Provider Manual. Section 8: Quality Assurance and Improvement

Transcription

1 Provider Manual

2 Table of Contents SECTION 8: QUALITY ASSURANCE AND IMPROVEMENT (QI)... 3 KAISER PERMANENTE QUALITY MISSION STATEMENT ORGANIZATIONAL STRUCTURE AND ACCOUNTABILITIES Kaiser Permanente Quality Management Department Contacts COMPLIANCE WITH REGULATORY AND ACCREDITING BODIES SENTINEL EVENTS Do Not Bill Events (DNBE) QUALITY REPORTS The Joint Commission Staffing-Effectiveness Indicators for Hospitals PROVIDER CREDENTIALING Credentialing and Recredentialing Processes Provider Notification of Status of Credentialing Application Provider Right to Review and Correct Erroneous Information Providers on Corrective Action Plan Status Confidentiality of Credentialing Information Organizational Provider Assessment/Reassessment PEER REVIEW COMPLIANCE WITH FACILITY AND OFFICE SITE REVIEWS Frequency of Facility and Office Site Reviews Site Review Evaluation Form Non-Compliance with Site Review Standards COMPLIANCE WITH MEDICAL RECORD Frequency of Medical Records Review Non-Compliance with Medical Records Standards ACCESSIBILITY STANDARDS Non-Compliance with Accessibility Standards PREVENTIVE CARE AND CLINICAL PRACTICE GUIDELINES PATIENT SAFETY POLICY Revised April

3 (QI) Kaiser Permanente Quality Mission Statement The mission of the organization is to enhance the health and well being of our Members through the delivery of high quality, affordable health care. Our team of professionals will provide exceptional Service with a commitment to integrity and remain focused on the needs of our Members. The Kaiser Permanente of Ohio Quality Program reflects our vision and values. It is designed to initiate, monitor, evaluate and improve standards of health care practice and customer Service on an ongoing basis. Kaiser Permanente is committed to providing appropriate care in an efficient and effective health care delivery system for its Members, employers, Practitioners and Plan Providers. A multi-disciplinary and integrated approach is used, which focuses on opportunities for improving operational processes, health outcomes, as well as Member and Plan Provider satisfaction. The Kaiser Permanente Quality Management (QM) program promotes the accountability of all Kaiser Foundation Health Plan of Ohio personnel as well as Ohio Permanente Medical Group (OPMG) Practitioners for the quality of care and Services that are provided to Kaiser Permanente Members. The quality of care Members receive is monitored by Kaiser Permanente s oversight of Plan Providers to ensure that all Members are receiving high quality care. Kaiser Permanente believes that Quality is Everyone s Job. Participating Plan Providers are monitored for various standards, including, but not limited to, the following: Member access to care. Member Complaint and satisfaction survey data of both administrative and quality of care issues. Compliance with Kaiser Permanente policies and procedures. Utilization management statistics. Quality of care indicators as necessary for Kaiser Permanente to comply with requirements of National Committee for Quality Assurance (NCQA), the Centers for Medicare & Medicaid Services (CMS), The Joint Commission, and other regulatory and accreditation bodies. Performance standards in accordance with your Agreement. 8.1 Organizational Structure and Accountabilities The Kaiser Permanente Quality Management (QM) program provides a link to the Medical Management, Clinical Risk Management, Claims Management, Customer Relations, Population Care Management/Disease Management, Patient Safety, Ohio Permanente Medical Group (OPMG), Care Experience Initiative, and administrative functions of Kaiser Foundation Health Plan of Ohio, along with Practitioner and Provider Review and Oversight activities. Revised April

4 Issues concerning quality should be directed to either the Plan Provider s Quality Department or directly to Kaiser Permanente s Performance and Patient Safety Department at for follow-up. To maintain an open line of communication, OPMG has established relationships with Plan Providers to participate in committees, which include but are not limited to: Disaster preparation. Infection control. Medical records. Nutrition. Pharmacy and therapeutics. Quality council. Questions or concerns regarding OPMG s participation in committees can be directed to the Associate Medical Director of Quality at Kaiser Permanente Quality Management Department Contacts Title Phone Number Reason for Contact Associate Medical Director of Quality Questions concerning OPMG involvement on committees Clinical Risk Manager Sentinel and Do Not Bill events, quality of care issues, peer review referrals 8.2 Compliance with Regulatory and Accrediting Bodies Kaiser Permanente participates in the National Committee for Quality Assurance (NCQA), Centers for Medicare & Medicaid Services (CMS), Medical Director Quality Review (MDQR), Health Plan Quality Oversight (HPQO), and the Ohio Department of Health (ODH) review activities in order to demonstrate Kaiser Permanente s compliance to regulatory and accrediting bodies. In accordance with these regulations, Plan Providers are expected to provide to Kaiser Permanente, on an annual basis, measures of clinical quality, access, and Member satisfaction results for both commercial and Medicare patients to support HEDIS (Healthcare Effectiveness Data and Information Set) data collection. HEDIS is one of the most widely used set of performance measures in the United States and includes 80 measures across eight domains of care. This information will be either conveyed electronically by Plan Providers or collected by Kaiser Permanente staff through chart review. If there are any issues regarding the data transfer process, Plan Providers should contact their respective IT Help Desks. Revised April

5 If necessary, in order to complete HEDIS reporting, Kaiser Permanente staff will contact Plan Providers for specific patient information related to medical care. The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule permits a plan provider to disclose protected health information to a health plan for quality-related health care operations, provided that the health plan has or had a relationship with the individual who is the subject of the information, and the protected health information requested pertains to the relationship. See 45 CFR (c)(4). Thus, a plan provider may disclose protected health information to a health plan for the plan s HEDIS collection purposes, so long as the period for which information is needed overlaps with the period for which the individual is or was enrolled in the health plan. Kaiser Permanente expects all applicable Plan Providers to have and maintain The Joint Commission accreditation or be approved by another recognized accrediting body, to be in compliance with all regulatory bodies (i.e., CMS), and to maintain a current certificate of insurance. If a Plan Provider receives any recommendations from these organizations, the Plan Provider is required to provide to Kaiser Permanente the surveys recommendations, along with the corrective action plan to resolve the identified issue or concern. Kaiser Permanente monitors the status of the above listed accreditations, licensures, certifications, etc. on an annual basis through the Ohio Permanente Medical Group (OPMG) Credentialing and Human Resources Department. To contact this department with an update or question, call toll-free , ext. 5541, or Kaiser Permanente maintains a corporate compliance program based upon the Office of the Inspector General s Seven Elements of an Effective Compliance Program. This includes a code of conduct entitled, Principals of Responsibility. For a complete description of our compliance program, see Section 9 of this Manual. 8.3 Sentinel Events Any unexpected occurrences involving a Kaiser Permanente Member, staff, etc., defined as a sentinel event, as defined by The Joint Commission, requires IMMEDIATE notification to Kaiser Permanente in accordance with Kaiser Permanente s Sentinel Event Policy. A full copy of the policy is available either through the Plan Provider s Quality Department or through the Kaiser Permanente s Performance and Patient Safety Department at Any such sentinel event should be reported to Kaiser Permanente s Clinical Risk Manager at All sentinel event reports are considered confidential and privileged quality/peer review documents Do Not Bill Events (DNBE) Plan Providers should notify Kaiser Permanente of any DNBE. Any such event should be reported to the Kaiser Permanente Clinical Risk Manager at Revised April

6 Upon learning of a DNBE, Kaiser Permanente will contact the reporting Plan Provider to discuss next steps. Member Cost Share may be waived and/or reimbursed and the Plan Provider s reimbursement may be affected. Refer to claim submission requirements for DNBE s in Section 5, Coding & Billing Validation and Do Not Bill Events, of this Manual. 8.4 Quality Reports Plan Provider performance for quality is monitored by Kaiser Permanente s Performance and Patient Safety Department via information exchange, mandatory reporting, and onsite reviews. In addition to actively participating in quality management activities, Plan Providers must provide access to Members medical records. Plan Providers should also ensure that they communicate openly with Members regarding appropriate treatments without penalty. In order for both Kaiser Permanente and Plan Providers to be in compliance with accrediting and regulatory bodies, various reports must be generated to track any quality issues. When issues are identified as a result of the reports, action plans must be developed by the Plan Providers and communicated to Kaiser Permanente s Clinical Risk Manager at Following is a list of the quality reports submitted by Plan Providers to the Kaiser Permanente Performance and Patient Safety Department: Transfers to ICU. Mortality rates. Unplanned removal/injury or repair of an organ or invasive procedure. Unplanned return to the operating room or special procedure room during an admission. Complications (major complications only). Unexpected death. Blood utilization. Skin care protocols and monitoring results. Medication errors (Nursing/Pharmacy). Patient falls. Restraint/seclusion monitors. Infection control surveillance data. The Joint Commission Staffing-Effectiveness Indicators for Hospitals. Update on Leapfrog Initiatives. Update on Institute for Healthcare Strategic Initiatives. Practitioner specific data as requested. As each Plan Facility collects and presents the data individually, questions regarding data collection tools and data files should be directed to each Plan Facility s respective Revised April

7 Quality Department. These reports, if available, and other criteria based on the Maryland Quality Indicator Project, should be submitted to Kaiser Permanente s Performance and Patient Safety Department on a quarterly basis no more than 30 days after the end of the quarter The Joint Commission Staffing-Effectiveness Indicators for Hospitals Reserved for future use. 8.5 Provider Credentialing In order to ensure the quality of Practitioners who treat Kaiser Permanente Members, Plan Providers are subjected to a vigorous credentialing process. All Plan Providers must be fully credentialed and approved to participate before treating Kaiser Permanente Members Credentialing and Recredentialing Processes Credentialing is an accountability of Kaiser Foundation Health Plan of Ohio and the Ohio Permanente Medical Group (OPMG). To fulfill this responsibility, the Credentials Committee was established in 1993 to develop credentialing policies and procedures and to review and make decisions regarding the credentialing and recredentialing of both OPMG Practitioners and the other Plan Providers. All Plan Providers must be fully credentialed and approved to participate before treating Kaiser Permanente Members. Plan Providers who employ Advanced Practice Nurses and/or Physician Assistants must first complete the credentialing process for these employees before they can render care to Kaiser Permanente Members. Initial credentialing requires a completed and signed CAQH (Council for Affordable Quality Health Care) application and primary source verification of licensure, hospital and healthcare organization privileges, Drug Enforcement Administration (DEA) registration, education and training, board certification, proof of professional malpractice coverage, and review of professional liability claims history. Applicants provide information concerning physical and mental health, and applications are reviewed for complete work history. Additional verifications include a query of the National Practitioner Data Bank/Healthcare Integrity and Protection Data Bank, and a query for Centers for Medicare and Medicaid Services (CMS) sanctions. Practitioners who are not already participating with the CAQH Universal Provider Datasource online can contact the Kaiser Permanente Credentialing Department at toll-free , ext. 5782, or for assistance in registering and accessing the CAQH application. Practitioners can also access the CAQH website at caqh.org to obtain instructions on receiving and filing a paper application form. Appointments are granted for a 2 year period. Practitioners are recredentialed every 2 years. Organizational providers are recredentialed every 3 years. Recredentialing requires submission of a current CAQH application and attestation, and re-verification of licensure, hospital/healthcare organization privileges, DEA registration, board Revised April

8 certification, proof of professional malpractice coverage, and review of professional liability claims history. The recredentialing process includes an update of physical/mental health status, query of the National Practitioner Data Bank/Healthcare Integrity and Protection Data Bank, and a query for CMS sanctions Provider Notification of Status of Credentialing Application At any time during the credentialing process, an applicant has the right to contact the Kaiser Permanente Credentialing Department to determine the status of their credentialing or recredentialing application. The Credentialing Department can be reached by telephone at toll-free , ext. 5782, or , via fax to or by sending an to ohiocredentialing@kp.org Provider Right to Review and Correct Erroneous Information Applicants are notified via a statement on the credentialing and recredentialing application of their right to review information obtained in conjunction with the credentialing process, except for professional references, recommendations or other information that is peer review protected. The applicant is notified of any information obtained in the credentialing process that varies substantially from that provided on the application, and the applicant then has the right to correct erroneous information submitted by another party Providers on Corrective Action Plan Status Reserved for future use Confidentiality of Credentialing Information Credentials files are maintained as confidential peer review documents of the Credentials Committee. The credentials files are maintained in a locked file room within locked file cabinets. The credentialing database is password-protected and authorized users are granted access to practitioner and provider information via field level security throughout the system. Access to credentials files is limited to those persons involved in conducting or overseeing credentialing and peer review activities Organizational Provider Assessment/Reassessment Kaiser Permanente contracts with organizational Providers, including hospitals, home health agencies, hospices, skilled nursing Facilities, nursing homes, free-standing surgical centers, behavioral health Facilities, and other ancillary Providers to provide care to Kaiser Permanente Members. Organizational Providers must meet contracting requirements and maintain credentials that include, at a minimum, the following: State licensure, as applicable. Accreditation by The Joint Commission or another recognized accrediting body as applicable based on the provider type. Certification by Centers for Medicare and Medicaid Services (CMS). Current, continuous liability coverage. Revised April

9 Initial assessment for an organizational Provider is valid for 36 months, at which time the organizational Provider is reassessed for continued compliance with the contracting requirements. If an organizational Provider receives any recommendations from a licensure, accreditation, or other regulatory entity, the organizational Provider is required to provide to Kaiser Permanente the surveys findings/recommendations, along with the corrective action plan to resolve the identified issue or concern. Kaiser Permanente monitors the status of the above listed accreditations, licensures, certifications, etc., upon expiration, and as the organizational Provider is reassessed every 36 months. For organizational Provider updates or questions, contact the Kaiser Permanente Credentialing Department at toll-free , ext. 5248, or , or send an to ohiocredentialing@kp.org. 8.6 Peer Review Kaiser Permanente will maintain a peer review process to promote and monitor credentialing, quality patient care, Member satisfaction, Member Complaints and administrative compliance with policies, procedures, rules and practices for all Plan Providers. Kaiser Permanente has established threshold for performance measures to include, but not limited to, the following key areas: Member satisfaction. Quality. Member Complaints and Grievances. Referrals. Utilization. HEDIS (Health Plan Employer Data and Information Set)/National Committee for Quality Assurance (NCQA). 8.7 Compliance with Facility and Office Site Reviews Kaiser Permanente reserves the right to perform environmental and medical record site reviews for any Plan Provider if requested as part of the contracting and/or credentialing process. This includes visits for a newly contracted Plan Provider, a new office location/relocation for an established Plan Provider, or a revisit to monitor compliance with a corrective action plan. A facility and office site review must be completed if an office site exceeds established thresholds for site-related Member Complaints pertaining to physical accessibility, physical appearance, or adequacy of waiting room and/or exam room space. Unannounced office site reviews may be conducted based on the urgency of a Complaint Frequency of Facility and Office Site Reviews Site reviews may be completed on all prospective Primary Care Physician (PCP), Ob/Gyn and Behavioral Health offices prior to consideration by the Kaiser Permanente Revised April

10 Credentials Committee. If an existing Plan PCP, Ob/Gyn or Behavioral Health Practitioner relocates, adds an additional practice location, or adds on to an existing office, a site review may be completed within 30 days of the relocation/opening of the new office. In addition, a site review of any Plan Provider office or Facility may be conducted at the request of the Associate Medical Director of Quality, the Kaiser Permanente Credentials Committee or the Performance and Patient Safety Department, or upon receipt of an environmental Complaint filed by a Kaiser Permanente Member Site Review Evaluation Form See the following page. Revised April

11 Kaiser Permanente-Ohio Site Visit and Evaluation Tool Date of Visit: Initial: New Site: Office Relocation: Complaint: Revisit: If complaint, brief description of issue: Group Name: TIN: Office Location: Phone: Fax: Practitioner(s) Names(s): Practitioner Type: PCP: Ob/Gyn: Behavioral Health: Other Specialty: Kaiser Permanente Reviewer: Title: Office Staff Assisting w/review: Title: OFFICE SITE SECTION Yes No Score Physical Accessibility and Appearance: Modern Older Needs Repair Renovated Handicapped accessible Well-lit waiting room At least two seats for every patient scheduled per hour (ie: 5 patients scheduled 10 seats) MD name on building or building directory All areas neat and clean Furniture in good repair At least two exits present Fire extinguisher present Fire alarm present Clear exit path Grab bar available in restroom Examination Rooms Yes No Score At least two exam rooms per practitioner At least one exam room can accommodate a wheelchair At least one sink with soap accessible to all exam rooms Exam table paper is changed between patients or table is cleaned with antibacterial cleaning agent between patients Verbal exchanges cannot be overheard Availability of Appointments Yes No Score PCP, OB/GYN: Urgent care within 48 hours Routine office visit within 4 weeks 24 hour emergency coverage Behavioral Health: Urgent care appointments obtained within 48 hours 24 hour life threatening emergency coverage Evaluation on non-life threatening emergencies within six hours Total Office Site Score: MEDICAL RECORD KEEPING PRACTICE SECTION Adequacy of Medical/Treatment Record Keeping Yes No Score Medical records are stored in office and protected from public access or stored in a centralized medical record department Have a process for follow up of abnormal test results Form for documenting patient demographic data Legible file markers or defined method to track information in consistent manner Patient information is not in plain view (computer screens, open medical records, faxes, test results) Discussed office documentation practices with practitioners or staff Total Medical Record Keeping Practice Score: Confidential/QA Purposes Revised: 8/2008 Revised April

12 Kaiser Permanente-Ohio Site Visit and Evaluation Tool Evaluation Score = Total # of yes /Total # standards scored for each section. 90% or greater: Quality Clearance 80-89%: Conditional Clearance, Action Plan Required <80%: Failing Score, Pending Clearance, Action Plan Required Recommendations: Evaluation Score: Clearance: Revisit Date: Office Site Section Medical Record Keeping Section COMMENTS: / / 19 = % 6 = % ITEM EXPLANATION DEFICIENCIES: ITEM EXPLANATION ACTION PLAN: Date of Review What Needs to be Done Who Will Do it When Is it to be Completed Resolution Confidential/QA Purposes Revised: 8/2008 Revised April

13 8.7.2 Non-Compliance with Site Review Standards Each element scored on the Site Visit and Evaluation Tool is worth one point. Quality clearance is given to all medical Facilities which score 90 percent or higher. Conditional quality clearance is given to medical Facility with a score of percent and they will be required to comply with a corrective action plan within 30 days of receiving the written request. Any medical Facility which scores less than 80 percent will be pending quality clearance until the site complies with the corrective action plan within 30 days of the request and a follow-up site visit is conducted. Follow-up visits for any purpose will occur within 6 months of the original site visit and will continue at least every 6 months until deficiencies are corrected. Findings and recommendations from site reviews, as well as any corrective action plans, are reported to the Credentials Committee. 8.8 Compliance with Medical Record Medical Record Standards The medical record standards below apply to patient medical records - both paper and electronic - maintained by Kaiser Foundation Health Plan of Ohio, the Ohio Permanente Medical Group (OPMG), and contracted Plan Providers. The intent of these standards is to promote timely, accurate, complete medical records. These standards are designed to permit effective confidential patient care, quality review and coding and billing in compliance with regulatory and accreditation requirements. Updates or changes to medical records standards will be posted on the Kaiser Permanente s Community Providers web site at providers.kaiserpermanente.org/oh. Maintenance Every Kaiser Permanente member is assigned a unique medical record number (MRN) that is generated at the time of enrollment or when the member first requests or receives services. Non-member patients will be assigned a unique medical record number when they first request or receive services at a Kaiser Permanente facility. Medical records will be maintained and stored in a manner that protects the safety and security of the records and the confidentiality of information. Only authorized personnel will have access to medical records. Medical records will be retained at least for the time period required by State and federal law. Revised April

14 The medical record will be available for all medical office visits, whether scheduled in advance or on the same day of service. The medical record will not be altered except to appropriately add or amend data. Original information must be legible. Superseded or historical versions of electronic data will be maintained. Documentation and Content Entries into the medical record must: Be in permanent ink when made on paper. Be dated and timed. Contain the legible identification of the provider, including name and credential/certification. Be authenticated by the author, which may be a handwritten or electronic signature. Have the patient s name, medical record number, or other identification on each page. In an electronic record, patient identification is located on each screen view or printed page. Be legible to someone other than the author. Be readable if documentation is scanned or copied. Be complete, accurate and timely. Medical records should contain the following information: Demographic/Personal Information: o Medical record number o Patient name o Current address o Home telephone number o Work telephone number, when applicable o Date of birth or age o Gender o Race o Ethnicity o Patient preferred language o Name and telephone number of person to notify in case of an emergency o Primary Care Physician (PCP) name o Information regarding the patient s advance directives General Clinical Information: o Allergies (including medication related allergies) and adverse reactions, or noted as none or no known allergies. o Past medical history including serious accidents, operations and illnesses. For children and adolescents (age 18 and younger), past medical history includes significant events in prenatal care, birth, operations, and childhood illnesses. Revised April

15 o Vital signs including height, weight, blood pressure, body mass index (BMI), and growth charts for children 2 20 years (including BMI) o Personal habits, such as sexual behavior, smoking and history of alcohol use and substance abuse for patients age 13 and older o Preventive screening and/or problem-oriented services were performed or offered to the patient. o An up-to-date immunization record for children (age 18 and younger), or an appropriate history for adults. o Problem list indicating significant illnesses and medical conditions. o Current medication list Progress Notes: o Patient s chief complaint or reason for visit. Where follow-up is the purpose of the visit, the condition that occasions the follow-up is specifically stated within the visit note. o Appropriate subjective and objective information pertinent to the patient s presenting complaints or purpose for visit. o Test (laboratory, pathology, radiologic or other diagnostic service) ordered as medically necessary. o Working diagnoses consistent with findings. o Treatment plans, therapies or other regimens are documented and are associated with current documented diagnoses and medical impressions. o Follow-up instructions and timeframe for follow up or the next visit. The specific time of return is noted in weeks, months, or as needed. o Unresolved problems from previous visits are addressed in subsequent visit notes. o Diagnoses support the medical necessity of care rendered. o When a patient does not present for a scheduled appointment, it should be clearly indicated in the medical record, with efforts to contact the patient documented. Messages: o An entry shall be made in the medical record of communication (telephone or electronic) relating to patient care, including, but not limited to: Any medical advice that is given; Any new illness or change in health status; and Test results or requests to return for additional testing procedures. Continuity of Care: o Documentation of all services provided directly by the primary care physician. o Evidence of appropriate use of consultants, as applicable. o Evidence of continuity and coordination of care between primary care and specialty practitioners. If a consultation is requested, there is a report from the consultant in the medical record that includes the reason for the consult and the identity of the authorized requestor. o Results of ancillary services and diagnostic tests ordered by a practitioner. o All diagnostic and therapeutic services for which the patient was referred by a practitioner, such as home health reports, specialty physician reports, hospital discharge reports, physical therapy reports, etc. Revised April

16 o Consultant summaries and laboratory and imaging study results filed in the medical record reflect Primary Care/Ordering Physician review. o Consultation and abnormal laboratory and imaging study results have an explicit notation in the record of any follow-up plans. o Operative report or procedure note documented immediately after surgery/ procedure Frequency of Medical Records Review Medical record reviews may be completed on all prospective Primary Care Physician (PCP), Ob/Gyn and Behavioral Health offices prior to consideration by the Kaiser Permanente Credentials Committee. If an existing PCP, Ob/Gyn or Behavioral Health Practitioner relocates, adds an additional practice location, or adds on to an existing office, a medical record review may be completed within 30 days of the relocation/opening of the new office. In addition, a random medical record review of any Plan Provider office may be conducted at the request of the Associate Medical Director, Quality, Clinical Performance and Research, the Kaiser Permanente Credentials Committee or the Performance and Patient Safety Department Non-Compliance with Medical Records Standards Each element scored on the Site Visit and Evaluation Tool (see Section of this Manual) is worth one point. Quality clearance is given to all offices which score 90 percent or higher. Conditional quality clearance is given to offices with a score of percent and they will be required to comply with a corrective action plan within 30 days of receiving the written request. Any medical Facility which scores less than 80 percent will be pending quality clearance until the medical Facility complies with the corrective action plan within 30 days of the request and a follow-up site visit is conducted. Follow-up visits for any purpose will occur within 6 months of the original site visit and will continue at least every 6 months until deficiencies are corrected. Revised April

17 8.9 Accessibility Standards Plan Providers have agreed to be available to Members 24 hours a day, 7 days a week. All Plan Providers must adhere to the following appointment access standards: Medical Care Regular and routine care: Care for non-urgent conditions Urgent care: After-hours care: Access to care after normal operation hours Behavioral Health Care Non-life-threatening emergency: Severe crisis, not life-threatening but with potential to become so, without intervention Urgent needs: Severe crisis, not life-threatening, including impaired ability to function in normal roles due to symptoms Accessibility Standard 30 days 24 hours a day Available 24 hours a day, 7 days a week, by answering service or direct pager Accessibility Standard Within 6 hours Within 48 hours Routine office visits: All other problems and symptoms not meeting definition of emergent or urgent; may have been present over time Within 10 working days Non-Compliance with Accessibility Standards Accessibility standards are monitored during site surveys and by reviewing Member Complaint and satisfaction data. If Kaiser Permanente reasonably determines that an access issue may adversely affect the care provided to Members, Kaiser Permanente may take corrective actions in accordance with your Agreement and applicable Laws and regulations Preventive Care and Clinical Practice Guidelines Kaiser Permanente is dedicated to helping support your clinical practice to provide quality care for our Members. Since quality is a keystone of our Medical Care Program, we have provided each Primary Care Physician and select Specialists with the Revised April

18 Kaiser Permanente Ohio Preventive Care and Clinical Practice Guidelines. If you need a copy of the current guidelines, contact your Network Associate. Preventive Care and Clinical Practice Guidelines are also available on Kaiser Permanente s Community Providers website at providers.kaiserpermanente.org/oh. You will be notified in your quarterly Provider Connection newsletter of any updates to the Preventive Care and Clinical Practice Guidelines posted on the website. The guidelines that have been developed are for screening, immunization, education, prenatal care, and condition/disease management. The Kaiser Permanente Guideline Committee oversees Preventive Care and Clinical Practice Guideline development. Several of the guidelines are produced by the Care Management Institute (CMI) of Kaiser Permanente. The CMI is a national organization of Kaiser Permanente that synthesizes knowledge about the best clinical approaches to create, implement and evaluate effective and efficient health care programs. Their data is evidence based and population oriented. CMI supports the Kaiser Permanente regions, their staff, and their clinicians to meet the needs of Members, Payors and the broader community. We encourage you to consider these guidelines in your clinical practice. You will continue to receive guideline updates and revisions on an ongoing basis. Feel free to provide us with feedback and suggestions as you review these guidelines. These guidelines are informational. They are not intended or designed as a substitute for the reasonable exercise of independent clinical judgment by Practitioners, considering each Member s need on an individual basis. Guideline recommendations apply to populations of patients. Clinical judgment is necessary to design treatment plans for individual patients Patient Safety Policy Patient safety is an integral component of Kaiser Permanente's Promise to provide high quality healthcare. Each component organization of Kaiser Permanente across all locations and its Practitioners, managers, employees, and Plan Providers are responsible for patient safety. This responsibility is designed to guide groups and individuals in achieving excellent performance in the safe and effective delivery of health care. It includes activities aimed at achieving the following: A unified and strong patient safety culture, with patient safety and error reduction embraced as a shared value. An environment that encourages responsible reporting of near misses and errors and that looks to fix systems and not blame. Established priorities that optimize the allocation of resources in the implementation of patient safety performance improvement strategies. Ongoing identification, sharing, and implementation of best practices from other parts of the organization and other industries. Routine patient safety and error prevention training and education for individuals and groups. Revised April

19 Relevant and meaningful monitoring and reporting of indicators and outcomes which guide continuous improvement and validate success. Kaiser Permanente aims to integrate patient safety into the fabric of our organization and be guided by the following three simple principles: Patient safety comes first. Patient safety is every patient's right. Patient safety is every individual s responsibility. We will establish appropriate structures, which include the Risk Management Patient Safety Committee, implement appropriate systems, strive to maintain appropriate staffing and skills, and be guided by the most appropriate strategy to deliver the safest quality healthcare possible, quality healthcare our Members can trust. Any questions regarding the Kaiser Permanente of Ohio patient safety policies and procedures can be directed to the Patient Safety Lead at Revised April