PHILOSOPHY

The Plan believes that the only way to achieve continuous quality improvement is to have its entire organization embrace a well defined Quality Improvement Program and Annual Work Plan in their day to day activities.

GOALS AND OBJECTIVES
• Assure high quality of care to all Plan members.

• Continuously monitor and improve the quality and safety of patient care and health delivery services by all practitioners with delineated clinical privileges.

• Continuously monitor and improve behavioral health care through education and collaboration with behavioral health practitioners.  This will be accomplished through reporting and analyzing behavioral health related HEDIS measures, the involvement of a behavioral health practitioner on the Physician Quality Committee to assist in decisions regarding behavioral health related utilization management (UM) issues and quality improvement activities, and the collaboration with area behavioral health practitioners to improve the continuity and coordination of the behavioral health care that our members receive.

• Oversee and assess medical care systems, processes and outcomes.

• Oversee and assess components of health service delivery.

• Oversee the credentialing and recredentialing of all health care practitioners and providers.

• Implement standards of care and practice guidelines as recognized by national specialty academics, nationally recognized authorities, and standards developed by the Quality Improvement Committee. Communicate standards and guidelines to practitioners and providers, when appropriate.

• Review and/or update criteria, guidelines and standards of care and services at least annually based upon UM and QI activities and results.

• Monitor compliance with standards of care and services.

• Monitor compliance with Medical Record standards.

• Implement improvement interventions as necessary.

• Monitor member and practitioner/provider complaints and grievances/appeals, the reasons for the complaint and grievance/appeal, and the Plan’s resolution turnaround time.

• Develop and maintain a monitoring system to detect trends.

• Assess effectiveness of improvement interventions.

• Establish and maintain a preventive process that identifies potential risk management issues.

• Conduct special reviews as specified by major employer groups and insured clients.

• Identify and report Public Health issues as it pertains to maintaining/improving the health status of the population.

• Recognize and evaluate new health care services, technologies, procedures, and pharmacological treatments, as well as their application for the population served.

• Demonstrate a commitment to improving safe clinical practice by fostering a supportive environment to help practitioners and providers improve the safety of their practices.  This may be accomplished through the distribution of information to practitioners to assist in facilitating a safer clinical environment.

• Distribute information to members to improve their knowledge about prevention of illness and clinical safety as it relates to their own healthcare.  Also to distribute information regarding clinical safety to facilitate informed decision making.

• Address patient safety issues in existing quality improvement activities and disease management programs through prevention and educational activities.

Scope
• QI encompasses the entire delivery system, including, but not limited to, hospital care, ambulatory care, ancillary services, emergency services, behavioral health services, preventive services, vision services, pharmacy, dental services, home health care, hospice care and extended care facilities.

• QI addresses both the quality and safety of clinical care and the quality of non-clinical aspects of service, including availability, accessibility, coordination and continuity of care, including referrals, case management, discharge planning, prior authorizations, practitioner and provider reimbursements, and complaints.

• The medical delivery system is monitored for both quality and utilization activities.  Both over-utilization and under-utilization are addressed.

• Departments that support and may be included in the QI process are Utilization Management, Worksite Wellness, Information Technology, Provider & Payor Relations, Client Services/Marketing and Member Services.

• The Plan provides for ongoing Internal Peer Review activities to ensure continuous quality improvement and will solicit the assistance of External Peer Review Organizations every two years to collect benchmark data to evaluate the Plan’s overall performance.

• Satisfaction Surveys are also conducted to obtain information pertaining to member and practitioner/provider perceptions of Plan policy and procedure.

• The Plan will achieve any performance levels as established by CMS, State, or NCQA with respect to standard measures. Performance measures may be contained in standardized national data collection and reporting instruments such as HEDIS® and CAHPS® and/or be State or CMS specific.