U.S. Office of Personnel Management - Recruiting, Retaining and Honoring a World-Class Workforce to Serve the American People

Introduction

Group Health Plan, (GHP) is committed to patient safety at the highest executive level. Based on the 1999 Institute of Medicine (IOM) Report, the annual morbidity and mortality rate was 44,000-98,000 from medical errors during hospitalizations. Seven thousand deaths were related to medication errors alone. The number of avoidable deaths in the ambulatory care setting is unknown. The Plan's Senior Medical Director is accountable for overseeing GHP's patient safety initiatives. Patient safety efforts are coordinated through the Plan's Health Services and Quality Improvement areas. The two primary goals of these efforts are to increase member awareness concerning patient safety and to encourage reporting by members, providers, vendors and the Plan's staff.

Our patient safety efforts focus on both medical errors and adverse events. The IOM defines a medical error as "the failure to complete a planned action as intended or the use of a wrong plan to achieve an aim". An adverse event is defined as "an injury caused by medical management rather than by the underlying disease or condition of the patient".

The Plan improves patient safety by:

• The Plan improves patient safety by:
• Matching healthcare needs with service delivery capability;
• Facilitating information transfer by clearing communication gaps;
• Adopting safe practices in specific clinical settings or for specific processes of care;
• And increasing safe medication use.

Specific Plan efforts for patient safety include:

• Disease Management Programs;
• Wellness and Preventive Health Reminder Program;
• Provider Credentialing Program;
• New Technology Assessment Program;
• Coventry Transplant Centers of Excellence;
• Adverse Event and Readmission Tracking System;
• Quality of Care and Quality of Service Investigation and Monitoring;
• Utilization Management Programs;
• Drug Utilization Review Capabilities, including the OxyContin Review Program;

Disease Management Programs for Diabetes and Congestive Heart Failure

Disease Management (DM) is a system of coordinated healthcare interventions for populations with conditions in which patient self-care efforts are significant. DM supports the practitioner and patient relationship that involves a specific plan of care. Emphasis includes the prevention of exacerbations and complications utilizing evidence-based practice guidelines and patient empowerment strategies. It also evaluates clinical, humanistic and economic outcomes on an ongoing basis with the goal of improving overall health. DM is safe, as it focuses on medication assessment and treatment guidelines. It is effective, as it matches patients with evidence based treatment protocols. It is patient-centered, as it offers individualized or disease specific interventions. DM uses case finding protocols to identify high risk or at risk patients, assessing individual needs and matching appropriate interventions with patients. Patients can expect to receive general and targeted information on a specific disease condition. A case manager is available to answer questions and assist patients to obtain care and maneuver through the sometimes complex health care system.

Wellness & Preventive Health Reminder Program

The Plan sends reminder birthday cards to encourage the members to receive timely pediatric and adolescent immunizations per established guidelines. Targeted reminder letters are sent to eligible females who have not had a Pap smear or mammogram per established guidelines as well. On an annual basis, the Plan's Quality Management Committee reviews the preventive health guidelines and recommendations from the US Preventive Services Task Force. They are adopted and then disseminated in the member newsletters and provider manual as well as on our website. Visit our website at www.ghp.com for the latest information.

Provider Credentialing Program

The goal of the provider credentialing program is to exercise reasonable care in the selection, evaluation and retention of competent participating providers. The elements verified for competency include state license, DEA certificate to administer scheduled medications, board certification status, work history, clinical privileges at a network hospital, education and training and malpractice insurance coverage. In addition, the practitioner's history of federal or state sanctions and malpractice claims are investigated using state and federal sources. These are all verified by original source documentation. All credentials are verified using the primary data source.

As noted above, the Plan ensures that these minimum standards are met for network participation every three years. The Plan also ensures that there are adequate specialty types and services available as well as minimizes unfavorable risk to health plan members by maintaining effective credentialing and recredentialing processes.

New Technology Assessment Program

Since medical techniques and/or devices for assessing and treating medical conditions are becoming more complex, substantial testing and evaluation are required before they can be considered safe and effective treatments for specific illnesses or conditions. To use a technique before it has been adequately tested and established may pose a risk to patient safety, or it may require use of substantial resources with no reasonable likelihood of benefit from treatment. To prevent exposure to unwarranted risk and to ensure the effective use of medical resources, GHP will exclude coverage for procedures, drugs, and devices that are determined to be experimental or investigational.

The Plan makes determinations on new technology according to scientifically and medically sound processes. In addition, the Plan appropriately categorizes those procedures, drugs, and devices as either medically necessary and appropriate or investigational to justify coverage under the terms of GHP Certificate of Coverage. Each determination is made in regards to the procedure, drug, or device in general, and its proposed use in treating the patient's specific condition and circumstances.

Coventry Transplant Centers of Excellence

Facilities considered for inclusion in the Coventry Transplant Centers of Excellence Network undergo a comprehensive credentialing and selection process. Transplant facilities must be United Network of Organ Sharing (UNOS) certified. Selection of facilities is based on data review including the number of transplants done and the outcomes of the transplants, both short-term and long-term. All facilities are monitored annually for the number of cases performed at each facility, their infection rate, their mortality rate, and the one year, two year, and five year survival rates.

Adverse Event & Readmission Tracking System

System GHP supports the recommendations by the IOM Report on patient safety through the development of an internal adverse events listing which includes the "Never Events" identified by the IOM.

The Plan monitors patient safety of its members by the identification of potential and/or actual adverse events. Referrals are made from any part of the health care delivery system. These include hospitals, ancillary services, pharmacies and physician offices. Member complaints are also monitored for any adverse events. In consultation with the Medical Director, the Quality Improvement staff investigates, tracks, analyzes and brings referred adverse events to the Peer Review Committee for action as needed.

Another mechanism to ensure that all adverse events are identified is the review of the adverse event reports provided by Coventry's Corporate Information System. These reports are monitored by the Quality Improvement staff on a quarterly basis. Since readmission to the hospital may indicate a potential quality of care issue, readmissions for the same diagnosis within certain time frames are also monitored.

Medical errors and other adverse events are monitored to identify patterns of preventable events and events related to individual network providers. Patterns or individual cases are investigated, tracked and trended as well. Appropriate action is taken to make improvements when needed.

Quality of Care/Quality of Service Investigation & Monitoring

The quality referral process is a systematic approach for patient safety and quality improvement used by the Plan to investigate potential quality of care issues and selected adverse events. It is also a process that identifies aberrances in specific practitioner and provider practice patterns. Quality of Care or Service referrals may be generated either externally or internally to the Health Plan, e.g., member or employer complaints, practitioner/provider concerns, and concerns identified by Plan staff.

Utilization Management Programs

Coventry provides utilization management services as part of its patient safety program. These utilization management services include review of services prior to, during, and if needed after the service delivery. Inpatient services, certain outpatient services and surgeries, injectable medications and drugs used to treat cancer, durable medical equipment, physical therapies and home care services require authorization. Pre-authorization of hospital admissions and outpatient services allows the Plan to determine the medical necessity and appropriateness of the service. In addition, health plan clinical staff participates with hospital staff in helping members plan for discharge to home as needed and for providing continuity as needed during this transition.

Drug Utilization Review Capabilities and the OxyContin Review Program

Caremark, Coventry's pharmacy benefit administrator, provides the following patient safety enhancements. When a member fills a prescription, there are edits in the pharmacy system to check on the maximum and minimum dosages per medication. The system checks on drug interactions with every prescription that is filled via the Caremark system, not just those filled at the individual pharmacy. Additionally, the pharmacy system checks for duplicate prescriptions. Other safety edits include:

• Drug Allergy
• Overuse Precaution
• Excessive Duration Alert
• Drug Disease Precaution
• Drug Pregnancy Precaution

Reports of illegal misuse and diversion have prompted Coventry to review the abuse potential of OxyContin. OxyContin has been reported as being abused by crushing, chewing, snorting or injecting the dissolved tablets. These practices result in the uncontrolled delivery of the drug and pose a significant risk to the abuser that could ultimately result in overdose and death. A system for prior authorization including criteria for coverage approved by the National Pharmacy and Therapeutics Committee on prescriptions for OxyContin was initiated. Effective September 1, 2002, prior authorization by the Plan is required for all new patients starting on OxyContin.