature:

Administrative Acknowledgement and Acceptance:

Signature of Medical Director: Date of Signature:

NEON QIC Policies & Procedures QIC-P14 Credentialing & Privileges Plan

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QIC Policy Name: Credentialing and Privileges Plan QIC Policy Code: QIC-P14

Effective Date: 2/22/04 Revision/Review Dates: 5/9/2007; 3/2/2011; 6/7/2011; 6/13/2012


Related QIC Policies: QIC-P1 QIP Fundamentals; QIC-P11 Risk Management Plan

Attachments:

Authorization: Refer to QIC-S1 Authorization Signatures QIP Goal Congruency: Patient Care; Patient Safety

AFFIRMATION:

NEON shall ensure that credentialing and privileging process is done in a timely manner with appropriate recordation at least every twenty-four months. This policy shall cover independent licensed practitioners (i.e., dentists, physicians, optometrists, and podiatrists) and midlevel practitioners (i.e., advanced practice nurses and physician assistants) and other licensed or certified health care practitioners (i.e., registered nurses, licensed practical nurses, medical assistants) as defined in the BPHC’s Policy Information Notice (PIN) 2002-22.

PURPOSE:

The purpose of this policy is to ensure quality and qualifications of NEON Licensed Independent Practitioners (LIP). The credentialing and recredentialing procedures herein specified reflect guidelines from the Joint Commission and the BPHC’s Policy Information Notice (PIN) 2002-22.

PROCEDURE: Herein noted below. CREDENTIALING, RE-CREDENTIALING, APPOINTMENT, & RE-APPOINTMENT A. Initial Credentialing of Licensed Independent Practitioners (excluding midlevel practitioners)

In order to initiate the credentialing process, the practitioner must submit the following items to the applicable Clinical Director (Medical or Dental):

1. A current valid license to practice in Ohio;

2. A current valid DEA certificate, if applicable;

3. A Curriculum Vitae that summarizes all professional activities related to the privileges applied for since graduation from professional school, accounting for any gaps in employment;

4. Specialty Board certificate, if applicable;

5. A completed NEON Professional Application.

Upon receipt of the above-noted items, the credentialing staff will perform the following tasks:

1. Create a hard-copy or electronic confidential file for the candidate.

2. Secure primary verification as to whether there was successful completion of the education and training stated, e.g. medical school, dental school, residencies, and fellowships.

3. Secure primary verification of the validity of the professional license for Ohio.


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4. Query the National Practitioner Data Bank on the practitioner, a query that includes any Medicaid or Medicare sanctions.

5. Query the references offered, using a NEON Professional References form.

6. Secure primary verification of Specialty Board Certification.

7. Verify that NEON or the practitioner has secured malpractice insurance coverage for the practitioner or is covered through deeming under the provisions of the Federal Torts and Claims Act (FTCA).

8. Have the candidate complete a NEON Adverse History Questionnaire.

9. Have the candidate provide a summary of continuing professional education that meets the minimum standard established by the State Licensing Board for at least two years prior to application.

10. Have the candidate complete the applicable NEON Delineation of Clinical Privileges form.

11. Verify the identity of the practitioner by viewing a valid picture identification issued by a state or federal agency (for example, a driver’s license or passport).

If privileges are granted by the Board of Trustees, the practitioner shall receive written notification from the Clinical Director that includes the duration of clinical privileges as well as the delineation of clinical privileges granted by the NEON Board of Trustees. Written notification will include any privileges requested which were denied.

Note: Primary source verification is required. Designated equivalent sources may be used as an alternative to the primary source. This could include AMA Physician Masterfile, ABMS for board certification, ECFMG for verification of graduation from a foreign medical school, AOA Physician Database, and FSMB for actions against a physician’s license. However, if this is not possible, a reliable secondary source (one who has performed primary source verification) may be used. Documentation must be kept of the efforts to reach the primary source.

Note: An external organization (for example, a credentials verification organization (CVO) or a Joint Commission-accredited health care organization functioning as a CVO may be used to collect credentialing information.

Note: Current licensure must be verified at the time of license expiration.

B. Recredentialing of Independent Licensed Practitioners (excluding midlevel practitioners)

Every two years, practitioners will be required to submit a Reappointment Application, which will update their credential file. The following steps will be taken:

1. Secure primary verification of the validity of the medical license.

2. Query the National Practitioner Data Bank on the practitioner, a query that includes any Medicaid or Medicare sanctions.

3. Secure primary verification of Specialty Board Certification, if the candidate attests to new certification or recertification since the previous review by NEON.

4. Review the studies performed by NEON that pertain to the following:


3

a. Consumer complaints that have been lodged against the practitioner, over the previous period of privileges, that have been dealt with and disposed of by Administration and properly filed in the practitioner’s credentialing file;

b. Results of quality of clinical care reviews;

c. Consumer satisfaction surveys;

d. Review and evaluation by Administration of the practitioner’s degree of general reliability and availability to his/her patient panel during the previous period of privileges, and practitioner’s general adherence to the organization policies, procedures, rules and regulations.

5. Secure a peer reference as to the current competency of the practitioner.

6. Secure primary verification of the practitioner’s hospital privileges, if applicable.

7. Have the candidate complete a NEON Adverse History Questionnaire.

8. Have the candidate provide a Continuing Professional Education summary that meets the minimum standard established by the State Licensing Board for at least the two years prior.

9. Have the candidate complete a delineation of privileges requested.

C. Appointment and Reappointment of Independent Licensed Practitioners (excluding midlevel practitioners)

The Human Resources Director shall review all credentialing files to verify that requisite primary verifications of the education and training have been performed for all practitioners applying for initial appointment or reappointment. At a minimum, a visible indication (e.g., signature) that this review has taken place shall be affixed to the credentialing file. Upon clearance by the Human Resources Director, the applicable Clinical Director (Dental Director or Medical Director) reviews the credentialing or re-credentialing materials and determines whether the candidate is qualified to be a NEON practitioner. The Clinical Director shall complete the applicable Delineation of Privileges form.

If the candidate is qualified, the Clinical Director petitions to the Board Quality Committee for the official appointment or reappointment of the practitioner. This action shall take place within ninety (90) days of receipt of a completed NEON Professional Application, if Temporary Privileges have not been granted, and within one hundred twenty (120) days of receipt of a completed NEON Profession Application, if Temporary Privileges have been granted.

The complete hard copy of the credentialing file kept on the individual practitioner is presented to the Board Quality Committee to review. A member of this Board committee shall place a signature in the credentialing file stipulating that a review has taken place. This Board committee presents its review findings to the Board of Trustees. The Board of Trustees votes whether to grant the privileges requested by the individual practitioner and recommended by the Clinical Director and Board Quality Committee. Privileges for an individual practitioner shall not be granted for a period that exceeds two (2) years.


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D. Initial Credentialing of Midlevel Practitioners

In order to initiate the credentialing process, the practitioner must submit the following items to the Clinical Director or the item shall be included in the credentialing file for subsequent review:

1. Current valid license to practice in Ohio;

2. A current valid DEA certificate, if applicable;

3. The candidate shall complete a NEON Adverse History Questionnaire.

4. The candidate shall provide a summary of Professional Continuing Education that meets the minimum standard established by the State Licensing Board for at least the two years prior and up to the most recent re-licensure, if applicable.

For the Advanced Practice Nurse:

a. A copy of a current valid Registered Nurse license to practice in Ohio;

b. A copy of a current Certificate of Authority issued for practicing in Ohio;

c. A copy of a certificate issued by a national certifying organization approved by the Ohio Board of Nursing to practice as a: Certified Nurse Midwife or a Certified Nurse Practitioner in one or more subcategories: Adult Nurse Practitioner; Family Nurse Practitioner; Pediatric Nurse Practitioner; or, Obstetrical-Gynecological/Women’s Health Care Nurse Practitioner.

For the Physician Assistant:

a. A copy of the Registration Certificate to practice in Ohio;

b. An executed Physician Assistant Supervision Agreement;

c. An executed Affidavit of Supervising Physician(s);

d. An executed Alternate Physician Agreement, if applicable.

e. A copy of the candidate’s Certification from the National Commission for Certification of Physician’s Assistants;

f. A copy of a State-approved Physician Assistant Utilization Plan specific to NEON and the candidate.

Upon receipt of the above-noted items, the credentialing staff will perform the following tasks:

1. Create a hard-copy confidential file for the candidate.

For Advanced Practice Nurses:

a. Verify that the candidate has a valid Registered Nurse license to practice, and a valid Certificate of Authority.

b. Verify that the candidate has a valid certificate issued by a national certifying organization approved by the Ohio Board of Nursing.

c. The Advanced Practice Nurse shall execute the current Standard Care Arrangement (SCA). The SCA must be executed by one or more NEON physicians of the appropriate specialty as applicable to the respective Advance Practice Nurse. A copy of the signature page shall be included in the credentialing file.


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For Physician Assistants:

a. Verify that candidate has a valid State Medical Board Registration Certificate;

b. Verify that candidate has a Certification by contacting the National Commission for Certification of Physician’s Assistants.

E. Recredentialing of Midlevel Practitioners

Every two years, practitioners shall be required to submit a Reappointment Application, which will update their credential file. Administration shall ensure that the following procedures are performed:

1. Secure primary verification of the validity of the clinical license.

2. Review the studies performed by NEON that pertain to the following:

a. Consumer complaints that have been lodged against the practitioner, over the previous period of privileges, that have been dealt with and disposed of by Administration and properly filed in the practitioner’s credentialing file;

b. Results of quality of clinical care reviews;

c. Patient satisfaction surveys;

d. Review and evaluation by Administration of the practitioner’s degree of general reliability and availability to his/her patient panel during the previous period of privileges, and practitioner’s general adherence to the organization policies, procedures, rules and regulations.

3. Secure a reference as to the current competency of the practitioner from a peer or supervising physician in the same discipline.

4. Document the practitioner’s status with Medicaid and Medicare pertaining to sanctions by querying the National Practitioner Data Bank.

5. Secure primary verification of the practitioner’s hospital privileges, if applicable.

6. The candidate shall complete a NEON Adverse History Questionnaire.

7. The candidate shall provide a summary of Continuing Professional Education (e.g., CME) that meets the minimum standard established by the State Licensing Board for the prior two years.

For Advanced Practice Nurses:

a. Verify that the candidate has a valid Registered Nurse license to practice.

b. The Medical Director shall review the Standard Care Arrangement for the respective Advanced Practice Nurse to make certain that it is in accordance to Ohio Administrative Code Section 4723.431.

c. The Advanced Practice Nurse shall execute a current Standard Care Arrangement (SCA) in January of each year. The SCA must be executed by one or more NEON physicians of the appropriate specialty as applicable to the respective Advance Practice Nurse. A copy of the signature page shall be included in the credentialing file.

For Physician Assistants:

a. Verify that candidate has a valid State Medical Board Registration Certificate;


6

b. Verify that candidate has a Certification by contacting the National Commission for Certification of Physician’s Assistants.

c. Include a copy of completed Supervising and Alternate physician forms in credentialing file.

d. The Medical Director shall review the Utilization Plan for the respective Physician Assistant. If there are any changes, submit a revised Utilization Plan to the State Medical Board of Ohio for approval. Include copy of Utilization Plan in credentialing file.

F. Initial Appointment and Reappointment of Midlevel Practitioners The Human Resources Director shall review all credentialing files to verify that requisite primary verifications of the education and training have been performed for all practitioners applying for initial appointment or reappointment. At a minimum, a visible indication (e.g., signature) that this review has taken place shall be affixed to the credentialing file. Upon clearance by the Human Resources Director, the applicable Clinical Director (Dental Director or Medical Director) reviews the credentialing or re-credentialing materials and determines whether the candidate is qualified to be a NEON practitioner. The Clinical Director shall complete the applicable Delineation of Privileges form.

If the candidate is qualified, the Clinical Director petitions to the Board Quality Committee for the official appointment or reappointment of the practitioner. This action shall take place within ninety (90) days of receipt of a completed NEON Professional Application, if temporary privileges have not been granted, and within one hundred twenty (120) of receipt of a completed NEON Profession Application, if temporary privileges have been granted.

The complete hard copy of the credentialing file shall be kept on the individual practitioner and will be presented to the Board Quality Committee to review upon request. A member of this Board committee shall place a signature in the credentialing file stipulating that a review has taken place. This Board committee presents its review findings to the Board of Trustees. The Board of Trustees votes whether to grant the privileges requested by the individual practitioner and recommended by the Clinical Director and Board Quality Committee. Privileges for an individual practitioner shall not be granted for a period that exceeds two (2) years.

G. Temporary Privileges of Independent Licensed Practitioners

The Chief Executive Officer may grant temporary Privileges to a practitioner during the period in which the credentialing or re-credentialing process is being completed. There are two circumstances for which the granting of temporary privileges would be acceptable:

1. To fulfill an important patient care need:

a. A situation where a physician or advanced practice nurse becomes ill or takes a leave of absence and a licensed independent practitioner is needed immediately to cover his/her practice until he/she returns (i.e., locum tenens).

b. A specific licensed independent practitioner has the necessary skills to provide care to a patient that a licensed independent practitioner currently privileged does not possess.

c. If any of the above apply (‘a’ or ‘b’), temporary privileges may be granted upon recommendation of the respective Clinical Director provided there is verification of current licensure and current clinical competence.

2. When an applicant with a complete, clean NEON Professional Application is awaiting review and approval of the Board Quality Committee and the governing body, provided the following apply:


7

a. There is primary source verification of current licensure, relevant training or experience, current competence, ability to perform the privileges requested, and other criteria required.

b. Documentation includes a curriculum vita, specialty Board certificate (if applicable), residency certificates (if applicable), a current Ohio license, and a current DEA.

c. The results of the National Practitioner Data Bank query have been obtained and evaluated.

d. The applicant practitioner has no current or previously successful challenge to licensure or registration, not been subject to involuntary termination of medical staff membership at another organization, and not been subject to involuntary limitation, reduction, denial, or loss of clinical privileges.

e. Malpractice coverage is assured through deeming and applicable supplemental malpractice insurance carriers.

Temporary privileges shall not be routinely used for other administrative purposes such as the following situations:

1. The licensed independent practitioner fails to provide all information necessary to the processing of his/her reappointment in a timely manner;

2. Failure of the Administrative staff to verify performance data and information in a timely manner.

In the case of a previously privileged practitioner, whose privileges have expired and the above situation applies, he/she shall be required to cease providing care in the facility until the reappointment process is completed.

Chief Executive Officer may grant temporary privileges for a limited period of time, not to exceed one hundred twenty (120) days, upon the recommendation of the applicable Clinical Director. In this case the Chief Executive Officer shall provide written notification to the practitioner and said notification shall include the duration of these clinical privileges as well as the delineation of clinical privileges specified by the applicable Clinical Director.

H. Delegation of Credentialing

In certain instances, NEON shall delegate to an entity the credentialing of certain practitioners who participate in on-site provision of clinical services to patients registered at NEON. Such delegation shall be limited to entities that are accredited by Joint Commission. Specialty practitioners covered under the delegation agreement shall be limited to those individuals who are directly employed by the entity or by an organization for which the delegated entity is the parent. Generally, the delegation of credentialing and re-credentialing shall be reserved for institutions that are engaged in on-site NEON clinical training programs.

The established and written credentialing policies and procedures of the delegated entity or its parent organization shall conform to NEON’s credentialing policies and procedures, herein specified, or those of the Joint Commission, at a minimum. NEON shall verify the delegated entity’s conformance by reviewing the entity’s written credentialing policies and procedures. NEON shall also verify that the delegated entity has adequate staffing who are properly certified to implement the entity’s credentialing policies and procedures. A formal agreement describing the specifics of the privilege of delegation of credentialing and re-credentialing shall be executed between NEON and the delegated entity, specific for each specialty.


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The delegated entity or subsidiary group shall be issued, relative to specific specialty practitioners, a statement of a delineation of privileges and a scope of clinical practice that they are to honor and abide by while practicing on-site at a NEON facility.

The delegated entity shall maintain established written policies and procedures for the suspension, reduction, or termination of a practitioner’s group association or privileges, as may be appropriate, based on the results of the credentialing/re-credentialing process. Such policies and procedures shall include a mechanism for the reporting of quality deficiencies resulting in the suspension or termination of practitioner’s privileges to the appropriate authorities including, but not limited to, the National Practitioner Data Bank.

Notwithstanding anything herein to the contrary, all final determinations regarding the approval of a specific practitioner or the suspension or termination of a practitioner’s clinical practice on-site at a NEON facility shall be that of NEON. Moreover, nothing in the agreement executed with the delegated entity shall affect NEON’s authority to terminate practitioners, or to exercise its other rights, under any formal service agreement with the entity or its subsidiaries.

If the credentialing and re-credentialing written policies and procedures and actual practices of the delegated entity or its subsidiaries are found to not conform with what is herein specified, NEON shall terminate the delegation agreement immediately.

SANCTIONS AGAINST PRACTITIONERS

Practitioners who are found in violation of policies or procedures of NEON may be placed on probation, have their privileges suspended, have their privileges reduced/modified, or have their privileges terminated.

Disciplinary Probation A practitioner may be placed on disciplinary probation when the situation is serious enough to warrant such action. Probation shall constitute an action approved by the Chief Executive Officer and can last up to ninety (90) days. Failure to achieve rehabilitation within the designated period of time (maximum of 90 days) shall result in termination of employment.

Rule violations are categorized as either minor or major. The lists of minor or major rule violations should be viewed as guidelines, which can be modified, in NEON’s sole discretion, as circumstances and good judgment warrant. A violation, which is classified as major, is considered the equivalent of two minor violations. Therefore, any combination of major and minor violations equaling or exceeding four minor violations will be sufficient justification for dismissal.

Suspension of Privileges

Suspension of privileges may be applied to a practitioner who has been cited with a significant violation of NEON policies and procedures that is not related to patient care. During the period of said suspension, the practitioner will not be allowed to perform patient care and will not be compensated proportionate to the length of time of the suspension. If after three (3) days, prior to which time the practitioner was not on approved leave of absence and was served a written notice of suspension in person, the violation is not rectified as determined by the respective Clinical Director, the practitioner will be subject to termination of privileges.

Reduction / Modification of Privileges


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If a Clinical Director determines by various means that the scope of privileges awarded to a given practitioner are too broad, overly inclusive, or inappropriate, privileges shall be reduced or modified. In this case the practitioner shall execute a revised Delineation of Privileges form, which in turn will be executed by respective Clinical Director.

Termination

Termination of privileges may be applied to a practitioner when it is determined that the practitioner has violated that terms of his/her employment agreement with NEON in which case the practitioner has been formally notified in writing that his/her contract has been voided and/or it is the determined that due to the failure of the practitioner to substantially perform his/her duties as the basis of employment with NEON it is concluded that it is in the best interests of NEON and its patients that the practitioner’s privileges be terminated and he/she be separated from the organization.

Termination of privileges may be applied to a practitioner who has been subject to more than 4 suspensions of privileges within a calendar year.

Appeals Process

Practitioners who have been sanctioned may appeal to the Clinical Director within 15 days of receipt of a sanction notification letter.

There is a formal grievance policy in the Personnel Policies and Procedures, which would be an avenue for appealing any sanction that the practitioner/employee feels is unwarranted.

Serious Quality Deficiency Reporting Requirements

It is mandated that NEON report to the State Licensing Board and the National Practitioner Data Bank practitioners who are found to have had serious quality deficiencies resulting in suspension or termination.

CREDENTIALING/RE-CREDENTIALING OF OTHER LICENSED OR CERTIFIED HEALTH CARE PRACTITIONERS The category of other licensed or certified health care practitioners includes the following employee types:

Pharmacists

Registered nurses

Licensed practical nurses

Certified or registered medical assistants

Radiology technicians

Ultrasound technicians

Licensed social workers

Laboratory technicians

Dental hygienists

Credentialing of other licensed or certified health care practitioners requires primary source verification of the individual’s license, registration, or certification only. Education and training may be verified by secondary source verification methods. Verification of current competence is accomplished through a


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thorough review of clinical qualifications and performance. Credentialing of other licensed or certified health care practitioners also requires secondary source verification of the following:

Government issued picture identification;

Immunization and PPD status;

Life support training (as applicable).

Credentialing of other licensed or certified health care practitioners must be completed prior to the individual being allowed to provide direct patient care services. Privileges for other licensed or certified health care practitioners are granted by the supervisor of the said staff person.

Renewal of privileges for other licensed or certified health care practitioners is required every 2 years at a minimum. This renewal of privileges is granted by the Human Resources Department after the following has been secured by the Human Resources Department:

1. Primary source verification of current licensure, registration, or certification;

2. Verification of current competence to perform per job description;

3. Absence of dissent by supervisor.

QUALITY IMPROVEMENT PROGRAM AUTHORIZATION ......Matthew Fitzsimmons Chairman, Board of Trustees NEON...

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