QI Program Goals and Objectives
The Quality Improvement Program monitors the availability, accessibility, continuity and quality of care for both physical and behavioral health services on an ongoing basis.
Monitor the quality of care and services provided by participating providers, practitioners, and independently contracted delegates to Horizon.
- Evaluate and maintain a high quality provider network through a formalized credentialing and recredentialing process.
- Maintain a structured, ongoing oversight process for quality improvement functions performed by practitioners, providers, and independently contracted delegates.
- Implement activities to monitor and address continuity and coordination of care between physical and behavioral health specialties and within the medical care system.
- Establish long-term collaborative relationships with the physician and provider network to consistently improve the quality and cost effectiveness of care and services delivered to our members.
- Specify standards of care, criteria and procedures as well as assess compliance with such standards and adequacy and appropriateness of health care resources utilized.
- Monitor member satisfaction with quality of care and services received from network physicians, providers, practitioners and delegates.
Maintain a systematic approach to monitor, evaluate, improve and ensure provider and member access to utilization management services.
- Assure that adequate resources are available to provide appropriate, accessible and timely health care services to all members according to evidence based rules.
- Evaluate new medical technology, new application of existing technologies and determine their coverage status in the context of Horizon’s benefit packages.
- Continually monitor, evaluate, and improve Horizon’s performance using benchmarks and goals based on national data.
- Ensure appropriate coordination of care between clinical settings.
Act on opportunities for improvement of the health status of members through the development and implementation of population health programs addressing health promotion, preventive health education, and disease and case management programs.
- Continually identify and outreach to members at risk and/or with gaps in care.
- Identify healthcare disparities in order to develop appropriate intervention tools including staff cultural competency education.
- Establish programs focused on the chronic conditions of our members in order to empower members to actively participate in and take responsibility for their own health through the provision of education, counseling, and access to quality health care providers and tools.
- Expand planned interventions in existing health management programs and strengthen coordination between clinical and behavioral health management activities, and appropriate discharge planning.
- Select, distribute and maintain preventive health guidelines that are: age, gender, culture, and risk status appropriate; describe the prevention or early detection interventions along with the recommended frequency and conditions under which the interventions are required; document the source upon which it is based, review and update bi-annually or as needed.
- Develop population based programs that address our member’s needs in the areas of wellness, members with emerging risk, multiple chronic conditions and patient safety and outcomes across medical setting. Promote member engagement/participation in these programs.
Maximize safety and quality of health care delivered to members through the continuous quality improvement process.
- Provide members with semiannual publications and access to a website that contains information to improve their knowledge about clinical safety issues.
- Collaborate with physicians, providers and practitioners to establish a means of promoting and maintaining safe clinical practices.
- Address patient safety through continuous review of quality care issues and require corrective action from providers involved.
- Evaluate and reward provider (physicians and hospitals) performance with respect to the quality of care delivered to members.
- Utilize evidence based practice guidelines, monitor and assess the extent to which members receive care consistent with the guidelines.
- Provide members with 24/7 access to clinical staff for informational questions and education about help with assessing their basic health care needs.
- Evaluate patient safety through continuous monitoring of polypharmacy utilization.
- Assess the over and under-utilization of services as needed.
Maintain a high level of satisfaction in members, physicians, providers and customers on the services provided by Horizon.
- Ensure easy and timely access to accurate information through customer service representatives, phone lines, internet or website.
- Resolve inquiries, complaints and appeals in a timely manner.
- Measure member and provider satisfaction through analysis of complaints and survey data to identify areas for improvement and develop improvement action plans.
Maintain compliance with state and federal regulatory requirements and accreditation standards.
- Monitor and update workflows and processes to continuously meet regulatory requirements for quality improvement and compliance as needed.
- Initiate and monitor quality improvement activities which meet or exceed accreditation standards.
- Fulfill the quality related reporting requirements of applicable state and federal statutes and regulations, as well as standards developed by independent external review and accreditation bodies.
QI Program Evaluation
Policies and procedures supporting the Quality Improvement Program are reviewed and approved annually by the appropriate committee and updated as needed. Based on the annual program evaluation, the prior year’s QI Work Plan is revised, and a new QI Work Plan for the coming year is developed to guide and focus the work for the next year.
The program evaluation includes information about the following:
- Review of progress and status of annual goals.
- Monitoring of previously identified issues.
- Evaluation of the effectiveness of each quality improvement activity.
- Review of trends of clinical and service quality indicators.
- Evaluation of the improvements occurring as a result of quality improvement efforts.
- Evaluation of the overall effectiveness of the Quality Improvement Program.
- Evaluation of adequacy of staff resources.
- Evaluation of program structure and processes.
- Goals and recommendations for the work plan for the following year.