Quality Improvement Program

EmblemHealth’s mission is to create healthier futures for our customers and communities. We do this by providing members with high quality service and a broad range of benefits, striving to simplify the provider experience, offering our purchasers high value, and partnering with the communities in which we live and work to improve their overall health.

The scope of activities within the Quality Improvement Program provides a framework to monitor and evaluate significant aspects of care and service provided to health plan members and their service delivery systems. EmblemHealth takes an active position in helping its members stay healthy, get better quickly, and live effectively with illness. Measures for monitoring important aspects of medical care, behavioral health care, and quality of service, including patient safety, have been developed and implemented. These activities include:

  • Quality 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
  • Care for the family caregiver

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 are 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.

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

  • Appeals data
  • Applicable Care Management Programs/Initiatives databases
  • Behavioral health data
  • Encounter data (data showing use of provider services by health plan enrollees)
  • CAHPS®1 (Consumer Assessment of Healthcare Providers and 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 demographic and census data
  • Utilization review data
  • Pharmacy data
  • Population-based member information
  • QARR (Quality Assurance Reporting Requirements)
  • Quality Compass
  • 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 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.