Federal Employee Health Benefits

John Deere Health Care Inc. Plan Patient Safety Initiatives

1. Case Management Programs:
   1. Addresses patient safety by serving to assist in the coordination of managed care efforts for the individual patient thus helping to reduce or prevent omission or duplication of orders when multiple providers are involved.
   2. United Resource Network (URN) addresses patient safety by providing JDH with a provider network for transplant services. URN utilizes evidence-based outcomes for provider selection based on facility specific volume and clinical outcome data.
   3. Emergency Room Management is a process whereby members are identified who have been to an emergency department beyond a selected threshold of five or more times in any calendar quarter. Analyses could include review of claim data, review of medical records for potential causes of excessive emergency room usage, and review of access and availability of practitioners. This initiative addresses patient safety by attempting to reduce the potential of adverse medical events that may occur from lack of primary care, the absence of coordinated care, potential drug interactions, unnecessary testing and treatments, omission or duplication of care, or patient non-adherence with a care plan, as well as, under and over utilization. See CM P&P 10.1; Emergency Room Monitoring.
2. Drug Safety:
   1. A combination of prospective, concurrent, and retrospective techniques are used to monitor for appropriate medication use and to ensure the safety of JDH members. These techniques include, but not limited to:
      • Potential drug and drug disease interactions
      • Multiple prescriptions within the same pharmaceutical class (polypharmacy)
      • Over and under utilization of medications to treat a specific disease process
      • Utilization of medications in excess of established guidelines
      • Suspected uncoordinated health care by multiple practitioners
      • Suspected inappropriate/excessive controlled substance usage
      • Suspected billing irregularities
   2. JDH monitors the FDA Center for Drug Evaluation and Review (CDER) for announcements of drug product recalls or drug product safety warnings.
   3. The on-line pharmacy claims processing system (Procare) provides real time review of patient medication records to detect the presence of inappropriate drug usage.
   4. Once an inappropriate drug usage case is identified, it is monitored by the Regional Pharmacy Manager, in consultation with the local medical director and/or local QI Committee until a satisfactory resolution is reached. See CM P&P 8.1; Special Utilization Patterns/Trends Case Review. In some instances the case is referred to and monitored by the Restricted Access Program. See CM P&P 8.2; Restricted Access Program.
3. Utilization Management:
   1. The concurrent hospital review process addresses patient safety by the review nurses monitoring the hospital record for medical necessity to support the acute inpatient level of care, potential quality of care concerns, and incident reports. Individual patient or practitioner/provider issues are reviewed with the local medical director. It is the decision of the medical director to assess the severity of the issues and directs corrective actions. See UM P&Ps, Section 8; Inpatient Review.
   2. Patient Safety is addressed via the Peer Review Process. Quality of care issues are reviewed by the local medical director and/or local QI Committee. Peer review takes into account standards of care, as well as, safe prescribing habits. Peer review is the key component to all review activities performed by the local medical directors and local QI Committees. See UM P&Ps Section 9; Medical Director/Physician Advisor Roles and Peer Review Process.
4. Health Management Programs:
   1. Disease management programs address patient safety by working to assist patients and physicians with the management across all aspects of specific disease processes. These programs identify standards of care that are then communicated to providers and patients. Disease management programs also educate patients and providers on the standards of care and the supporting evidence. Individual patients whose care is not following the established standards are identified. Once identified, their providers are notified. These programs are especially important to help identify over and under utilization, patient non-compliance, and care that does not meet the standards, thus assisting to reduce adverse medical events. Clinical practice guidelines go hand in hand with the disease management programs and addresses patient safety by communicating evidenced based standards of care to providers and patients. When followed, standards of care can help to reduce unnecessary medications and/or procedures in turn reducing the potential for adverse medical events. Guidelines are distributed to providers via the Provider Update, Physician Manual, direct mail, and the JDH provider website. Guidelines are distributed to patients via periodic direct mail reminders, the member newsletter, healthTALK, and the JDH member website. The disease management/clinical practice guidelines include:
      • Asthma
      • Diabetes
      • Pregnancy Management
      • Heart Failure
      • Use of Warfarin in Atrial Fibrillation
      • Depression
      • Antibiotics selection in ambulatory care
      • Hyperlipidemia
      • Hypertension
      • LDL Cholesterol management Post-MI
      • ESRD
   2. As with clinical practice guidelines, preventive health guidelines, along with preventive health initiatives, also help address patient safety by communicating evidence based guidelines to physicians and members. When followed, preventive guidelines can help reduce the frequency of routine screening tests not supported by medical evidence in turn reducing the potential for false positive test results and sequentially adverse medical events. Education targets the need to prevent the disease to avoid the potential adverse medical events that may result from acquiring these preventable diseases, e.g., rubella, pertussis, pneumonia, etc. Preventive health guidelines include:
      • Childhood Immunizations
      • Adolescent Immunizations
      • Flu/Pneumonia immunization for select high risk populations
      • Immunizations for adults and pregnant women
      • Cervical Cancer Screening
      • Chlamydia Screening
      • Colorectal Screening
      • EPSDT Screenings for the Medicaid populations (IA Medicaid and TennCare)
5. Quality Improvement:
   1. The medical record review process works to address patient safety in a variety of ways by evaluating various key components of the medical record that have been determined by state and federal regulations, as well as, JDH to be critical components of managing the care of individual patients. These key elements are reviewed for consistency and quality, as well as access and availability of providers. The presence of these key elements helps physicians avoid medication errors and potential adverse medical events. See QI P&P Section 15; Ambulatory Medical Record Review.
   2. The quality of care/quality of service member complaint process addresses patient safety by taking appropriate action to resolve member complaints and by helping to identify any trends in quality of care or service that may occur with individual providers. This information is used during the recredentialing process. See QI P&P 19A; Identifying and Tracking Member Reported Quality of Care/Service Issues.
   3. The Quality Improvement Committee process addresses patient safety at the local and home office level. The local QI Committees report directly to the Council of Medical Directors which reports to the Corporate QI Committee. One of the functions of these committees is to review any quality of care concerns brought before them from a lower subcommittee or local medical director. Quality of care issues may range from practitioners not meeting appropriate clinical guidelines, care that caused an adverse outcome, and/or care that may have put a patient at risk. It is the function of these committees to educate practitioners, and when education efforts have been exhausted, proceed with sanctions and potential termination processes, as appropriate. See Committee Charters; W drive/QI dept/Charters.
   4. The credentialing/recredentialing processes also address patient safety:
      • Termination with Cause policy: This process involves summary suspension of a practitioner's contract when a significant quality of care/service issue has been identified. Suspension of a practitioner's contract prevents continued unacceptable care to JDH members. Affected members are notified immediately of the summary suspension.
        See CR P&P 7B; Participating Practitioner Summary Suspension Process
        See CR P&P 7A; Participating Practitioner Termination Procedure
      • The recredentialing process addresses patient safety by utilizing all information collected regarding a practitioner's practice pattern when that practitioner is due for recredentialing. As appropriate, the practitioner's file is reviewed for medical record review results, evidence of education, evidence of sanctions, quality of care/service issues, and any other pertinent information. All information is reviewed and could negatively impact the practitioner's continued contract with JDH. See CR P&P 8; Physician Credentialing/Recredentialing.
      • JDH prefers to contract only with hospitals and ancillary providers that are JCAHO accredited or other nationally recognized accreditation organization. JCAHO requires stringent patient safety standards that include, but not limited to:
        • accuracy of patient identification
        • effectiveness of communication
        • medication and procedure safety
        • effectiveness of clinical alarm systems
        • reducing the risk of health care acquired infection

        To meet the access needs of JDH members in rural areas, it is occasionally necessary to contract with non-JCAHO accredited hospitals and ancillary providers. In those instances, JDH examines their Medicare or State survey and documentation of any corrective actions. In addition JDH examines the following:

        • CLIA certification
        • radiology certification
        • pharmacy license
        • patient safety program that must include a computerized ordering system

        Annually, JDH publishes in the Provider Update and healthTALK the number and percent of JDH contracted hospitals that are JCAHO accredited and those that are non-JCAHO accredited but have passed JDH standards for credentialing.
        See CR OP 1B; Organization Provider Credentialing Criteria
        See CR OP 1C; Organization Provider Recredentialing Criteria

6. Administrative Patient Safety Activities:

   In addition to the activities listed above, JDH participates in many other patient safety activities. These activities, listed on the CDM Work Plan, include, but not limited to:

   • State and federal regulatory oversight reviews
   • NCQA compliance
   • Participation in HEDIS and CAHPS
   • Practitioner/Provider contracting
   • Access & availability reporting
   • Behavioral health care coordination and continuity of care
   • Delegation oversight activities
   • Patient Safety information is regularly distributed to members via healthTALK and is available on the JDH member website
   • Patient Safety information is distributed to providers via the Provider Update and is available on the JDH provider website.

   RESPONSIBILITY:

   • Vice President; Medical Management
   • Director, Technology Assessment and Patient Safety
   • Manager, QI and Accreditation

   MONITORING AND EVALUATION:

   1. The Patient Safety Program will be monitored quarterly via the CDM Work Plan.
   2. The Patient Safety Program will be evaluated annually via the CDM Final Program Evaluation.

   REFERENCES:

   • CM P&P 10.1; Emergency Room Monitoring
   • CM P&P 8.1; Special Utilization Patterns/Trends Case Review
   • CM P&P 8.2; Restricted Access Program
   • UM P&Ps, Section 8; Inpatient Review
   • UM P&Ps Section 9; Medical Director/Physician Advisor Roles and Peer Review Process
   • QI P&P Section 15; Ambulatory Medical Record Review.
   • QI P&P 19A; Identifying and Tracking Member Reported Quality of Care/Service Issues
   • Committee Charters
   • CR P&P 7B; Participating Practitioner Summary Suspension Process
   • CR P&P 7A; Participating Practitioner Termination Procedure
   • CR P&P 8; Physician Credentialing/Recredentialing.
   • CR OP 1B; Organization Provider Credentialing Criteria
   • CR OP 1C; Organization Provider Recredentialing Criteria
   • NCQA Standards: QI 1; Element A and C, QI 2; Element D, UM 13; Element C