Clinical guidelines

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MI | MO | NE | NEBH | NV | NH | NJ | NY |OH | RI | TN | WA | WV | WI

"6.5.3.3 Standards and Guidelines
The Contractor will use the following standards and guidelines for Preventive Care as designated by DHS. The Contractor will adopt these standards and guidelines as a baseline for assessment against which care actually delivered can be compared. For Quality of Care studies in the health services delivery areas, the Contractor will use the specific standards set forth in the pertinent subsections... For other clinical or health services delivery areas where DHS has not specified clinical standards or practice guidelines, the Contractor will submit these standards or guidelines to DHS for approval six weeks prior to conducting the studies.

A. Pediatric:
Periodic health screen schedule based on the most recent recommendations of the American Academy of Pediatrics (AAP). Immunization schedule based on recommendations of either the Advisory Committee on Immunization Practices or the AAP shall be acceptable.

B. Adult:
Guidelines based on the Report of the United States Preventive Services Task Force.

C. Obstetric:
Minimum standards based on recommendations of the American College of Obstetrics and Gynecology…" California Contract, page 91.

"XIV. SERVICE DELIVERY…
4. Scheduling and wait times: The Contractor shall establish clinically appropriate scheduling guidelines for various types of appointments necessary for the provision of primary and specialty care including but not limited to: well-child checks, routine physicals, prenatal care, diagnosis and treatment of acute pain or injury, and follow-up appointments for chronic conditions. The guidelines must be part of the Contractor’s Quality Assurance Program, as described in Section XVII of the Contract, and communicated in writing to Participating Providers in the Contractor’s network…" Colorado Contract, pages 46-47.

"XV. UTILIZATION MANAGEMENT…
A. Utilization Management Program...
3. Utilization determinations shall be based on written clinical criteria and guidelines developed or adopted with involvement from practicing Physicians and other Participating Providers, or nationally recognized standards. These guidelines and criteria shall be periodically reviewed and updated and shall, with the exception of internal or proprietary quantitative thresholds for Utilization Management, be readily available, upon request, to affected participating providers, Members, and the public." Colorado Contract, pages 52, 53.

"XV. QUALITY ASSURANCE…
9. The Contractor shall impose practice guidelines for the following:
a. Perinatal, prenatal, and postpartum care for women,
b. Birthing and neonatal care for infants,
c. Conditions related to persons with Disabilities or Special Health Care Needs, and
d. Well child care.

The standards and indicators shall be based on nationally approved guidelines, although modifications may be granted by the Department to address regional variations. These standards and guidelines must be available upon request of the Department and Clients no later than July 1, 1998, and shall be available to non-Members at cost." Colorado Contract, pages 55-56.

"STANDARDS FOR INTERNAL QUALITY ASSURANCE PROGRAMS FOR HEALTH PLANS...
Standard II: Systematic Process of Quality Assessment and Improvement...
C. Use of clinical care standards/practice guidelines
1. The QAP studies and other activities monitor quality of care against clinical care or health services delivery standards or practice guidelines specified for each area identified.
2. The clinical standards/practice guidelines are based on reasonable scientific evidence and are developed or reviewed by plan providers.
3. The clinical standards/practice guidelines focus on the process and outcomes of health care delivery, as well as access to care.
4. A mechanism is in place for continuously updating the standards/practice guidelines.
5. The clinical standards/practice guidelines shall be included in provider manuals developed for use by MCO providers or otherwise disseminated to the providers as they are adopted.
6. The clinical standards/practice guidelines address preventive health services.
7. The clinical standards/practice guidelines are developed for the full spectrum of populations enrolled in the plan.
8. The QAP shall use these clinical standards/practice guidelines to evaluate the quality of care provided by the MCO's providers whether the providers are organized in groups, as individuals, as IPAs, or in combinations thereof…" Connecticut Contract, Appendix I, pages 1-3.

"12.2 Internal Quality Assurance and Utilization Management Program
The MCO must have an internal written quality assurance plan (QAP) that monitors, assures, and improves the quality of care delivered over a wide range of clinical and health service delivery areas. The QAP will be reviewed semiannually by the State or more frequently if necessary. Emphasis should be placed on, but need not be limited to, clinical areas relating to maternity, pediatric and adolescent development (including EPSDT), family planning and well-women care, as well as on key access or other priority issues for Medicaid patients such as reducing the incidence of sexually transmitted diseases, acquired immune deficiency syndrome, smoke related illnesses, etc.

Contractors must satisfy at a minimum: ...
(f) Describe methodologies and mechanisms for tracking issues over time with an emphasis on improving health outcomes; such mechanisms should be developed in accordance with the guidelines of the Guide to Clinical Preventive Services (Report of the U.S. Preventive Services Task Force), the EPSDT guidelines, or other criteria based on scientifically or clinically validated analysis…" Delaware RFP, pages II.70-II.71.

"ARTICLE II - QULAITY ASSURANCE AND MANAGEMENT
A. GENERAL REQUIREMENTS...
2. Provider shall implement clinical care standards and practice guidelines that are based on national guidelines, or promulgated by professional medical associations, or other expert committees." District of Columbia Contract, page 33.

"27. Quality Assurance...
c. The plan shall conduct quality-of-care studies which: ...
(2) Use clinical care standards or practice guidelines objectively evaluate the care the entity delivers or fails to deliver for the targeted clinical conditions.
(3) Use quality indicators from the clinical care standards or practice guidelines to screen and monitor care and services delivered..." Florida Contract, pages 49-50.

FLMH

"2.18 Quality Assurance Requirements...
C. The plan's quality assurance program shall have peer review component and a peer review authority responsible for the following scope of activities: ...
5. The development and maintenance of a review process which includes... adherence to standards generally accepted by professional group peers..." Florida Mental Health RFP, page 43.

"44.020 Quality Assurance Programs...
The QAP shall at a minimum be consistent with and incorporate the required components as specified in the 'Standards for Internal Quality Assurance Programs of HMOs, HIOs and PHPs contracting with Medicaid' as published by the U.S. Department of Health and Human Services, Health Care Financing Administration, Medicaid Bureau...

* Standards for Availability and Accessibility - The QAP shall have established standards for access to services which are to be compared to the plan's actual performance. Access and availability include standards for the availability of appointments and limits on waiting periods for a scheduled appointment.

* Standards for Facilities - The QAP shall establish standards for the facilities in which recipients receive care.

* Medical Records Standards - The QAP shall establish standards for the accessibility and availability of medical records and the information to be recorded and maintained in the records. A record review system to assess and assure conformance with standards shall be established." Hawaii RFP, pages 59-61.

"EXHIBIT A
Quality Assurance (QA)

1. All services provided by or arranged by Contractor to be provided shall be in accordance with prevailing professional community standards. Contractor shall establish a program that systematically and routinely collects data to review which includes quality oversight and monitoring performance and patient results. The program shall include provision for the interpretation of such data to Contractor's practitioners. Contractor shall have in effect a program consistent with the utilization control requirements of 42 CFR Part 456. This program will include, when required by the regulations, written plans of care and certifications of need of care...

4. Contractor shall provide Department with the QAP written guidelines which delineate the QA process, specifying: ...
b. Use of Quality Indicators - Quality indicators are measurable variables relating to a specified clinical area, which are reviewed over a period of time to monitor the process of outcomes of care delivered in that clinical area:
• Contractor shall identify and use quality indicators that are objective, measurable, and based on current knowledge and clinical experience.
• Contractor shall document that methods and frequency of data collected are appropriate and sufficient to detect need for program change.
• For the priority clinical areas specified by Department, Contractor shall monitor and evaluate quality of care through studies which address, but are not limited to, the quality indicators also specified by Department…" Illinois HMO Contract, Exhibit A, pages A1-A5.

"4.6.9.1 Quality Improvement Program and Reporting Standard…
The MCO must meet the following reporting requirements:
The MCO’s QI program shall be based on an annual written plan, specific to Hoosier Healthwise members, that meets OMPP’s approval, and includes: goals; structure; authority; responsibilities; scope; methods of evaluation (such as methods used in bi-annual quality of care chart audits which the MCO is required to perform); and mechanisms for acting upon improvement information generated. The plan must be submitted to OMPP and the MCO monitoring contractor within ninety (90) days of the effective date of the contract. The QI plan must include but not limited to the following:
* Goals and objectives. Goals shall include:
- Description of methods used for practice guidelines, with documented references..." Indiana RFP, pages 4-33 - 4-35.

"Section 7. Quality and Appropriateness of Care
Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state's Medicaid plan, and continue on to Section 8.

7.1. Describe the methods (including external and internal monitoring) used to assure the quality and appropriateness of care, particularly with respect to well-baby care, wellchild care, and immunizations provided under the plan. (2102(a)(7)(A))

Indiana will utilize a number of different strategies to assure quality and appropriateness of care under Phase II of the CHIP program. The State is contracting with an evaluation consultant who will develop performance criteria, and also provide assistance in designing the evaluation and annual reports. The performance criteria will be an important tool for measuring quality of care, particularly with respect to well-baby care, well-child care, and immunizations. A more detailed discussion of performance measures and the evaluation consultant can be found in Section 9.

Quality assurance requirements are imposed on MCOs that contract with the State under Hoosier HealthWise. MCOs must have quality improvement (QI) programs in place that meet the federal requirements (42 CFR 434.34) and the National Committee for Quality Assurance (NCQA) standards. The QI programs must be based on annual plans that are approved by the OMPP. In addition, MCOs must meet a number of other QI requirements, including: establishing a QI Committee overseen by the MCO Medical Director; submitting Quarterly QI reports; conducting focused studies, including medical data abstraction and data entry, in areas of clinical priority for the Indiana Medicaid population; establishing internal systems for monitoring services; conducting a quality of care chart audit of providers of services; attending monthly Hoosier HealthWise Quality, Improvement Committee (QIC) meetings; submitting QI data to the State; and taking other steps to improve quality of services." Indiana SCHIP Amendment, Attachment C-3, pages 28-30.

"4.19 Practice Guidelines and New Technology
If the HMO adopts and enforces clinical practice guidelines, the HMO shall have written policy outlining the mechanism for the adoption of the clinical practice guideline. Guidelines shall be based on reasonable medical evidence or a consensus of relevant practitioners (e.g., guidelines promulgated by the Agency for Health Care Policy and Research) and shall be reviewed and updated periodically. The guidelines shall be communicated to Providers and, as necessary, to Enrollees...
Clinical practice guidelines and technology review determinations shall not exclude any medically necessary Covered Services defined herein," Iowa Contract, page 37.

"7.5.1 Quality Improvement System...
(a) The quality Improvement Plan shall contain: ...
(8) Practice guidelines or standards against which clinical care is compared. The standards or guidelines shall be based on reasonable medical evidence, involve practitioners, be reviewed at least every two years and be routinely distributed to the Partnership practitioners, and reviewed by the persons conduction quality improvement studies." Kentucky RFA, pages 34-35.

"10.09.64.09...
.09 Quality Assurance System-General.
Unless an applicant satisfies the requirements of Regulation .08 of this chapter, it shall include in its application the following information or descriptions: ...
M. A copy of the applicant's practice guidelines used to assist practitioners in approaching health care issues in a systematic, appropriate manner…" Maryland COMAR 10.09.64.09.

"Section 2.10 Quality Management...
C. Clinical Practice Guidelines

The Contractor shall develop or adopt implement and monitor Clinical Practice Guidelines relevant to MassHealth Enrollees. The Contractor shall include, at a minimum;
1. Development, adoption and use of practice guidelines or explicit criteria that are based on reasonable scientific evidence and reviewed by the Providers and the Medical Director;
2. A process for updating the guidelines periodically;
3. A mechanism for communication of the guidelines to Providers;
4. Assessment of Provider performance in relation to the guidelines; and
5. Assessment of impact of guidelines on Enrollee outcomes or health status…" Massachusetts Contract, pages 57-60.

"II-P QUALITY ASSESSMENT AND PERFORMACE IMPROVEMENT PROGRAM STANDARDS
1. Quality Assessment and Performance Improvement Program Standards...
The written plan must also describe how the Contractor will:
*Establish clinical and non-clinical priority areas and indicators for assessment and performance improvement...
*Develop and/or adopt clinically appropriate practice parameters and protocols/guidelines and give the Contractor's providers enough information about the protocols the enable them to meet the established standards…" Michigan Contract, pages 42-44.

"2.16.1 Internal Staff: ...
a. The qualifications and responsibilities must include but need not be limited to what follows below: ...
20) Maintain current medical information pertaining to clinical practice and guidelines." Missouri RFP, page 80.

"15.9 Quality Assurance Subcommittees:...The Department will utilize the most recent HEDIS criteria, and other continuous QI specifications, to measure compliance in all of the following areas:
15.9.1 Utilization Management: The Department shall provide oversight and monitor the plan in the following areas:
(a) Development of practice guidelines…" Nebraska Contract, page 123.

"15.9.6 Preventative Health: The Department shall provide oversight and monitor the plan in the following areas: ...
(b) Development of the Preventative Health Guidelines (annually and any updates)...
(e) Development and Use of Consensus Guidelines…" Nebraska Contract, page 127.

NEBH

"13.9 Quality Assurance Subcommittees: The Department shall focus on the following activities, in the form of subcommittees...The Department will utilize the most recent HEDIS criteria, and other continuous QI specifications, to measure compliance in all of the following areas:
13.9.1 Utilization Management - The Department shall provide oversight and monitor the PHP in the following areas:
(a) Development of practice guidelines…" Nebraska Behavioral Health Contract, page 88.

"USE OF QUALITY INDICATORS
Quality indicators are measurable variables relating to a specified clinical or health services delivery area, which are reviewed over a period of time to monitor the process or outcomes of care delivered in that area.
1. The Contractor identifies and uses quality indicators that are objective, measurable, and based on current knowledge and clinical experience.
2. For the priority areas selected by the state, the Contractor monitors and evaluates quality of care through studies which include, but are not limited to, the quality indicators also specified by the HCFA's Medicaid Bureau.
3. Methods and frequency of data collection are appropriate and sufficient to detect need for program change.

C. USE OF CLINICAL CARE STANDARDS/PRACTICE GUIDELINES
1. The QAP studies and other activities monitor quality of care against clinical care or health service delivery standards or practice guidelines specified for each area identified in 'A., a. and b.' above.
2. The standard/guidelines are based on reasonable scientific evidence and are developed or reviewed by plan providers.
3. The standards/guidelines focus on the process and outcomes of health care delivery, as well as access to care.
4. A mechanism is in place for continuously updating the standards/guidelines.
5. The standards/guidelines shall be included in provider manuals developed for use by Contractor providers or otherwise disseminated to providers as they are adopted.
6. The standards/guidelines address preventive health services.
7. Standards/guidelines are developed for the full spectrum of populations enrolled in the plan.
8. The QAP shall use these standards/guidelines to evaluate the quality of care provided by the Contractor's providers, whether the providers are organized in groups, as individuals, or in combinations thereof.

D. ANALYSIS OF CLINICAL CARE AND RELATED SERVICES
1. Appropriate clinicians monitor and evaluate quality through the review of individual cases where there are questions about care, and through studies analyzing patterns of clinical care and related service. For quality issues identified in the QAP's targeted clinical areas, the analysis includes the identified quality indicators and uses clinical care standards or practice guidelines.
2. Multi disciplinary teams are used, where indicated, to analyze and address systems issues.
3. From 1. and 2., clinical and related service areas requiring improvement are identified." Nevada Contract, pages 59-60.

"Article VII
Quality Improvement Program

7.1 The Contractor shall ensure the delivery of quality care with the primary goal of improving the health status of Enrollees. The Contractor shall maintain an active commitment to Continuous Quality Improvement/Quality Management in all aspects of its service delivery.

(A) Principal components of the Quality Improvement Program...

(1) The QIP must include: ...
(c) Indicators for the quality of clinical care and nonclinical aspects of services...
(vi) Practice guidelines, if available." New Hampshire General Service Agreement, page 25.

"ARTICLE 15
QUALITY MANAGEMENT AND UTLIZATION REVIEW...
15.4 The contractor shall establish, implement, and adhere to a written Quality Management Program (QMP) which includes also a Utilization Review Plan…
15.6 The contractor's QMP shall include the following standards: ...
B. Systematic process of quality assessment and improvement including: ...
2. Use of quality indicators;
3. Use of clinical care standards/practice guidelines…" New Jersey Contract, pages 76-77.

"STANDARDS FOR INTERNAL QUALITY ASSURANCE PROGRAMS OF HMOs, HIOs, and PHPs CONTRACTING WITH MEDICAID...
STANDARD II: SYSTEMATIC PROCESS OF QUALITY ASSESSMENT AND IMPROVEMENT ...
C. Use of clinical care standards/practice guidelines -
   1. The QAP studies and other activities monitor quality of care against clinical care or health service delivery standards or practice guidelines specified for each area identified for each area identifies in 'A,' above.
   2. The standards/guidelines are based on reasonable scientific evidence and are developed or reviewed by plan providers.
   3. The standards/guidelines focus on the process and outcomes of health care delivery, as well as access to care.
   4. A mechanism is in place for continuously updating the standards/guidelines.
   5. The standards/guidelines shall be included in provider manual developed for use by HMO providers or otherwise disseminated to providers as they are adopted.
   6. The standards/guidelines address preventive health services.
   7. Standards/guidelines are developed for the full spectrum of populations enrolled in the plan…" New Jersey Contract, pages 203-205.

"16. QUALITY ASSURANCE...
16.2 Standards of Care
The Contractor must adopt practice guidelines consistent with current standards of care, complying with recommendations of professional specialty groups such as the American Academy of Pediatrics, the American Academy of Family Physicians, the U.S. Task Force on Preventive Care, the New York State Child/Teen Health Program (C/THP) standards for provision of care to individuals under age 21, the American Medical Association's Guidelines for Adolescent and Preventive Services, the US Department of Health and Human Services Center for Substance Abuse Treatment, the American College of Obstetricians and Gynecologists and the AIDS Institute Clinical Standards for Adult and Pediatric Care." New York Contract, page 16-1.

"5101:3-26-071 MANAGED CARE PLAN: INTERNAL QUALITY ACTIVITIES...
(3) THE MCP MUST CONDUCT QUALITY OF CARE STUDIES IN ACCORDANCE WITH THE FOLLOWING: ...
(c) PRACTICE GUIDELINES OR CLINICAL CARE STANDARDS MUST BE INCORPORATED IN THE EVALUATION OF EACH QUALITY OF CARE STUDY THAT:
   (i) ARE BASED ON EXISTING SCIENTIFIC EVIDENCE AND ARE DEVELOPED AND/OR REVIEWED BY MCP PROVIDERS;
   (ii) FOCUS ON THE PROCESSES AND OUTCOMES OF HEALTH CARE DELIVERY;
   (iii) ADDRESS PRVENTIVE HEALTH SERVICES;
   (iv) ARE INCORPORATED IN PROVIDER MANUALS AND DISSEMINATED TO PROVIDERS WHEN DEVELOPED AND ADOPTED; AND
   (v) ARE REVIEWED AND UPDATED ON AN ONGOING BASIS.

(d) RESULTS OF QUALITY OF CARE STUDIES MUST BE MONITORED AND ANALYZED BY CLINICIANS INCORPORATING THE IDENTIFIED QUALITY INDICATORS AND PRACTICE GUIDELINES OR CLINICAL CARE STANDARDS TO IDENTIFY AREAS REQUIRING IMPROVEMENT." Ohio RFP, Appendix E, OAC 5101:3-26-071, pages 1-7.

"2.12.03.01 General
Contractor agrees to have written policies and procedures to monitor utilization of services by its members and to assure the quality and accessibility of care being provided in its network. Such policies and procedures shall:
- Conform to Federal Health Care Quality Improvement System (HCQIS) guidelines
- Assure that the UR and QA Committees meet on a regular schedule
- Provide for regular UR/QA reporting to the Contractor management and Contractor providers, including profiling of provider utilization patterns." Rhode Island RFP, page 42.

"GUIDELINES FOR INTERNAL QUALITY MONITORING PROGRAMS OF MANAGED CARE ORGANIZATIONS CONTRACTING WITH TENNCARE

STANDARD I: WRITTEN QMP DESCRIPTION...
G. Systematic Process of Quality Assessment and Improvement...
The QMP has written guidelines for its quality of care studies and related activities which include: ...

2. Use of Quality Indicators -
Quality indicators are measurable variables relating to a specified clinical or health services delivery area, which are reviewed over a period of time to monitor the process or outcomes or care delivered in that area.
a. The organization identifies and uses quality indicators that are objective, measurable, and based on current knowledge and clinical experience… include, but are not limited to, the quality indicators also specified by the HCFA's Medicaid Bureau or by the State...

3. Use of Clinical Care Standards/Practice Guidelines...
   b. The standards/guidelines are based on reasonable scientific evidence and are developed or reviewed by plan providers.
   c. The standards/guidelines focus on the process and outcomes of health care delivery, as well as access to care.
   d. A mechanism is in place for continuously updating the standards/guidelines.
   e. The standards/guidelines shall be included in provider manuals developed for use by managed care providers or otherwise disseminated to providers as they are adopted.
   f. The standards/guidelines address preventive health services…" Tennessee contract, pages QCM -2-3.

"Clinical and Health Services Delivery Areas of Concern, Quality Indicators, and Clinical Practice Guidelines for Quality Improvement in TennCare Coordinated Care Plans...

IV. CLINICAL PRACTICE GUIDELINES/STANDARDS:
The identification of areas needing improvement and the creation of a baseline for future assessment necessitates specifying goals or standards for health services to which care actually delivered can be compared. Item I-G-3 in the Guidelines states, in part, that:
'a. The QMP studies and other activities monitor quality of care against clinical care or health services delivery standards or practice guidelines specified for each clinical or health services delivery area identified in I-G-1, above…'

Clinical care standards, practice guidelines, practice options and practice advisories are all types of 'practice parameters'. Practice parameters are recommendations or an agreed upon set of principles for the delivery of certain types or aspects of health care. They are promulgated by authoritative bodies such as professional associations or ad-hoc 'expert committees'. Because professional judgement may often vary, there can frequently be more than one set of practice parameters addressing the same topic. However, the vast majority of medical professional organizations endorse the use of practice parameters in improving the quality of medical care.

For this reason, the Guidelines recommend monitoring quality of care using clinical care standards or practice guidelines for each clinical or health services delivery area selected by the organization or State for study. For the Federally recommended clinical areas of pregnancy and childhood immunizations, commonly accepted sources of guidelines are:
The American Academy of Pediatrics (AAP),
The U.S. Department of Health and Human Services' Public Health Service (PHS), and
The American College of Obstetricians and Gynecologists (ACOG)…" Tennessee Contract, pages QCM-17-24.

"GUIDELINES FOR EXTERNAL QUALITY REVIEW OF RISK REIMBURSEMENT TENNCARE COORDINATED CARE ORGANIZATIONS

III. CONCEPTUAL APPROACH...
A. Focused Pattern of Care Studies...
2. Study Design...
b. Specifying Practice Guidelines for use in Assessing Care - When the EQRO monitors and evaluates care, it should compare the plan's performance against some concept of 'good' care. What constitutes 'good care' should be identified before data is obtained from plans about the health care it delivers. The TennCare document 'Guidelines for Internal Quality Monitoring Programs of Managed Care Organizations Contracting with TennCare' calls for coordinated care organizations themselves to monitor and evaluate the care they deliver through the use of clinical practice guidelines acceptable to the State.

Practice guidelines, practice standards, practice advisories, or practice parameters are all terms used to refer to recommended "best practice" strategies for clinical decision making and patient care. Although the terminology may vary, all can serve as sources of quality indicators against which care delivered by the managed care organization can be assessed. This document uses the term "practice guidelines" although, for purposes of this document, any of these terms may be used interchangeably. Sources of practice guidelines may be found in the American Medical Association publication, "Directory of Practice Parameters", which is published annually, or may be identified from several other sources, including government and public health publications, recommendations from medical leadership and plan providers, as well as from published practice parameters.

Ideally, the practice guidelines which the managed care organization uses to assess care, and the guidelines used by the external review organization, should be identical...Regardless, the EQRO shall review care in accordance with explicit guidelines approved by the State...

c. Defining and Quality Indicators that will be Monitored and Evaluated to Assess Care - From the practice guidelines, specific variables are derived to serve as indicators of the quality of care. These "quality indicators" are objective pieces of information that will be collected and analyzed to provide information to answer the study questions. For pregnancy, for example, selected quality indicators could include: birth weight, weeks of gestation at first prenatal visit, number of prenatal visits prior to delivery, or birth outcome (fetal loss of live birth)…" Tennessee Contract, pages QCM-25-28.

"V. PREVENTIVE HEALTH SERVICES
A. ADOPTION of PREVENTIVE HEALTH (PH) GUIDELINES [PH 1]
The contractor must have preventive health guidelines for prevention and early detection of illness and disease.

B. DISTRIBUTION of GUIDELINES to PRACTITIONERS [PH 2]
The contractor must distribute preventive health guidelines and any updates to its practitioners." Washington Contract, QIP-2000 Standards, page 31.

"QAPI communication
The MCO must establish procedures for formal and ongoing communication and collaboration among the policymaking body and other functional areas of the MCO (e.g., health services management and member services), especially with respect to: ...
* Developing practice guidelines…" West Virginia Contract, Exhibit F, page 6.

"III-4 PRACTICE GUIDELINES AND NEW TECHNOLOGY
The MCO must adopt and disseminate practice guidelines that are based on reasonable medical evidence or a consensus of health care professionals in the particular field, consider the needs of the enrolled population, are developed in consultation with contracting health care professionals, and are reviewed and updated periodically. The guidelines should be communicated to providers as appropriate. The MCO must ensure that decision with respect to utilization management, enrollee education, coverage of services, and other areas to which the guidelines are applicable are consistent with the guidelines.

The MCO must develop and implement written policies and procedures for evaluating new medical technologies and new uses of existing technologies…" West Virginia Contract, Exhibit F, page 14.

"Standard II: Systematic Process of Quality Assessment and Improvement...
C. Use of clinical care standard practice guidelines
1. The OAP studies and other activities monitor quality of care against clinical care or health services delivery standards or practice guidelines specified for each area identified by the State and the plans.
2. The clinical standards/practice guidelines are based on reasonable scientific evidence and are developed or reviewed by plan providers.
3. The clinical standards/practice guidelines focus on the process and outcomes of health care delivery, as well as access to care.
4. A mechanism is in place for continuously updating the standards/practice guidelines.
5. The clinical standards/practice guidelines shall be included in provider manuals developed for use by plan providers or otherwise disseminated to the providers as they are adopted.
6. The clinical standards/practice guidelines address preventive health services.
7. The clinical standards/practice guidelines are developed for the full spectrum of populations enrolled in the plan.
8. The QAP shall use these clinical standards/practice guidelines to evaluate the quality of care provided by the plan's providers, whether the providers are organized in groups, as individuals, as IPAs, or in a combination thereof." West Virginia RFA, Appendix E, pages E2-E3.

"Y. QUALITY IMPROVEMENT (QI)...
3. Monitoring and Evaluation
a. The QI program must monitor and evaluate the quality of clinical care and service in institutional settings, non-institutional settings, and specialty areas (e.g., mental health and substance abuse) on an ongoing basis. Important aspects of care (i.e., high volume, high risk, problematic, high cost, high profile care and services) are identified and prioritized for the development of practice guidelines...

b. Provider performance must be measured against practice guidelines and standards adopted by the QI Committee. Areas identified for improvement must be tracked and corrective actions taken when warranted. The effectiveness of corrective actions must be monitored until problem resolution occurs." Wisconsin Contract, pages 21, 23-24.