28 Tex. Admin. Code § 11.1901 - Quality Improvement Structure for Basic, Single Service, and Limited Service HMOs

(a) Basic, single service, and limited service HMOs must develop and maintain an ongoing QI program designed to objectively and systematically monitor and evaluate the quality and appropriateness of care and services and to pursue opportunities for improvement. Unless the HMO has no enrollees, the QI program should include the active involvement of one or more enrollee(s) who are not employees of the HMO.

(b) The HMO governing body is ultimately responsible for the QI program. The governing body must:

(1) appoint a quality improvement committee (QIC) that must include practicing physicians and individual providers, and may include one or more enrollee(s) from throughout the HMO's service area, none of whom may be employees of the HMO;

(2) approve the QI program;

(3) approve an annual QI plan;

(4) meet at least annually to receive and review reports of the QIC or group of committees and take action when appropriate; and

(5) review the annual written report on the QI program.

(c) The QIC must evaluate the overall effectiveness of the QI program.

(1) The QIC may delegate QI activities to other committees that may, if applicable, include practicing physicians, individual providers, and enrollees from the service area.

(A) All committees must collaborate and coordinate efforts to improve the quality, availability, and accessibility of health care services.

(B) All committees must meet regularly and report the findings of each meeting, including any recommendations, in writing to the QIC.

(C) If the QIC delegates any QI activity to any subcommittee, then the QIC must establish a method to oversee each subcommittee.

(2) The QIC must use multidisciplinary teams, when indicated, to accomplish QI program goals.

Notes

28 Tex. Admin. Code § 11.1901

The provisions of this §11.1901 adopted to be effective December 8, 1997, 22 TexReg 11684; amended to be effective July 31, 2002, 27 TexReg 6701; amended to be effective February 24, 2005, 30 TexReg 854; amended to be effective November 15, 2006, 31 TexReg 9298; Adopted by Texas Register, Volume 42, Number 16, April 21, 2017, TexReg 2262, eff. 8/1/2017