Quality Management (QM) Program Goals and Objectives
The goals and objectives of the QM Program are: To improve the quality of medical and behavioral health care and service provided to Members through administrative simplification and a comprehensive and ongoing system of monitoring measurable performance indicators (including indicators based on high-volume, high-risk, and problem-prone services, data from customer satisfaction surveys, complaints/occurrences, and appeals, and other relevant sources), evaluating results relative to established goals and benchmarks, and acting to promote improvement To maintain a process for adopting and updating both preventive health guidelines and nonpreventive (i.e. acute and chronic) clinical practice guidelines for both medical and behavioral health related conditions which are evidence-based, ensuring dissemination to Plan practitioners and Members to facilitate decision-making about appropriate health care for specific clinical circumstances To identify, develop, and/or enhance activities that promote Member safety and encourage a reduction in medical errors. This includes medication errors through a program of Member and practitioner/provider focused educational initiatives and profiling activities, that may include, but are not limited to, data from claims, medical record reviews, surveys, complaints/ occurrences, and pharmacy claims To ensure a network of qualified practitioners and providers by: – demonstrating compliance with all applicable accrediting and regulatory credentialing/ recredentialing requirements. – including language in practitioner/provider contracts requiring participation in the QM Program and access to medical records. To promote communication with practitioners/providers of care/service about quality activities, providing feedback on results of plan-wide and practice-specific performance assessments, and collaboratively developing improvement plans To disseminate information on...
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