The Quality Program (QP) supports our commitment to ongoing quality care for our members. We have developed standards and performance goals and continue to monitor them to identify improvement opportunities.

Participation in the Quality Program

Participation in our QP activities is required in our agreements with physicians, other health care professionals and facilities. Participation may include:

  • Site visits and record review
  • Adherence to clinical standards
  • Credentialing or re-credentialing
  • Quality of care concerns or complaints
  • Providing evidence of preventive health promotion
  • Providing data for various medical records audits such as the annual Healthcare Effectiveness Data and Information Set (HEDIS®) audit

Providers may be asked to review and provide feedback on proposed or ongoing clinical activities and development of clinical practice guidelines at focus groups or Medical Advisory Committees.

Quality Program scope

The scope of the QP includes developing improvement opportunities and activities throughout our Company that directly impact the experience of our members, physicians, other health care professionals or facilities:

  • Develop focused quality improvement activities (QIAs) including:
    • Clinical QIAs
    • Service QIAs
  • Monitor activities throughout our Company to further the "integration of our processes" including:
    • Access
    • Availability
    • Quality surveys
    • Staff qualifications
    • Advance directives
    • Case Management
    • Member satisfaction
    • Provider satisfaction
    • Inter Rater Reliability
    • Medical record keeping
    • Quality of care concerns
    • Community collaboration
    • Under and over utilization
    • Pharmacy education programs
    • Disease management programs
    • Clinician performance monitoring
    • Coaching and wellness programs
    • Utilization Management: Physical and Behavioral Health
  • Monitor patient safety activities to fulfill our commitment to the safe delivery of care to our members.
  • Support contractual and regulatory compliance.
  • Develop and administer the QP to provide an organizational structure, resources and coordination of quality processes within the Company.

Health Strategies Committee of the Board of Directors

Our Board of Directors has participating providers as directors and on the Health Strategies Committee. This committee meets quarterly to discuss issues surrounding the health care delivery system and provider-related quality improvement activities.