: Quality Management Program
(408) 885-5610
The Quality Management (QM) Program supports many of the activities of the Utilization Management, Provider Relations, Member Services, and Health Education Departments at Valley Health Plan. QM performs a number of ongoing and ad hoc quality and care review studies throughout the year. VHP’s goal is to conform to regulatory standards set by the DMHC, the California Department of Health Services and all other regulatory agencies. The Section 13 program closely monitors and promptly incorporates relevant statutory and regulatory changes. All providers must participate in the VHP QM program as part of the contractual agreement with VHP. • • • • • • • • •
HEDIS (Health Plan Employer Data and Information Set) VHP also selects other clinical areas not covered by the HEDIS studies. Access Survey, Audit, Dashboard Audit of Primary Care Provider Sites and Medical Records Audit Behavioral Health Provider Sites and Medical Records Provider and Member Satisfaction Surveys Potential Quality Issues (PQIs) Provider Groups Contracted Hospitals
Goals and Objectives a) Design and maintain a QM structure and process that supports continuous quality improvement, including measurement, analysis, intervention, and reassessment. b) Pursue opportunities for improvements in the health status of the enrolled population through preventive care services, health education, and disease management. c) Establish clinical and service indicators (with appropriate performance goals and benchmarks) reflecting the demographic characteristics of the Membership. d) Annually measure Member satisfaction with providers and Plan through trending and analysis of the Member grievance process. e) Annually measure provider satisfaction and address sources of dissatisfaction. f) Develop priorities of focused studies, emphasizing high volume services and providers, high-risk populations, and other quality improvement areas. g) Ensure timeliness of Credentialing/ Re-credentialing of providers. h) Coordinate QM with performance monitoring activities throughout VHP. i) Develop an annual Work Plan that includes a schedule of activities with measurable objectives and monitoring of previously identified issues. j) Evaluate annually the effectiveness of the previous year’s QM activities and interventions. Trend clinical and service indicators from year to year. k) Ensure provider performance in quality of care and service areas, medical record keeping, preventive health, accessibility of medical and behavioral healthcare, environmental safety, and health safety. l) Maintain and enforce a Conflict of Interest and Confidentiality policy for the protection of Peer Review activities and confidential Member and provider information. m) Ensure that the Health Plan does not exert undue economic pressure that might delay or withhold medically necessary services. www.valleyhealthplan.org rev.2020
Section 13
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SECTION 13 QUALITY MANAGEMENT PROGRAM
QM monitors and/or performs activities which may include the following:
