Quality Improvement Program

EmblemHealth’s mission is to create healthier futures for our customers and communities. This will be done by providing members with a broad range of benefits and conscientious service; striving to enhance the experience for health care professionals; offering high value to those who purchase our health plans; working with government agencies to increase access to coverage; and partnering with the communities in which we live and work to improve their overall health.

The Quality Improvement Program establishes a framework and processes that continuously work to improve the health care and services our members receive. We routinely monitor and review the following areas to ensure that our members have access to the highest quality medical and behavioral care and services.

  • 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

The Quality Improvement Program 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 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.

We use various data sources to measure quality improvement processes and outcomes, determine barriers to improvement, and identify appropriate ways to improve quality and overcome barriers. Data sources include:

  • Appeals data
  • Applicable case management databases
  • Encounter data (data showing use of provider services by health plan enrollees)
  • CAHPS®¹ (Consumer Assessment of Healthcare Providers & Systems)
  • Claims data
  • Complaints from doctors and members
  • Enrollment data
  • Health Outcomes Survey data
  • HEDIS®² (Healthcare Effectiveness Data and 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
  • Quality improvement projects/studies
  • Utilization

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

Authority and Responsibility of the Quality Improvement Program
The Boards of Directors of the EmblemHealth companies, through their respective Quality Improvement Committees, oversee 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, occurs through the Quality Improvement Committee structure.

The Quality Improvement Committee is responsible for the following:

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

Learn more about the Quality Improvement Program.

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)

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 the address where we should send the printed copy.