The need for quality assessment and improvement programs in health care practice is steadily growing. Consumers increasingly demand quality and third parties require its documentation. Optometric practice is no different from any other health care practice in this respect. The challenge facing the optometrist is in assimilating the various requirements, guidelines, and sources of information into an effective practice management program.
To meet this growing need in 1993, the American Optometric Association established a Commission on Quality Assessment and Improvement (CmQAI) to serve as a clearing house for quality management issues facing the profession. Members of the CmQAI monitor developments in the health care industry, its funding agencies, and its oversight organizations to distill out what is needed in optometric practice.
This Quality Assessment and Improvement Manual for Optometric Practices is based on the information available to date. It offers the individual optometrist a place to start, along with sources of information on the evolving needs for quality assessment and improvement programs.
The objective of a quality assessment and improvement (QAI) plan is to outline a program to enhance and improve patient care and the practice environment. This guide is designed to assist the optometrist in the development of a QAI program suitable to the needs of a practice. Since quality improvement is by nature an evolving process, this document and subsequent updates will be posted at the AOA Member Web site: www.aoa.org.
Components of a QAI Plan
The components of a QAI plan may include:
The mission statement helps define the purpose of a practice. The mission statement should reflect a vision statement, core values, and strategic plan.
|Sample:||Eye Care Group’s mission is to work as a team to provide the highest standard of eye care services and products for our patients.|
Program Goals and Objectives
The mission statement gives the staff direction when setting goals and developing action plans to meet those goals.
Practice goals and objectives might include:
|Sample:||Strive to identify opportunities for improvement in quality of eye care services. Provide training to improve interpersonal communication skills with team members and patients.|
[Adapted from Health Law Trends, Arent, Fox, Kintner, Plotkin, and Kahn, www.arentfox.com]
Develop a written definition of quality of care and service as they relate to patient care in the practice.
Quality of care is important to the needs of the patients, practitioners, and purchasers of health care. Quality of care is often defined according to the expectations of these “customers” in terms of quality of service which:
All of the above elements contribute to patients’ perception of quality, which is reflected in their loyalty to the practice.
Responsibilities for Program Functions
These are the basics of continuous quality improvement and can be applied to almost any area of service within the practice.
Scope of Program
Ensure that the scope of the QAI program is comprehensive. High-volume, high-risk services, and care of acute and chronic conditions should be assessed. Adopt established optometric clinical practice guidelines or other explicit criteria for quality eye care. Maintain a current list of QAI projects and activities for the year, including:
Evaluation of Program Effectiveness
The QAI program should be evaluated at least annually and revised as necessary. The evaluation should:
As a general statement, health care fraud can be defined as the making of materially false statements or representations of fact to obtain a payment or other benefit, whereas abuse is any practice that directly or indirectly results in the unnecessary increased costs or utilization of medical services or products. [http://www.hcfa.gov/medicare/fraud] The Centers for Medicare and Medicaid Services’ (CMS) efforts toward investigation and prosecution of fraud and abuse have had significant effects on improving the solvency of Medicare, thus acting as a driving force in eliminating fraud and abuse.
A wide host of entities are charged with investigation of fraud and abuse. These include the Office of the Health & Human Services Inspector General (OIG), CMS, private carriers, Medicare and Medicaid carriers, Peer Review Organizations, the Department of Justice, FBI, IRS, and the Social Security Administration. While the importance of proper billing and coding cannot be stressed enough, the publication of the Office of Inspector General Compliance Program for Individual and Small Group Physician Practices in October 2000 has broadened the grasp of the meaning of fraud and abuse. Although the OIG states that a compliance program is voluntary, it would be difficult to defend that position after an investigation has been initiated. As federal and state agents and prosecutors use more aggressive ways to uncover and fight fraud and abuse, implementation of an effective compliance program into a practice becomes a necessary proactive measure.
The Compliance Program for Individual and Small Group Physician Practices http://www.oig.hhs.gov/fraud/complianceguidance.html [Follow links to: Compliance Guidance ! 09/25/00 Final Compliance Program Guidance for Individual and Small Group Physician Practices] has been developed to help health care providers use internal controls within their practice to combat fraudulent conduct.
The OIG Compliance Program guidance for individual and small group practices contains seven basic components:
Implementation of all seven elements on a full scale for a small practice is a daunting process. However, the OIG Compliance Program for Individual and Small Group Physician Practices does offer a realistic step-by-step approach that allows practitioners to develop a program that suits the needs of their practice without a significant amount of dedication of staff time or funding.
Information Sources for the Optometrist
A wealth of information resources exists, at virtually no cost, which will enable the optometrist to implement a compliance program within the office. (See additional articles of information below.) CMS’s Medicare training Web site (http://www.hma.com/free_medicare_training.htm) offers various training programs to understand the impact of the compliance plan and offer practical suggestions for designing one for a practice. Many practitioners have found that networking with local hospital resources has provided them with the basics to allow for initiating the process within their practice. For those practitioners at high risk, the use of experts in health care consulting or an attorney well versed in health care law may be a more appropriate step.
Becoming acquainted with the laws and regulations used to fight fraud and abuse allows a more thorough internal review of the practice to reduce or eliminate areas of risk, thereby improving the effectiveness of the compliance program.
Additional compliance articles:
To become a member of a network of health care providers in a particular managed care organization (MCO), the optometrist will first be evaluated by that organization through the process of credentialing. The requirements of an MCO’s credentialing and recredentialing program will be used to assess one’s ability to deliver care to the patients. It is a highly visible part of an MCO’s credibility to offer quality care within the managed care industry. The MCO’s credentialing process will normally concentrate on an established set of criteria required for accreditation of the MCO by organizations such as the National Committee for Quality Assurance (NCQA), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), or the American Accreditation Healthcare Commission (URAC). The criteria used by the MCO must be verified by appropriate documentation and maintained in files by its credentialing department.
AOA Recommended Credentialing Standards for Optometrists
The entire credentialing process by the MCO may take 60 to 180 days after receipt of the information. Most plans will not allow their patients to be seen by a provider until the credentialing is completely finished. The applicant has the right to review information submitted in the credentialing process and to correct erroneous information.
The optometrist’s delivery of care during the two- or three-year interval between credentialing and recredentialing is further documented and maintained in the MCO’s credentialing files through the following data:
Possible MCO action may be taken when there is documented evidence of problems or issues with the delivery of care. These actions may extend to:
Delineation of privileges refers to the process by which clinical privileges are requested, recommended, and granted. A licensed optometrist is eligible to apply for hospital privileges and/or medical staff membership and to request permission to provide patient care services independently in the hospital, within well-defined limits based on professional license, experience, competence, ability, and judgment.
“The Guidelines for Delineation of Clinical Privileges for Optometry,” available from the AOA Clinical Care Group, are designed to serve as a model for hospitals to establish, review, and modify hospital-specific criteria for their individual privilege delineation process. The Guidelines are available on request by calling the AOA at (314) 991-4100, ext. 4237.
The medical record should contain information that properly documents precisely what services were provided. The medical record must be able to stand on its own without the benefit of the doctor to defend it. In general, if you did not record it, you did not perform it. Standards for medical record review have been published by several accrediting agencies as well as the CMS. In general, the following standards are consistent among the various organizations. However, keep in mind that these represent the minimum standards and certainly are not inclusive of all standards of which an MCO, plaintiff’s medical expert, or federal representative may use in the review of the medical records.
For additional information regarding documentation, the Documentation Guidelines for Evaluation and Management Services, published by the CMS in 1997, may be referenced at www.hcfa.gov/medlearn/emdoc.htm.
Patient satisfaction may be considered to be one of the desired and expected outcomes of care. An expression of satisfaction or dissatisfaction is the patient’s judgment on the quality of care in all its aspects, particularly with the practitioner’s interpersonal skills.
It is important for optometric offices to measure patient satisfaction because:
Patients’ Perception of Care
Perception of care by patients often determines the financial success of a practice, and it can affect the patients’ trust in their doctor. Doctors should understand their patients’ needs and wants as well as their satisfaction, or dissatisfaction, with the various aspects of care. Impressions of the office visit may begin with the availability of parking. This may be followed by the interaction with reception staff and conclude with how well the optometrist explained the diagnosis and treatment plan. Throughout the entire encounter, patients are greatly influenced by their perception of access to the doctor.
Managed care plans may ask providers for proof that their accessibility meets certain guidelines and that patients will have access to the provider in an appropriate and timely manner. Access can easily become a risk management issue if patients are delayed in seeking care due to poor telephone access, minimal or poor after-hours coverage, inability to receive follow-up care, or delay in the triage process of an eye- or visionrelated disorder. To meet accessibility guidelines the optometric practice should consider:
Patients’ Rights and Responsibilities
A generic bill of rights for the optometric patient lists precisely what services and treatment the patient can expect in the optometric office. Topics that might be included in the list of patient rights are:
It is important that patients also be informed of their responsibilities to the practice. Topics that might be included in the list of patient responsibilities are:
Appeals and Grievances
Managed care and other third-party plans may require that optometrists contracting for services have a formal process for patient grievances.
Successful practices have utilized one or more of the following policies/procedures for dealing with patient grievances:
Sampling Patient Satisfaction
There are many methods of sampling patient satisfaction. The optometrist should select the means that makes the best sense for patients and practice and meets the needs of any managed care organization asking for data on patient satisfaction.
Surveys are a widely used method of sampling patient satisfaction. Although the survey may be simple in concept, survey results are not simple to interpret and validate. It is useless to seek genuine feedback from patients if the practitioner is unwilling to change to meet the patients’ needs and desires that the patient satisfaction surveys indicate.
Development of patient satisfaction surveys should consider the following factors:
Choice of Population
Questionnaires may be direct about patient services or they may be more open-ended, asking the patient to freely comment on services received. It is more difficult to quantify the results of open-ended questions; however, they provide insight into what is important to the patient, whereas specific, direct questions limit the patient’s responses to topics that the doctor or staff felt were key indicators of patient satisfaction. Response rates to surveys have to be reasonable to be able to validate the results. One criterion might be that at least 30% of the population using the services during the period of study should respond to the survey for it to be a valid representation of overall patient satisfaction. (http://www.acponline.org/journals/news/apr00/surveys.htm) An example of a patient satisfaction questionnaire is included in this section.
Delivery of the Questionnaire
Some examples of delivery are as follows:
A problem with in-house surveys and surveys in which there is direct contact between the patient and the office staff is that the patient may be reluctant to provide information about an unsatisfactory experience without assurances of confidentiality and anonymity in responses. Therefore, responses may be biased to those who found the visit satisfying.
Assessment of Results
Results of the survey should be assessed for positive and negative responses. Efforts should be made to identify opportunities for improvement and development of corrective action plans as part of the quality improvement program of the practice.
Summary: Steps to Measuring Patient Satisfaction
Click here for a sample Patient Satisfaction Survey.
Risk management is defined as clinical and administrative activities that organizations undertake to identify, evaluate, and reduce the risk of injury to members, staff, and visitors and the risk of loss to the organization itself.3 While it is natural for optometrists to think of risk management in terms of financial risk to the practice itself, the actual goal is to improve procedures leading to higher-quality patient care. Although heightened interest in risk management activities often stems from litigation, responding only to outcomes of such litigation simply results in higher cost (i.e., "defensive") health care rather than higher-quality health care.4 To be effective, risk management activities must be proactive rather than reactive and they must be directed toward processes rather than individual events.
Risk management procedures must also be manageable. On reviewing all of the identifiable risks associated with optometric practice, there is a natural tendency to become overly aggressive in establishing management standards. Unfortunately, if the process becomes too complex and burdensome, it is often rejected entirely. The goal is to establish a risk management program that is first, manageable, and second, effective for the most important risks.
Types of Risk
The first step in the development of optometric risk management activities is to establish categories of risk important in optometric practice. This can best be done through analysis of outcomes of optometric care and of similar health care delivery systems. Fortunately, the nature of optometric care is such that adverse outcomes are rare. Studies have shown that optometrists do in fact make accurate diagnoses and dispositions of ocular disease, including the treatment of ocular disease.5-7 These studies help to explain the well-known fact that professional liability insurance rates for optometrists are substantially lower than for other health care providers.
Favorable outcomes in existing studies, however, also make it difficult to establish risk categories—though we know that some significant risks exist, as evidenced by outcomes of litigation. An analysis of legal outcomes, may therefore serve as a basis for identifying risks, as long as analyses are directed toward processes rather than singular events and as long as recommended standards are designed to improve patient care rather than simply to defend the provider.
An analysis of claims data was presented in the Optometrists Risk Management Seminar at the American Optometric Association’s 96th Annual Congress, Anaheim, California, in June 1993. The most common causes of optometric claims were listed as misdiagnosis or mismanagement of: glaucoma, retinal detachment, and ocular disease in contact lens patients. Disease-related litigation against optometrists appeared to follow three common threads:
The more-prominent risks associated with optometric practice appear to be related to the actual delivery of care (i.e., diagnosis and management of ocular disease or ocular signs of systemic disease). The AOA Optometric Clinical Practice Guidelines contain recommendations for eye and vision examinations and for many specific eye health conditions commonly encountered by optometrists. Procedures to minimize risk are already well established, and may be summarized as follows:
Despite the fact that optometrists encounter many types of disease entities in clinical practice, relatively few of these diseases are represented in the majority of lawsuits. In a 1989 review of 50 malpractice claims against optometrists, it was found that most cases involved either retinal detachment, glaucoma, or tumors (including both ocular and brain tumors).8
In a similar study of 700 ophthalmologic malpractice cases, it was found that most cases involved retinal detachment, management of topical drug therapy, glaucoma, trauma/intraocular foreign body detection, and vascular retinopathy.9 On the basis of these reports, it would seem logical to concentrate risk management procedures in the following areas:
Other Aspects of Risk Management
Other aspects of risk management that can easily be overlooked, yet are important enough to address individually, are:
HIPAA (Health Insurance Portability and Accountability Act of 1996)
Information is also available at the AOA Members Web site.1,2
Continuity of Care
Continuity of care is a logical yet easily overlooked extension of direct patient care. It is usually patients who become lost to followup that claim loss or injury associated with primary eye care.11 In a busy practice, it is easy to lose track of patients who fail to return for followup as expected, particularly when the majority of patients represent little or no risk. Patient tracking systems are, therefore, widely recommended and diversely implemented.12
Referral for Consultation or Treatment
The extent to which an optometrist can provide treatment varies depending on state scope of practice laws and individual certification. When the patient requires care beyond the optometrist’s scope of practice and/or area of competence, the optometrist is responsible to initiate a prompt referral for consultation with, or treatment by, the patient’s primary care physician, other medical specialist, an ophthalmologist, or an optometrist with advanced training and experience. Followup to determine the patient’s compliance or noncompliance with the referral is recommended to assure continuity of care. Documentation of the referral or request for consultation and the patient’s response should be made in the patient record.
Satisfaction with previous care is an important factor in the patient’s decision to return for follow-up care.11 Patients who remember only some unrelated, unpleasant experience in their office visit can easily forget about the health risks explained to them during that visit. Common annoyances for patients include:
Regardless of whether there has actually been an adverse outcome of care, patients who are dissatisfied are more likely to resort to litigation. Consequently, patient satisfaction must be an integral part of quality assessment and improvement activities.
Well-established office procedures for providing urgent or emergent patient care are an important aspect of primary care delivery. Patients must have access to emergency eye care either directly from their primary care provider or from a suitable alternate source made known to them by that provider. This procedure may be documented by office policy as well as by literature dispensed to patients.
Optometrists bear responsibility for negligent or wrongful acts, not only on their part in the course of patient care, but also on the part of the office staff in their employment. Inadequate training, failure to supervise, and delegating tasks to nonqualified personnel are examples of common potential liability risks. Providing an organized staff development program - including orientation and inservice training or continuing education programs, an up-to-date office procedure manual, and employee handbooks - constitutes good risk management practice.
Although product liability has been displaced by disease detection and management as a prominent optometric risk management concern, it is still an important issue. Product liability can be broadly categorized as either ocular injury resulting from use of eyewear or dissatisfaction with the eyewear itself. Most important is establishing the risk associated with possible breakage of eyeglasses. This risk may be minimized by following a policy of inquiring about environments in which spectacles or contact lenses would be worn and prescribing either polycarbonate or other protective eyewear as needed.13
Patient dissatisfaction with eyewear can be minimized by following a policy of verifying all eyewear, according to ANSI standards, before dispensing. Spectacle verification forms should include entries for: sphere, cylinder, axis, decentration, prism, add, segment height, and interpupillary distance.13 Verification may easily be documented in the patient record upon receipt of the eyewear.
Office and Premises Safety
While optometric office premises offer relatively few risks for either patients or staff, some rather significant risks can exist.14 The office and premises should be constructed, maintained, and equipped to protect the health and safety of patients, personnel, and visitors in compliance with appropriate regulations [e.g., Occupational Safety and Health Administration (OSHA) and Americans with Disabilities Act (ADA)].
Patients who become injured due to hazards in or around the office can sue for damages. While searching for potential hazards in or around the office, it is important to remember that not everyone who visits the office will be capable of recognizing even ordinarily minor hazards.
Office standards should include an ongoing program for the maintenance, calibration, and replacement of equipment and instruments and for the removal/disposal of ophthalmic materials and medications that are past their expiration dates.
Patients and staff are susceptible to infectious disease transmission in the office. This risk is steadily increasing as more and more optometrists become involved in the management of infectious ocular disease. It is made worse by the increasing prevalence of AIDS and hepatitis B and the resurgence of TB. In response, the AOA Primary Care Committee has published infection control guidelines, which should be implemented in the optometric practice as needed.15
OSHA has additional standards on health and safety for employees. These standards are not necessarily specific to optometric practice, but the optometrist must be aware of them to promote employee safety in the workplace. Under OSHA’s regulations, employers are required to inform all of their employees of all potential risks within the workplace. Topics include:
Additional information on OSHA regulations can be obtained from any regional OSHA office, or visit their Web site at a href="http://www.osha.gov" target="_blank">www.osha.gov.
The doctrine of informed consent is based on the principle that patients have a right to know enough about potential risks versus potential benefits of treatments to make a decision about whether to accept treatment. Informed consent is not just a document to be signed by the patient. It is a process that starts with a reasonable explanation by the doctor of risk versus benefit for procedures or treatments that could potentially have an adverse effect on the patient. Obtaining informed consent from a patient should meet reasonable expectations for explaining possible side effects and offering an opportunity to decline the procedure, while emphasizing the importance of having the procedure done. Informed consent procedures and forms should be in compliance with all applicable laws, regulations, and professional standards of care.
Assessment of Risk Management Procedures
The key to a good risk management system is to concentrate on processes rather than events. It is all-too-easy to look at an adverse outcome and point out errors in patient management. It is somewhat more difficult to look at random episodes of high-risk patient care and point out potential errors in practice patterns. When the actual incidence of high-risk episodes is low, as in the general practice of optometry, the task of assessment can become even more difficult. In some offices, it is difficult to find enough records of high-risk patient encounters to effectively apply high-risk assessment instruments. In other offices, there may be such an abnormally high number of high-risk patient records that general practice standards simply would not address the known risks. Therefore, it is important that practice patterns and assessment instruments be developed which are first, applicable to essentially all patient encounters, and second, likely to address the needs of high-risk patients whenever encountered.
Click here for a Self-Assessment of Risk Management.
Utilization Management (UM) involves managing the use of health care services to ensure that patients receive medically necessary and appropriate, high-quality care in the most cost-effective manner. Optometrists can understand this definition as most incorporate the concepts of some forms of utilization management in their own patient care routines, whether they are aware of it or not.
Every managed care organization in which optometrists participate as panel providers will have a formal UM program. The NCQA has published clearly defined standards for a UM program that the MCOs are required to understand and implement. [www.ncqa.org/pages/communications/publications/umcertpubs.htm] UM is a very important part of the scoring process for the accreditation of MCOs, which will apply significant resources to this program for it to function as it was intended. Accreditation is a high priority for MCOs in the competition for patient enrollees.
It is important that optometrists understand what a UM program is, how it will affect their office, and what they can do to assist in the development of a responsible UM program for the managed care plan to which they belong and for their own office. The emphasis that managed care places on quality of care measurements makes this undertaking a high priority for an optometric practice.
UM involves managing the use of health care services to ensure that patients receive medically necessary care. The determination of medical necessity for care given by optometrists is of great importance. The optometrist’s decision on medical necessity for eye care proposed for a patient may, or may not, coincide with the MCO’s decision on medical necessity for the same proposed treatment. It is critical the optometrist understand and be able to determine medical necessity as established by the MCO to eliminate billing problems and patient relationship difficulties. The optometrist must be able to discuss with the patient the element of medical necessity as determined by the examination and how that may differ from the patient’s plan’s determination.
Managed care organizations will publish documents that explain their coverage of benefits. This publication is sent to all members of the MCO and should be sent to all participating providers on the network. This publication is the first source of those treatment regimens the plan considers when determining medical necessity for members. An example of one regimen of care that is not often found in this benefit program is vision therapy. Optometrists must be able to clearly define to the patient the concept of medical necessity as determined by their examination and how that may differ from what the plan considers to be medically necessary for vision health care.
The MCO will also prepare an involved plan that outlines all the criteria for every service they will be responsible for reimbursing providers. This includes all of the eye health care reimbursable codes. The MCOs will establish their own criteria based on published criteria in various specialties. The AOA’s clinical practice guidelines are an excellent source of published criteria that could be used by MCOs in establishing their criteria for approval and payment of eye care procedures. The goals of clinical practice guidelines are to offer the best clinical result in the most cost-effective way and to reduce variations in treatment modalities from one provider to another.
The AOA Optometric Clinical Practice Guidelines identify appropriate utilization strategies for eye and vision examinations and management of specific ocular conditions and diseases. These guidelines can be translated into good UM review criteria (clinical indicators) for use in identifying utilization of inappropriate or unnecessary services and improving the quality of optometric care provided.
The MCO is required to involve appropriate actively practicing providers in the development of the criteria and their application. The managed care organization may request optometrists to participate in the systematic development of eye care criteria and under what circumstances these criteria are appropriate. The optometric profession and the published clinical practice guidelines of the AOA are valuable to MCOs in the UM program development. The MCO’s UM program is required to explain in writing how optometrists may obtain a copy of the UM criteria, and these criteria must be available to optometrists upon request.
The AOA Optometric Clinical Practice Guidelines are also an excellent source for establishing an optometrist’s own practice guidelines. The establishment of office practice guidelines is an integral part of an optometrist’s UM program. Optometrists should have a complete copy collection of the AOA’s entire clinical practice guidelines in their office for easy reference, as well as a copy of the UM criteria for every plan to which they belong.
The MCO’s UM Program
The MCO’s UM program will have substantial involvement of a designated senior physician and will be run on a day-to-day basis by licensed health care professionals, usually nurses. Any denial of care must be reviewed by a licensed physician. A physician reviewer must be available by phone to discuss denial determinations. Optometrists should not hesitate to discuss adverse determinations for requested care with the designated physician representatives of the MCO.
Improvements in the quality of health care delivery have resulted from the integration of case management services with the MCO’s disease management programs. These stress the management of selected disease states, such as diabetes, and promote improved outcomes.
The efficiency of the MCO’s UM program has also been enhanced by recent developments in the use of Web-enabled technology, more-sophisticated software programs, and the electronic transfer of patient care data.
Many UM programs are incorporating policies and procedures designed to be sensitive to patient privacy concerns and potential conflicts of interest. These often result in upgraded confidentiality requirements and clinical peers being required to sign conflict of interest statements. Optometrists should closely monitor privacy and confidentiality requirements of all plans in which they participate, as well as their own office privacy and confidentiality processes found in their written compliance programs.
UM processes may also play a role in protecting patients from medical errors and adverse outcomes. Automated UM systems have the capability of flagging unexpected events that may be indicators of a problem in the quality of health care delivery. This alert may prompt a review of the patient’s file by a case management nurse or physician.
Timeliness of Care Decisions
MCOs are under strict time constraints for making utilization management decisions. The timeliness requirements are designed to accommodate the clinical urgency of the patient’s health care situation.
For instance, a request to pre-certify treatment for non-urgent care must be decided on by the MCO within two working days of obtaining all necessary information, and the provider must be notified within one working day of the MCO making the decision. Denials of non-urgent care require the MCO to provide electronic or written confirmation of the decision to both optometrists and members within two working days. All denials of care notices to optometrists must contain the specific review criteria used in the decision or the member’s benefits provision that addresses the care requested.
For urgent care situations, the time constraints get even tighter. The MCO must make the decision and notify the optometrist within one calendar day of receiving the precertification request.
Complaints and Grievances
The MCO will have a detailed plan to continuously track complaints and grievances submitted by patients and providers. This allows the MCO to evaluate appropriateness of care issues that the complaints and grievances bring to the attention of the plan. An effective tracking program includes the important aspect of resolutions, as a quality measurement.
The optometrist may be contacted for information concerning a particular complaint submitted by a patient. It is very important to respond immediately and completely to the MCO about the patient’s issue. Thorough documentation in the clinical record is critical to being able to respond completely and in a legally sufficient manner.
Satisfaction with Services
The random surveying of members’ and providers’ satisfaction with services provided may be included in the MCO’s UM program. Every year detailed surveys are mailed to members and providers, asking specific questions about the satisfaction with such experiences as timeliness of care or service, adequacy of explanations of care or service, and degree of satisfaction with care rendered or services given. The MCO is required to address sources of dissatisfaction expressed by members or providers with action plans for resolution of issues identified by the surveys.
Optometrists are encouraged to conduct their own on-going patient satisfaction surveys to identify potential problem areas within their practices. They should also complete any provider satisfaction survey sent to them by the plans they belong to as participating providers.
External Review of MCO’s Decision-making Process
The external review process is in many ways similar to utilization review in that it is a process to determine if a particular medical service is medically appropriate or if a particular administrative process has been followed correctly. However, the external review process is detached from both the MCO and the patient, and is therefore free of financial disputes that could affect the final determination. It typically occurs after all appeal mechanisms available within the MCO have been exhausted. The reviews are conducted by external review organizations not affiliated with the MCO.
External reviews can be voluntary on the part of the MCO or mandated by law. Both the NCQA and American Accreditation HealthCare Commission/URAC have incorporated external review in their accreditation requirements. As of 2001, 39 states and the District of Columbia have enacted legislation establishing external review requirements for their covered populations. A complete list of these states may be found in a publication on the American Association of Health Plans’ Web site: www.aahp.org.
Examples of disputes that may be eligible for an external review process would include adverse determinations of medical necessity, denied access to out-of-network practitioners, or whether an MCO’s administrative requirements for access to specialty care practitioners were correctly followed.
Delivery of Appropriate Eye Health Care
The managed care organization will have established mechanisms and protocols in place to detect the potential of under-utilization of care or over-utilization of care to its members. Either of those situations will impact negatively on the quality of overall care delivered by the network providers. The MCO is required to routinely analyze data collected to identify under- and over-utilization, and will have appropriate interventions available whenever it merits action. For example, an MCO may review the history of eye care for patients who have been diagnosed as having cataracts to determine whether these patients were appropriately referred to an ophthalmic surgeon or were continued being seen by the optometrist.
If every patient in whom an optometrist diagnoses a cataract is referred for a surgical evaluation, there could be a case for over-utilization of ophthalmic referral services, since not all cataracts are appropriate for referral to the surgeon. Clinical practice guidelines are important to establish the appropriate decision point for referral to the surgeon. With many of these patients, the optometrist can continue to monitor the cataract until it is appropriate to refer for a surgical evaluation. Over-utilization may also occur if the optometrist sees the patient an excessive number of times per year for cataracts that are clinically stable. However, if an optometrist does not refer a patient with a cataract that meets clinical guidelines for a referral for surgical evaluation, there might be a case for under-utilization of ophthalmic surgical services. Patients who should be considered cataract surgical candidates and who are not referred for the evaluation may not be receiving quality eye care. The importance of the awareness of established clinical guidelines should not be underestimated when ensuring appropriateness of eye health services.
This Quality Assessment and Improvement Manual for Optometric Practices is based on currently available information for health care practice. The needs of individual optometric practices may vary, meaning that their QAI programs could vary accordingly. Likewise, published guidelines for general health care practice tend to undergo evolving change, meaning that individual QAI programs must be able to grow. This QAI manual offers a place for optometrists to start and provides resources to help them follow the evolving trends.
Prepared by current and past members of the American Optometric Association, Commission on Quality Assessment and Improvement
Updated January 2002
Lyman C. Norden, O.D., Coordinating Editor
Mary S. Loshin, O.D., Chair
Carol L. Brown, O.D., Former Chair
Jeffrey T. Keller, O.D., M.P.H., Former Chair
Carl F. Gruning, O.D., Former Chair
Robert P. Aitken, O.D.
Allen J. Blume, O.D.
James D. Colgain, O.D.
Sarah C. Gordon, O.D.
William W. Hately, O.D.
James R. Hoffman, O.D.
Susan R. Johnson, O.D.
David S. Loshin, O.D.
Ms. Zoe Lyle
Francis L. McVeigh, O.D.
Lesley L. Walls, O.D.
Diana L. Watkins, O.D.
Roger J. Wilson, O.D.
Siu G. Wong, O.D., M.P.H.