2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Quality Improvement ProgramNational Committee for Quality AssurancePHP has participated in the National Committee forQuality Assurance (NCQA) accreditation programsince 2000 and Presbyterian Insurance Company,Inc., has participated since 2009. Presbyterian’sgoal is to achieve national excellence by earning an“excellent” NCQA Health Plan status in all HealthMaintenance Organization (HMO) and PreferredProvider Organization (PPO) products. This goalcan only be achieved with the combined efforts ofhealth plan employees, network practitioners, andproviders. In addition, PHP participates in theNCQA Medicare Advantage HMO and PPOdeeming program, which is available for healthplans participating with the Centers for Medicareand Medicaid Services (CMS) regulatoryrequirements.An “excellent” accreditation status is awarded tohealth plans that provide service and clinical qualitythat meets or exceeds rigorous requirements forquality improvement. Evidence shows that healthplans with an excellent NCQA status do more toimprove the health of their members.An NCQA health plan accreditation survey includesa review of quality improvement, utilizationmanagement, credentialing and recredentialing,member rights and responsibilities, and innovativecommunications using the internet. It also includesdelegation activities, improvement in clinicaleffectiveness of care measures, and improvementin member satisfaction. Health plans thatparticipate in NCQA accreditation are re-evaluatedannually to monitor quality care and service.Focus on ExcellencePresbyterian is guided by principles and practicesthat promote the continuous improvement ofbusiness operations, medical care, behavioralhealth care, and all services provided to membersand providers. Quality improvement structures andprocesses are planned, systematic, and clearlydefined. Presbyterian uses the Baldrige HealthCare Criteria for Performance Excellence. We alsoemploy process improvement tools such as thePresbyterian Improvement Model and Lean SixSigma. Using the Baldrige criteria ensures we havea balanced focus on our employees, members, andpartners as we target benchmark performance inclinical, service, and operational excellence.The Improvement Model is a process improvementtool used to gain and apply knowledge. It isdesigned to help employees effectively thinkthrough problems and processes that will ultimatelyresult in improved outcomes. Focusing on theImprovement Model questions accelerates thebuilding of knowledge by emphasizing a frameworkfor learning, using data, and designing effectivetests or trials.The focus of Lean is improved efficiency and thereduction of waste. The focus of Six Sigma isimproved effectiveness. Lean Six Sigma forimprovement follows a disciplined course of actionwith each project. The process most commonlyused is called by its acronym, DMAIC, whereproblem boundaries are identified (Define),opportunities quantified (Measure), root causesdetermined (Analyze), solutions identified and12-22014 Practitioner and Provider Manual - Ver. 3