General Quality of Care Review: Preparing the Quality Review

5115.1 – General Quality of Care Review: Preparing the Quality Review Decision (QRD) Form (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) Once a determination is made about the specific concern(s) to be addressed, the QIO should prepare a QRD Form containing all potential concerns that have been identified (See Appendix 5-1.3“Quality Review Decision (QRD) Form.”). The QRD Form is the only form authorized for identifying, documenting, and summarizing the quality of care concerns addressed in the review. The QRD Form is designed to account for the multiple individuals involved in a Quality of Care review and to ensure that information related to every Quality of Care Concern is maintained in an organized, detailed, and consistent fashion throughout the review process. Pursuant to the QIO contract, the QIO uses the CMS-designated case review system to prepare a QRD Form that sets out each individual concern and forwards the review materials and associated medical information to the Initial Determination Peer Reviewer within three (3) business days of receiving the medical information. In completing the QRD Form, the QIO should do each of the following: 1. Identify each Quality of Care Concern; 2. Identify the quality of care with regard to the admission diagnosis and treatment plan established for the beneficiary, if applicable; 3. Research evidence-based practices related to each Quality of Care Concern(s), while considering the definition of Quality Care, including reference to relevant norms and criteria. If no quality of care standard(s) exists, then the QIO will use available norms, best practices, and established guidelines, to recommend a potential quality of care standard(s). In order to identify all applicable criteria and norms to be applied pursuant to §476.100, the QIO must thoroughly research all available information, including: • Nurse screening criteria (e.g., InterQual, Milliman, etc.); • Generally available resources, including information available via Internet searches; 4. Complete an Assessment section for each Quality of Care Concern; 5. Evaluate additional information pertinent to the case, but unrelated to the standard(s) of care. This evaluation may include: • CMS-available information, including web-based resources (e.g., Nursing Home and Hospital Compare); • State-based resources, including web-based literature and information as well as practitioner-specific information related to license revocations and referrals to the State medical conduct organizations; 6. Research all available data, a minimum of three (3) years from the date of service, to determine whether similar complaints have been received on the same practitioner and/or provider and/or if other potential concerns related to the same practitioner and/or provider are identifiable; and 7. Utilize the medical information received to prepare the information needed to complete the review and forward it to the Initial Determination Peer Reviewer.