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QUALITY IMPROVEMENT PROGRAM
A. Goals
• Coordinate all quality management audits and quality improvement activities through the
QIC;
• Monitor and evaluate the quality of clinical healthcare, service quality, process
improvement, Member and Provider satisfaction, complaint/grievance resolution and
Provider network credentialing/re-credentialing;
• Monitor and evaluate Provider practice patterns, develop improvement plans as needed,
and review performance to assess whether improvements have occurred;
• Promote and monitor preventive health services;
• Identify educational needs of Members, Providers, customers, and staff, and develop
resources to meet those needs;
• Maintain accurate data to ensure QI Program integrity;
• Ensure compliance with applicable accreditation and regulatory requirements;
• Conduct an annual review of all QI actions, assessing the improvement achieved through
the initiatives of the QI Work Plan, and revising the Work Plan when necessary;
• Document and share improvements in healthcare delivery as a result of QI initiatives.
B. Quality Improvement Committee (“QIC”)
The QIC is responsible for the overall design and implementation of quality improvement activities for
the organization, as well as for the oversight of QI activities carried out by other committees and reports
these activities to the Board of Directors. The QIC ensures that all quality improvement tasks and
functions are a reflection of Membership involvement, the participation of Participating Providers, and
the compliance with all applicable regulatory and accreditation mandates.
Healthcare Effectiveness Data and Information Set (HEDIS®)
HEDIS® (a standardized data set) is developed and maintained by the National Committee for Quality
Assurance (NCQA), an accrediting body for managed care organizations. The HEDIS® measurements
enable comparison of performance across plans. The sources of HEDIS® data include administrative
data (claims/encounters) and medical record review. HEDIS® measurements include measures such as
Comprehensive Diabetes Care, Adult Access to Ambulatory and Preventive Care, Glaucoma Screening
for Older Adults, Controlling High Blood Pressure, and Breast Cancer Screening.
Plan-wide HEDIS® measures are reported annually and is a mandated activity for Health Plans
contracting with The Centers for Medicare and Medicaid Services (CMS).
All records are handled in accordance with Bravo Health’s privacy policies and in compliance with the
Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. Only the minimum
necessary amount of information, which will be used solely for the purpose of this HEDIS® initia
tive,
will be requested. HEDIS® is considered a quality related health care operation activity and is
permitted by the HIPAA Privacy Rule [see 45 CFR 164.501 and 506].
Bravo Health HEDIS® results are available upon request. Contact the Health Plan’s Quality
Improvement Department.
