Quality assurance at hmc
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Quality Assurance at HMC. 10/08 Learning & Development. Objectives. By the end of this module, you will be able to:. State the purpose of the Complaint & Risk Reporting process State the definition of “complaint” as defined by HMC Identify the steps to take for non-HMC complaints

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Quality Assurance at HMC

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Quality Assuranceat HMC

10/08 Learning & Development


Objectives

By the end of this module, you will be able to:

  • State the purpose of the Complaint & Risk Reporting process

  • State the definition of “complaint” as defined by HMC

  • Identify the steps to take for non-HMC complaints

  • Complete and submit a complaint using the Complaint Entry form

  • Complete and submit a Risk Report form


HMC Complaint Reporting


Purpose

  • To ensure the delivery of quality services to our customers

  • To assure members and clients of HMC’s commitment to

safeguarding Protected Health Information (PHI)


Policy

Health Management Corporation supports the delivery of high quality services by providing a mechanism for recording, investigating, resolving and reporting complaints that pertain to HMC services and employees.


Definition

  • HMC defines a complaint as:

  • An unsolicited verbal or written expression of dissatisfaction involving HMC and services provided by HMC.

  • It may be received from our program participants, an employee of a client, an involved provider, or an HMC employee.


Definition

  • Any complaints received not related to HMC or services provided by HMC must be directed to the health plan as there are specific business and accreditation needs that are impacted by timeliness of complaint reporting to the health plan.

  • The health plan Customer Service units responsible for logging and investigating these types of complaints vary by geography, product and client.

Please do not delay the progress for complaints that need to be handled by the health plan in a timely manner by entering them in the HMC system; redirect to the health plan.


Process


Process

*You will receive a confirmation page to confirm your report has been sent for review.


Form Navigation

The User’s Manual contains step by step instructions for the Complaint Entry Form and Risk Management Report completion

After selecting the “Customer Feedback” link from the “Regional Care Center Links” page, the Report Services page displays. The user can make a selection from 3 links: User’s Manual, Complaint Report, & Risk Reports.

To enter a complaint, click on the “Complaint Entry Form” link.


Form Navigation

10/15/2008

Clyde Barrow

Nurse Coach

Nashville

ConditionCare

Bonnie Parker

In the “Entrant Detail” section, complete Today’s Date, your First and Last Name, your Title, your Care Center Location, your Department, & the name of your Department Manager.


Form Navigation

Participant

Mary Bozell

ConditionCare

123456

08/29/1961

Tennessee

PO23456

Anthem SE

In the “Complainant Detail” section, complete the Type of Complainant (client, member/participant, provider, or HMC employee), Complainant’s First & Last Name, Program, Case Number, Date of Birth, State of Residence, Insured ID# and the name of the Client .


Form Navigation

Participant

Mary Bozell

ConditionCare

Include as much detail about the complaint in this space. Be specific without including personal opinions/judgments. Some examples include: Excessive hold time, Participant called program 3x without an answer, Participant requested calls only at night and has received 3 calls in the morning…

123456

08/29/1961

Tennessee

PO23456

Anthem SE

In the Complaint Detail section, complete the Date the Issue was Identified, the Date the Issue Occurred and the Object of the Complaint (Access Issue, Clinical Issue, Operational Process, Service Issue, or Privacy/Security Issue) and a detailed description of the complaint.


Form Navigation

After you have completed the Complaint Entry form, click on the “Submit Form” button


Form Navigation

The confirmation page is displayed after clicking on the “Submit Form” button.


Process


Resolution

  • Complaint processing is mandated by our accrediting bodies and also

ensures our participants receive their program benefits in an

appropriate manner

  • The QI department resolves all complaints in writing within 30 business days

  • The QI department is responsible for trending the data and reporting the

findings to the Quality Improvement Committee (QIC) quarterly


HMC Risk Reporting


Purpose

  • To ensure the appropriate documentation and investigation of any

incidents for which HMC may be accountable


Policy

Health Management Corporation (HMC) investigates any incident, which may result in potential harm or liability for the corporation or for any internal or external customers.


Definition

  • A possibility of loss or injury. Situations requiring completion of a Risk Management Report may include, but are not limited to:

  • Caller refusing EMS activation

  • HMC associates implying a diagnosis for a participant

  • HMC associates recommending a specific medication

  • Breach of confidentiality/non-permitted use/disclosure of PHI

  • Security incidents regarding electronic PHI and/or overall security

of company systems

  • HMC associates who document information in the data management

system that is not congruent with information reported by the participant


Process


Process

*You will receive a confirmation page to confirm your report has been sent for review.


Form Navigation

The User’s Manual contains step by step instructions for the Complaint Entry Form and Risk Management Report completion

After selecting the “Customer Feedback” link from the “Regional Care Center Links” page, the Report Services page displays. The user can make a selection from 3 links: User’s Manual, Complaint Report, & Risk Reports.

To enter a risk report, click on the “Risk Management Report” link.


Form Navigation

10/15/2008

10/15/2008

Clyde Barrow

Nurse Coach

X

X

12345

X

X

Complete the date the Incident occurred, the date you complete the report, your first and last name, your title, the HRS case number if it applies, checkmark the applicable box under: Report Initiated By, Program and the Incident Type


Form Navigation

Provide a detailed description of the incident that occurred in this space. Be specific without including personal opinions.

X

Provide a detailed description of the incident that occurred. Click the “Submit Form” button.


Form Navigation

The confirmation page is displayed after clicking on the “Submit Form” button.


Process


Process

If

Then


Resolution

  • HMC associates complete Risk Management Reports for

any incident that may result in actual or potential liability for HMC

  • The Quality Improvement department forwards privacy breaches

to the Privacy Manager within 1 business day of receipt

  • The Quality Improvement department immediately begins an

investigation into Risk Reports

Quality Assurance at HMC begins with you and we thank you for your commitment to our participants, clients and HMC.


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