Provider Manual

Quality Improvement Program

This section describes the program Commonwealth Care Alliance has designed to ensure the provision of the highest possible quality health care to its members.

Overview

Commonwealth Care Alliance is committed to providing the highest quality, most effective health care to its members. In pursuance of this, Commonwealth Care Alliance's framework for quality improvement is designed to integrate quality assessment and performance improvement activities throughout all levels of its care delivery system. As a "consumer governed" organization, Commonwealth Care Alliance's Quality Program is structured to ensure that the consumer's perspective is built in to all elements of its quality assurance activities. An underlying tenet of the program is that a true partnership between those receiving care and those providing and managing care can promote autonomy, independence, and better health outcomes.

The Quality Program is designed to:

Understand the needs, expectations, and satisfaction of members and caregivers and implement improvements to incorporate these perspectives into care delivery and system operations
Continually improve organizational and clinical processes throughout the delivery system based upon analysis of available data and clinical, administrative, and member input from across the network
Improve clinical quality by identifying and disseminating best clinical practices throughout the network

Program Objectives

To assure the effective, timely and safe delivery of care and care coordination to members at the optimal level of quality
To assess and evaluate the quality and appropriateness of care across the provider network
To design effective mechanisms for problem identification, assessment and resolution at the individual, practice site, and system-wide levels
To assess, evaluate and monitor key areas of clinical care and care coordination and identify opportunities for improvement when indicated
To promote mechanisms for the integration of risk management, utilization review and other activities in a comprehensive quality Improvement program
To identify deviations from standards and address such deviations in a manner that optimizes health outcomes
To ensure that professional competency and practices are routinely and reliably monitored and evaluated
To ensure program compliance with state, federal, contractual and other regulatory requirements

Quality Program Structure

Board of Directors

The Board of Directors is comprised of up to 15 members appointed by Commonwealth Care Alliance's corporate members; the two consumer advocacy groups Health Care for All and Boston Center for Independent Living and assumes final authority and responsibility for quality of care and professional practices including:

Approval of Commonwealth Care Alliance's annual Quality Program
Recommendations related to Commonwealth Care Alliance's quality assessment and performance improvement activities

The Board of Directors delegates responsibility for the development and oversight of Commonwealth Care Alliance's Quality Program to the President/Chief Executive Officer/Chief Medical Officer who delegates responsibility for components of the program to Commonwealth Care Alliance clinical staff.

Patient Care Assessment Committee

The Patient Care Assessment Committee (PCAC) is a committee of the Board, chaired by a member of the Board of Directors and staffed by Commonwealth Care Alliance's Medical Director. Membership is inclusive of Board representatives and multi-disciplinary clinical representation, drawn from the Commonwealth Care Alliance provider network. Among the responsibilities of the PCAC is the development, approval, and monitoring of the organization's annual Quality Program workplan and evaluation, approval of practice guidelines, and the oversight of all delegated and non-delegated credentialing activities.

Ethics Committee

The Ethics Committee is a subcommittee of the PCAC, comprised of clinical professionals both internal and external to Commonwealth Care Alliance, with a particular focus on those bringing an expertise in the area of medical ethics. Among the responsibilities of the Ethics Committee is the provision of input into decision-making with regard to end-of-life issues and advance directives.

Quality Committee

The Quality Committee is an internal Commonwealth Care Alliance committee whose responsibilities include the development, coordination, and facilitation of all quality improvement activities throughout the organization, including monitoring and evaluation, and the development of the organization's annual Quality Program workplan for recommendation to the PCAC for review and approval.

The Quality Committee assumes responsibility for:

Designating areas to be monitored and evaluated
Generating suggestions for quality improvement activities
Designing mechanisms for problem identification and prioritization, assessment, resolution, and follow-up evaluation
Selecting criteria for monitoring activities
Reviewing and analyzing all monitoring activities and assisting in developing focused improvement plans
Evaluating the annual Quality Program with regard to its effectiveness in addressing issues of quality of patient care and professional practice
Reviewing policies and procedures annually and as needed, related to implementation of quality improvement initiatives

Utilization Management Committee

The Utilization Management Committee, a standing committee of Commonwealth Care Alliance, oversees the development and implementation of an effective utilization management program. The Utilization Management Committee is responsible for monitoring the quality, continuity, and coordination of care, including monitoring for overutilization and underutilization of services. These activities are coordinated closely with Commonwealth Care Alliance's Quality Program.

Utilization Management Committee responsibilities include the regular review, monitoring and analysis of utilization and cost information associated with the delivery of care and services to members across the network. Members are appointed by Commonwealth Care Alliance's Chief Medical Officer and include appropriate Commonwealth Care Alliance clinical staff, consultants, and multidisciplinary clinical representation from the provider network, as well as others as appropriate on an ad hoc basis.

Quality Improvement Program Scope

Commonwealth Care Alliance has identified 14 domains of quality in which we focus our evaluation and measurement efforts and for which numerous specific measures are monitored with specific performance goals for improvement based on key criteria. The domains include:

Access to care
Evidence-based care
Safe care
Consistent care
Coordinated care
Continuity of care
Compassionate care
Culturally competent care
Care in the community
Member empowerment
Member health status
Member satisfaction
Provider satisfaction
Provider competency

Quality Program Workplan

Commonwealth Care Alliance annually chooses activities that facilitate the organizations achievement of its quality improvement goals. Activities are tracked in the Commonwealth Care Alliance Quality Program workplan.

Annual Quality Program Evaluation

The Board of Directors, Patient Care Assessment Committee, and the Quality Committee review the annual Quality Program workplan and assess the results of the plan annually. This evaluation guides next steps and the development of a quality program workplan for the coming year.

Confidentiality

All persons participating in quality improvement activities adhere to Commonwealth Care Alliance's confidentiality policy which is compliant with HIPAA rules and regulations. Results of improvement activities and reports do not contain any identified patient information, and if necessary, are coded or reported in aggregate. All information generated by improvement activities is protected by applicable state/federal laws and regulations.

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Last Updated 1/19/12

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