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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 - PowerPoint PPT Presentation
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Quality Assuranceat HMC
10/08 Learning & Development
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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
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HMC Complaint Reporting
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Purpose
To ensure the delivery of quality services to our customers
To assure members and clients of HMC’s commitment tosafeguarding Protected Health Information (PHI)
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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.
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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.
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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.
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Process
Step Action
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Access the HMC Intranet through your desktop and select “Operations” on the left side of the screen
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Click on the appropriate “Care Center” link
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Click on “View Links”
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Process
Step Action
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Click on the “Customer Feedback” link
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Click on the “Complaint Entry Form” link
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Complete each section of the complaint entry form and click the “Submit Form” button
*You will receive a confirmation page to confirm your report has been sent for review.
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Form Navigation
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.
The User’s Manual contains step by step instructions for the Complaint Entry Form and Risk Management Report completion
To enter a complaint, click on the “Complaint Entry Form” link.
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Form Navigation
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.
10/15/2008Clyde BarrowNurse CoachNashvilleConditionCareBonnie Parker
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Form Navigation
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 .
Participant
Mary Bozell
ConditionCare123456
08/29/1961
Tennessee
PO23456
Anthem SE
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Form Navigation
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.
Participant
Mary Bozell
ConditionCare123456
08/29/1961
Tennessee
PO23456
Anthem SE
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…
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Form Navigation
After you have completed the Complaint Entry form, click on the “Submit Form” button
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Form Navigation
The confirmation page is displayed after clicking on the “Submit Form” button.
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Process
If Then
You are not able to access the Complaint Entry Form
Submit your complaint to the following email box: [email protected]
Include the following details:
*Your first and last name
*Care Center location
*First & last name of the complainant
*Name of client
*Insured ID number
*Case Number
*Detailed/specific description of the complaint
Any of the required information is not available
Include as much information as possible and submit the information via email
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Resolution
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
Complaint processing is mandated by our accrediting bodies and alsoensures our participants receive their program benefits in an appropriate manner
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HMC Risk Reporting
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Purpose
To ensure the appropriate documentation and investigation of anyincidents for which HMC may be accountable
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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.
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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 securityof company systems
HMC associates who document information in the data managementsystem that is not congruent with information reported by the participant
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Process
Step Action
1
Access the HMC Intranet through your desktop and select “Operations” on the left side of the screen
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Click on the appropriate “Care Center” link
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Click on “View Links”
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Process
Step Action
4
Click on the “Customer Feedback” link
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Click on the “Risk Management Report” link
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Complete each section of the Risk Management Report and click the “Submit Form” button
*You will receive a confirmation page to confirm your report has been sent for review.
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Form Navigation
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.
The User’s Manual contains step by step instructions for the Complaint Entry Form and Risk Management Report completion
To enter a risk report, click on the “Risk Management Report” link.
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Form Navigation
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
10/15/2008 10/15/2008
XX
Clyde Barrow
Nurse Coach
X12345
X
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Form Navigation
Provide a detailed description of the incident that occurred. Click the “Submit Form” button.
X
Provide a detailed description of the incident that occurred in this space. Be specific without including personal opinions.
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Form Navigation
The confirmation page is displayed after clicking on the “Submit Form” button.
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Process
If Then
You are not able to access the Risk Management Report Form
Submit your Risk Management Report to the following email box: [email protected]
Include the following details:
*Your first and last name
*Care Center location
*First & last name of the complainant
*Name of client
*Insured ID number
*Case Number
*Detailed/specific description of the complaint
Any of the required information is not available
Include as much information as possible and submit the information via email
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Process
There are any transmission errors Contact the compliance line at:
1-800-647-1948
If Then
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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 breachesto the Privacy Manager within 1 business day of receipt
The Quality Improvement department immediately begins aninvestigation 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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