Quality Improvement

The Quality Improvement Program implements mechanisms to identify, monitor, evaluate, and resolve issues that impact the accessibility, availability, continuity, and quality of care and service provided to our members. Key objectives include the following:

Monitor access and availability to medical and behavioral health care, as well as services and implement corrective action for improvement as identified
Provide communication with members, physicians, and providers on issues of quality medical care to promote improvements in the health status of members
Develop and distribute information that improves knowledge regarding clinical safety, general wellness and disease prevention as it relates to self care
Monitor and evaluate quality of care, quality of service, member satisfaction and provider satisfaction and implement interventions as needed
Maintain mechanisms to ensure that cost containment activities do not adversely affect the quality of care provided to members

Responsibilities of Blue Cross and Blue Shield of Oklahoma

Qualified staff is properly trained for the Quality Assurance/Quality Improvement (QA/QI) program with oversight by a licensed physician.
Health care practices are monitored and evaluated for the sole purpose of improving the quality of care and quality of services rendered by participating providers.
All information obtained by the QA/QI staff is used solely for the purpose of improving member care through quality management. Such information is confidentially maintained and protected.
A variety of evaluation methods are used, such as surveys, access studies, medical record reviews, clinical studies and utilization studies.
The written Quality Improvement program is updated at least annually. Information is available to providers regarding activities of the QA/QI program. We appreciate your willingness to work with and would be glad to share our annual report with you. A copy may be obtained by making a request to:

Medical Director, Healthcare Quality
Blue Cross and Blue Shield of Oklahoma
1400 South Boston
Tulsa, OK 74119-3612

Responsibilities of the provider

Supply complete and detailed clinical information to allow Blue Cross and Blue Shield of Oklahoma to make an informed decision
Participate in Quality Assurance/Quality Improvement activities, including provider surveys and on-site visits.
Cooperate with QA/QI staff to provide medical records or other appropriate medical information upon request and in a timely manner.

Patient Access to Care — Blue Cross and Blue Shield of Oklahoma access standards

Routine health evaluation: appointment available within 30 working days.
Sick non-urgent appointment (illness which does not have a sudden onset of symptoms): appointment available within 5 working days.
Urgent appointment (sudden onset of symptoms): appointment available within 24 hours or refer to level of urgent care services.
After-hours: Ability to reach call coverage after hours.
Follow-up for chronic condition: appointment available within 30 working days.
Emergency situation: Blue Cross and Blue Shield of Oklahoma and BlueLincs HMO defines emergency care as treatment for an injury, illness or condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a reasonable and prudent layperson could expect the absence of medical attention to result in: serious jeopardy to the subscriber’s health; serious impairment to bodily function; or serious dysfunction of any bodily organ or part.
Consultant/Specialist: initial specialty referral — appointment available within 14 working days.
Consultant/Specialist: urgent specialty referral — appointment available within 24 hours.
Waiting time in clinic: no longer than 1 hour waiting time in clinic prior to seeing physician (waiting time begins at the time of scheduled appointment.)

Provider Standards of Care — Medical record documentation standards

Ancillary Provider – Dialysis Service Standards

All Facility Types Except Dialysis Standards

A Provider will ensure that covered services reported on claim forms are supported by documentation in the medical record and adhere to the general principles of medical record documentation including the items listed below:

There is an organized medical record filing system.
Personal/ biographical data is present and includes the date of birth, sex, marital status, address, employer, and home and work telephone numbers.
Every page contains patient's identification.
All entries are dated.
Each entry contains author identification (signed or initialed by practitioner). Electronic signatures are acceptable, provided authorization for its use is included in the signature line.
Family/social history is noted in the record.
The medical record is legible to the reviewer.
Medication allergies and/or adverse reactions, or if applicable, “no known allergies” are prominently noted in the record.
There is a past medical history (PMH) present for members seen on > 3visits which includes serious accidents, operations or illnesses. For members < 18 years old, have a PMH present which includes prenatal care/birth information, operations and childhood illnesses.
A current problem list is present and notes significant illnesses and medical conditions.
Members > 12 years and who have been seen on > 3 visits will have notations that address smoking/ETOH/substance abuse.
Immunization records are current, or a note indicates immunizations are up-to-date.
There is a medication list present.
Visit notes include: reason for visit, physical findings, appropriate diagnostic tests and plan of treatment.
Follow-up care and plans are documented.
Unresolved problems are addressed in subsequent visits.
The practitioner initials consults, ancillary services, lab, and imaging study report.
If the member is hospitalized, the record will include the following: operative report (if applicable) and hospital discharge summary.
Working diagnoses are consistent with findings.
There is evidence of continuity and coordination of care between primary and specialty practitioners.
Preventive services are provided in accordance with Blue Cross and Blue Shield of Oklahoma/BlueLincs HMO guidelines.
Confidentiality policy regarding PHI and Informed Consent for release of records utilized.

Physical setting and safety standards

Office is accessible to the disabled -- parking space with signage/painted parking space, wheelchair ramp, office entrance and restroom door wide enough for wheelchair and restroom has grab bars.
Office appearance is clean and organized.
Appearance of office staff is neat and professional.
Waiting area is pleasant, comfortable with adequate seating.
Exam room/consulting office design ensures patient privacy.
Each exam room has adequate lighting, sink with running water. If no sink with running water available, then a 60% alcohol content bactericidal hand washing solution is present for use.
There are provisions for appropriate disposal of sharps.
There are provisions for appropriate disposal of biohazardous materials/waste.
Controlled drugs are properly handled -- locked cabinet, log maintained.
Visible, charged fire extinguisher (A, B & C).
Exit signs visible.