Quality Improvement Program Form

Overview of Quality Improvement (QI) Program Scope and Purpose The scope of quality improvement activities includes quality improvement-related regulatory compliance and performance on measures of member wellbeing, care quality, and member experience. Monitoring measures and activities allows identification of areas of risk and opportunities for improvement so that corrective action and performance improvement can be initiated in a timely manner. Areas within the program scope include:  Network Adequacy  Coordination with Behavioral Healthcare  Clinical Practice Guidelines  Complaints and Appeals  Delegation Oversight  Credentialing  Pharmacy Services  Performance Improvement Projects (PIPs), Chronic Care Improvement Program (CCIP)  CAHPS and QHP Enrollee Satisfaction Survey Data Collection and Reporting  Potential Quality of Care Concerns/Issues  Availability and Accessibility of Care  Claims Payment Processes  Care Management and Disease Management  Customer Service  HEDIS® Data Collection and Reporting  Provider Satisfaction Survey Reporting  Provider and Member Involvement and Education

QI PROGRAM GOALS AND OBJECTIVES

1. Establish QI as an entity-wide function by enlisting participation, input, and investment by providers, members, and stakeholders throughout the entity to accomplish QI initiatives.
2. Promote patient safety through identifying and responding to high-risk patient safety areas such as potential quality of care issues, sentinel events, potentially preventable admissions and readmissions, and adverse pharmaceutical utilization patterns.
3. Promote member wellness preventive care, and population health.
4. Promote high quality, effective, and comprehensive health care of chronic conditions.
5. Align activities to comply with federal and state guidelines as well as NCQA accreditation standards. QUALITY IMPROVEMENT METHODOLOGY The plan follows the Institute for Healthcare Improvement (IHI) Model1 for improvement to systematically conduct performance improvement activities. The IHI Model emphasizes rapid-cycle testing to learn which interventions, in which contexts can predictably produce improvements.

The model has two parts:

1. Three fundamental questions are asked in any order. These can be used as pre- planning activities in preparation for entering the Plan Do Study Act (PDSA) cycle.
2. The PDSA cycle guides the test of a change to determine if the change is an improvement. The plan designs improvement projects to address problems and improve performance based on annual goals and priority topics. Teams may also initiate projects when internal surveillance and monitoring identify high-priority opportunities for improvement. The various areas of surveillance and monitoring are covered under the QI program scope and program activities sections later in this document. The planning step includes the following activities:  Analyze the sources of performance variation and identify root causes of performance.  Prioritize root causes based on potential impact and resources needed to access.  Select interventions to address priority root causes based on evidence, internal data, and subject matter expertise.  Establish goals/objectives and select indicators to monitor performance.  Develop a data collection plan. After planning, the project team implements process changes or other interventions to improve areas of clinical care, service, and operations that demonstrate undesirable performance variation. Teams may choose to test interventions on a small scale initially or proceed with full implementation. The impact of process changes is monitored at regular intervals, depending on the needs of the project. This monitoring typically includes quantitative and qualitative measures of implementation fidelity and other process measures to evaluate the initial impact on performance. Long-term, outcome measures are used to understand the impact of the changes on health, safety, experience or other goals. Measurement is used to understand whether changes are occurring as planned and whether those changes are leading to the desired improvements. These measures allow adjustments to process changes or interventions as needed to attain progress toward goals. PATIENT SAFETY The plan incorporates mechanisms into the QI Program to monitor and address patient safety for members. These mechanisms include:  Teams monitor patient access to emergent and urgent care on an annual basis to evaluate whether members can receive time-sensitive care and are not placed at risk when care is needed. When access deficiencies are identified, the plan notifies providers of noncompliance and conducts a follow-up survey to monitor resolution.  The plan uses utilization review (UR) processes to assess medical necessity of admissions and see that patients are cared for in the most appropriate setting for the period required. These processes include UR nurses applying non-physician review criteria and communicating with the attending physician and regional medical director when questions about admission arise. Teams assess the use of utilization review criteria through inter-rater reliability audits to validate that it is applied consistently and not misused by UR staff. When deficiencies are identified, feedback is provided to UR staff.

 The plan uses provider credentialing to certify that providers are qualified to safely care for patients and have no adverse determinations on record that would render them unsuitable to provide care. The credentialing process includes data collection and analysis in multiple areas to identify any existing problems and confirm requirements are met.  The plan uses clinical practice guidelines to encourage providers to follow evidence- based recommendations for care. Teams update existing guidelines and adds new guidelines at least every two years; more often as appropriate. The plan monitors provider adherence to clinical practice guidelines annually and initiates communication, feedback, and monitoring for resolution when non-adherence is identified.  The plan uses the Potential Quality Indicator (PQI) process to identify, investigate, and act on quality-of-care issues. These may be important single events, sentinel events, or a pattern of undesirable events. Events may involve plan staff or providers, or external staff, providers, or facilities. The plan initiates corrective action to address root causes and monitors to ratify the problem is resolved.  The plan uses disease management and case management processes to support continuity and coordination of care. This includes activities to encourage optimal member health and proper management of health conditions to prevent further decline. The plan measures the effectiveness of these activities with multiple indicators.  The plan monitors and conducts ongoing activities to certify the safety of pharmaceutical ordering and administration. This includes: o Retroactive Drug Utilization Review program to educate providers about medication ordering patterns that can impact safety, such as drug-to-drug interactions, high risk medications in the elderly, duplicate therapy, etc. o Monitoring of drug overutilization to prevent adverse events and stop abusers. o Monitoring the percent of Members receiving high-dose opioid therapy who also have a pharmacy claim for Naloxone.  The plan establishes and implements Performance Improvement Projects (PIP), Chronic Condition Improvement Plans (CCIP) and Qualified Health Plan (QHP) Quality Improvement Strategies to improve areas of patient safety, such as: o Improving member medication adherence for diabetes and hypertension medications o Reduction of potentially preventable admissions, readmissions and emergency room visits  The plan monitors member complaints and appeals to address any problems identified, including issues that could impact patient safety. If quality of care issues is identified, these are also investigated and addressed.  The plan monitors member satisfaction through the CAHPS survey and other surveys. When issues that affect patient safety are identified, these are addressed and monitored to reach resolution.

MEMBERS’ RIGHTS AND RESPONSIBILITIES The plan addresses member rights and responsibilities with the membership using multiple strategies.

ADDRESSING MEMBERSHIP CULTURAL AND LINGUISTIC NEEDS The plan conducts multiple activities to address the cultural and linguistic needs of its membership.

HEALTH INFORMATION SYSTEMS The plan integrates information from multiple data sources to maintain internal health information systems. Data is used to identify opportunities for improvement, plan, implement QI activities, and evaluate QI activities. QI Program data and documentation are maintained throughout the year and are available to regulatory agencies upon request for audit and quality program oversight purposes and provided at the QIS monthly meeting. The plan contracts with an NCQA-certified auditor for annual HEDIS® project as required to confirm that data reported are valid and reliable. REGULATORY REPORTING, EXTERNAL AUDIT, AND ACCREDITATION The plan cooperates fully with all required regulatory reporting and external audits, including audits by the Texas Department of Insurance, HCQIA, HHSC, CMS, and their contractors. By cooperating with this reporting, the plan makes quality outcome measures available to CMS and HHSC that will be used in plan ratings and enable beneficiaries to compare health plan performance and select between them. To receive a full copy of the QI Program Description, contact the Health Plan at 1-844-633- 5325.