PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

in the provision of care and service to Parkland KIDSfirst, Parkland CHIP Perinate, and Parkland CHIP Perinate
Newborn members. Final authority for implementation of the Quality Program rests with the governing board.
The monitoring and evaluation of clinical care reflects all components of the delivery system and the full range
of services. The delivery system includes both individual practitioners and institutional providers. The
monitoring and evaluation of services includes availability (number and geographic distribution of practitioners,
appointment availability, etc.), accessibility (practitioners and PCHP phone systems, after-hours coverage, etc.),
and acceptability (appropriate services delivered in the appropriate manner).
PCHP annually assesses the effectiveness of its QAPI Program for the previous SFY measurement period,
supported by presentation of results, analysis, and actions taken in the measurement period. Meaningful issues
are selected for study and improvement based on the health needs of significant groups within the population.
Ongoing improvement issues include improving preventive health visits, reducing unnecessary emergency room
visits, improving access and availability of care, and perinatal care.
Continuity and coordination of care is evaluated across health care settings and practitioners. Methods can
include medical record review for presence of advance directives, discharge plans, and signing of abnormal test
results; evaluation of the referral process, case management interventions, systems for tracking and notifying
practitioners of abnormal lab/radiology results.
Mechanisms are also in place to identify patterns of under- and over- utilization. Methods can include doctor
profiles, review of practitioner performance against practice guidelines, trending and tracking of complaint data,
sentinel events and adverse outcomes, and number of member encounters per Primary Care Provider.
Access and availability of care are monitored through appointment availability for preventive care, routine
primary care and urgent care, 24 hours access, number and geographic distribution of Primary Care Providers,
and phone service standards.
All aspects of member care and satisfaction are important to Parkland KIDSfirst, Parkland CHIP Perinate, and
Parkland CHIP Perinate Newborn. Provider participation in PCHP and CHIP sponsored training programs as
well as the aforementioned issues are carefully scrutinized and Parkland KIDSfirst, Parkland CHIP Perinate,
and Parkland CHIP Perinate Newborn work in conjunction with the cooperation of their doctor and facility
partners to maintain a program of the highest quality. PCHP complies with all HHSC and Texas Department of
Insurance (TDI) requirements pertaining to the QAPI Program.
Practice Guidelines
Clinical Practice Guidelines summarize evidence based management and treatment options for specific diseases
or conditions. They are based on scientific clinical and expert consensus information from nationally
recognized sources and organizations such as the National Institute of Health, the American Academy of
Pediatrics, the center or Disease Control and Prevention, the National Heart Lung and Blood Institute, the
American College of Obstetrics and Gynecology, national disease associations and peer-reviewed, published
literature.
Practice guidelines are developed from national guidelines and adopted locally through the Medical Advisory
Committee that includes practicing physicians who participate in the Plan. This group also suggests topics for
guideline development, based on relevance to enrolled membership, with selection of high volume, high risk,
problem prone conditions as the first priority. PCHP guidelines can be located in the appendices of this
Provider Manual.
The intent of the guideline is to promote consistent application of evidence-based treatment methodologies to
reduce unnecessary practice variation. Guidelines are also used to measure the impact of health management
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