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2010 QUALITY IMPROVEMENT PROGRAM

The mission of the EmblemHealth companies is to provide access to affordable and quality health coverage in ways that respect and respond to our members’ fundamental needs.

In line with this mission, the Quality Improvement Program (QIP) establishes processes that work to continuously improve upon the services and medical and mental health care our members receive from our network of doctors, practitioners, hospitals, clinics and other providers. The result is a plan that better serves the needs of our customers and regulatory and accreditation bodies.

The QIP monitors and evaluates aspects of care and services that are provided to members.
Measures that have been developed and implemented for monitoring important aspects of medical care, mental health care and quality of service include:

• Quality of care
• Quality of service
• Patient safety
• Care management
• Member and physician satisfaction
• Accessibility
• Availability
• Business transformation/Lean Six Sigma
• Delegation
• Member complaints and appeals
• Member decision support tools
• Cultural diversity
• Human resources
• Integrative wellness

Information about our progress in meeting our goals for many 2010 QI initiatives are shared throughout the year in the provider and member newsletters.

The Quality Improvement Committee (QIC) and the QIP
The Boards of Directors of the EmblemHealth companies – through the 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 their designee.

The QIC is responsible for the following:

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

The QIP is reviewed annually and amended as necessary. The specific initiatives and activities outlined in the program are expanded upon and 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 and to help determine the initiatives for the following year.

The QIC includes a broad spectrum of practitioner involvement, including network physicians and mental health practitioners. Please see the Quality Improvement Committee Structure for the various committees and subcommittees that support the functions of QIP and report their activities to the QIC.

Mental health care practitioners participate in the Mental Health & Substance Abuse Subcommittee that reports to the Health Status Improvement Committee, which advises the QIC. Also, network physicians participate in the Health Status Improvement Committee, the Credentialing/Recredentialing Committee, Pharmacy and Therapeutics Committee, Medical Policy Subcommittee and the Peer Review Subcommittee, which also advise the QIC.

We use various data sources and software for measuring quality improvement.
The data sources used for quality improvement measurement, analysis of barriers and determinations of appropriate interventions include, but are not limited to:

• Appeals data
• Applicable case management databases
• Encounter data
• CAHPS®² (Consumer Assessment of Healthcare Providers & Systems)
• Claims data
• Complaints from practitioners, providers and members
• Enrollment data
• Heath Outcomes Survey data
• HEDIS® ¹(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 about the New York population
• Utilization review data
• Pharmacy data
• Population-based and/or specific member information
• Projects
• Provider-specific information
• Quality Compass
• Surveys completed by practitioners, providers and members
• 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.

¹HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA) ²CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ)

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