Provider Manual
 Section 8: Quality Assurance and
Improvement
KAISER PERMANENTE OF OHIO
Table of Contents
SECTION 8: QUALITY ASSURANCE AND IMPROVEMENT (QI) ............................... 3
KAISER PERMANENTE QUALITY MISSION STATEMENT .................................................................... 3
8.1 ORGANIZATIONAL STRUCTURE AND ACCOUNTABILITIES ....................................................... 3
8.1.1 Kaiser Permanente Quality Management Department Contacts................................................ 4
8.2 COMPLIANCE WITH REGULATORY AND ACCREDITING BODIES ............................................... 4
8.3 SENTINEL EVENTS ........................................................................................................................ 5
8.3.1 Do Not Bill Events (DNBE) .............................................................................................................. 5
8.4 QUALITY REPORTS ....................................................................................................................... 6
8.4.1 The Joint Commission Staffing-Effectiveness Indicators for Hospitals ..................................... 7
8.5 PROVIDER CREDENTIALING ........................................................................................................ 7
8.5.1 Credentialing and Recredentialing Processes ............................................................................... 7
8.5.2 Provider Notification of Status of Credentialing Application..................................................... 8
8.5.3 Provider Right to Review and Correct Erroneous Information .................................................. 8
8.5.4 Providers on Corrective Action Plan Status .................................................................................. 8
8.5.5 Confidentiality of Credentialing Information ............................................................................... 8
8.5.6 Organizational Provider Assessment/Reassessment .................................................................... 8
8.6 PEER REVIEW................................................................................................................................ 9
8.7 COMPLIANCE WITH FACILITY AND OFFICE SITE REVIEWS ........................................................ 9
8.7.1 Frequency of Facility and Office Site Reviews .............................................................................. 9
8.7.1.1 Site Review Evaluation Form ............................................................................................. 10
8.7.2 Non-Compliance with Site Review Standards ............................................................................ 13
8.8 COMPLIANCE WITH MEDICAL RECORD ................................................................................... 13
8.8.1 Frequency of Medical Records Review ........................................................................................ 16
8.8.2 Non-Compliance with Medical Records Standards ................................................................... 16
8.9 ACCESSIBILITY STANDARDS ...................................................................................................... 17
8.9.1 Non-Compliance with Accessibility Standards........................................................................... 17
8.10 PREVENTIVE CARE AND CLINICAL PRACTICE GUIDELINES .................................................. 17
8.11 PATIENT SAFETY POLICY ......................................................................................................... 18
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Section 8: Quality Assurance and Improvement (QI)
Kaiser Permanente Quality Mission Statement
―The mission of the organization is to enhance the health and well being of our Members
through the delivery of high quality, affordable health care. Our team of professionals
will provide exceptional Service with a commitment to integrity and remain focused on
the needs of our Members. The Kaiser Permanente of Ohio Quality Improvement
Program reflects our vision and values. It is designed to initiate, monitor, evaluate and
improve standards of health care practice and customer Service on an ongoing basis.‖
Kaiser Permanente is committed to providing appropriate care in an efficient and
effective health care delivery system for its Members, employers, Practitioners and Plan
Providers. A multi-disciplinary and integrated approach is used, which focuses on
opportunities for improving operational processes, health outcomes, as well as Member
and Plan Provider satisfaction.
The Kaiser Permanente Quality Management (QM) program promotes the accountability
of all Kaiser Foundation Health Plan of Ohio personnel as well as Ohio Permanente
Medical Group (OPMG) Practitioners for the quality of care and Services that are
provided to Kaiser Permanente Members. The quality of care Members receive is
monitored by Kaiser Permanente’s oversight of Plan Providers to ensure that all
Members are receiving high quality care. Kaiser Permanente believes that ―Quality is
Everyone’s Job.‖
Participating Plan Providers are monitored for various standards, including, but not
limited to, the following:
Member access to care.
Member Complaint and satisfaction survey data of both administrative and
quality of care issues.
Compliance with Kaiser Permanente policies and procedures.
Utilization management statistics.
Quality of care indicators as necessary for Kaiser Permanente to comply with
requirements of National Committee for Quality Assurance (NCQA), the Centers
for Medicare & Medicaid Services (CMS), The Joint Commission, and other
regulatory and accreditation bodies.
Performance standards in accordance with your Agreement.
8.1 Organizational Structure and Accountabilities
The Kaiser Permanente Quality Management (QM) program provides a link to the Medical
Management, Clinical Risk Management, Claims Management, Customer Relations,
Population Care Management/Disease Management, Patient Safety, Ohio Permanente
Medical Group (OPMG), Care Experience Initiative, and administrative functions of Kaiser
Foundation Health Plan of Ohio, along with Practitioner and Provider Review and
Oversight activities.
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Issues concerning quality should be directed to either the Plan Provider’s Quality
Department or directly to Kaiser Permanente’s Performance Improvement and Patient
Safety Department at 216-362-2191 for follow-up.
To maintain an open line of communication, OPMG has established relationships with
Plan Providers to participate in committees, which include but are not limited to:
Disaster preparation.
Infection control.
Medical records.
Nutrition.
Pharmacy and therapeutics.
Quality council.
Questions or concerns regarding OPMG’s participation in committees can be directed to
the Associate Medical Director of Quality Improvement at 216-479-5322.
8.1.1 Kaiser Permanente Quality Management Department Contacts
Title
Phone Number
Reason for Contact
Associate Medical Director of
Quality Improvement
Clinical Risk Manager
216-479-5322
216-362-2191
Questions concerning OPMG
involvement on committees
Sentinel and Do Not Bill events,
quality of care issues, peer
review referrals
8.2 Compliance with Regulatory and Accrediting Bodies
Kaiser Permanente participates in the National Committee for Quality Assurance
(NCQA), Centers for Medicare & Medicaid Services (CMS), Medical Director Quality
Review (MDQR), Health Plan Quality Oversight (HPQO), and the Ohio Department of
Health (ODH) review activities in order to demonstrate Kaiser Permanente’s compliance
to regulatory and accrediting bodies.
In accordance with these regulations, Plan Providers are expected to provide to Kaiser
Permanente, on an annual basis, measures of clinical quality, access, and Member
satisfaction results for both commercial and Medicare patients to support HEDIS®
(Healthcare Effectiveness Data and Information Set) data collection. HEDIS® is one of
the most widely used set of performance measures in the United States and includes 80
measures across eight domains of care. This information will be either conveyed
electronically by Plan Providers or collected by Kaiser Permanente staff through chart
review. If there are any issues regarding the data transfer process, Plan Providers
should contact their respective IT Help Desks.
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If necessary, in order to complete HEDIS® reporting, Kaiser Permanente staff will
contact Plan Providers for specific patient information related to medical care.
The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule permits a
plan provider to disclose protected health information to a health plan for quality-related
health care operations, provided that the health plan has or had a relationship with the
individual who is the subject of the information, and the protected health information
requested pertains to the relationship. See 45 CFR 164.506(c)(4). Thus, a plan
provider may disclose protected health information to a health plan for the plan’s
HEDIS® collection purposes, so long as the period for which information is needed
overlaps with the period for which the individual is or was enrolled in the health plan.
Kaiser Permanente expects all applicable Plan Providers to have and maintain The Joint
Commission accreditation or be approved by another recognized accrediting body, to be
in compliance with all regulatory bodies (i.e., CMS), and to maintain a current certificate
of insurance. If a Plan Provider receives any recommendations from these
organizations, the Plan Provider is required to provide to Kaiser Permanente the
surveys’ recommendations, along with the corrective action plan to resolve the identified
issue or concern.
Kaiser Permanente monitors the status of the above listed accreditations, licensures,
certifications, etc. on an annual basis through the Ohio Permanente Medical Group
(OPMG) Credentialing and Human Resources Department. To contact this department
with an update or question, call toll-free 1-800-524-7371, ext. 5541, or 216-479-5541.
Kaiser Permanente maintains a corporate compliance program based upon the Office of
the Inspector General’s Seven Elements of an Effective Compliance Program. This
includes a code of conduct entitled, ―Principals of Responsibility.‖ For a complete
description of our compliance program, see Section 9 of this Manual.
8.3 Sentinel Events
Any unexpected occurrences involving a Kaiser Permanente Member, staff, etc.,
defined as a sentinel event, as defined by The Joint Commission, requires IMMEDIATE
notification to Kaiser Permanente in accordance with Kaiser Permanente’s Sentinel
Event Policy. A full copy of the policy is available either through the Plan Provider’s
Quality Department or through the Kaiser Permanente’s Performance Improvement and
Patient Safety Department at 216-362-2191.
Any such sentinel event should be reported to Kaiser Permanente’s Clinical Risk
Manager at 216-362-2191. All sentinel event reports are considered confidential and
privileged quality/peer review documents.
8.3.1 Do Not Bill Events (DNBE)
Plan Providers should notify Kaiser Permanente of any DNBE. Any such event should
be reported to the Kaiser Permanente Clinical Risk Manager at 216-362-2191.
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Upon learning of a DNBE, Kaiser Permanente will contact the reporting Plan Provider to
discuss next steps. Member Cost Share may be waived and/or reimbursed and the
Plan Provider’s reimbursement may be affected. Refer to claim submission
requirements for DNBE’s in Section 5, Coding & Billing Validation and Do Not Bill
Events, of this Manual.
8.4 Quality Reports
Plan Provider performance for quality is monitored by Kaiser Permanente’s
Performance Improvement and Patient Safety Department via information exchange,
mandatory reporting, and onsite reviews. In addition to actively participating in quality
management activities, Plan Providers must provide access to Members’ medical
records. Plan Providers should also ensure that they communicate openly with
Members regarding appropriate treatments without penalty.
In order for both Kaiser Permanente and Plan Providers to be in compliance with
accrediting and regulatory bodies, various reports must be generated to track any
quality issues. When issues are identified as a result of the reports, action plans must
be developed by the Plan Providers and communicated to Kaiser Permanente’s Clinical
Risk Manager at 216-362-2191.
Following is a list of the quality reports submitted by Plan Providers to the Kaiser
Permanente Performance Improvement and Patient Safety Department:
Transfers to ICU.
Mortality rates.
Unplanned removal/injury or repair of an organ or invasive procedure.
Unplanned return to the operating room or special procedure room during an
admission.
Complications (major complications only).
Unexpected death.
Blood utilization.
Skin care protocols and monitoring results.
Medication errors (Nursing/Pharmacy).
Patient falls.
Restraint/seclusion monitors.
Infection control surveillance data.
The Joint Commission Staffing-Effectiveness Indicators for Hospitals.
Update on Leapfrog Initiatives.
Update on Institute for Healthcare Improvement Strategic Initiatives.
Practitioner specific data as requested.
As each Plan Facility collects and presents the data individually, questions regarding
data collection tools and data files should be directed to each Plan Facility’s respective
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Quality Department. These reports, if available, and other criteria based on the
Maryland Quality Indicator Project , should be submitted to Kaiser Permanente’s
Performance Improvement and Patient Safety Department on a quarterly basis no more
than 30 days after the end of the quarter.
8.4.1 The Joint Commission Staffing-Effectiveness Indicators for Hospitals
Reserved for future use.
8.5 Provider Credentialing
In order to ensure the quality of Practitioners who treat Kaiser Permanente Members,
Plan Providers are subjected to a vigorous credentialing process. All Plan Providers
must be fully credentialed and ―approved to participate‖ before treating Kaiser
Permanente Members.
8.5.1 Credentialing and Recredentialing Processes
Credentialing is an accountability of Kaiser Foundation Health Plan of Ohio and the
Ohio Permanente Medical Group (OPMG). To fulfill this responsibility, the Credentials
Committee was established in 1993 to develop credentialing policies and procedures
and to review and make decisions regarding the credentialing and recredentialing of
both OPMG Practitioners and the other Plan Providers. All Plan Providers must be fully
credentialed and ―approved to participate‖ before treating Kaiser Permanente Members.
Plan Providers who employ Advanced Practice Nurses and/or Physician Assistants
must first complete the credentialing process for these employees before they can
render care to Kaiser Permanente Members.
Initial credentialing requires a completed and signed CAQH® (Council for Affordable
Quality Health Care) application and primary source verification of licensure, hospital
and healthcare organization privileges, Drug Enforcement Administration (DEA)
registration, education and training, board certification, proof of professional
malpractice coverage, and review of professional liability claims history. Applicants
provide information concerning physical and mental health, and applications are
reviewed for complete work history. Additional verifications include a query of the
National Practitioner Data Bank/Healthcare Integrity and Protection Data Bank, and a
query for Centers for Medicare and Medicaid Services (CMS) sanctions. Practitioners
who are not already participating with the CAQH® Universal Provider Datasource online
can contact the Kaiser Permanente Credentialing Department at toll-free
1-800-524-7371, ext. 5782, or 216-479-5782 for assistance in registering and
accessing the CAQH® application. Practitioners can also access the CAQH® website
at caqh.org to obtain instructions on receiving and filing a paper application form.
Appointments are granted for a 2 year period. Practitioners are recredentialed every 2
years. Organizational providers are recredentialed every 3 years. Recredentialing
requires submission of a current CAQH® application and attestation, and re-verification
of licensure, hospital/healthcare organization privileges, DEA registration, board
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certification, proof of professional malpractice coverage, and review of professional
liability claims history. The recredentialing process includes an update of
physical/mental health status, query of the National Practitioner Data Bank/Healthcare
Integrity and Protection Data Bank, and a query for CMS sanctions.
8.5.2 Provider Notification of Status of Credentialing Application
At any time during the credentialing process, an applicant has the right to contact the
Kaiser Permanente Credentialing Department to determine the status of their
credentialing or recredentialing application. The Credentialing Department can be
reached by telephone at toll-free 1-800-524-7371, ext. 5782, or 216-479-5782, via fax to
216-479-5554 or by sending an email to ohiocredentialing@kp.org.
8.5.3 Provider Right to Review and Correct Erroneous Information
Applicants are notified via a statement on the credentialing and recredentialing
application of their right to review information obtained in conjunction with the
credentialing process, except for professional references, recommendations or other
information that is peer review protected. The applicant is notified of any information
obtained in the credentialing process that varies substantially from that provided on the
application, and the applicant then has the right to correct erroneous information
submitted by another party.
8.5.4 Providers on Corrective Action Plan Status
Reserved for future use.
8.5.5 Confidentiality of Credentialing Information
Credentials files are maintained as confidential peer review documents of the
Credentials Committee. The credentials files are maintained in a locked file room within
locked file cabinets. The credentialing database is password-protected and authorized
users are granted access to practitioner and provider information via field level security
throughout the system. Access to credentials files is limited to those persons involved
in conducting or overseeing credentialing and peer review activities.
8.5.6 Organizational Provider Assessment/Reassessment
Kaiser Permanente contracts with organizational Providers, including hospitals, home
health agencies, hospices, skilled nursing Facilities, nursing homes, free-standing
surgical centers, behavioral health Facilities, and other ancillary Providers to provide
care to Kaiser Permanente Members. Organizational Providers must meet contracting
requirements and maintain credentials that include, at a minimum, the following:
State licensure, as applicable.
Accreditation by The Joint Commission or another recognized accrediting body
as applicable based on the provider type.
Certification by Centers for Medicare and Medicaid Services (CMS).
Current, continuous liability coverage.
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Initial assessment for an organizational Provider is valid for 36 months, at which time
the organizational Provider is reassessed for continued compliance with the contracting
requirements.
If an organizational Provider receives any recommendations from a licensure,
accreditation, or other regulatory entity, the organizational Provider is required to
provide to Kaiser Permanente the surveys’ findings/recommendations, along with the
corrective action plan to resolve the identified issue or concern.
Kaiser Permanente monitors the status of the above listed accreditations, licensures,
certifications, etc., upon expiration, and as the organizational Provider is reassessed
every 36 months. For organizational Provider updates or questions, contact the Kaiser
Permanente Credentialing Department at toll-free 1-800-524-7371, ext. 5248, or
216-479-5248, or send an email to ohiocredentialing@kp.org.
8.6 Peer Review
Kaiser Permanente will maintain a peer review process to promote and monitor
credentialing, quality patient care, Member satisfaction, Member Complaints and
administrative compliance with policies, procedures, rules and practices for all Plan
Providers.
Kaiser Permanente has established threshold for performance measures to include, but
not limited to, the following key areas:
Member satisfaction.
Quality.
Member Complaints and Grievances.
Referrals.
Utilization.
HEDIS® (Health Plan Employer Data and Information Set)/National Committee for
Quality Assurance (NCQA).
8.7 Compliance with Facility and Office Site Reviews
Kaiser Permanente reserves the right to perform environmental and medical record site
reviews for any Plan Provider if requested as part of the contracting and/or credentialing
process. This includes visits for a newly contracted Plan Provider, a new office
location/relocation for an established Plan Provider, or a revisit to monitor compliance
with a corrective action plan. A facility and office site review must be completed if an
office site exceeds established thresholds for site-related Member Complaints
pertaining to physical accessibility, physical appearance, or adequacy of waiting room
and/or exam room space. Unannounced office site reviews may be conducted based
on the urgency of a Complaint.
8.7.1 Frequency of Facility and Office Site Reviews
Site reviews may be completed on all prospective Primary Care Physician (PCP),
Ob/Gyn and Behavioral Health offices prior to consideration by the Kaiser Permanente
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Credentials Committee. If an existing Plan PCP, Ob/Gyn or Behavioral Health
Practitioner relocates, adds an additional practice location, or adds on to an existing
office, a site review may be completed within 30 days of the relocation/opening of the
new office. In addition, a site review of any Plan Provider office or Facility may be
conducted at the request of the Associate Medical Director of Quality Improvement, the
Kaiser Permanente Credentials Committee or the Performance Improvement and
Patient Safety Department, or upon receipt of an environmental Complaint filed by a
Kaiser Permanente Member.
8.7.1.1 Site Review Evaluation Form
See the following page.
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Kaiser Permanente-Ohio
Site Visit and Evaluation Tool
Date of Visit: __________________ Initial:  New Site:  Office Relocation:  Complaint:  Revisit: 
If complaint, brief description of issue: ___________________________________________________________________
_____________________________________________________________________________________________________
Group Name: ________________________________________________________________ TIN: ____________________
Office Location: _____________________________________________Phone:____________________________________
_____________________________________________Fax: _____________________________________
Practitioner(s) Names(s): _______________________________________________________________________________
_______________________________________________________________________________
Practitioner Type: PCP:  Ob/Gyn:  Behavioral Health:  Other Specialty: ______________________________
Kaiser Permanente Reviewer: ___________________________________Title: _________________________________
Office Staff Assisting w/Review: _________________________________ Title:__________________________________
1.
2.
3.
1.
2.
3.
OFFICE SITE SECTION
Physical Accessibility and Appearance:  Modern  Older  Needs Repair  Renovated
Handicapped accessible
Well-lit waiting room
At least two seats for every patient scheduled per hour (ie: 5 patients scheduled 10 seats)
MD name on building or building directory
All areas neat and clean
Furniture in good repair
At least two exits present
Fire extinguisher present
Fire alarm present
Clear exit path
Grab bar available in restroom
Examination Rooms
At least two exam rooms per practitioner
At least one exam room can accommodate a wheelchair
At least one sink with soap accessible to all exam rooms
Exam table paper is changed between patients or table is cleaned with antibacterial cleaning agent between
patients
Verbal exchanges cannot be overheard
Availability of Appointments
PCP, OB/GYN:
Urgent care within 48 hours
Routine office visit within 4 weeks
24 hour emergency coverage
Behavioral Health:
Urgent care appointments obtained within 48 hours
24 hour life threatening emergency coverage
Evaluation on non-life threatening emergencies within six hours
Total Office Site Score:
MEDICAL RECORD KEEPING PRACTICE SECTION
Adequacy of Medical/Treatment Record Keeping
Medical records are stored in office and protected from public access or stored in a centralized medical
record department
Have a process for follow up of abnormal test results
Form for documenting patient demographic data
Legible file markers or defined method to track information in consistent manner
Patient information is not in plain view (computer screens, open medical records, faxes, test results)
Discussed office documentation practices with practitioners or staff
Total Medical Record Keeping Practice Score:
Yes
No
Score
Yes
No
Score
Yes
No
Score
Yes
No
Score
Confidential/QA Purposes
Revised: 8/2008
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Kaiser Permanente-Ohio
Site Visit and Evaluation Tool
Evaluation Score = Total # of ‘yes’/Total # standards scored for each section.
90% or greater: Quality Clearance
80-89%:
Conditional Clearance, Action Plan Required
<80%:
Failing Score, Pending Clearance, Action Plan Required
Recommendations:
Evaluation Score:
Clearance:
Office Site Section
Medical Record Keeping
Section
_____/
19 = ___ __%
_____/
6 = ______%
Revisit Date:
COMMENTS:
ITEM
EXPLANATION
DEFICIENCIES:
ITEM
EXPLANATION
ACTION PLAN:
Date of Review
What Needs to be Done
Who Will Do it
When Is it to be
Completed
Resolution
Confidential/QA Purposes
Revised: 8/2008
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8.7.2 Non-Compliance with Site Review Standards
Each element scored on the Site Visit and Evaluation Tool is worth one point. Quality
clearance is given to all medical Facilities which score 90 percent or higher.
Conditional quality clearance is given to medical Facility with a score of 80 – 89 percent
and they will be required to comply with a corrective action plan within 30 days of
receiving the written request.
Any medical Facility which scores less than 80 percent will be pending quality clearance
until the site complies with the corrective action plan within 30 days of the request and a
follow-up site visit is conducted. Follow-up visits for any purpose will occur within 6
months of the original site visit and will continue at least every 6 months until
deficiencies are corrected.
Findings and recommendations from site reviews, as well as any corrective action
plans, are reported to the Credentials Committee.
8.8 Compliance with Medical Record
Medical Record Standards
The medical record standards below apply to patient medical records - both paper and
electronic - maintained by Kaiser Foundation Health Plan of Ohio, the Ohio Permanente
Medical Group (OPMG), and contracted Plan Providers. The intent of these standards is
to promote timely, accurate, complete medical records. These standards are designed
to permit effective confidential patient care, quality review and coding and billing in
compliance with regulatory and accreditation requirements. Updates or changes to
medical records standards will be posted on the Kaiser Permanente’s Community
Providers web site at providers.kaiserpermanente.org/oh.
Maintenance
Every Kaiser Permanente member is assigned a unique medical record number (MRN)
that is generated at the time of enrollment or when the member first requests or
receives services.
Non-member patients will be assigned a unique medical record number when they first
request or receive services at a Kaiser Permanente facility.
Medical records will be maintained and stored in a manner that protects the safety and
security of the records and the confidentiality of information. Only authorized personnel
will have access to medical records.
Medical records will be retained at least for the time period required by State and
federal law.
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The medical record will be available for all medical office visits, whether scheduled in
advance or on the same day of service.
The medical record will not be altered except to appropriately add or amend data.
Original information must be legible. Superseded or historical versions of electronic
data will be maintained.
Documentation and Content
Entries into the medical record must:
Be in permanent ink when made on paper.
Be dated and timed.
Contain the legible identification of the provider, including name and
credential/certification.
Be authenticated by the author, which may be a handwritten or electronic
signature.
Have the patient’s name, medical record number, or other identification on each
page. In an electronic record, patient identification is located on each screen
view or printed page.
Be legible to someone other than the author.
Be readable if documentation is scanned or copied.
Be complete, accurate and timely.
Medical records should contain the following information:
Demographic/Personal Information:
o Medical record number
o Patient name
o Current address
o Home telephone number
o Work telephone number, when applicable
o Date of birth or age
o Gender
o Race
o Ethnicity
o Patient preferred language
o Name and telephone number of person to notify in case of an emergency
o Primary Care Physician (PCP) name
o Information regarding the patient’s advance directives
General Clinical Information:
o Allergies (including medication related allergies) and adverse reactions, or
noted as ―none‖ or ―no known allergies.‖
o Past medical history including serious accidents, operations and illnesses.
For children and adolescents (age 18 and younger), past medical history
includes significant events in prenatal care, birth, operations, and childhood
illnesses.
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o Vital signs including height, weight, blood pressure, body mass index (BMI),
and growth charts for children 2 – 20 years (including BMI)
o Personal habits, such as sexual behavior, smoking and history of alcohol use
and substance abuse for patients age 13 and older
o Preventive screening and/or problem-oriented services were performed or
offered to the patient.
o An up-to-date immunization record for children (age 18 and younger), or an
appropriate history for adults.
o Problem list indicating significant illnesses and medical conditions.
o Current medication list
Progress Notes:
o Patient’s chief complaint or reason for visit. Where ―follow-up‖ is the purpose
of the visit, the condition that occasions the follow-up is specifically stated
within the visit note.
o Appropriate subjective and objective information pertinent to the patient’s
presenting complaints or purpose for visit.
o Test (laboratory, pathology, radiologic or other diagnostic service) ordered as
medically necessary.
o Working diagnoses consistent with findings.
o Treatment plans, therapies or other regimens are documented and are
associated with current documented diagnoses and medical impressions.
o Follow-up instructions and timeframe for follow up or the next visit. The
specific time of return is noted in weeks, months, or as needed.
o Unresolved problems from previous visits are addressed in subsequent visit
notes.
o Diagnoses support the medical necessity of care rendered.
o When a patient does not present for a scheduled appointment, it should be
clearly indicated in the medical record, with efforts to contact the patient
documented.
Messages:
o An entry shall be made in the medical record of communication (telephone or
electronic) relating to patient care, including, but not limited to:
 Any medical advice that is given;
 Any new illness or change in health status; and
 Test results or requests to return for additional testing procedures.
Continuity of Care:
o Documentation of all services provided directly by the primary care physician.
o Evidence of appropriate use of consultants, as applicable.
o Evidence of continuity and coordination of care between primary care and
specialty practitioners. If a consultation is requested, there is a report from
the consultant in the medical record that includes the reason for the consult
and the identity of the authorized requestor.
o Results of ancillary services and diagnostic tests ordered by a practitioner.
o All diagnostic and therapeutic services for which the patient was referred by a
practitioner, such as home health reports, specialty physician reports, hospital
discharge reports, physical therapy reports, etc.
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o Consultant summaries and laboratory and imaging study results filed in the
medical record reflect Primary Care/Ordering Physician review.
o Consultation and abnormal laboratory and imaging study results have an
explicit notation in the record of any follow-up plans.
o Operative report or procedure note documented immediately after surgery/
procedure.
8.8.1 Frequency of Medical Records Review
Medical record reviews may be completed on all prospective Primary Care Physician
(PCP), Ob/Gyn and Behavioral Health offices prior to consideration by the Kaiser
Permanente Credentials Committee. If an existing PCP, Ob/Gyn or Behavioral Health
Practitioner relocates, adds an additional practice location, or adds on to an existing
office, a medical record review may be completed within 30 days of the
relocation/opening of the new office. In addition, a random medical record review of any
Plan Provider office may be conducted at the request of the Associate Medical Director,
Quality, Clinical Performance Improvement and Research, the Kaiser Permanente
Credentials Committee or the Performance Improvement and Patient Safety
Department.
8.8.2 Non-Compliance with Medical Records Standards
Each element scored on the Site Visit and Evaluation Tool (see Section 8.7.1.1 of this
Manual) is worth one point. Quality clearance is given to all offices which score 90
percent or higher.
Conditional quality clearance is given to offices with a score of 80 – 89 percent and they
will be required to comply with a corrective action plan within 30 days of receiving the
written request.
Any medical Facility which scores less than 80 percent will be pending quality clearance
until the medical Facility complies with the corrective action plan within 30 days of the
request and a follow-up site visit is conducted. Follow-up visits for any purpose will
occur within 6 months of the original site visit and will continue at least every 6 months
until deficiencies are corrected.
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8.9 Accessibility Standards
Plan Providers have agreed to be available to Members 24 hours a day, 7 days a week.
All Plan Providers must adhere to the following appointment access standards:
Medical Care
Accessibility Standard
Regular and routine care:
Care for non-urgent conditions
Urgent care:
30 days
24 hours a day
After-hours care:
Access to care after normal operation hours
Behavioral Health Care
Available 24 hours a day,
7 days a week, by
answering service or
direct pager
Accessibility Standard
Non-life-threatening emergency:
Severe crisis, not life-threatening but with potential to
become so, without intervention
Within 6 hours
Urgent needs:
Severe crisis, not life-threatening, including impaired
ability to function in normal roles due to symptoms
Within 48 hours
Routine office visits:
All other problems and symptoms not meeting
definition of emergent or urgent; may have been present
over time
Within 10 working days
8.9.1 Non-Compliance with Accessibility Standards
Accessibility standards are monitored during site surveys and by reviewing Member
Complaint and satisfaction data. If Kaiser Permanente reasonably determines that an
access issue may adversely affect the care provided to Members, Kaiser Permanente
may take corrective actions in accordance with your Agreement and applicable Laws
and regulations.
8.10 Preventive Care and Clinical Practice Guidelines
Kaiser Permanente is dedicated to helping support your clinical practice to provide
quality care for our Members. Since quality is a keystone of our Medical Care Program,
we have provided each Primary Care Physician and select Specialists with the
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Kaiser Permanente Ohio Preventive Care and Clinical Practice Guidelines. If you need
a copy of the current guidelines, contact your Network Associate. Preventive Care and
Clinical Practice Guidelines are also available on Kaiser Permanente’s Community
Providers website at providers.kaiserpermanente.org/oh. You will be notified in your
quarterly Provider Connection newsletter of any updates to the Preventive Care and
Clinical Practice Guidelines posted on the website.
The guidelines that have been developed are for screening, immunization, education,
prenatal care, and condition/disease management. The Kaiser Permanente Guideline
Committee oversees Preventive Care and Clinical Practice Guideline development.
Several of the guidelines are produced by the Care Management Institute (CMI) of
Kaiser Permanente. The CMI is a national organization of Kaiser Permanente that
synthesizes knowledge about the best clinical approaches to create, implement and
evaluate effective and efficient health care programs. Their data is evidence based and
population oriented. CMI supports the Kaiser Permanente regions, their staff, and their
clinicians to meet the needs of Members, Payors and the broader community.
We encourage you to consider these guidelines in your clinical practice. You will
continue to receive guideline updates and revisions on an ongoing basis. Feel free to
provide us with feedback and suggestions as you review these guidelines.
These guidelines are informational. They are not intended or designed as a substitute
for the reasonable exercise of independent clinical judgment by Practitioners,
considering each Member’s need on an individual basis. Guideline recommendations
apply to populations of patients. Clinical judgment is necessary to design treatment
plans for individual patients.
8.11 Patient Safety Policy
Patient safety is an integral component of Kaiser Permanente's Promise to provide
high quality healthcare. Each component organization of Kaiser Permanente —
across all locations — and its Practitioners, managers, employees, and Plan
Providers are responsible for patient safety. This responsibility is designed to guide
groups and individuals in achieving excellent performance in the safe and effective
delivery of health care. It includes activities aimed at achieving the following:
A unified and strong patient safety culture, with patient safety and error
reduction embraced as a shared value.
An environment that encourages responsible reporting of near misses and
errors and that looks to fix systems and not blame.
Established priorities that optimize the allocation of resources in the
implementation of patient safety performance improvement strategies.
Ongoing identification, sharing, and implementation of best practices from
other parts of the organization and other industries.
Routine patient safety and error prevention training and education for
individuals and groups.
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Relevant and meaningful monitoring and reporting of indicators and
outcomes which guide continuous improvement and validate success.
Kaiser Permanente aims to integrate patient safety into the fabric of our
organization and be guided by the following three simple principles:
Patient safety comes first.
Patient safety is every patient's right.
Patient safety is every individual’s responsibility.
We will establish appropriate structures, which include the Risk Management
Patient Safety Committee, implement appropriate systems, strive to maintain
appropriate staffing and skills, and be guided by the most appropriate strategy to
deliver the safest quality healthcare possible, quality healthcare our Members can
trust.
Any questions regarding the Kaiser Permanente of Ohio patient safety policies and
procedures can be directed to the Patient Safety Lead at 440-846-2723.
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