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QIO TRANSMITTAL SERIES ISSUE: Quality Review Process - Printable
pages The Foundation will utilize various
tools to identify potential quality of care problems. Objective measures such as CMS's generic
quality of care categories and the ISD discharge screens will be used by the
Foundation's Case Review Specialists on cases being reviewed which require
quality/discharge review. The use of
registered nurses as Case Review Specialists also affords the Foundation the
benefit of identifying potential quality of care problems not covered by a
generic quality or discharge screen. Cases with potential quality of care
problems identified by a Case Review Specialist will be reviewed by a QIO
Physician Consultant. This Physician
Consultant will be, to the extent possible, of the same specialty as the
physician under review. On any case where the Physician
Consultant raises a concern that requires further review, an initial
notification will be sent to the involved physician (including residents and
interns) and to the provider affording them an opportunity to respond to the
issue(s) raised. Because potential
and confirmed quality concerns require the attention of both the provider and
physician concerned, the notice is to be sent to both the involved physician
and the provider where the services were performed. Notices which are sent to the provider will be sent to both the
Administrator and the Chief of Staff.
The Administrator may request that his/her copy of the notice be
routinely sent to an individual who will represent the Administrator. This request must be provided to the
Foundation in writing. However, the
Chief of Staff copy must be sent to the hospital's Chief of Staff. An alternative representative will not be
allowed. The physician, Chief of Staff and
Administrative staff representative are encouraged to consult with one
another to formulate a coordinated response that addresses the concern(s)
raised. The potential quality notice will: 1.
Include a brief
description of the quality concern; 2.
Include an
explanation of the potential or actual adverse outcome; 3.
Advise the involved
physician and provider of their right to submit written comments/additional
information on the case and/or to request an opportunity to discuss the case
within twenty (20) days of the date of the initial notification; and 4.
Advise the involved
physician and provider that failure to respond/provide additional information
will result in the confirmation of the quality concern and final
notification. The physician(s) and/or a physician
hospital representative may discuss the case with a QIO Physician Consultant. If such discussion is desired, it must be
indicated in the written response. The Foundation will make arrangements
for a Physician Consultant to contact the physician(s) requesting discussion. A non-physician hospital representative
may discuss the case with a Foundation staff member. If such discussion is desired, it must be
indicated in the written response.
The Foundation will then contact the hospital party requesting
discussion during routine business hours. If the physician and/or provider does
not respond, the potential quality concern raised on the case will become the
final QIO determination and a final notification to this effect will be
issued. If the physician and/or provider agrees
with the Physician Consultant about the quality issue raised, it will become
the final QIO determination and a final notification to this effect will be
issued. If the physician and/or provider does
provide additional information, the information will be provided to a QIO
Physician Consultant for consideration/review. This may be the same Physician Consultant who initially
reviewed the case. If
the review with the additional information provided by the physician and/or
provider results in the determination that no quality problem exists for the
case, the review is concluded and a final notification of no quality concern
will be sent. This final notification
to the physician and provider will: 1.
Advise the parties
that review of the additional information submitted has resulted in the
determination that no quality concern exists on the case; and 2.
Advise the parties
that the case is closed and that no further action will be taken on the case. If
the review with the additional information provided by the physician and/or
provider results in the determination that a quality concern exists on the
case, a final determination notice to this effect will be issued. This notice will: 1.
Advise the parties
of the identified concern, including a description of and explanation of the
concern; 2.
Advise the parties
of any QIO determination of action(s) to be taken by the parties to address
the problem; 3.
Advise the parties
of any QIO immediate action to be taken as a result of the determination; and 4.
Advise the parties
of the right to request (in writing) a re-review of the quality determination
within 30 days of receipt of the final determination. If a physician or provider dissatisfied
with a final quality concern determination requests a re-review of that
determination, the request must be made in writing. The case will be reviewed by a QIO Physician Consultant who was
not involved in the initial determination.
The physician or provider does not need to submit new information to
be entitled to a re-review. The
Physician Consultant will: 1.
Review any
additional information furnished by the physician or provider and re-review
the final determination about the quality concerns; 2.
Make a final
determination regarding the quality concern(s) and the source(s) of the
quality concern(s). A notice of Re-review of Quality Concern
will be sent to the physician and provider for every case where a re-review
is requested. The re-review is an
administrative, not a regulatory process.
No additional review or appeal beyond the re-review of the final
quality concern is available. November
2002 Next
Chapter: Beneficiary
Requested Quality of Care Reviews |
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Copyright © 2005 Northeast Health Care Quality Foundation, all rights
reserved |
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