Quality Management is an all encompassing philosophy that supports our organization’s management infrastructure, policies & procedures and practices. Quality Management is driven by five basic principles:
As defined, Quality Management embraces features of both Quality Assurance and Quality Improvement and goes one step further to embody our management philosophy.
Facey Medical Group and Facey Medical Foundation conduct diligent internal processes and audits that review physician and allied health professional provider credentials, medical records, compliance with privacy laws, administration, quality management programs, continuity of care, diagnostic training, medication management, facility and environmental safety and surgical procedures. We place special emphasis on education, guidance and strategic involvement of practicing physicians.
It is the policy of Facey Medical Group and Facey Medical Foundation to provide health services to all patients in a culturally competent and non-discriminatory manner without regard to race, ethnicity, national origin, religion, sex, age, mental or physical disability or medical condition, sexual orientation, claims experience, medical history, evidence of insurability (including conditions arising out of acts of domestic violence), genetic information, or source of payment or ability to pay.
Further, services will be provided in a non-discriminatory manner to all members, including those with limited English proficiency or reading skills, the sensory impaired, and those with diverse cultural or ethnic backgrounds. Please refer to Language Assistance (LAP) Section under Providers for a LAP Overview and LAP Training. This includes a grid of Health Plan Language Interpreter Services phone numbers to assist with verbal translation and ADA Sign Language translators for patients.
It is the policy of Facey Medical Group and Facey Medical Foundation to adhere to the access standards established by the Industry Collaboration Effort (ICE), the Health Plans and the Department of Managed Health Care (DMHC) Time-elapsed Access Regulations. These regulations establish the minimum compliance standards for enrollee accessibility to primary, specialist, behavioral health, and ancillary care providers. This applies to all DMHC licensed health care service plan contracted practitioners (e.g. HMO, POS, PPO, Medi-Cal, Healthy Families, Healthy Kids and Access for Infants and Mothers). Please refer to the Access Standards Section under Providers for DMHC appointment timeframes and the entire ICE approved policy for your reference.
It is the policy of Facey Medical Group and Facey Medical Foundation to address and resolve all patient concerns in a timely and efficient manner through the involvement of appropriate physicians and management staff. Closure of all complaints/appeals must be reached within the timeframe specified by the health plan. All grievances and appeals will be forwarded to Blue Cross or the appropriate health plan (HMO), but an internal investigation will be initiated upon receipt.
Appeals will be reviewed by the Medical Director of Quality Management and a response to the health plan will be formulated based on chart review, health plan benefit interpretation and criteria as well as any additional information from the provider(s) on an as needed basis.
All complaints and appeals received from the HMO’s will require a formal written response and medical record request within the time period specified by the HMO, depending on the urgency. All medical records requested by the HMO will be sent out according to the health plan’s specified timeframes for Routine, Urgent and Expedited.
DEFINITION: A patient complaint is defined as any concern voiced by a patient that cannot be resolved directly by the physician or staff interacting with the patient. The concern may reach the Medical Group directly from the patient or via the health plan.
An appeal is defined as a request by the patient or provider to reconsider a service request decision.
Patient complaints at Primary Care, OB/GYN, inpatient, residential, ambulatory facilities providing mental health/substance abuse services and new facilities or locations will be monitored continually, investigated and/or referred to the appropriate individual(s) responsible for resolving the issue at all practice sites. These types of complaints will be forwarded as appropriate to the designated health plans as indicated by ICE guidelines.
A Site Visit will be conducted for all new practice and as appropriate to investigate patient complaints. The structured site review evaluates the following:
Physician quality of care issues will be forwarded to Quality Management for investigation by the Medical Director of Quality Management or his designee. Such complaints regarding the clinical care of patients by physicians will be shared in a confidential manner with the individual physician involved and the respective Department Chair. The Medical Director of Quality Management, as appropriate, will forward the complaint and the physician response to the Peer Review Committee.
It is the policy of Facey Medical Group that based on HMO contractual language a contracted physician may request that an HMO/PPO patient be removed from his or her care subject to the nature and severity of the event(s). The physician should document that he or she has warned the patient of the consequences of failure to follow medical advice or adhere to recommended treatment plans, including failure to keep appointments. The patient will be verbally counseled by the provider when he/she does not follow medical advice or treatment plans. This discussion should also be documented in the medical record. At the discretion of the provider a letter may be sent to the patient outlining the expected behaviors and the timeframe to exhibit requested changes in behavior. The Quality Management Department can assist you during this process.
Important Note: Prior to dismissing the patient from your practice please contact the Facey Medical Foundation Quality Management Department for assistance with transferring the member to another Specialist if continued care is required.
Facey Medical Group is a caring and innovative team dedicated to enthusiastically improving the quality of life and health of the people we serve.
We believe that you, as our patient, have certain rights:
We also believe that you, as our patient, have certain responsibilities when receiving care from Facey Medical Group: