Quality Improvement Program

EmblemHealth’s mission is to provide quality health coverage in ways that respect and respond to our members’ fundamental needs.

The Quality Improvement Program (QIP) continuously works to improve the health care and services our members receive. We routinely monitor and review the following categories to ensure that our members have access to the highest quality medical and behavioral care:

  • Quality of care
  • Quality of service
  • Patient safety
  • Care management
  • Member and physician satisfaction
  • Accessibility
  • Availability
  • Delegation
  • Member complaints and appeals
  • Health management tools
  • Cultural diversity

Learn more about our Quality Improvement Program.

The Quality Improvement Committee (QIC) and the QIP
The boards of directors of the EmblemHealth companies—through their respective quality improvement committees—evaluate the QIP work plan. The overall responsibility for executing the QIP resides with EmblemHealth’s senior vice president and chief medical officer and/or his designee.

The QIC is responsible for the following:

  • Recommending policy decisions.
  • Planning, designing, implementing, coordinating and analyzing quality improvement activities.
  • Instituting needed actions and ensuring follow up as appropriate.
  • Ensuring practitioner participation in the QIP through planning, design, implementation, committee participation and/or review.

The QIP is reviewed once a year. Details about the program are tracked in the work plan. The work plan is updated quarterly and is monitored and approved by the QIC. There is also an annual evaluation of the program conducted to summarize and analyze the year's work. This helps determine the plan for the following year.

There are a number of committees and subcommittees that support the QIP and report their activities to the QIC. A broad spectrum of practitioner involvement, including designated physicians and behavioral health practitioners, occurs through the Quality Improvement Committee Structure.

We use various data sources and software for measuring quality improvement.

The following data sources are used to measure quality improvement, determine barriers to improvement and create ways to overcome these barriers. Determinations of appropriate interventions include, but are not limited to:

  • Appeals data
  • Applicable case management databases
  • Encounter data
  • CAHPS®1 (Consumer Assessment of Healthcare Providers & Systems)
  • Claims data
  • Complaints from practitioners, providers and members
  • Enrollment data
  • Heath Outcomes Survey data
  • HEDIS®2 (Healthcare Effectiveness Data & Information Set)
  • Integrated data collection systems that collect member and provider information
  • Laboratory data
  • Medical records
  • National and regional epidemiological and demographic data
  • Utilization review data
  • Pharmacy data
  • Population-based member information
  • QI projects/studies
  • Provider information including surveys
  • Quality Compass®3
  • Utilization

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.

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)

If you cannot print this information and would like a paper copy, please send your request, along with your name and address, to chelfman@emblemhealth.com.