Quality Improvement Program
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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