Purpose

The Quality Improvement (QI) Program is designed to provide a formal ongoing process by which the health plan, participating providers and practitioners utilize objective measures to monitor and evaluate the quality of services, both clinical and administrative, provided to members. This program, which addresses both general medical and behavioral health care and services, defines and facilitates a systematic approach to identify and pursue opportunities to improve services and resolve identified problems.  The QI Program is updated, reviewed and approved by Paramount’s Medical Advisory Council and Board of Directors on an annual basis. It is also reviewed by applicable regulatory bodies as required.

Goals and Objectives

Specific program objectives have been developed to guide quality improvement activities. The objectives of the QI Program are:

• To continuously improve both clinical and administrative service delivery to members through a systematic process of monitoring critical performance indicators and implementing specific strategies to improve the process, safety, and outcomes of all services provided to members
• To support the appropriate integration of general medical and behavioral health clinical care provided to members
• To annually evaluate the overall efficiency and effectiveness of the QI Program, including its structure, processes and outcomes
• To assure that all members are treated with dignity and respect, and are provided with appropriate patient education and information necessary to actively participate in personal health care decisions
• To promote the use of evidence-based guidelines as the basis for clinical decision making
• To integrate and support public health goals into clinical quality improvement activities as appropriate
• To maintain regulatory compliance related to plan Quality Assurance and Improvement activities
• To maintain a commendable or excellent accreditation status with the National Committee for Quality Assurance (NCQA)

Paramount works in cooperation with participating hospitals, physicians and other providers and practitioners to assure the quality and safety of patient care services. Paramount focuses upon those quality improvement activities unique to its role as a Health Maintenance Organization.

The Quality Improvement Process

Paramount is committed to the application of the continuous quality improvement cycle for clinical services.  Quality indicators are applied across all product lines (commercial, Medicaid, Medicare).  Clinical monitors cross all demographic groups (from infants and children to older adults), inpatient and outpatient care settings and types of services (preventive, acute and chronic care provided by primary care physicians and specialists, including behavioral health).  The process is based on the principles of management by fact and the "Plan, Do, Check and Act" cycle.

The QI Work Plan specifies actions and time frames for each individual quality improvement project. The process for developing and implementing a quality improvement plan is as follows:

1. A problem is identified through a variety of sources (e.g., member complaints, providers, over or under utilization, clinical quality or safety, or administrative quality indicators).
2. The issues with the greatest impact on the enrolled population are identified based on demographics, utilization and cost of care.  Quality indicators are then selected (i.e., it is determined what will be measured and how it will be measured).  Through this step, it is determined what data is appropriate for measurement.
3. Data is collected and reviewed for performance and/or outcomes.
4. Targets for improvement are set.
5. A specific work plan is developed that will lead to improvement in performance and/or outcomes.
6. The plan is approved or modified as necessary and implemented.
7. After an appropriate time period, new data may be gathered to assess the success of the plan for improvement or data may be gathered at regular intervals on an ongoing basis for continuous assessment of performance.
8. Through analysis of the data, barriers to improvement are identified.
9. Based on the analysis, a decision is made regarding the next step:
   a. Continue the process as is with the same indicators/data monitoring
   b. Continue the process with modifications (i.e., implement additional interventions to remove identified barriers)
   c. Add new monitors/quality indicators
   d. Stop monitoring
10. New thresholds are developed or current targets are maintained.
11. A new work plan is developed.

This process is applied to clinical, service and administrative indicators. The quality indicators and quality improvement work plans are compiled into the corporate QI Work Plan, which is evaluated at least annually. For clinical indicators, the evaluation is reviewed by the Medical Advisory Council, which then provides assistance with the development of the new work plan. Administrative indicators are developed by individual operating departments and are approved by the respective vice presidents.  Performance is reviewed by the Administrative Staff through quarterly and annual reports. The Board of Directors reviews the corporate QI Evaluation and QI Work Plan on an annual basis as part of its oversight of the entire quality improvement process.

Documentation of Paramount's implementation of the QI cycle is provided in three major documents.  To request copies of any of these documents, call Member Services at 419-887-2525 or 1-800-462-3589, or by email at phcquality@promedica.org.

Quality Improvement Program Description

The QI Program Description is a general description of Paramount’s QI program.  This document is updated and approved annually by the Medical Advisory Council, the Administrative Staff and the Board of Directors.

Quality Improvement Evaluation

The QI Evaluation is an annual evaluation of the prior year's quality improvement activities, which includes recommendations for the next year. This document is updated and approved annually by the Medical Advisory Council, the Administrative Staff and the Board of Directors.

Quality Improvement Work Plan

The QI Work Plan is a detailed, two-year work plan and timetable for the health plan's clinical and service quality improvement activities for the current and subsequent calendar years. The QI Work Plan is developed as an outgrowth of the evaluation of the previous year's QI activities and incorporates the recommendations from that evaluation. This document is updated and approved annually by the Medical Advisory Council, the Administrative Staff and the Board of Directors.

Quality Improvement Activities

Based upon the impact on the enrolled population, continuing needs of the diverse populations served, regulatory requirements, employer group expectations and a review of the cost and frequency of services, the Medical Advisory Council supported the development of clinical quality improvement initiatives focused on these specific areas:

• Acute low back pain
• Advance directives
• Adult and pediatric immunizations
• Adult and pediatric asthma
• Adult and pediatric preventive health
• Alcohol screening and intervention
• Cardiovascular disease risk reduction
• Cholesterol management
• Chronic heart failure
• Hypertension
• Diabetes
• Pre-diabetes
• Breast cancer screening
• Cervical cancer screening
• Management of menopause
• Gastrointestinal disease management
• Health promotion for older adults
• Senior risk assessment and management process
• Reminder system for preventive and disease management services
• HEALTHCHEK exams in the Paramount Advantage population
• Prenatal and postpartum care
• Depression management
• Medical records standards
• OB risk assessment
• Tobacco cessation

These topics influence preventive services, management of acute conditions, chronic illness and behavioral health services, and impact a large portion of the Paramount population, regardless of the product line in which the member is enrolled. Based on the Medical Advisory Council's recommendations, quality improvement activities focus on these areas to provide continuity and the ability to successfully assess the impact of specific interventions.