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Quality Program

  • CONFIDENTIALITY
  • PROGRAM REVIEW

  • MISSION:

    The Health Alliance Plan (HAP) Quality Program aims to assure that safe, effective, patient centered, timely, efficient, and equitable clinical care and services are provided to members/enrollees.  HAP seeks to demonstrate value and improve quality through the elimination of over, under, and misuse of services. The Quality program focuses on coordinating activities for continuous quality improvement of clinical care and safety (including general medical and behavioral health care) and of services across HAP’s delivery system by:

    • identifying organizational opportunities for improvement;
    • implementing interventions to improve the safety, quality, availability and accessibility of, and member satisfaction with, care and services;
    • promoting members' health, through health promotion, disease prevention and condition management;
    • assisting in the development of informed patients engaged in healthy behaviors and active self-management;
    • measuring, assessing, and/or coordinating the following:
       
      • evidence-based clinical quality
      • patient safety
      • practitioner availability and accessibility
      • member and practitioner satisfaction
      • supporting the continued development of proactive provider practices

    Quality Management (QM) works collaboratively with other departments to support and help achieve administrative, clinical, and service quality improvements, to assure appropriate utilization and to enhance continuity of care for HAP's commercial and Medicare Advantage members. Health Alliance Plan is the parent organization of two for-profit subsidiaries and provides administrative and clinical services on their behalf. Relevant aspects of the HAP Quality Program apply to HAP's subsidiaries, Alliance Health and Life (AHL) and Preferred Health Plan (PHP). More specifically, service quality, clinical quality, and elements of patient safety are addressed for the AHL product. Service quality and patient safety elements are addressed for HAP Preferred (PHP) products.


    OBJECTIVES:

    The objectives of the HAP Quality Program are:

    1. To assure and improve continually the value (member and practitioner satisfaction), quality, safety, availability, accessibility, appropriateness, and effectiveness of behavioral and medical health care services.
       
    2. To assess health services provided to the enrolled population through the use of appropriate data collection, sampling, validation, and analysis techniques to identify opportunities for improvement.
       
    3. To establish areas of clinical priority, establish and update related preventive service and clinical practice guidelines in consultation with affiliated practitioners, disseminate the guidelines, and promote and assure compliance with the guidelines.
       
    4. To develop data-driven disease and condition management strategies to improve practitioner, provider, and member compliance with clinical guidelines and standards, thus enhancing members' health.
       
    5. To engage in health promotion and education for practitioners, providers, and members in areas of clinical priority to enhance members' health and encourage active self-management.
       
    6. To regularly evaluate HAP practitioner and provider qualifications and competence through credentialing and recredentialing programs, peer review activities, performance monitoring and investigation, and quality improvement activities.
       
    7. To participate in national and local initiatives to support transparency initiatives in the areas of quality, safety, utilization, access, and satisfaction.
       
    8. To actively seek out and participate in national and local collaboratives and recognition programs to improve performance and achieve recognition as a quality leader.

    HISTORY:

    The Quality Program has been a primary focus of Health Alliance Plan since its founding. The program has been regularly evaluated and updated since that time. The HAP Board of Directors approved HAP's original Quality Assurance Program document on May 10, 1988. HAP's Quality Assurance Program was renamed the Quality Management Program in 1991 and was renamed the Quality Program in 2005 to reflect plan-wide involvement. The Quality Program document has been reviewed and revised annually since 1991. HAP's Quality Assurance Committee was created with the original Quality Assurance Program in May 1988 and has been meeting regularly since that time. The Quality Assurance Committee was renamed the Quality Management Committee in 1991 and renamed the Quality Improvement Council (QIC) in 2001. HAP has conducted an annual evaluation of the Quality Program since 1991.

    Initially the QIC had subcommittees addressing Credentialing and Peer Review activities. A significant revision in committee structure took place in 2001 with several new subcommittees or committee reporting relationships established. New subcommittees included the following: Service Quality Committee, and Hospital Quality/Patient Safety Committee. Reporting relationships were formalized with the Utilization Coordination Committee, the Pharmacy Oversight Committee, and the Privacy/Security Committee.

    HAP's commitment to public accountability for the quality program has been demonstrated through our involvement with the National Committee for Quality Assurance's (NCQA) accreditation and HEDIS programs. HAP's HMO was awarded Full NCQA Accreditation in 1993 and again in 1995 and 1998. In 1999, HAP's accreditation for the Commercial product was upgraded to Excellent based on improved HEDIS results. In 2001, HAP again received "Excellent" accreditation for the Commercial HMO product and Commendable accreditation for Senior Plus, HAP's Medicare + Choice HMO.

    In June 2004, HAP underwent a multi-product line accreditation review. HAP received "Excellent" accreditation for both the Commercial and Medicare HMO products. In a subsequent survey conducted in June 2007, HAP received excellent accreditation for both the Commercial and Medicare HMO products.


    SCOPE:

    HAP has a proud, long-standing commitment to quality improvement initiatives that encompass the full spectrum of care and services provided by HAP. The Quality Program is dedicated to fulfilling that commitment by working with the physician and provider community to establish evidence-based clinical guidelines and service standards. The guidelines and measures are used to develop tools to provide feedback to patients and physicians to encourage improvement. The Quality Program applies to members enrolled through commercial and Medicare products in HAP and its subsidiaries. Components of the Quality Program include Annual Goals and Objectives approved by the Quality Improvement Council (QIC) from which health plan staff develops the Annual Quality Program Work Plan.

    Specific clinical quality initiatives within the Quality Program and Annual Work Plan are categorized into one of the following six groups based on the intensity and scope of the efforts in that area. These priorities may be subject to change during the year based on new information and/or changing regulatory, accreditation, and/or purchaser needs.

    • Chronic Care Management: Chronic care management is a system of coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts are significant (Source: DMAA). Disease management programs are the most resource-intensive and have the broadest scope of any of HAP's quality programs. Disease management includes: evidence-based care guidelines; identification of a registry of patients; stratification into risk groups based on clinical needs; member interventions to promote patient self-management and empowerment; physician education and support; and evaluation, analysis and reporting to assess effectiveness and enhance program design. Intervention categories included in disease management programs are outbound telephonic member contact by HAP nurses, active provider education, active patient education, provider profiling, targeted patient reminders and clinical practice guidelines.
       
    • Quality Improvement: Quality improvement is a systematic approach to measurement, analysis and intervention that defines a distinct area of opportunity, seeks to identify the causes of suboptimal performance/outcomes and targets interventions to address the identified causes. Quality improvement programs include provider and patient education, provider profiling, targeted patient reminders, physician and member incentives, and guideline implementation activities.
       
    • Health Promotion: Health promotion programs include guideline implementation activities and general or targeted provider and/or patient education (i.e., office posters, educational mailings).
       
    • Evidence-based Medicine: Practice Guideline implementation programs include clinical practice and preventive service guidelines, regular monitoring for performance issues and passive provider and member education (i.e., information available on the Internet and in newsletters).
       
    • Pay-for-Performance: The initiatives focus on developing programs to support clinical quality and safety performance improvements through measurement, reporting, recognition, and incentives. This includes partnering with other internal and external customers to align mutual efforts to transition care into a high quality seamless delivery system.
       
    • Hospital Quality/Patient Safety: Hospital quality initiatives seek to improve, support, and promote quality of care, outcomes and safe patient care for members through consumer and physician education/information, collaboration, quality contracting, and recognition. The initiatives incorporate hospital performance information, analysis, and research findings to align with corporate strategies. This Committee works closely with the Pay-for-Performance Work Group to provide data, research, and support in meeting strategic hospital objectives.

    STRUCTURE:

    1. HAP Board of Directors
      The HAP Board of Directors is responsible for the quality of health services delivered to members. The Board delegates general oversight, review and approval of the Quality Program, Work Plan and Evaluation to its subcommittee, the HAP Board Quality Committee (BQC). AHL and PHP have separate Boards of Directors, which are composed of the HAP Board Executive Committee membership. The Board meets four times annually.
       
    2. AHL Board of Directors
      The AHL Board is empowered to act on behalf of the corporation to perform all acts that are permitted to be performed by corporations under Michigan Law. The Board is solely responsible for the quality program and structure of AHL. Currently, the Board is made up of the same individuals who serve on the HAP Board of Directors Executive Committee. The Board meets four times annually.
       
    3. HAP Board Quality Committee
      A subcommittee of the HAP Board of Directors, the HAP Board Quality Committee (BQC) is responsible for overseeing and assuring the quality, safety, appropriateness, and cost effectiveness of the clinical care and services provided to members. The HAP BQC meets three times annually. Through this subcommittee, the Board provides support for initiatives, policies, and resources necessary to accomplish this goal.
       
      The subcommittee meets and reports to the Board on quality improvement activities at least annually. Members of the subcommittee are ex officio members of the HAP Quality Improvement Council (QIC).
       
    4. Physician Leadership
      The Chief Medical Officer is responsible for oversight of the Quality Program and the Quality Improvement Council. He/she is accountable to the HAP, AHL and PHP Boards of Directors for the Quality Program and reports regularly to the Boards and/or their Quality Committee on activities, progress, and outcomes of the quality program. A Senior Associate Medical Director is designated to work closely with the Director of Quality Management in the implementation of the Quality Program. Duties of the Senior Associate Medical Director for Quality include but are not limited to Chair of the Quality Improvement Council, participation on the Board Quality Committee, the Peer Review Committee, the Credentials Committee and the Credentialing Oversight Committee, and ongoing consultative support for all Quality Program activities. Physician involvement in appropriate disease management and preventive health improvement programs is provided by designated Associate Medical Directors assigned to individual project teams.The Associate Medical Director for Behavioral Medicine is involved in all behavioral health aspects of the Quality Program. Duties of the Associate Medical Director for Behavioral Medicine include but are not limited to participation on the QIC, Credentials Committee, Pharmacy and Therapeutics Committee and the Coordinated Behavioral Health Management (CBHM) Utilization Management and Quality Improvement Council, as well as serving as clinical expert for the behavioral health disease management project team.
       
    5. HAP Quality Improvement Council (QIC) and Other Committees
      The Senior Associate Medical Director for Quality chairs the Quality Improvement Council (formerly the Quality Management Committee). The QIC includes practitioners from the HAP delivery system, research or administrative representatives of provider groups, HAP Associate Medical Directors and HAP senior staff. In addition, members of the Board Quality Committee are ex officio members of the HAP Quality Improvement Council. The QIC evaluates and approves the Quality Program and Work Plan, and monitors progress toward meeting program goals and objectives. The QIC oversees patient safety, clinical, administrative, and service quality improvement throughout the plan; recommends policy decisions; and is accountable to the Board through its Quality Committee. The QIC meets a minimum of five times per year.
       
      A number of organizational committees or subcommittees are charged with functions linked to support the Quality Program. These committees and subcommittees provide reports to the QIC as applicable, at least once a year and upon request.
       
      • The Peer Review Committee (PRC) acts on behalf of the QIC to identify, review, monitor and aid in the improvement of the technical and professional performance of affiliated practitioners and providers. The PRC meets at least four times per year and is chaired by the Senior AMD for Quality or his/her designee.
         
      • The Credentialing Committee acts on behalf of the QIC and the PQC to verify, review and evaluate the credentials of affiliated practitioners/providers and practitioners/providers seeking affiliation. The Credentialing Committee meets at least 18 times per year or as needed to meet work volume in a timely manner and is chaired by the Senior AMD for Quality or his/her designee.
         
      • The Credentialing Oversight Committee acts on behalf of the QIC and the PQC to monitor delegated credentialing programs and identify opportunities for improvement. Additionally, the Committee reviews and revises credentialing policies, and assures that the credentialing program complies with regulatory and accrediting requirements. The Credentialing Oversight Committee meets at least four times per year and is chaired by the Senior AMD for Quality or his/her designee.
         
      • The Service Quality Committee (SQC) acts on behalf of the QIC to monitor accessibility, availability of and satisfaction with administrative and clinical services and to identify opportunities for improvement. The SQC meets at least three times per year.
         
      • The Hospital Quality/Patient Safety Committee acts on behalf of the QIC and serves to monitor, evaluate, educate, and report patient safety performance data, identify centers of excellence, to support patient safety improvement efforts across the delivery system. The Committee works with internal customers on quality contracting and Pay for Performance initiatives, participates in national and local patient safety initiatives such as Leapfrog, Michigan Health and Safety Coalition, Interplan Workgroup Patient Safety Council, and applicable HFHS groups. This includes participation in collaboratives such as the Greater Detroit Area Health Council, Save Lives Save Dollars hospital initiative to foster safety and quality care improvements.
         
      • The Utilization Coordination Committee (UCC) acts on behalf of the QIC to oversee the performance of utilization management activities for both medical and behavioral health by Health Management Services and its delegated utilization management entities. The UCC meets at least monthly to review and assess audit materials, activity report data, utilization management program documents, clinical criteria with input from network practitioners and other relevant information on HMS and the delegated entities in order to gauge the level of their performance with HAP's expectations and to implement, when necessary, corrective action plans to ensure compliance with the National Committee on Quality Assurance (NCQA) standards. The UCC is chaired by an Associate Medical Director.
         
      • The Pharmacy Oversight Committee is the policy-making body for global issues and major business decisions relating to pharmacy services on behalf of HAP and the QIC. Guidance is provided for pharmacy formulary, contracting, utilization management, quality management and clinical pharmacy operated through Pharmacy Care Management. The Pharmacy Oversight Committee is composed of the HAP Chief Medical Officer, the HAP Chief Operating Officer, the HAP Chief Finance Officer, the Chief Executive Officer of Community Care Services, one (1) HAP Associate Medical Director, the Chair of the Ambulatory Pharmacy and Therapeutics Committee, the Vice President of Pharmacy Care Management, and the Director of Pharmacy Care Management. The Committee meets quarterly and is chaired by the HAP Chief Medical Officer.
         
      • The Ambulatory Pharmacy and Therapeutics Committee is responsible for optimizing the quality of drug therapy for HAP patients while controlling drug costs through the approval and availability of efficacious, safe, and cost-effective medications. Prescribing and market share data are used to identify further strategies and to provide feedback to prescribers and the Committee. The Committee oversees the routine collection of data for assessment of outpatient drug use, adverse drug events and medication errors. The Committee works cooperatively with other system committees to identify opportunities to enhance ambulatory drug therapy and integrate formulary and drug use evaluation with condition management and wellness programs. The committee meets monthly and is chaired by a physician leader. Membership includes physician, nurse and pharmacist representatives from across the HAP delivery system.
         
      • The HAP Privacy and Security Committee develops and oversees the implementation of and compliance with the NCQA privacy guidelines and the HIPAA federal privacy and security regulations on a company and subsidiary-wide basis. The committee meets at least six times per year and is chaired by HAP's Privacy and Security Officers.
         
      Additional forums utilized to exchange ideas and obtain input for the HAP Quality Program include the Henry Ford Health System Corporate Quality Committee, HAP Corporate Operating Council, and the Network Medical Directors' Committee.
       
      • The Henry Ford Health System, HAP's parent company, provides ongoing support for HAP's Quality Program. The Henry Ford Health System Quality Forum consists of senior administrative, nursing, and physician leaders from the Henry Ford Medical Group, Henry Ford Hospital, Health Alliance Plan, Henry Ford Macomb Hospital, Henry Ford Macomb Hospital-Warren Campus, Henry Ford Wyandotte Hospital, Behavioral Services, and Community Care Services. Additional representatives include the Henry Ford Health System Chief Quality Officer, the Henry Ford Health System Vice-President of Planning and Performance Improvement, and other quality professionals supporting the Forum's improvement teams. The Quality Forum is responsible for identifying improvement opportunities, integrating improvement efforts across departments and business units, and tracking progress on System goals. Chaired by the Henry Ford Health System President and CEO, the Quality Forum reports its progress to the Henry Ford Health System Board of Trustees Quality Committee. The Forum meets monthly.
         
      • The HAP Quality Management department contributes to the HFHS Blue Book of quality initiatives.
         
    6. Quality Management (QM), Clinical Care Management (CCM), and Information Sources
      Quality Management and Clinical Care Management are responsible for developing, supporting, and/or implementing the HAP Quality Program and work plans. Responsibilities include but are not limited to:
       
      • Staffing the QIC and many of its subcommittees
      • Performing quality assessment, measurement, evaluation, and improvement activities
      • Supporting other HAP departments in clinical, service, and operational/administrative quality improvement activities
      • Providing consultation and expertise regarding quality improvement, process improvement, and measurement techniques
      • Providing guidance on and information to support identification of priority areas for improvement
      • Partnering with Credentialing staff to provide oversight of delegated credentialing functions and performance monitoring activities
         
      QM and CCM rely upon data sources including: member complaint reports, survey results, medical records, the Clinical Care Management System, utilization statistical reports, HEDIS results using MedMeasures beginning in 2002, benefit manual, Cactus and MCSource. Implemented in October 2001, MCSource now serves as the repository and front-end reporting tool for claim, encounter, lab result, pharmacy, member, member contract, employer group, provider and practitioner data. MCSource also performs advanced encounter grouping functions and includes advanced logistic models for predicting utilization and examining program effectiveness.
       
    7. Internal Collaboration
      To support quality management across the delivery system, QM staff work collaboratively with individuals and departments involved in research, patient safety, clinical assessment and quality improvement throughout the Henry Ford Health System. Within HAP, QM also works cooperatively with all departments to evaluate member and provider satisfaction; access to care and availability of practitioners; and to promote quality improvement, process improvement, patient safety, member education and provider education. A few examples are listed below:
       
      Provider Development works to align HAP's delivery system in support of selected quality improvement efforts through negotiation of contracts and incentive programs incorporating quality goals and requiring cooperation with HAP initiatives.
       
      Medical and Business Informatics (MBI) provides data analytic support to identify and address medical management opportunities including overuse and misuse of services. MBI produces provider profiles, routine utilization statistics, program evaluations and other reports to support decision-making.
       
      Planning and Marketing Support interacts and partners with the purchaser community to assure HAP's quality initiatives address purchaser expectations.
       
      Worksite Health Promotion addresses purchaser requests while supporting HAP's clinical quality improvement priorities.
       
      Pharmacy Care Management participates on disease management teams and other workgroups to provide expertise and assure alignment of clinical and pharmacy initiatives.
       
      Credentialing ensures that affiliated practitioners and providers meet HAP credentialing standards through initial and recredentialing activities in alignment with regulatory and accreditation standards. Credentialing maintains accurate provider and practitioner data, databases. Credentialing collaborates in local and national credentialing initiatives such as statewide credentialing applications to standardize processes.
       
    8. External Collaboration
      Health Alliance Plan strongly believes in a collaborative approach to quality improvement and health promotion in the community. Through collaboration we can learn from each other and apply best practices and develop a common message and set of priorities for physicians and the community. HAP staff actively participates in a number of external groups to support common efforts to improve the health of our members and community. These include the Greater Detroit Area Health Council (GDAHC), Save Lives Save Dollars initiative, Michigan Quality Improvement Consortium, Michigan Association of Health Plans and their Foundation, Michigan Department of Community Health, Alliance of Community Health Plans and topic-specific groups such as the Detroit Asthma Coalition, the Alliance for Immunization in Michigan, the Michigan Cancer Consortium, the American Diabetes Association, and inter-plan workgroups.
       
    9. Delegation
      Health Alliance Plan does not delegate any quality improvement functions. HAP delegates specific appropriate credentialing-related components of the quality program through formal agreements with affiliated institutions or groups. The QIC delegates to the Credentialing Oversight Committee, QM and Credentialing the responsibility for oversight and evaluation of delegated credentialing functions, to assure that policies, procedures, and performance are comparable to non-delegated functions. QM and Credentialing also assure that HAP maintains compliance with state regulations and accrediting standards. Establishment of new delegated agreements involves participation of staff from the QM, Credentialing, Governance, and Legal and Regulatory Affairs departments.

    CONFIDENTIALITY:

    The confidentiality of member, provider and practitioner, and HAP business information is of utmost concern in conducting activities of the Quality Program. HAP maintains all relevant information in accordance with established HIPAA, regulatory, and accreditation standards. This includes storage, access, disposal, disclosure of the aforementioned information.


    PROGRAM REVIEW:

    The program description shall be reviewed and evaluated annually by the QIC and the Board of Directors, and revised or updated as necessary. QM will establish a work plan annually with input and approval from the QIC. The work plan will include goals, objectives, planned activities, timeframe, and responsible party(ies). Progress is monitored regularly with mid-year and year-end evaluations submitted to the QIC for review, input and approval.

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