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Quality Improvement

The Molina Healthcare of Washington, Inc. Quality Improvement Program (QIP) is established to provide the structure and key processes that enable the health plan to carry out its commitment to ongoing improvement of care and service, and improvement of the health of its members. The QIP assists the organization to achieve these goals. It is an evolving program that is responsive to the changing needs of the health plan's customers and the standards established by the medical community, regulatory and accrediting bodies.

To meet the purpose, goals and scope of the Quality Improvement Program, QI activities as reflected in the 2008 QI Work Plan will be focused in the following areas. Through the 2007 Program Evaluation, ongoing measurement and analysis, Molina Healthcare has identified the following priority areas.

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. See Health Management Programs
  • Monitoring the outcomes of care against national 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 as appropriate.
  • Oversight of delegated processes to ensure delegated organizations meet Molina Healthcare standards.

Identification of appropriate safety and error avoidance initiatives for Molina Healthcare 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 practices in their practice through the provider newsletter, member profiles and the Molina web site.
  • Dissemination of information regarding important safety activities and 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.
  • 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.

  • 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.
  • Evaluation of Molina Healthcare 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. See Clinical Practice Guidelines
  • Review of clinical performance measures including HEDIS to identify actions for improvement.
  • Identification of legislative and benefit changes that enhance health promotion.
  • Annual review of practitioner satisfaction surveys and proposed activities for improvement.

 

Management of health care practitioner and provider credentialing/
g 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. See Medical Record Keeping Review Policy

Oversight of member satisfaction measurement and improvement activities:
  • Review of all sources of member satisfaction 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.

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