Surgical Quality Care Program

About our Program

Pilot Update: Is your clinic participating in L&I’s Orthopedic and Neurological Project (Ortho/Neuro)? If so, you qualify to become an early adopter of the Surgical Quality Care Program. Read on to learn more about this new program.

The Surgical Quality Care Program (SQC Program) is a pay-for-quality initiative. It rewards participating musculoskeletal surgeons for consistently implementing our administrative best practices. These best practices are designed to improve the outcomes of workers injured on the job.

What this means to the patient

Surgeon(s) is engaged in administrative best practices that address:

Utilization of the department’s Medical Treatment Guidelines and Opioid Prescribing Guidelines
A reduction or elimination of the risk of harm to the worker
Avoidance of obstacles that inhibit the workers’ release to work
Utilization of their Surgical Health Services Coordinator (SHSC) as a resource to answer questions and help navigate the workers’ care

What this means to the surgeon and their clinic

The SQC Program offers surgeons and their clinics both financial and non-financial rewards.

Financial rewards

Monetary incentives proportional to best practice adoption (See the Provider Incentives tab to learn more).

Non-financial rewards

Participation in the SQC Program offers tools and resources that are not readily available. These may include:

Performance reports to identify trends
Access to an SHSC
Special designation through L&I’s Find-A-Doctor application.

Best Practices

Benefits tied to the administrative best practices

How the SQC Program’s four administrative best practices (BP) are meaningful to the patient.

Best Practice (BP)	Significance	Expectation	Performance Threshold
BP #1: Complete and submit an Activity Prescription Form (APF) before and after surgery.	Available to many parties tied to the claim. Outlines the treatment plan along with the recovery expectations when there is a change in patient restrictions.	Surgeon meets with the patient in the 90 days prior to non-emergent * surgery and submits an APF Surgeon (or their PA) meets with the patient in the 90 days following surgery and submits an APF.	At least 85% of surgical claims will have both a pre and post surgery APF submitted by the appropriate provider.
BP #2: Perform surgeries within 21 days of authorization.	Taken from a "whole patient" perspective, a timely surgery may help to eliminate some preventable permanent conditions, thus improving recovery.	Schedule authorized surgeries promptly. Procedures preformed outside of the 21 days aren't considered timely for this quality indicator's performance threshold.	At least 80% of the surgeries requiring both utilization review (UR) and claim manager authorization are performed within 21 calendar days of the claim managers' notice of authorization.
BP #3: Before surgery, establish release-to-work plans and goals with the patient.	Sets a return to work expectation with the patient and a goal for them to work towards. Prevents the patient from actualizing a prolonged post-op disability condition. Encourages patient to start a conversation with their employer about opportunities for light duty work or reduced hours.	A successful outcome involves more than pathophysiology. Returning to work is part of achieving maximal physical recovery. Prolonged disability affects a patient's career, their economic well being, and their life.	For at least 85% of non-emergent* surgical claims, the surgeon will have met with the patient and jointly established some release to work plans and goals prior to surgery (not on the day of surgery).
BP #4: Review and integrate communications from ancillary provides into the rehab plan.	L&I has made it easier for surgeons to be informed about the patient's rehabilitative process with the Physical Medicine Progress Report (PMPR). Offers an ability to correct/modify recovery plan without an office visit.	The surgeon (or their PA) should review and sign the PMPR. Return the signed PMPR to the ancillary provider AND to L&I. These PMPRs can be a resource in building/maintaining the patient's care plans, filling out more accurate APFs and/or job analyses.	A surgeon or PA will have reviewed and signed off on 90% of the PMPRs they've received within 14 calendar days of the date they were received.
Strategic hint - many accomplishments in a single visit A surgical authorization is more probable if the surgeon sees the patient to determine/verify need for surgery. In that pre-surgical appointment, discuss some post-operative release to work plans and goals with the patient (BP #3). Submit an APF showing the surgical plan along with the release to work plans and goals (BP #1).

^{* Emergent surgery is defined as injury date followed by surgery within 11 calendar days.}

Provider Incentives

Both the dollar amount and payment frequency of the financial incentives tied to the SQC Program will be announced shortly. Until notified otherwise, simply continue to bill L&I for the Ortho/Neuro project incentive (1071M) just as you have over the years.

Adoption levels

An adoption level will be assigned to each SQC Program participant as determined by how thoroughly the surgeon or their clinic has implemented the administrative best practices (BP).

Low Adopter
- Assigned at the clinic level only.
- Reserved for clinics that fail to reach BP # 1 and BP # 2 performance thresholds.
Medium Adopter
- Assigned at the clinic level only.
- Awarded to clinics that reach BP # 1 and BP # 2 performance thresholds.
- This is the highest level a clinic may reach.
High Adopter
- Assigned at the surgeon level only.
- Awarded exclusively to those surgeons that reach all four BP performance thresholds.
- Cannot be achieved without the services of a Surgical Health Services Coordinator.
High Adopter - Sustained
- Assigned at the surgeon level only.
- Other criteria under consideration.

Chart outlining the best practice tiers for surgical care.

Requirements and Eligibility

The SQC Program is restricted to musculoskeletal surgeons that:

Are participants in L&I’s Orthopedic and Neurological Surgeon Quality Project (Ortho/Neuro)
Are credentialed as an L&I provider, with an active L&I provider ID number
Regularly treat workers injured on the job, be it State Fund or Self-Insured
Have completed the Surgical Quality Care Program's orientation
Meet the program’s clinical entrance criteria for Medical Treatment Guidelines, Opioid Prescribing Guidelines utilization review, and reoperation rate criteria. (This program holds the surgeon accountable for their physician assistants’ (PA’s) prescribing practices.)

SHSC Coordination

The Surgical Health Services Coordinators (SHSCs) help providers, workers, and employers in many ways.

Learn more about Health Services Coordination, qualifications, and standard work that is performed.

Benefits of having an SHSC

Reduce transition times to and from surgical care.
Assist workers, employers and health care providers navigate L&I processes.
Identify and mitigate barriers to treatment, recovery and return to work.
Improve release/return-to-work planning.
Removes some of your administrative burden by responding to requests from claim managers, vocational counselors and employers.

SHSC options

A clinic’s relation to an SHSC may come as:

The SHSC’s employer
The SHSC’s client through a contract agreement

While SHSCs are not L&I employees, some community health care partners offer SHSCs. Reach out to us for more information.

SHSC billable services

SHSCs must first get an L&I Provider ID in order to bill services to state-fund claims.

Service Description	Code	Details	Rate
Surgical Coordination Intake (SCI)	1083M	Payable once in the life of the claim	$152.70
Surgical Health Services Coordinators’ Standard Services	1088M	Billable in six-minute increments for activities that remove claim/treatment barriers or positively influence the recovery and/or release to work.	$9.40

Frequently Asked Questions

What adoption level will I start out at?

You will come in at the clinic level if it is currently participating in the program. If not affiliated to a currently enrolled clinic, you will be offered a one-year onboarding process to gain familiarity to the new best practices and working with an SHSC.