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EXTERNAL PROVIDERS

 

Quality Management

 

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:
 

 
  • A focus on patient centered care and patient-provider relationships
  • An emphasis on continuously improving performance in all areas
  • An emphasis on efficient operational and care systems and patient safety
  • The active involvement of leaders and empowerment of employees
  • The use of data-driven decision making across the organization
 

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.
 

Anti-discrimination/Cultural Competency:
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.
 

Appointment/Access Standards
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.
 

Patient Complaint/Appeal Process:
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:

            a. Physical accessibility
            b. Physical appearance
            c. Adequacy of waiting and exam room space
            d. Availability of appointments
            e. Adequacy of medical record keeping
            f. Equipment
 

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.
 

Member Behavioral Warning / Dismissal Process:
 

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.
 

Patient Bill of Rights:
 

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:
 

 

  1. You have the right to receive appropriate access to treatment.
  2. You have the right to know the names and responsibilities of all health care professionals who are caring for you.
  3. You have the right to be treated with respect, recognition of your dignity and right to privacy.
  4. You have the right to receive treatment that is appropriate and consistent with your medical needs.
  5. You have the right to receive information about Facey Medical Group, its services, practitioners and providers, and members’ rights and responsibilities.
  6. You have the right to participate with practitioners in decision-making regarding your health care.
  7. You have the right to candid discussion of appropriate or medically necessary treatment options for your condition regardless of cost or benefit coverage.
  8. You have the right to voice complaints or appeals about Facey Medical Group or the care provided.
  9. You have the right to receive clear and complete information about your condition and care, including explanations of procedures, tests, treatments and alternatives (including risks and benefits), in order to give informed consent or refuse treatment.
  10. You have the right to receive a timely response to any reasonable service request.
  11. You have the right to confidential handling of all communications and medical information maintained at Facey, as provided by law and professional medical ethics.
  12. You have the right to be represented by parents, guardians, family members or other conservators if you are unable to fully participate in your treatment decisions. These rights will apply to them as well.
  13. You have the right to make recommendations regarding Facey’s member rights and responsibilities policy.
  14. You have the right to access services & information in an alternative format and in any language that is prevalent among Facey patients.
  15. You have the right to be free from all forms of abuse or harassment.
  16. You have the right to exercise your rights without being subjected to discrimination or reprisal.


We also believe that you, as our patient, have certain responsibilities when receiving care from Facey Medical Group.
 

 
  1. You have the responsibility to provide complete and accurate information to the best of your ability about your health, any medications (including over-the-counter products and dietary supplements), and any allergies or sensitivities which Facey and its practitioners need to know in order to care for you.
  2. You have the responsibility to ask for clarification about any aspect of your care which you do not fully understand and to participate in developing mutually agreed upon treatment goals.
  3. You have the responsibility to follow the agreed upon plans and instructions for your care.
  4. You have the responsibility to notify your health care provider if you notice any change in your health.
  5. You have the responsibility to extend reasonable courtesy toward all health care providers during the treatment process.
  6. You have the responsibility to provide a responsible adult to transport you home from the facility and remain with you for 24 hours if required by your provider.
  7. You have the responsibility to inform your provider about any living will, medical power of attorney or other directive that could affect your care.
  8. You must accept personal financial responsibility for any charges not covered by your insurance.