1. (a) A basic or limited services HMO shall develop and maintain an ongoing quality improvement (QI) program designed to objectively and systematically monitor and evaluate the quality and appropriateness of care and services and to pursue opportunities for improvement. Unless the HMO has no enrollees, the QI program shall include the active involvement of one or more enrollee(s) who are not employees of the HMO.

2. (b) The governing body is ultimately responsible for the QI program. The governing body shall:

   1. (1) appoint a quality improvement committee (QIC) that shall include practicing physicians and individual providers; and may include one or more enrollee(s) from throughout the HMO's service area. For purposes of this section, if an enrollee(s) is appointed to the committee, the enrollee(s) may not be an employee of the HMO;
   2. (2) approve the QI program;
   3. (3) approve an annual QI plan;
   4. (4) meet no less than annually to receive and review reports of the QIC or group of committees and take action when appropriate; and
   5. (5) review the annual written report on the QI program.

3. (c) The QIC shall evaluate the overall effectiveness of the QI program.

   1. (1) The QIC may delegate QI activities to other committees that may, if applicable, include practicing physicians and individual providers, and enrollees from the service area.

      1. (A) All committees shall collaborate and coordinate efforts to improve the quality, availability, and accessibility of health care services.
      2. (B) All committees shall meet regularly and report the findings of each meeting, including any recommendations, in writing to the QIC.
      3. (C) If the QIC delegates any QI activity to any subcommittee, then the QIC must establish a method to oversee each subcommittee.
   2. (2) The QIC shall use multidisciplinary teams, when indicated, to accomplish QI program goals.

Source Note:The provisions of this §11.1901 adopted to be effective December 8, 1997, 22 TexReg 11684; amended to be effective July 31, 2002, 27 TexReg 6701; amended to be effective February 24, 2005, 30 TexReg 854; amended to be effective November 15, 2006, 31 TexReg 9298.