QUEST Integration - Quality Improvement Program

Original Effective Date:

08/01/1994

Current Effective Date:

01/01/2015

The Quality Improvement (QI) program reflects HMSA's commitment to facilitate ongoing improvement in the delivery of high quality healthcare. The Quality Oversight Committee (QOC), which is a subcommittee of the HMSA Board of Directors, is charged with providing oversight for the QI program.

Highlights of HMSA's QI program are presented in an annual report called Pursuing Quality, which is sent to all participating physicians. Physicians may request a copy of this publication by writing to:

Provider Services
HMSA
P.O. Box 860
Honolulu, HI  96808-0860

Physicians may also obtain Pursuing Quality by visiting our web site at www.hmsa.com or by calling a Provider Teleservice Representative at (808) 948-6330 on Oahu or 1 (800) 790-4672 from the Neighbor Islands.

Purpose

The purpose of the QI program is to increase the quality of care for HMSA members by optimizing the delivery of cost-effective healthcare services. This goal is achieved by monitoring clinical care, clinical service and organizational service.

Quality Improvement (QI) Program Goal and Objectives

The goal of HMSA's QI program is to monitor the clinical care, clinical service and organizational service provided to members while identifying opportunities for prioritizing, improving and implementing quality improvement activities.

Objectives of the QI program are:

• To provide information and resources to members, providers and other stakeholders who can improve the process of care
• To implement population-based health management and pharmaceutical management programs
• To practice the principles of continuous quality improvement
• To reduce variations in care and clinical practice patterns

Quality Improvement (QI) Program Activities

The primary activities of the QI program focus on preventive care and disease management. These activities include:

• Data analysis and reporting, particularly for programs involving asthma care, diabetes treatment and screening programs (mammography, immunizations, etc.)
• Member satisfaction surveys, such as the annual Consumer Assessment of Health Plans Survey (CAHPS®)
• Accessibility standards and timeliness (see Accessibility Standards)
• Practitioner credentialing (see Physician Credentialing)
• Monitoring member complaints
• Utilization monitoring

Quality Improvement Committee (QIC)

The QIC is composed of practicing physicians who work with the QOC to administer the QI program. The QIC monitors the effectiveness of the QI program and receives progress reports regarding the following topics:

• Credentialing of providers
• Member and practitioner satisfaction
• Utilization management
• Complaints and appeals
• Preventive health services
• Results of quality improvement studies

Quality Improvement (QI) Program Subcommittees

Several subcommittees support the objectives of the QI program and provide for a more systematic approach to managing the objectives of the QI work plan. These include the PCMH Medical Director Leadership Collaborative Committee, PCP Round Table Group, Best Quality Team, Utilization Management Committee, Pharmacy and Therapeutics Advisory Committee, Medical Management Operations Group, Benefit Trend Group, Technology Evaluation Committee, and the Office of Medical Directors.

Evaluation of the Quality Improvement (QI) Program

The QI program is evaluated annually to assess the extent to which the scope, methodology, and activities succeed in meeting performance standards as they relate to HMSA's purpose, goals and objectives. Quality improvement activities are reviewed to determine their appropriateness, compliance with clinical standards, and impact on the quality of patient care and service rendered.

Evaluation of the QI program should result in:

• Improved performance in the delivery of healthcare and services where the plan has identified problems and corrective actions have been implemented.
• Identifying the plan's performance in quality improvement as it relates to improved outcomes and patient satisfaction using HEDIS 3.0 measurements and other metrics.
• Ensuring an appropriate level of effectiveness and efficiency in the plan's performance.

Utilization Management

Utilization management ensures quality care is provided without compromising cost effectiveness or appropriateness. The level, type and costs of services are reviewed through focused pre-payment and post-payment reviews of claims and concurrent review of member treatment while the member is confined in a hospital or other inpatient facility.

Responsibilities of Providers

One of the objectives of HMSA’s Quality Improvement Program is to provide information and resources to providers who can improve the process of care. The participation of providers in ongoing HMSA quality improvement activities is necessary to continuously monitor and improve care. Some of these activities may include:

• Medical Care Evaluation Studies
• Clinical Practice Guidelines
• Peer Review
• Practice Pattern Analysis Based on Claims Data
• Audit of Medical Records
• Problem Identification & Resolution
• Priority-Setting

Revision History