U.S. Office of Personnel Management - Recruiting, Retaining and Honoring a World-Class Workforce to Serve the American People

Specific activities we want you to know about: We have Registered Nurses who perform site visits at provider's offices to review your care, medications, and medical records/confidentiality. We assess and monitor your medical records on a routine basis. We first do this when a provider joins the panel and then every two years after. We want to ensure that patient safety and education is promoted at provider's offices. Credentialing Department Registered Nurses review your medical records for the following items:

• Correct patient name and identification; Medication allergies and adverse reactions are prominently noted and in the appropriate place; and all information is legible by someone other than the writer;
• Significant illnesses and conditions are indicated on your medical history form or problem list;
• Your past medical history is easily identified, including serious accidents, operations, and illnesses;
• Past medical history and education for your dependents (18 years and younger) includes prenatal care, birth, operations, and childhood illnesses;
• Appropriate notation and education concerning the use of cigarettes, alcohol, and substance abuse for patients 14 years and over;
• An immunization record is initiated for your dependents ages 18 years and younger;
• The documentation within your chart provides appropriate subjective and objective information for presenting complaints;
• Providers order laboratory or other diagnostic studies for you and/or your dependents that are appropriate;
• The primary care physician initials consultation, lab, and imaging reports filed in your chart, or uses some other method to signify review. Consultation, abnormal lab, and imaging study results have an explicit notation in the notes for follow-up plans;
• Working diagnoses are consistent with findings; Treatment plans are consistent with diagnoses;
• Evidence of informed consent regarding your treatment plan;
• Encounter forms or progress notes have a notation, when indicated, regarding follow-up care, calls, or visits; Physicians note the specific time of your return in weeks, months, or whenever necessary; Unresolved problems from previous office visits are addressed in subsequent visits;
• There is neither an under utilization nor over utilization of consultants; If a consultation is requested for you, there is a note from the consultant in the record.
• There is no evidence that you are placed at an inappropriate risk by a diagnostic or therapeutic problem; and there is evidence that preventive screening and services are offered to you in accordance with the organization's practice guidelines.
• Other items that we routinely assess during site visits include: appropriate maintenance of your medication lists; proper maintenance of your problem lists; evidence of an advanced directive for you, the patient; exam rooms and entrance/exit doors are handicap accessible; routine maintenance of all fire extinguishers; proper placement and plain view of all fire exit signs; emergency evacuation plan is in place; toilet/washroom facilities are clean and equipped with a grab bar; parking lot is of an adequate size and is well-maintained; exam rooms are clean and neat with needle receptacles located near the area of use; 24-hour availability for off-hour emergencies; office is following all OSHA regulations regarding blood-borne pathogens, TB skin tests, eyewash stations, and biological/hazardous waste exposure.

Our Goal or expected outcome from these activities: We expect all network panel providers to be in compliance with these requirements to ensure that continuous patient safety and education are provided to you.

Specific tools used to evaluate results of this activity: We request quality performance plans if a provider's office experiences some difficulty during the site visit. A registered nurse from the Plan will thoroughly explain to the office all that will need to be initiated and in place for a second site visit, if one is required.

Our Quality and Credentialing Department oversees patient safety.

The plan, along with your druggist, works to prevent prescription mistakes when you get your prescription filled. If there is a chance that one prescribed medicine might react with another prescribed medicine that you are taking, your druggist is notified when he or she enters your prescription into the computer. If you request a refill too soon, this could indicate that you may not be taking the medicine as your doctor prescribed. The plan will notify your druggist. If this occurs, your druggist can not refill your medicine under the plan benefit without making sure your doctor approves it. The plan will also notify your druggist if there is more than the normal amount of medicine, such as pain medicine, prescribed by more than one doctor for you or prescribed more frequently than normal. At this time, your druggist can not fill the medicine under the plan benefit until he or she checks with your doctor to make sure that you are getting the right amount of medicine.

If you have a chronic disease such as diabetes, congestive heart failure, asthma, emphysema, or high blood pressure, the plan has Registered Nurses who will help you learn how to manage your condition. This is called Disease Management. The Registered Nurse, called a Nurse Case Manager, will contact you to determine what help you may need. She will work with your doctor and other health care providers along with your family as needed. She will help you with arranging the preventative care and testing that is indicated for your condition. She will help you and your family learn about your care. If you need special equipment or home health services, she will work with you to obtain them within the plan's network of providers when possible. If you are in the hospital or nursing home, the Nurse Case Manager will work with the facility to make discharge plans that will meet your needs.

Some of the Plan network hospitals offer evidence-based guidelines to doctors for treatment recommendations. Available guidelines include the following: acute heart failure, pneumonia (community acquired), chronic obstructive pulmonary disease, acute ischemic stroke, bronchiolitis for children, breast feeding, surgical management of primary breast cancer, diagnostic evaluation of breast cancer, early stage breast cancer adjuvant therapy, diabetes in the adult, and partial hip fracture.

The Case Manager will share information about how you are doing with your doctor so he or she is kept aware of how you are progressing. The plan provides network doctors with information about medicine costs, use of generic medicines, and the number of plan approved medicines they prescribe in a report. This helps ensure that the proper medicines are available to you and that you get the best benefit from your plan.

We hold meetings with Physician Office Managers on a quarterly basis. Office managers are generally the main point of contact for implementing any initiatives at a provider's office. We publish and review provider newsletters during these meetings. The provider newsletters will include discussions on site visits and overall patient safety issues. Office manager's use the newsletters as reference material to discuss with their provider's when they return to the office.

The Plan has a quality program for network doctors. Network doctors receive periodic report cards which provide information that can assist the doctors in providing quality care to their patients. The report cards include pharmacy, quality, and cost of utilization. This information helps the doctor to know how his or her practice compares with similar practices of other doctors.

The pharmacy report card provides cost information about generic drugs, formulary drugs, overall drug costs, and number of prescribed drugs for their patients. This information may assist the doctor to reduce the co-pays which his or her patients pay for their drugs.

The quality report card provides your doctor with the percentage of patients who are receiving the following prevention testing: mammogram, pap test, cholesterol screening, and prostate specific antigen. The quality report card also provides the percentage of the doctor's diabetic patients who receive the following testing/screening: hemoglobin A1c, LDL, and monitoring for nephropathy. This information may assist the doctor to know how well his patients are receiving necessary prevention testing.

The utilization report cards provide information to your doctor about the frequency and costs of various types of care that you receive. The types of care include hospital admissions, office visits and emergency room visits, diagnostic tests, surgical procedures, treatments including therapy and counseling, and lab testing. While it is vital that you get necessary health care, excessive use of health care resources has negative effects.

The plan's network hospitals have programs that monitor many different safety factors such as falls, medicine errors, infections, pain control, staffing, and drills in the event of fires or other disasters, to name a few. The plan works hard to make sure that decisions on the services you or your doctor request are made as quickly as possible so that you receive the care you need in a timely manner. The plan has a Registered Nurse who helps new members safely transition to network providers so that their care is not interrupted. The plan's Medical Director is readily available to the nursing staff to be certain that the right decision is made to provide the services to meet your health care needs.