品質改善計劃

安保健康保險的使命在於為我們的客戶及社區建立更健康的未來。We do this by providing members with high quality service and a broad range of benefits, striving to simplify the provider experience, offering our purchasers high value, and partnering with the communities in which we live and work to improve their overall health.

The scope of activities within the Quality Improvement Program provides a framework to monitor and evaluate significant aspects of care and service provided to health plan members and their service delivery systems. EmblemHealth takes an active position in helping its members stay healthy, get better quickly, and live effectively with illness. Measures for monitoring important aspects of medical care, behavioral health care, and quality of service, including patient safety, have been developed and implemented. These activities include:

  • 醫療品質
  • 服務品質
  • 患者安全
  • Utilization management program
  • 會員和醫師滿意度
  • 服務的使用情況
  • 服務的提供情況
  • 服務委派
  • Member complaints, grievances, and appeals
  • Member decision support tools
  • 文化多元性
  • 關懷家庭照顧者

The Quality Improvement Program is reviewed annually and amended as necessary. Details about the program and the timeline for completing the review process are set forth in the annual Quality Improvement Work Plan. The status of the work plan items are updated quarterly and reviewed by the Quality Improvement Committee. 每年對於該計劃進行年度評估以總結並且分析品質改善計劃的成效。這將有助於確定下一年度的計劃。

We use various data sources to measure quality improvement processes and outcomes, determine barriers to improvement, and identify ways to improve quality and overcome barriers. 數據來源包括:

  • 上訴資料
  • Applicable Care Management Programs/Initiatives databases
  • Behavioral health data
  • 就醫資料(顯示醫療保險計劃會員使用醫療服務提供者服務的數據)
  • CAHPS®1 (Consumer Assessment of Healthcare Providers and Systems)
  • 醫療保險理賠資料
  • 醫生及會員的投訴
  • 醫療保險投保資料
  • 健康結果調查資料
  • HEDIS®2 (Healthcare Effectiveness Data and Information Set)
  • 蒐集會員和醫療服務提供者資訊的整合性資料蒐集系統
  • 化驗室資料
  • 醫療記錄
  • National and regional epidemiological demographic and census data
  • 醫療使用之審核資料
  • 藥房資料
  • 以人口為基礎的會員資訊
  • QARR (Quality Assurance Reporting Requirements)
  • Quality Compass
  • 品質改善專案/研究
  • Telephone response data
  • 醫療使用之審核資料
  • Various provider and member surveys

Software includes, but is not limited to, claims systems, National Committee for Quality Assurance-approved HEDIS software, credentialing and recredentialing software, Microsoft products, and other systems to support the clinical and service interventions.

品質改善計劃的主管當局及職責
安保健康保險公司的董事會透過其各別的品質改善委員會來監督品質改善計劃。執行品質改善計劃的整體職責則由安保健康保險的品質改善委員會承擔。品質改善計劃透過各種委員會及次委員會發揮其功能,並向品質改善委員會報告其活動內容。營運責任已委派給各相關部門主管。在整個品質改善委員會架構中都一直有廣泛的醫療專業人員參與其中,包括指定的醫療及行為健康醫生。

品質改善委員會負責以下事項:

  • 政策建議及核准。
  • 規劃、設計、執行、協調和分析品質改善的各項活動。
  • Instituting needed improvement actions and ensuring follow-up as appropriate.
  • 確定執業醫生透過規劃、設計、活動執行、參與委員會及/或審查等流程參與品質改善計劃。

Learn more about the Quality Improvement Program.

1CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

2HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

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