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Quality Management Program Overview VHP is committed to continuous and measurable improvement in the delivery of quality health care for its members. VHP’s culture, systems and processes are structured around its mission to continuously monitor performance to improve the health of all enrolled members. The VHP Quality Management (QM) department oversees clinical quality assurance (QA), quality monitoring, and performance improvement (PI). One of the requirements of the National Committee for Quality Assurance is that VHP utilize provider performance data for quality and performance improvement. VHP agreements with providers require their cooperation with VHP’s QM and PI activities. VHP conducts ongoing systematic review of health care services provided to members. Services are coordinated and monitored using applicable accrediting standards, regulatory requirements, and statutes, promulgated by the following organizations, including not but limited to: • National Committee for Quality Assurance (NCQA) • Accreditation Association of Ambulatory Health Care (AAAHC) • Centers for Disease Control and Prevention (CDC) • Centers for Medicare and Medicaid Services (CMS) • Department of Managed Health Care (DMHC) • California Health and Safety Code (HSC) • California Department of Insurance (CDI) • Office of the Patient Advocate (OPA) • Covered California (CoCA) Quality Management, in collaboration with other teams throughout VHP, is responsible for the following activities: • Define, oversee, continuously evaluate, and improve the quality, efficacy and efficiency of health care delivered through its provider network. • Ensure that medically necessary covered services are available and accessible to members, taking into consideration the member’s cultural and linguistic needs. • Ensure VHP’s contracted network of providers cooperates with VHP’s PI and quality improvement (QI) initiatives. • Ensure that timely, safe, medically necessary, and appropriate care is available. • Ensure that VHP consistently meets quality standards as required by contract, regulatory agencies, accreditation bodies, recognized care guidelines, and the health care industry. • Promote health education and disease prevention designed to promote life-long wellness by
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CH 20: Quality Management
2021 / Provider Manual
