QUALITY IMPROVEMENT PROGRAM OVERVIEW
We’re always seeking ways to improve care and services for our members. That's why we have a Quality Improvement Program (QIP) plan each year. The QIP is a written description of the medical and service improvements we’ll be focusing on during the year. It details the activities and goals and identifies the staff in charge of making sure that we continue to assess and improve the care and services our members receive.
The program’s goal is to set up a framework and processes that help us to continually improve our medical and behavioral health care and services. We accomplish this by reviewing information such as claims data, member complaints and appeals, patient safety information, member and physician satisfaction, patient medical records, and information we receive from pharmacies and laboratories.
2009 QUALITY IMPROVEMENT PROGRAM
The Plan’s corporate mission is to provide access to affordable, quality health coverage in ways that respect and respond to members’ fundamental needs.
In line with this mission, the QIP establishes a framework and processes that facilitate continuous improvement in service and medical and behavioral health care for members. The result is a plan that better serves the needs of members, employers, employees, participating practitioners, providers, accounts, service partners, brokers, consultants and regulatory and accreditation bodies.
The scope of activities within the QIP provides a framework to monitor and evaluate significant aspects of care and service provided to members and their service delivery systems. Measures for monitoring important aspects of medical care, behavioral health care and quality of service, including patient safety, have been developed and implemented. These activities include:
- Quality of Care
- Quality of Service
- Patient Safety
- Care Management
- Member and Physician Satisfaction
- Accessibility
- Availability
- Business Transformation / Lean Six Sigma
- Delegation
- Member Complaints and Appeals
- Member Decision Support Tools
- Cultural Diversity
- Human Resources
- Integrative Wellness
The HIP NY Board of Directors, the GHI HMO Board of Directors and the GHI Board of Directors have delegated the authority for the QIP, Work Plan and Evaluation to their respective Quality Committees of the Board. The overall responsibility for the QIP resides with our executive vice president and chief medical officer and/or the designees. Operational accountability has been delegated to the appropriate department heads.
The Quality Improvement Committee (QIC) is responsible for policy decisions, planning, designing, implementing, coordinating, analyzing, evaluating Quality Improvement (QI) activities, instituting needed actions and ensuring follow up as needed and appropriate. The QIC also ensures practitioner participation in the QIP through planning, design, implementation, committee participation and/or review.
There are various committees and subcommittees that support the functions of the QIP and report their activities to the QIC at least bi-monthly. A broad spectrum of practitioner involvement, including designated physicians and behavioral health practitioners, occurs through the Quality Improvement Committee Structure. Behavioral health care practitioners participate in the Mental Health & Substance Abuse Subcommittee that reports to the Clinical Quality Improvement Committee (CQIC), which advises the QIC. Network physicians participate in the CQIC, the Credentialing/Recredentialing Subcommittee, Peer Review Subcommittee, Health Status Improvement Subcommittee, and the Pharmacy and Therapeutics Subcommittee, which advise the QIC.
The data sources used for QI measurement, analysis of barriers and determination of appropriate interventions include, but are not limited to, encounter data, claims data, utilization review data, pharmacy and laboratory data, enrollment data, medical records, appeals data, practitioner and provider complaints, member complaints, applicable case management databases and Heath Outcomes Survey data.
Additional data sources include HEDIS®1 (Healthcare Effectiveness Data & Information Set); CAHPS®2 (Consumer Assessment of Healthcare Providers & Systems); practitioner, provider and member surveys; Quality Compass; and national and regional epidemiological and demographic data about the New York population. Integrated data collection systems collect member and provider information, utilization, projects, population-based and/or specific member information, and provider specific information.
Software includes, but is not limited to, claims systems, National Committee for Quality Assurance approved HEDIS software, credentialing and recredentialing software, Microsoft products and other systems to support the clinical and service interventions.
The QIP is reviewed annually and amended as necessary. The specific initiatives and activities outlined in the program are expanded and tracked in the work plans. These work plans are updated quarterly, monitored and approved by the QIC. There is also an annual evaluation of the program to summarize and analyze the year’s work and help determine next year’s initiatives.
Information about our progress in meeting our goals for many of the 2009 QI initiatives is shared throughout the year in provider and member newsletters.
1HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA)
2CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)
If you cannot print this information and would like a paper copy, please send your request, along with your name and address, to mkielbasa@emblemhealth.com.
