Federal Employee Health Benefits

HMO Health Ohio Patient Safety Initiatives

Medical Mutual™ is committed to a comprehensive patient safety program to afford our members a network of providers that consistently demonstrate safe healthcare practices.

Medical Mutual has a well-developed and comprehensive Quality Improvement (QI) Program, which is responsive to the ever-changing healthcare environment and strives to improve the quality and safety of our members' healthcare. Our program employs a team approach to identify, trend, and address quality and safety issues.

The Clinical Quality Improvement (CQI) Committee, under the leadership of the Chief Medical Officer, oversees the QI Program. The Committee is made up of practicing physicians of various specialties, and is responsible for the investigation of all potential breaches of quality or safety during medical care.

The QI Program integrates data collected from multiple sources to identify opportunities to improve quality and safety. Components of the QI Program include:

• Care Management Activities (Utilization Management/Case Management/Health Management Programs, Medical Review, Chart Audit)
• Hospital Incurred Injuries or Adverse Occurrence Tracking
• Focused Studies of Clinical Care and Service
• Clinical Practice Guideline Development, Distribution and Monitoring
• Accessibility Standards Development and Monitoring
• Inpatient Mortality Monitoring and Analysis
• Investigation of Member Complaints
• Office Safety Review
• Prescription Medication Monitoring
• Member/Provider Safety Education
• Sentinel Event Monitoring

Medical Mutual's Care Management Department identifies potential quality and safety issues using the following methods:

• Monitoring and detailed investigation of member injuries while hospitalized, including falls, burns, medication errors, or any other incident associated with medical care
• Tracking of all member deaths that occur in the hospital to identify and review any case where there may have been a quality or safety issue
• Tracking of quality of care issues that have the potential, if not corrected, to lead to member injury
• Detailed investigation and tracking of all member complaints regarding quality or safety of medical care
• On-site visits to physician offices to assess the level of safety and quality

All safety or quality issues are referred to the CQI Committee for detailed review. Should a physician or hospital pose serious threats to patient safety, termination from the Medical Mutual network may be the action taken to protect our members.

Medical Mutual also takes proactive measures to ensure safe, high quality medical care through the following:

1. Distribution of evidence-based Clinical Practice Guidelines for common conditions that offer physicians treatment recommendations for the highest quality care:
   • Asthma
   • Chronic obstructive pulmonary disease (COPD)
   • Diabetes
   • Congestive heart failure (CHF)
   • Depression
   • Chronic pain
   • Alcohol abuse

   Because non-adherence with these guidelines may indicate poor quality or unsafe care, Medical Mutual physicians are routinely monitored for adherence. Non-adherence may result in physician re-education or other corrective action necessary to ensure member safety.

2. Medical Mutual offers health management (HM) programs for people with the following medical conditions:
   • Diabetes
   • Heart failure
   • Asthma
   • Chronic obstructive pulmonary disease (COPD)
   • Chronic pain
   • Depression
   • End stage renal disease
   • High risk pregnancy

   There is also a special program for members who are pregnant. These programs are all part of the SuperWell™ health management family.

   The SuperWell programs provide members personal access on a regular basis with healthcare professionals, printed educational materials, and 24-hour-a-day help and advice lines. The goal of the health management programs is to help members successfully manage their conditions and to reduce emergency visits, hospital admissions and unscheduled physician office visits. The education component of these programs also helps members recognize when the quality or safety of their medical care may be less than optimal.

3. Prescription drug monitoring is completed through Medical Mutual's Pharmacy Benefit Manager, Medco Health. Policies and procedures have been established to identify and prevent adverse medication occurrences. Three areas of Drug Utilization Review (DUR) were created to safeguard against harmful drug therapy:
   • Concurrent DUR: At the time a prescription is filled, a computerized system identifies and issues alerts to the pharmacist for potential safety issues, such as improper dosage, conflict with patient drug allergies, or interaction with other medications
   • Retrospective DUR : All prescription drug claims are reviewed to identify drug interaction, drug/age conflicts, therapy duplication, misuse/abuse, and exceeding maximum dosage or length of therapy
   • High utilization DUR: All prescription drug claims are reviewed to identify patterns of utilization associated with excessive prescribing

   In addition, Medco Health offers prior authorization review for a number of drugs that have the potential for harm if prescribed incorrectly.

   In our efforts to improve the safety and quality of the medical care for diabetic members, Medical Mutual will assist members in finding physicians who have achieved certification in the National Committee for Quality Assurance (NCQA) Diabetes Physician Recognition Program. Physicians who have earned this recognition demonstrated outstanding performance on key measures of diabetes care. Information for members regarding how to find a recognized physician are published in the member newsletter and on the Medical Mutual Web site.

   Because Medical Mutual believes that education is the best defense against poor quality or unsafe medical care, information about various aspects of safety is routinely included in our member, physician, and hospital newsletters, and on our Web site, www.MedMutual.com.

   In 2004, the patient safety program will be expanded in the following ways:

   • Installation of a computer system that will allow accurate ranking of the quality of medical care rendered by a specific doctor or facility. This information will be used not only to identify safety concerns, but also to recognize providers that offer outstanding quality and safety to our members.
   • Completion of a survey of all Medical Mutual network hospitals regarding compliance with national patient safety standards. Results will be made available to members so they may choose facilities that have demonstrated high levels of safety.