Quality Improvement Strategy

Quality Improvement Activities

• Improvement of the health status of the health plan membership through:
• Implementation of programs to address the priority needs associated with the major high-risk, acute and chronic illnesses faced by plan members. These programs will include preventive health, health education, disease management (health management), and care guidelines.
• Monitoring the outcomes of care against national and available regional practice standards.
• Utilization of multi-disciplinary and multi-dimensional teams to address process improvements that can enhance care and service, including primary, specialty and behavioral health practitioners.
• Oversight of delegated processes to ensure delegated organizations MHM standard.
• Identification of appropriate safety and error avoidance initiatives for MHM members in collaboration with the primary care provider through:
• Evaluation of pharmacy data for provider alerts about drug interactions, recall, and pharmacy over and under-utilization.
• Education of members regarding their role in receiving safe, error free health care services through the member newsletter and the Molina web site.
• Education of providers regarding improved safety processes in their practice through the provider newsletter, member profiles and the Molina web site.
• Dissemination of information regarding important safety activities and Health Delivery Organization (HDO) audit findings for safety concerns to members and providers.
• Evaluation for safe clinic environments during office site reviews.
• Education to members regarding safe practices at home through health education and incentive programs.
• Intervention for identified safety issues as identified through case management, care management and the grievance and clinical case review process.
• Collection of data regarding hospital activities relating to member safety.
• Dissemination of information to providers and members regarding activities in the network related to safety and quality improvement.
• Evaluation of the continuity and coordination of care through annual analysis of data to include:
• Transition of Care processes and the effectiveness of inter-provider communications and documentation.
• Medical record audits.
• Tracking quality of care issues, including adverse events.
• Focused health management programs.
• Member and practitioner satisfaction surveys and complaint and appeal review.
• Identification of chronically ill or complex new patients through assessment processes.
• Oversight of delegated activities.
• Monitoring over-utilization and under-utilization through:
• Tracking quality of care issues, including adverse outcomes and sentinel events.
• Review of clinical performance measures including HEDIS to indentify actions for improvement oversite of member satisfaction.
• Review all sources of member satisfaction including but not limted to CAHPS Survey disenrollment information, complaints and appeals to identify opportunities for improvement.
• Member complaint and appeal review.
• Utilization review and case management reports.
• Practitioner medical, pharmacy and utilization profiles.
• Performance measures relative to implementation of preventive and clinical practice guidelines
• Oversight of delegated group member satisfaction and utilization.
• Evaluation of access and availability of care and service through:
• Measurement and evaluation of geographic access to primary care physicians, key specialists, hospitals and other health care services.
• Evaluation of appointment access and availability of after-hours care and after hour information offered by practices.
• Evaluation of MHM Member Services telephone access.
• Evaluation of all satisfaction measures for availability and access to care.
• Oversight of delegated activities.
• Management of Molina Healthcare's interface with practitioners, providers, members and state agencies to implement programs, including:
• Inclusion of contracted practitioners and providers in the planning and implementation of clinical programs.
• Review, approval, and dissemination of preventive health and clinical practice guidelines and measurement of adherence with current recommendations.
• Review of clinical performance measures including HEDIS results to identify actions for improvement.
• Identification of legislative and benefit changes that enhance health promotion.
• Annual review of practitioner surveys and proposed activities for improvement.
• Management of health care practitioner and provider credentialing/recredentialing to include:
• Review of credentialing/recredentialing policies and procedures.
• Peer review of credentialing/recredentialing decisions.
• Peer review of investigated quality of care issues and proposed corrective action plans.
• Oversight of delegated credentialing activities.
• Ensure that medical records comply with standards of structural integrity and contain evidence of appropriate medical practices for quality care by:
• Review of medical record audit results and corrective actions.
• Practitioner education and corrective action where indicated.
• Oversight of member satisfaction measurement and improvement activities:
• Review of all sources of member satisfaction information including, but not limited to, CAHPS Surveys, disenrollment information, complaints and appeals and identify opportunities for improvement.
• Design and evaluate initiatives to improve satisfaction.
• Evaluation of the effectiveness of QI activities in producing measurable improvements in the care and service provided to members through:
• Organization of multi-disciplinary teams, including clinical experts, to analyze service and process improvement opportunities, determine actions for improvement, and evaluate results.
• Track the progress of quality activities through appropriate quality committee minutes and review/update the QI work plan quarterly.
• Revise interventions as required based on analysis.

Quality Improvement Methodology

• Establish standards and benchmarks
• Collect data
• Analyze data and determine performance levels
• Identify opportunities for improvement
• Prioritize opportunities
• Establish clear improvement objectives
• Design and implement interventions
• Measure effectiveness

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