Quality Improvement

Quality Improvement

The Quality Improvement (QI) Department identifies opportunities for improvement of care and services to both our members and providers. This is accomplished by assisting with the identification, investigation, implementation and evaluation of corrective actions that continuously improve and measure the quality of clinical and administrative service. This Quality Improvement Program covers all lines of business, including but not limited to, Medi-Cal and Medicare. A formal evaluation of the Quality Improvement functions is performed annually.

Focus Area

Specific key elements of focus for the Quality Improvement Department may include but are not limited to:

  • Provider accessibility and availability
  • Provider satisfaction
  • Provider credentialing
  • Clinical practice guidelines
  • Under and over utilization
  • Adverse outcomes/sentinel events
  • Medical record keeping practices
  • Facility site reviews
  • Member satisfaction/grievances
  • Timeliness of handling claims
  • High risk and high volume services
  • Oversight of IPA QM function

The Quality Improvement Program is designed to objectively and systematically monitor and evaluate the quality, appropriateness and outcome of care and services delivered to our members and to provide mechanisms that continuously pursue opportunities for improvement and problem resolution.

QI Annual Evaluations/ Program Goals

administers a robust ongoing Quality Improvement Program with a goal to ensure that members receive the highest quality of care and services.

Provider Notifications/Updates (NCQA )

Initial Health Assessment (IHA)

Facility Site Review Policy and Procedures

Site Accessibility by individuals with physical disabilities; Fire Safety and Prevention and Emergency Non-Medical Procedures; Medical and lab equipment maintenance; Emergency healthcare services; Staff qualifications... Click on the following link for the complete Facility Site Review Policy and Procedures.

Quality Improvement Incentive Program (Q.I.I.P)

More on Quality Improvement

Access to Care Standards, Provider Survey Results, Survey Results (CAHPS®), Study Results (HEDIS®), Click here!