We want our members to receive the best care. We have a Quality Improvement (QI) Program to help us meet this goal and to fix any problems that we find. The QI Program is designed to continuously improve the health of our members and their healthcare experience. Each year we set higher goals to improve the service we provide. Through the use of different data sources, the Alliance can measure the effectiveness of our initiatives, identify opportunities for improvement, and implement interventions designed to support our providers and members.

Contact

Provider feedback is important to the success of our QI program. If you would like to share your suggestions about our QI program, or to request more information about the Alliance’s QI Program or to request a paper copy of our detailed QI Program Description, please contact:

Program Description and Work Plans

Program Goals

Below are program goals for the QI program:

  • Help doctors and hospitals improve quality of care
  • Help members get the best care
  • Increase member and doctor satisfaction
  • Measure and improve the quality of our service
  • Protect member information

Program Scope

The scope of the QI program is comprehensive and encompasses major aspects of care and service in the Alliance delivery system, and the clinical/non-clinical issues that affect our membership.

These include:

  • Acute, chronic, and preventive care services for children and adults
  • Availability and access to care, clinical services, and care management
  • Case review of suspected instances of poor quality
  • Clinical practice guideline development, compliance, and revision
  • Continuity and coordination of care
  • Credentialing and recredentialing services.
  • Cultural and linguistic issues
  • Member and provider satisfaction
  • Patient safety
  • Perinatal, primary, specialty, emergency, inpatient, and ancillary care
  • Special needs populations including Seniors and Persons with Disabilities or persons with chronic conditions
  • Utilization trends including over-and under-utilization

Methods and Procedures

The Alliance uses several methods to identify aspects of care that are the focus of QI activities.

CAHPS®

Annually, the Alliance measures member satisfaction using the CAHPS® (Consumer Assessment of Healthcare Providers and Systems) survey. Also known as the Member or Patient Experience, the survey looks at health plan performance and members’ experiences in the provider office. The survey is sent to members and parents of child members every spring. The Alliance uses the survey results to identify opportunities to improve member satisfaction. For more information about CAHPS®, please click here.

HEDIS®

The Alliance’s QI strategies focus on measurement of quality and identifying opportunities for improvement. One way we assess our quality of care is through HEDIS (Healthcare Effectiveness Data and Information Set). For more information about HEDIS® and tools to help you with the HEDIS® measures, please click here.

Other Data Sources

Data sources used to identify areas of improvement also include, but are not limited, to the following:

  • Claim and encounter submissions
  • Credentialing, medical record review, and audit findings
  • Pre-service, concurrent, post-service and pharmacy utilization review data
  • Member and provider grievance and appeal data
  • Potential Quality Issue tracking/trending data

Annual Work Plan

The Alliance prepares an annual QI Work Plan that describes the quality management goals and objectives, planned projects, and activities for the year, including continued follow-up on previously identified quality issues, and a mechanism for adding new activities to the plan as the need is identified. The work plan delineates the responsible party and the time frame in which planned activities will be implemented.

The work plan addresses the following:

  • Evaluation of the QI program
  • Monitoring previously identified issues
  • Program scope
  • Quality of clinical care
  • Quality of service
  • Safety of clinical care
  • The staff member responsible for each activity
  • Time frame within which each activity is to be achieved
  • Yearly objectives
  • Yearly planned activities

To view the Alliance QI Department Work Plan, please click here.

Population Needs Assessment

The Population Needs Assessment (PNA) is an annual report that describes Medi-Cal member demographics, disease prevalence, health disparities, gaps in programs, and planned actions to resolve identified gaps. The goal of the PNA is to improve health outcomes and ensure that the Alliance is meeting the needs of all its Medi-Cal members.