CHAPTER 6. QUALITY MANAGEMENT PROGRAMS

IC 27-13-6
    Chapter 6. Quality Management Programs

IC 27-13-6-1
Procedures; establishment
    Sec. 1. (a) A health maintenance organization shall establishprocedures based on professionally recognized standards to assessand monitor the health care services provided to enrollees of theorganization.
    (b) The procedures established under this section must includemechanisms to implement corrective action when necessary and toassess the availability, accessibility, and continuity of care.
As added by P.L.26-1994, SEC.25.

IC 27-13-6-2
Internal quality management program required
    Sec. 2. A health maintenance organization shall have an ongoinginternal quality management program to monitor and evaluate thehealth care services it provides, including:
        (1) primary and specialist physician services; and
        (2) ancillary and preventive health care services;
across all institutional and noninstitutional settings.
As added by P.L.26-1994, SEC.25.

IC 27-13-6-3
Quality management program requirements
    Sec. 3. The quality management program required by section 2 ofthis chapter must include at least the following:
        (1) A written statement of the scope and purpose of the healthmaintenance organization's quality management program,including a written statement of goals and objectives thatemphasizes improved health status in evaluating the quality ofcare rendered to enrollees.
        (2) The organizational structure responsible for qualitymanagement activities.
        (3) Any contractual arrangements, when appropriate, fordelegation of quality management activities.
        (4) Confidentiality of policies and procedures.
        (5) A system of ongoing evaluation activities.
        (6) A system of focused evaluation activities.
        (7) A system for credentialing providers and performing peerreview activities.
        (8) Duties and responsibilities of the designated physicianresponsible for the quality management activities.
As added by P.L.26-1994, SEC.25.

IC 27-13-6-4
Written statement of quality management activities
    Sec. 4. The quality management program required by section 2 ofthis chapter must contain a written statement describing the system

of ongoing quality management activities, including the following:
        (1) Problem assessment, identification, selection, and study.
        (2) Corrective action, monitoring, evaluation, and reassessment.
        (3) Interpretation and analysis of patterns of care rendered toindividual patients by individual providers.
        (4) Comparison between patterns of care, including outcomes,rendered to patients by providers and the cost to the healthmaintenance organization of that care.
        (5) A written statement describing the system of focused qualityassurance activities based on representative samples of theenrolled population that identifies method of topic selection,study, data collection, analysis, interpretation, and reportformat.
As added by P.L.26-1994, SEC.25.

IC 27-13-6-5
Written plans for correcting insufficient service
    Sec. 5. The quality management program required by section 2 ofthis chapter must contain written plans for taking appropriatecorrective action whenever the quality management programdetermines that:
        (1) inappropriate or substandard services have been provided;or
        (2) services that should have been provided were not provided.
As added by P.L.26-1994, SEC.25.

IC 27-13-6-6
Patient record system
    Sec. 6. A health maintenance organization shall ensure the use andmaintenance of an adequate patient record system that will facilitate:
        (1) documentation and retrieval of clinical information toenable the health maintenance organization to evaluatecontinuity and coordination of patient care; and
        (2) the assessment of the quality of health and medical careprovided to enrollees.
As added by P.L.26-1994, SEC.25.

IC 27-13-6-7
Reporting quality management program activities
    Sec. 7. A health maintenance organization shall establish amechanism for periodic reporting of quality management programactivities to the governing body, providers, and appropriate staff ofthe organization.
As added by P.L.26-1994, SEC.25.

IC 27-13-6-8
Records of proceedings; confidentiality
    Sec. 8. A health maintenance organization shall:
        (1) record the proceedings of formal quality managementprogram activities; and        (2) maintain its documentation of the quality managementprogram in a confidential manner.
As added by P.L.26-1994, SEC.25.

IC 27-13-6-9
Inspection of records by commissioner
    Sec. 9. The commissioner may inspect the records of a healthmaintenance organization's quality management program. The healthmaintenance organization shall cooperate with the inspections bymaking available to the commissioner the records requested by thecommissioner, while protecting the confidentiality of enrolleemedical records.
As added by P.L.26-1994, SEC.25.

IC 27-13-6-10
Hospital accreditation
    Sec. 10. (a) A health maintenance organization may not refuse toenter into an agreement with a hospital solely because the hospitalhas not obtained accreditation from an accreditation organizationthat:
        (1) establishes standards for the organization and operation ofhospitals;
        (2) requires the hospital to undergo a survey process for a feepaid by the hospital; and
        (3) was organized and formed in 1951.
    (b) This section does not prohibit a health maintenanceorganization from using performance indicators or quality standardsthat:
        (1) are developed by private organizations; and
        (2) do not rely upon a survey process for a fee charged to thehospital to evaluate performance.
As added by P.L.259-1995, SEC.3.