Quality management

The QM Program addresses issues related to quality management

The QM Program addresses issues related to quality management and quality performance measures to ensure both state and national compliance. Annually, the health plan evaluates the effectiveness of the QM and Utilization Management Programs identifying specific opportunities for improvement.

The general quality goals:

• Develop and maintain quality improvement processes, structures and resources in support of the organization-wide commitment to provision of quality healthcare for all members
• Development of effective methods to measure outcome of care and services provided to members, as well as interventions to achieve continuous and measurable improvements
• Continuous collaboration with appointed entities to develop and implement structures and programs fostering coordination and continuity of care
• Compliance with applicable federal, state, regulatory, contractual and accreditation requirements
• Ensuring adequate accessibility to care and services
• Monitor and ensure members receive seamless, continuous and appropriate attention throughout the continuum of care
• Ensure members have access to appropriate care management programs, including Case Management and Condition Care
• Coordinate, monitor and report QM activities to appropriate committees
• Conduct root cause analysis for benchmarks or goals unmet
• Implement and monitor programs designed to improve the quality and safety of members through member and provider education
• Ensure effective credentialing and recredentialing processes for providers who comply with state, federal and accreditation requirements
• Ensure the confidentiality of members is maintained at all times
• Analyze member and provider satisfaction survey results and implement effective interventions to address areas of dissatisfaction
• Oversight of all delegated activities to ensure compliance with all state, federal and accrediting organizations
• Promote improved continuity and coordination of care between medical and behavioral healthcare
• Develop and implement programs based on population analysis and incorporate culturally and linguistically appropriate services into Anthem