QUALITY IMPROVEMENT PROGRAM OVERVIEW
We are always seeking ways to improve the care and services that HIP members receive. That's why we develop a Quality Improvement Program (QIP) plan each year. This plan is a written description of all of the medical and service improvement activities that we will focus on during the year. It details all of the activities and goals and identifies the staff in charge of making sure we continue to assess and improve the care and services our members receive.
The goal of the Quality Improvement Program (QIP) is to set up a framework and processes that will help make sure we continually improve the medical and behavioral health care and service received by our plan members. We monitor and evaluate that care and service 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.
2008 QUALITY IMPROVEMENT PROGRAM
The Plan 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 goal of the Quality Improvement Program (QIP) is to establish a framework and processes that will facilitate continuous improvement in medical and behavioral health care, and service received by Plan members. As a result of this ongoing improvement and monitoring process, the Plan will better serve 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
- Business Transformation / Lean Six Sigma
- Delegation
- Member Complaints and Appeals
- Member Decision Support Tools
- Cultural Activities
The HIP NY Board of Directors, the GHI HMO Board of Directors and the GHI PPO Board of Directors have delegated the authority for the QIP, Work Plan and Evaluation to their respective Quality Committee of the Board. The overall responsibility for the QIP resides with the Plans' Executive Vice President and Chief Medical Officer and/or designee. 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 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 which support the functions of the QI program and report their activities to the QIC at least bi-monthly. A broad spectrum of practitioner involvement including designated physicians and behavioral health practitioners occur through the Quality Improvement Committee Structure. Behavioral health care practitioners participate on the Mental Health & Substance Abuse Subcommittee that reports to the Clinical Quality Improvement Committee which advises the QIC. Network Physicians participate on the Clinical Quality Improvement Committee, Credentialing/Recredentialing Subcommittee, Peer Review Subcommittee, Health Status Improvement Subcommittee and Pharmacy and Therapeutics which advise the QIC.
The data sources used for quality improvement measurement, analysis of barriers and determining appropriate interventions includes but is not limited to, encounter data, claims data, utilization review data, pharmacy, laboratory, 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) data, CAHPS®2 (Consumer Assessment of Healthcare Providers & Systems) data, 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, NCQA 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 upon and tracked in the work plans. These work plans are updated quarterly, monitored and approved by the Quality Improvement Committees. There is also an annual evaluation of the program conducted to both summarize and analyze the years work and help determine the initiatives for the next year.
Information and our progress in meeting our goals for many of the 2008 QI Initiatives is shared throughout the year in the 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.
