The organized method for monitoring, evaluating and improving the quality, safety and appropriateness of health care, including behavioral health care, which encompasses mental health and substance use disorders, services to members through related activities and studies is known as the quality improvement (QI) program.
To provide accountability for the quality of health care delivery and service. This is accomplished through the commitment of the board of directors and the physician quality and the health plan quality improvement committees to develop and carry out a quality assurance plan that has a systematic approach to assessing, measuring, defining and resolving medical care, including behavioral health and service issues.
The Plan believes that the only way to achieve continuous quality improvement is to have its entire organization embrace a well-defined quality improvement program and annual work plan in their day-to-day activities.
Goals and objectives
- Assure high quality of care to all Plan members.
- Continuously monitor and improve the quality and safety of patient care and health delivery services by all practitioners with delineated clinical privileges.
- Continuously monitor and improve behavioral health care (includes care for both mental health and substance use disorders) through education and collaboration with appropriate health care practitioners. This will be accomplished through reporting and analyzing behavioral health related HEDIS® measures, the involvement of a behavioral health practitioner on the physician quality committee to assist in decisions regarding behavioral health related utilization management (UM) issues and QI activities; and the collaboration with general medical and treatment-specific behavioral health practitioners to improve the continuity and coordination of the member’s overall medical care received under the Plan, which is inclusive of any behavioral health care.
- Oversee and assess medical care systems, processes and outcomes.
- Oversee and assess components of health service delivery.
- Oversee the credentialing and recredentialing of all health care practitioners and providers.
- Implement standards of care and practice guidelines as recognized by national specialty academics, nationally recognized authorities, and standards developed by the physician quality committee.
- Communicate standards and guidelines to practitioners and providers, when appropriate.
- Review and/or update criteria, guidelines and standards of care and services at least annually based upon UM and QI activities and results.
- Monitor compliance with standards of care and services.
- Monitor compliance with Medical Record standards.
- Implement improvement interventions as necessary.
- Monitor member and practitioner/provider complaints and appeals, the reasons for the complaint and appeal, and the Plan’s resolution turnaround time.
- Satisfaction surveys are conducted to obtain information pertaining to member and practitioner/provider perceptions of and experiences with the Plan and its services. A U.S. Agency for Healthcare Research and Quality (AHRQ) Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey is completed for commercial and ND Medicaid Expansion members, a CMS Qualified Health Plan (QHP) Enrollee Experience Survey (EES) is completed for Marketplace members and a behavioral health care and services survey is completed for those members receiving behavioral health care services. Satisfaction surveys are also conducted to assess member experience with various Plan programs, for example, the disease/health management, complex case management, and the health information line. Provider surveys are conducted annually to assess provider satisfaction with the health plan.
- Develop and maintain a monitoring system to detect trends.
- Assess effectiveness of improvement interventions.
- Establish and maintain a preventive process that identifies potential risk management issues.
- Conduct special reviews as specified by major employer groups and insured clients.
- Recognize and evaluate new health care services, technologies, procedures, and pharmacological treatments, as well as their application for the population served.
- Demonstrate a commitment to improving safe clinical practice by fostering a supportive environment to help practitioners and providers improve the safety of their practices. This may be accomplished through the distribution of information to practitioners to assist in facilitating a safer clinical environment.
- Distribute information to members to improve their knowledge about prevention of illness as it relates to their own health care. Also to distribute information regarding clinical safety to facilitate informed decision making.
- Address patient safety issues, potential disparities in clinical care and service, and needs associated with complex health conditions (i.e., physical or developmental disabilities, severe and persistent mental illness (sometimes referred to as SPMI) and substance abuse disorders; multiple chronic conditions) in existing QI activities and disease/health management programs through prevention and educational activities. These needs are also addressed in the complex case management program, for those members identified as eligible. These needs are addressed through coordination of care for members and by identifying and reducing barriers to services for members with complex conditions.
- Cultural and linguistic needs of the membership are assessed by analyzing census data, CAHPS®, EES demographic data and member reported data collected in the EPIC system. An assessment of the practitioner network is completed based on these needs as well. Cultural and linguistic needs would be addressed as necessary to reduce health care disparities, and to improve, cultural competency in materials and communication, and network adequacy to meet the needs of underserved groups. Educational materials are provided in other languages on our website for members. Cultural and linguistic needs are assessed during the initial assessment for members in the Complex
- Case Management Program and updated as needs are identified during subsequent discussions with the case manager.
- QI encompasses the entire delivery system, including, but not limited to, hospital care, ambulatory care, ancillary services, emergency services, behavioral health services (including mental health and substance use disorders), preventive services, vision services, pharmacy, dental services, home health care, hospice care and extended care facilities.
- QI addresses both the quality and safety of clinical care and the quality of non-clinical aspects of service, including availability; accessibility; coordination and continuity of care, which includes referrals, case management, discharge planning, authorizations, provider reimbursements, member/provider satisfaction, and the Plan’s complaint (grievance) and appeal processes.
- The medical delivery system is monitored for both quality and utilization activities. Both over-utilization and under-utilization are addressed; this includes monitoring for member/provider fraud, waste, and abuse.
- Departments that support and may be included in the QI process are care management, utilization management, worksite wellness, information technology, provider relations, Client Services, operations, planning and regulation, which encompasses the Plan’s compliance/policy and marketing departments and member services.
- The Plan will achieve any performance levels as established by CMS, State or NCQA with respect to standard measures. Performance measures may be 1) contained in standardized national data collection and reporting instruments such as HEDIS® and CAHPS® /EES and/or 2) tailored to standards that are CMS, State or NCQA-specific.
Sanford Health Plan complies with all applicable federal requirements, including HIPAA, state and NCQA regulations regarding privacy, security, breach notification and confidentiality. Any Plan employee or any participating practitioner or provider engaging in QI activities must uphold the established principles of patient/physician confidentiality and individual privacy. All QI worksheets, study results and other related materials will remain confidential. Reference to practitioners and providers as well as members will be by number or symbol only. Committee members will not release any information regarding a provider or member, unless it is required by law or is necessary to coordinate health care services or secure the health or safety of a member. Such instances will be documented and actions will be in accordance with federal and state laws and regulations.
HEDIS (Healthcare Effectiveness Data and Information Set) is a set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare health care quality. Originally, HEDIS was designed to address private employers’ needs as purchasers of health care. It has since been adapted for use by public purchasers, regulators and consumers. Quality improvement activities, disease management programs and practitioner profiling efforts have all used HEDIS as a core measurement set.
To demonstrate our commitment to providing the highest quality of care and service, Sanford Health Plan would like to present our HEDIS report along with the quality improvement activities and disease management programs implemented by the Plan. This data provides you, our customer, with the information you need to judge our success in meeting our goals in various performance areas. The HEDIS measures, which are reported on an annual basis, are divided into domains that all reflect different aspects of care. The results are presented to you in comparison to national benchmarks. The HEDIS results are also compared to the Healthy People 2020 goals, where available. Healthy People 2020 is a set of 10-year health objectives for the United States aimed at health promotion and disease prevention initiatives. These goals were developed by the U.S. Department of Health and Human Services with the input of public health and prevention experts and a wide range of government officials and organizations.
This report is Sanford Health Plan’s commitment to our customers that we will continue to provide cost effective, quality care and service.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).