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  • Quality Improvement > Monitoring and Evaluation

    Quality Improvement Program Evaluation

    The Quality Improvement Leadership, in collaboration with all relevant EmblemHealth departments, prepares the Annual QIP Evaluation which:

    • Describes completed and ongoing QI activities that address quality and safety of clinical care and quality of service.
    • Identifies oversight and evaluation of the QIC, the effectiveness of the Quality Improvement Committee structure and the organizational structures that support implementation.
    • Evaluates and analyzes the results of each Quality Improvement activity described within the program and Work Plan, including delegated functions, implemented during the year.
    • Identifies trends in measure performance over time reflecting the quality and safety of clinical care and quality of service. This includes quantitative analysis of changes in trends and interventions as a result of the trends.
    • Identifies meaningful improvements in care and service.
    • Evaluates the overall effectiveness of the QIP, including progress towards influencing network-wide safe clinical practices.
    • Includes limitations and barriers to improvement identified by staff as a result of direct experience with the examined processes.
    • Identifies opportunities for improvement, including adequacy of resources, committee structure, practitioner participation and leadership involvement in the QIP.
    • Recommends activities for the next calendar year, including existing activities to be continued into the next calendar year.

    The Quality Improvement Program Work Plan

    Each year, the Quality Improvement Directors, with input from the Plan’s resources including, but not limited to, Quality Management and Disease Management develop a Quality Improvement Program Work Plan (QIPWP) for the upcoming year. The QIPWP integrates the following Quality Improvement elements from both clinical and administrative areas:

    • Yearly planned activities
    • Yearly written, measurable objectives for each activity
    • Identification of the person(s) responsible for implementation and management, initiation of the time frame, and the targeted completion date
    • Metrics for quality of care concerns and service monitors
    • Schedules of:
      • Reports to the QIC
      • Document reviews/approvals
      • Delegated activities reporting
      • The evaluation of the utilization management program
      • The annual evaluation of the Quality Improvement Program

    The QIP, the QIP Evaluation and the QIPWP are presented to the Health Status Improvement Committee for feedback, and to the QIC and Quality Committees of the Boards of Directors for final approval, in accordance with the QIPWP.

    Information about EmblemHealth's annual Quality Improvement Program is also available on our Web site. The provider and member newsletter (News&Notes and Health Matters, respectively) also contain updates on the quality initiatives.

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    Glossary terms found on this page:

    An entity contracted with EmblemHealth to perform various services including utilization review, credentialing and claims processing. Also called managing entities and carve outs.

    A coordinated system of preventive, diagnostic and therapeutic measures intended to provide cost-effective, quality health care for a patient population who have or are at risk for a specific chronic illness or medical condition.

    A health care benefit arrangement that is similar to a preferred provider organization in administration, structure and operation but does not cover out-of-network care. Also called an Exclusive Provider Organization.

    An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.

    Specific circumstances or services listed in the contract for which benefits will be limited.

    Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

    An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.

    The group of physicians, hospital, and other medical care providers that a specific plan has contracted with to deliver medical services to its members.

    A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.

    A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:

    • Doctor of medicine
    • Doctor of osteopathy
    • Dentist
    • Chiropractor
    • Doctor of podiatric medicine
    • Physical therapist
    • Nurse midwife
    • Certified and registered psychologist
    • Certified and qualified social worker
    • Optometrist
    • Nurse anesthetist
    • Speech-language pathologist
    • Audiologist
    • Clinical laboratory
    • Screening center
    • General hospital
    • Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes

    A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.

    The process to objectively and systematically monitor and evaluate the quality, timeliness and appropriateness of covered services, including both clinical and administrative functions, to pursue opportunities to improve health care and resolve identified problems in any of these services.

    A review to determine whether covered services that have been provided or are proposed to be provided to a member, whether undertaken prior to, concurrent with or subsequent to the delivery of such services are medically necessary. Also called Coordinated Care.


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