Programa de mejoras de calidad

La misión de EmblemHealth es crear futuros más saludables para nuestros clientes y comunidades. We do this by valuing and respecting EmblemHealth’s customers, partners, and employees; committing to building a culture of inclusion; being nimble and proactively seeking out opportunities to improve and innovate; and developing partnerships and working together.

El alcance de las actividades dentro del Programa de mejora de calidad brinda un marco para controlar y evaluar aspectos significativos de la atención y el servicio que se brindan a los miembros del plan de salud y sus sistemas de entrega de servicio. EmblemHealth takes an active role in helping its members stay healthy, get better quickly, and live effectively with illness. Measures for monitoring important aspects of medical care, mental health care, and quality of service, including patient safety, have been developed and implemented. Incluyen:

  • Quality of care, including continuity and coordination of care.
  • Quality of service.
  • Patient safety.
  • Utilization management program.
  • Member and provider satisfaction.
  • Accessibility.
  • Availability.
  • Delegation. 
  • Member complaints, grievances, and appeals.
  • Member decision support tools.
  • Cultural diversity.

El Programa de mejora de calidad se evalúa una vez por año y se modifica según sea necesario. En el plan de trabajo anual de mejora de calidad, se establecen los detalles del programa y el plazo para completar el proceso de evaluación. The status of the work plan items is updated quarterly and reviewed by the Quality Improvement Committee. Se realiza una evaluación anual del programa para resumir y analizar la efectividad del Programa de mejora de calidad. Esto ayuda a determinar el plan para el año siguiente.

 

We use various data sources to measure quality improvement processes and outcomes, determine barriers to improvement, and identify ways to improve quality and overcome obstacles. Las fuentes de datos incluyen:

  • Appeals data.
  • Applicable Care Management programs/initiatives databases. 
  • Mental health data.
  • Encounter data (data showing use of provider services by health plan enrollees).
  • CAHPS®1(Consumer Assessment of Healthcare Providers and Systems).
  • Claims data.
  • Complaints from doctors and members.
  • Enrollment data. 
  • Health Outcomes Survey (HOS) data.
  • HEDIS®2(Healthcare Effectiveness Data and Information Set).
  • Integrated data collection systems that collect member and provider information.
  • Laboratory data.
  • Medical records.
  • National and regional epidemiological demographic and census data. Epidemiology is the study of the distribution and causes/risk factors of health-related states and events in specified populations.
  • Utilization review data. 
  • Pharmacy data.
  • Population-based member information.
  • QARR (Quality Assurance Reporting Requirements).
  • Quality Compass®.3
  • Quality improvement projects/studies.
  • Telephone response data.
  • Utilization review data.
  • Various provider and member surveys.

El software incluye, entre otros, sistemas de reclamaciones, software HEDIS aprobado por el Comité Nacional para el Control de Calidad, software de acreditación y reacreditación, productos de Microsoft y otros sistemas para dar apoyo a las intervenciones clínicas y de servicios.

 

Autoridad y responsabilidad del Programa de mejoras de calidad
The Boards of Directors of the EmblemHealth companies, through the EmblemHealth, Inc. Quality Committee, oversee the Quality Improvement Program. La responsabilidad general para ejecutar el Programa de Mejora de Calidad reside en el Comité de Mejora de Calidad de EmblemHealth. Various committees and subcommittees support the functions of the Quality Improvement Program and report their activities to the Quality Improvement Committee. La responsabilidad operativa ha sido delegada a los directores de los departamentos correspondientes. A broad spectrum of medical professional involvement, including designated medical and behavioral health doctors, occurs through the Quality Improvement Committee structure.

 

El Comité de Mejoras de Calidad es responsable de lo siguiente:

  • Recomendar y aprobar las políticas.
  • Planificar, diseñar, implementar, coordinar y analizar las actividades de mejoras de calidad.
  • Instaurar las accesiones de mejoras necesarias y garantizar el seguimiento adecuado.
  • Ensuring provider participation in the Quality Improvement Program through the process of planning, design, implementation of activities, committee participation, and/or review.

Learn more about the Quality Improvement Program.

 

Si no puede imprimir esta información y le gustaría recibir una copia impresa, llame al Departamento de Control de Calidad al 888-447-5451. Leave a message with your name and address, and we will send a printed copy to you.

 

1CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).
2HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA)..
3
Quality Compass® is a registered trademark of the National Committee for Quality Assurance (NCQA).

 

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