The Health Plan of San Joaquin (HPSJ) is a Knox-Keene state licensed health care service plan operating under the regulatory oversight of the California Department of Managed Health Care (DMHC). HPSJ is contracted with the State of California Department of Health Care Services (DHCS) to serve as the local initiative in San Joaquin County and Stanislaus County for the Medi-Cal beneficiaries, and the Managed Risk Medical Insurance Board (MRMIB) to serve the Aid for Infants and Mothers (AIM) Program. The AIM Program offers full scope health benefits for pregnant women who qualify for the program in San Joaquin and Stanislaus Counties. San Joaquin Health Administrators serves as a Third Party Administrator for The County of San Joaquin, whose benefit plans are designed and funded by the County.
The Quality Management and Improvement (QMI)Plan is designed to meet the contract requirements set by the State of California and the Health Plan Standards established by the National Committee for Quality Assurance (NCQA). HPSJ is currently preparing for NCQA Accreditation Survey to be conducted in May, 2015.
STATEMENT OF PURPOSE
The purpose of the Quality Management and Improvement (QMI) Program Description is to describe the framework within HPSJ’s organization that continuously assesses, plans, implements, evaluates and improves the quality of care and services rendered by our network providers and received by our members and participants. The QMI Program Description shall support HPSJ’s mission and vision through the development and maintenance of a quality driven network of care for all lines of business. The QMI Program Description provides a clear definition of authority for the QMI Program, its relationship to other components and departments within the organization, and its accountability to the governing body of the organization. This document describes the program’s mission, philosophy, goals, objectives, and staff and committee hierarchy. The Program Description, along with the attached Work Plan, outlines the major initiatives the QMI Program will undertake in the coming year.
HPSJ is committed to ensuring that Continuous Quality Improvement (CQI) occurs within our organization, as well as, throughout our provider network. The Quality Management Department is structured to facilitate ongoing quality improvement processes and activities throughout each department. All department leaders and other identified stakeholders play critical roles in developing and evaluating the annual Quality Management & Utilization Management (QMUM) Work Plan. The Director of Quality Management provides the Quality Operations Committee (QOC) and the Quality Management & Utilization Management Committee with regular subcommittee updates in addition to briefings on the progress of the annual QMUM Work Plan.
It is through the collaborative efforts of all identified stakeholders that the goals of the QMI Program are met. Therefore, the QMI program is structured to include the participation and collaboration of staff, the provider network, contracted health plans, state agencies and members. Staff is trained in continuous quality improvement principles. Quality Improvement team members receive tools, techniques and training to aid them in their quality improvement activities. Quality improvements are made through ongoing work with representatives of relevant clinical and medical systems, such as, mental health and substance abuse practitioners, primary care practitioners and administrative staff. Our QI efforts are further enhanced through consultation with our partner health plans to which we may delegate quality management, credentialing, member rights and responsibilities, and utilization management functions, along with state agencies and other subject matter experts.
SCOPE OF QMI PROGRAM
The scope of the QMI Program is comprehensive and addresses both the quality and safety of medical and behavioral health care provided to our members and participants for all lines of business. Behavioral Health care is a benefit for the Medi-Cal and AIM members and is administered by HPSJ. For Medi-Cal members HPSJ delegates the behavioral health services for members with behavioral health conditions with mild and moderate levels of impairment. Behavioral health services for members with severe functional impairment are “carved out” of the contract by the state to the County Behavioral Health System. Coordination of medical and behavioral health care is an integral part of HPSJ’s Care Management Program.
The QMUM Work Plan delineates the critical performance measures that define the scope and range of the Quality Management and Improvement Program.
- Accessibility of services
- Availability of services
- Grievances and Appeals
- Clinical quality improvement
- Service quality improvement
- Adverse outcomes/sentinel events
- Member satisfaction/experience (CAHPS)
- Practitioner satisfaction/experience
- Clinical practice guidelines
- Continuity and coordination of care
- Effectiveness of the quality improvement program
- Patient safety
- Delegation Oversight
Other areas that have an impact on the QMI Program include:
- Practitioner/Provider credentialing and re-credentialing
- Utilization management processes and outcomes
- Inter-rater reliability testing
- Practitioner performance
- Pharmacy management
- Facility site reviews
- Data Governance
QUALITY MANAGEMENT AND IMPROVEMENT PROCESS
PLAN-DO-CHECK-ACT (PDCA) is the continuous quality improvement model utilized by HPSJ.
QUALITY MANAGEMENT AND IMPROVEMENT PROGRAM GOALS
The goals of the QMI Program are to:
- Promote an organization-wide commitment to quality of care and service with strong leadership involvement in improving quality.
QUALITY MANAGEMENT AND IMPROVEMENT PROGRAM OBJECTIVES
The objectives of QMI Program are to:
- Align all organizational wide performance improvement activities with strategic goals.
- Review and redefine as necessary the authority, responsibility, and information flow for the redesigned measurement, analysis, and improvement process.
CULTURAL AND LINGUISTIC (C&L) PROGRAM
The C&L program is managed by the Health Education/Cultural and Linguistic Administrator (HECLA), who is responsible for assessing the cultural and linguistic and health education needs of our membership and implementing appropriate actions based on the assessment.
HPSJ provides behavioral health services for members with mild and moderate functional impairment and the services for members with severe impairment are carved out to the County Behavioral Health Services Agencies. To ensure the coordination and delivery of medically necessary behavioral health care services HPSJ has established a Memorandum of Understanding with San Joaquin and Stanislaus Behavioral Health Service Agencies that provide screening and interventions for members with Severe Mental Health outpatient and inpatient needs. HPSJ has contracted with Beacon Health Services and College Health IPA to provide screening, care coordination and management of members with Mild-to-Moderate Mental Health outpatient behavioral health needs.
ORGANIZATIONAL STRUCTURE LEADERSHIP AND ACCOUNTABILITY
The San Joaquin County Health Commission (CHC) has the ultimate authority and responsibility for the management of quality of care and service delivered by HPSJ. The CHC is HPSJ’s governing body whose role it is, is to oversee, approve, promote and support the strategic plan, goals and objectives. The CHC has the ultimate responsibility for the direction and oversight of the QMI program. The CHC:
- Reviews and approves the annual quality improvement program description.
- Reviews and approves the annual quality improvement work plan.
- Reviews and approves the annual quality improvement program evaluation.
- Reviews and approves other reports about quality improvement activities as provided by the Quality Management Utilization Management Committee.
- Ensures appropriate resources to implement the quality improvement program.
Chief Medical Officer (CMO)
HPSJ maintains 1 (one) full time Chief Medical Officer who has an unrestricted license in the state of California as a physician in the field of medicine. The CMO reports to the Chief Executive Officer and communicates directly with the County Health Commission, as necessary. The CMO has ultimate responsibility and oversight for the QMI Program and activities.
Medical Director (MD)
HPSJ maintains one full time Medical Director who has a valid, unrestricted license in the state of California as a physician in the field of medicine. The MD reports to the CMO and is responsible for managing the operations of the Medical Management Department.
Assistant Medical Director (AMD)
Provides clinical decision-making and support in a manner that ensures the delivery of quality health care that supports organization objectives and meets contractual and regulatory requirements. The AMD’s report to the Medical Director
Behavioral Health Medical Director (BHMD)
A psychiatrist with an unrestricted license issued by the state of California serves as Behavioral Health Services Medical Director and is an active participant on the QMUM Committee. The psychiatrist is involved in all behavioral aspects of the QMI Program and provides input on all behavioral health care related issues, and policies and procedures. The BHMD serves as a resource to other Committees and staff regarding behavioral health issues; and participates in the development or revision of behavioral health: clinical practice guidelines, medical necessity criteria, new technology assessment processes and performance and outcomes measures.
Director of Quality and Disease Management (DQDM)
The DQDM is a licensed Masters prepared Registered Nurse, responsible for the direct oversight, supervision and management of the QMI Program activities. The DQDM reports to the CMO.
Quality Management Manager (QMM)
The Quality Management Manager is a Registered Nurse licensed by the State of California. The QMM reports to the DQDM and is responsible for developing, planning and implementing the Quality Management and Improvement Programs for HPSJ.
Director of Case and Utilization Management (DCUM)
The DCUM reports to the CMO and is a BSN prepared clinician, responsible for the direct oversight, supervision and management of the Case and Utilization Management Program activities.
Director of Clinical Programs (DOCP)
The DOCP reports to the CMO and is a pharmacist with an unrestricted license issued by the State of California who oversees the integrity of quality data collection, reporting and analysis.
Director of Pharmacy (DOP)
The DOP is a pharmacist with an unrestricted license issued by the State of California. The DOP reports to the CMO and is responsible for the overall management and supervision of pharmacy personnel and the Pharmacy Benefit Manager.
Compliance Officer (CO)
The Compliance Officer reports to the CEO and is responsible for oversight and management of all compliance related issues within the organization
The QMI Program has staff and analytic resources available to achieve program objectives.
FUNCTIONAL AREAS WHICH SUPPORT THE QMI PROGRAM
- Member Services
- Provider Services
- Contracting/Network Development
- Utilization Management
- Privacy and Security
- Information Technology
- Assoc. Medical Directors
HPSJ is committed to a culture of “patient safety” as a high-level priority. On an ongoing basis, HPSJ fosters a Patient Safety culture that is communicated throughout the organization. HPSJ is committed to developing and implementing activities to improve patient safety and clinical practice.
ANNUAL QUALITY MANAGEMENT AND IMPROVEMENT PROGRAM EVALUATION
An evaluation of the QMI Program is completed at the end of each fiscal year. The annual evaluation is conducted by the QM staff in conjunction with designated department leaders.
QUALITY MANAGEMENT AND IMPROVEMENT WORK PLAN
The quality management and improvement work plan is the schedule of activities for the QMUM Programs. The QMUM work plan is not a static document. It is approved annually by the QMUM Committee but is revised and developed more fully in response to the analysis of performance data, interventions, remeasurement timeframes and the addition and deletion of indicators on an ongoing basis.