Quality Management Program description and plan

The Blue Cross and Blue Shield of Kansas (BCBSKS) Quality Management Program (QMP) is reviewed and approved by the BCBSKS Steering Committee annually. The Steering Committee (SC) delegates authority to the Quality Management Committee (QMC) to conduct QMP activities. The QMP is responsible for promoting systematic and objective measurements, monitoring and evaluating services and work processes, and implementing quality improvement activities based upon the reported outcomes. The QMP monitors both clinical and non-clinical services under the scope of URAC Health Plan, including BlueCross BlueShield Kansas Solutions (Solutions), Case Management (CM), and Disease Management (DM) accreditations. The QMP reviews performance measures from several sources including performance oversight of delegated health plan functions. BCBSKS provides staff and resources necessary to support the day-to-day operation of the QMP.

The QMP is under the clinical direction of the vice president of medical affairs division/chief medical officer. The QMC is responsible for oversight and direction of the QMP. The QMC ensures all applicable policies and procedures are reviewed and updated annually and acts as the approving body for URAC Health Plan, CM, and DM Quality Improvement Project(s) (QIP).

The Administrative Quality Committee (AQC) is not a component of the QMP. The AQC is a separate and distinct committee that conducts provider peer review quality of care investigations as defined and authorized by K.S.A. 65-4915. The activities and records of the AQC are maintained separately and are exempt from QMP oversight.

Quality Management Committee

Mission statement: Oversee health plan, case management, and disease management programs to ensure member and provider trust.

The QMC is an inter-departmental committee with representation from: customer service, provider relations, sales and marketing, regulatory compliance, medical affairs, legal, information technology, claims, and engineering services. Staff members who work directly with quality activities will also serve as members of the QMC. The QMC meets at least quarterly to review quality activities and to monitor any QIPs that it has approved. The QMC provides annual reporting to the BCBSKS steering committee.

Roles and responsibilities of the Quality Management Committee

• Monitor changes in federal, state, corporate, Department of Labor, HIPAA, and URAC standards/guidelines to promote compliance.
• Develop the QMP utilizing key indicators and measures of member and provider service, which may include clinical care, compliance rates and/or adverse events.
• Provider oversight for performance reporting for URAC Health Plan, CM, and DM activities including those that are delegated to another entity.
• Monitor Health Plan, CM, and DM audit results and member and/or provider surveys to promote quality improvements related to department processes.
• Monitor the tracking and trending of data related to member and provider service.
• Provide guidance to staff on quality management priorities and projects as well as recommend implementation of corrective action plans for identified problems and/or process improvement.
• Review QMC policies and procedures.
• Review, approve, and monitor the progress of QIP(s)/goals related to Health Plan, CM and DM activities that relate to key processes and performance measures.
• Facilitate communication of QMC activities to steering committee, department staff and providers as appropriate via meeting minutes, educational presentations, and departmental meetings.
• Evaluate the effectiveness of the QMP by conducting an annual evaluation.
• Communicate status of the QMP, and present the QMP description and plan to steering committee for approval annually.
• Maintain approved records of all committee meetings including reports, decisions, action items, meeting minutes, and attendees.

Quality improvement process

BCBSKS, as part of its Health Plan QMP, measures and analyzes data to improve performance in the areas of:  consumer satisfaction, access and availability surveys, HEDIS measures calculated from claims data, outcome reports of targeted quality improvement activities, and claims data. Performance measures may include, but are not limited to:

• Compliance with URAC Standards
• Access to services
• Complaints
• Provider, client, and member satisfaction
• Network adequacy
• Clinical quality outcomes
• Member safety

Applicable departments conduct analysis of measures by determining any trends directly related and relevant to quality of services realized by the consumer. If ongoing monitoring and measurements reveal improvement opportunities, individual departments will implement action plans or develop a quality improvement project (QIP) and present to QMC for approval. Status reports on all QMC approved QIPs are presented to the QMC at least quarterly to demonstrate improvement and the expected performance levels are being realized. These reports include quantifiable baseline measures and re-measures when appropriate. Once an acceptable level of performance is achieved, as defined by BCBSKS, periodic re-measurement of performance may be conducted to ensure sustained improvement.

Quality improvement project selection criteria

The QMC uses the following criteria to guide in the selection and prioritization of quality improvement projects. Projects are designed to support the overall quality measurement strategy approved by clinical leadership. Projects are designed to generate a measurable impact by attaining measurable performance goals and improve consumer health outcomes or internal work processes based on various factors (number of cost savings). Considerations include, but are not limited to:

• Degree (high>low) and nature (positive/negative) of consumer impact
• Financial considerations
• Ability to execute successfully
• Time constraints

Quality improvement projects

The QMC commissions a minimum of five ongoing quality improvement projects for URAC-governed health plan activities. At any given time, BCBSKS shall have underway no fewer than five QIPs for activities that address opportunities for error reduction or performance improvement.  For URAC Health Plan accreditation, a minimum of three QIPs will be active at all times: All three must focus on clinical quality and at least one of the three must address consumer safety for the population served. For CM and DM, each program must have two QIPs, one of which must address consumer safety for the population served. A single QIP can be submitted for two accreditations if it addresses the functions covered by both accreditations. Projects will relate to key indicators of quality, be member focused, and designed to improve performance. For Health Plan, clinical leadership staff members and at lease one participating provider will provide input for all clinical quality improvement projects. For CM and DM, if the QIP is clinical in nature, a senior clinical staff person will provide input on clinical quality measures and/or clinical aspects of performance.

All QIP requests for approval must contain informational elements from the URAC quality improvement project description form to ensure URAC elements are met.

Reporting QIP results to the QMC is based on incremental performance measurement periods as defined in each QIP which is quarterly or at a minimum annually. Reporting to QMC is accomplished via verbal and written reports from the appropriate department. If a QIP results are concerning, QMC has the right to have results reported for two more quarters to ensure sustainable results. QMC has the ultimate oversight for approval of any QIP and retiring any QIP.

Clinical Quality Improvement Committee (CQIC)

Under the direction of the QMC this team applies the quality improvement project selection criteria to prepare and recommend QIPs to QMC for approval. Approved QIPs and completed QIPs (which are typically monitored for a minimum of two years) are integrated into the annual quality strategies. This committee is led by the medical director of quality improvement, disease management, care coordination and medical policy; this person also is a member of QMC.
 

Steering committee approved: March 27, 2017.