Peach State Provider Office Manual - Peach State Health Plan ...

PROVIDER REVIEWThe Peach State Quality Improvement Program includes review of processes followed in theprovision of health services, through oversight of the QIC Committee. The QIC contains at leastfive participating physicians from varying specialty areas including Family Practice, Pediatrics,Obstetrics & Gynecology, and Psychiatry. The ad hoc members of the QIC Committee includerepresentatives from other departments of Peach State. The QIC and its subcommittees functionas Peer Review Committees as needed to conduct appropriate confidential peer review activities.FEEDBACK ON PHYSICIAN SPECIFIC PERFORMANCEAs part of the re-credentialing process, performance data on each provider is reviewed andevaluated by the Credentialing Committee. This review of provider specific performance datamay include, but is not limited to:• Site evaluation results including medical record audit, appointment availability, after hoursaccess, cultural proficiency and in office waiting time• Preventive care, including Health Check exams, immunizations, lead screening, andscreening for detection of kidney disease• Prenatal care• Complaint and appeal data• Utilization management data including referrals/1000 and bed days/1000 reports• Sentinel events and/or adverse outcomes• Compliance with clinical practice guidelinesFEEDBACK AFTER FOCUSED STUDIESResults from focused studies and audits are shared with providers either at the time of the auditor by follow-up letter. These studies may include perinatal care, asthma management andimmunizations.FEEDBACK OF AGGREGATE RESULTSAggregate results of studies and guideline compliance audits are presented to the QI Committee.Participating physician members of the QIC provide input into action plans and serve as a liaisonwith physicians in the community. Aggregate results are also published in the quarterly providernewsletter or a special provider mailing may be distributed.At least annually, a provider relations specialist meets with primary care providers and highvolume specialists to review policies, guidelines, indicators, medical record standards, andprovide feedback of audit/study results. These sessions are also an opportunity for providers tosuggest revisions to existing materials and recommend priorities for further initiatives. When aguideline, indicator, or standard is developed in response to a documented quality of caredeficiency, Peach State disseminates the materials through an in-service training program toupgrade providers' knowledge and skills. The Peach State Medical Directors and Pharmacist alsoconduct special training and meetings to assist physicians and other providers with quality andservice improvement efforts.104Provider Services1-866-874-063302/22/2011