Quality Improvement Strategy


Quality Improvement Activities

To meet the purpose, goals and scope of this program, QI activities as reflected in the QI Work Plan will be focused in the following 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.
  • 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

A cyclic, continuous, systematic process is used to improve performance and communicate clinical and service quality issues. This process is used throughout the organization to help individuals improve procedures, systems, quality, cost, and outcomes related to their areas of responsibility. The model includes the following steps:

  • 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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