Quality Improvement Program

The scope of activities within the Quality Improvement Program provides a framework for EmblemHealth to monitor, evaluate, and improve the quality and safety of clinical care and services it provides to its members. EmblemHealth takes an active role in helping its members stay healthy, get better quickly, and live effectively with illness. Measures for monitoring important aspects of medical care, mental health care, and quality of service, including patient safety, have been developed and implemented. They include:

• Quality of care, including continuity and coordination of care.
• Quality of service.
• Patient safety.
• Utilization Management program.
• Member and physician satisfaction.
• Accessibility.
• Availability.
• Delegation.
• Member complaints, grievances, and appeals.
• Member decision support tools.
• Cultural diversity and health equity.

The Quality Improvement Program is reviewed annually and amended as necessary. Details about the program and the timeline for completing the review process are set forth in the annual Quality Improvement Work Plan. The status of the work plan items is updated quarterly and reviewed by the Quality Improvement Committee. An annual evaluation of the program is conducted to summarize and analyze the effectiveness of the Quality Improvement Program. This helps determine the plan for the following year.

EmblemHealth uses various data sources and software to measure quality improvement processes and outcomes, determine barriers to improvement, and identify ways to improve quality and overcome obstacles. Data sources include:

• Appeals data.
• Applicable Care Management programs/initiatives databases.
• Behavioral health data.
• CAHPS^®1 (Consumer Assessment of Healthcare Providers and Systems).
• Children’s Consumer Perception Survey data.
• Claims data.
• Complaints from doctors and members.
• Encounter data (data showing use of provider services by health plan enrollees).
• Enrollment data.
• Health Outcomes Survey (HOS) data.
• HEDIS^®2 (Healthcare Effectiveness Data and Information Set).
• Home and community-based services data.
• Integrated data collection systems that collect member and provider information.
• Laboratory data.
• Medical records.
• National and regional epidemiological, demographic, and census data. Epidemiology is the study of the distribution and causes/risk factors of health-related states and events in specified populations.
• Utilization review data.
• Pharmacy data.
• Population-based member information.
• Evidenced-based practice guidelines that comply with recommendations of professional specialty groups or the guidelines of programs.
• QARR (Quality Assurance Reporting Requirements).
• Quality Compass^®3.
• Quality improvement projects/studies.
• Telephone response data.
• Utilization review data.
• Various provider and member surveys.

Software includes, but is not limited to, claims systems, National Committee for Quality Assurance-approved HEDIS software, credentialing and recredentialing software, Microsoft products, and other systems to support the clinical and service interventions.

Authority and Responsibility of the Quality Improvement Program
The Board of Directors of the EmblemHealth companies, through the EmblemHealth, Inc. Quality Committee, oversees the Quality Improvement Program. The overall responsibility for executing the Quality Improvement Program resides with EmblemHealth’s Quality Improvement Committee. Various committees and subcommittees support the functions of the Quality Improvement Program and report their activities to the Quality Improvement Committee. Operational accountability has been delegated to the appropriate department heads. A broad spectrum of medical professional involvement, including designated medical and behavioral health doctors and pharmacists, occurs through the Quality Improvement Committee structure.

The Quality Improvement Committee is responsible for the following:

• Recommending and approving policy for effective operation of the Quality Improvement Program and the achievement of Quality Improvement Program objectives.
• Receiving, analyzing, and evaluating performance reports of the quality of care and services provided to members and the quality of service to practitioners; and identifying, selecting, and prioritizing actions to improve quality based on their significance.
• Ensuring follow-up, as appropriate, and monitoring of quality improvement initiatives and action plans to ensure that quality improvement goals continue to be achieved and are effective.  
• Overseeing the analysis and evaluation of the Quality Improvement Program and assessing the results of quality improvement activities.
• Ensuring provider participation in the Quality Improvement Program through the process of planning, designing, implementation, and/or review of activities and committee participation.

Learn more about the Quality Improvement Program.

If you cannot print this information and would like a paper copy, please call the Quality Management Department at 888-447-5451. Leave a message with your name and address, and we will send a printed copy to you.

¹CAHPS^® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

²HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

³Quality Compass^® is a registered trademark of the National Committee for Quality Assurance (NCQA).