Internal Quality Management Program Sample Clauses
Internal Quality Management Program. A. The Contractor shall establish and maintain an internal quality management program following the basic principles of Total Quality Management (TQM) and Continuous Quality Improvement (CQI) that are presently used throughout most industries. This program will be applied to all aspects of the Contractor's performance under this contract. The Contractor shall share TQM and CQI results with HSD.
B. The Contractor shall have a quality improvement/quality management program description, work plan and program evaluation that is updated each contract year and provided to HSD for review and approval in a manner to be specified.
C. The Contractor’s internal quality management program will include procedures for conducting quarterly internal audits by each HCBS waiver type on a representative random sample of level of care reviews, level of care determinations, service plans and budgets to validate consistent and accurate application of criteria, and that utilization review functions are performed according to established timeframes. Results will be reported to HSD/MAD.
D. The Contractor shall conduct regular monitoring of inter-rater reliability of individuals performing UM activities and shall ensure that a remediation process is established and utilized for individuals not meeting at least 90 percent of agreement on sample cases.
E. The Contractor’s quality management program shall include data entry accuracy.
Internal Quality Management Program a) Contractor must operate a quality management program which is approved by SDOH and which includes methods and procedures to control the utilization of services consistent with Article 49 of the PHL and 42 CFR Part 456. Enrollee's records must include information needed to perform utilization review as specified in 42 CFR Sections 456.111 and 456.211. The Contractor's approved quality management program must be kept on file by the Contractor. The Contractor shall not modify the quality management program without the prior written approval of the SDOH.
b) The Contractor shall incorporate the findings from reports in Section 18 of this Agreement into its quality management program. Where performance is less than the statewide average or another standard as defined by the SDOH and developed in consultation with DOHMH, MCOs and appropriate clinical experts, the Contractor will be required to develop and implement a plan for improving performance that is approved by the SDOH and that specifies the expected level of improvement and timeframes for actions expected to result in such improvement. In the event that such approved plan proves to be impracticable or does not result in the expected level of improvement, the Contractor shall, in consultation with SDOH, develop alternative plans to achieve improvement, to be implemented upon SDOH approval. If requested by SDOH, the Contractor agrees to meet with the SDOH and DOHMH to review improvement plans and quality performance.