SECTION 13.482. Quality Assurance and Quality Improvement

(a) An HCC must establish, implement, and administer a continuous quality assurance and quality improvement program that includes defined policies and processes to:

(1) promote evidence-based medicine and best practices;

(2) secure patient engagement;

(3) promote coordination of care across a continuum of care; and

(4) measure and report the quality of health care services and the impact on cost.

(b) Unless otherwise approved by the commissioner, the program must include:

(1) appropriate practice evaluation tools applicable to the services provided by the HCC, including:

(A) Consumer Assessment of Healthcare Providers and Systems surveys developed by the Agency for Healthcare Research and Quality;

(B) Agency for Healthcare Research and Quality standards, as available; and

(C) National Quality Forum-endorsed standards;

(2) periodic review; and

(3) policies for coordinating with the HCC's quality improvement committee to make necessary updates and adjustments.

(c) The patient engagement process must include, as appropriate:

(1) evaluating the health needs of its enrolled population;

(2) communicating clinical knowledge to patients and patient representatives clearly and understandably;

(3) promoting patient engagement, including engagement in treatment decisions; and

(4) establishing written standards for patient communications.

(d) The processes to promote coordination of care across a continuum of care must include, as appropriate:

(1) a method or system to identify high-risk individuals; and

(2) processes to manage care throughout an episode of care and during transitions.

(e) The processes for measuring and reporting quality of health care services and impact on cost must include:

(1) measurement and evaluation of health care services and processes described in subsection (a)(1) - (3) of this section; and

(2) as appropriate, a process for medical peer review and arrangements for sharing pertinent medical records between participants and ensuring the record's confidentiality.

Source Note: The provisions of this §13.482 adopted to be effective March 31, 2013, 38 TexReg 2100