HNS Policy   

Overview 

HNS is committed to the delivery of safe, effective, cost-efficient health care to members of our contracted health care plans and to improving the quality of services provided directly by HNS, and the services provided by the health care professionals contracted with HNS.

The goals of the QMI Program are to provide a safe, effective, cost-efficient health care delivery system; to objectively and systematically monitor and evaluate the quality and appropriateness of services provided by our contracted health care professionals and by HNS, to pursue opportunities for improvement and to resolve identified problems in a timely manner.

Contracted health care professionals are required to participate in HNS' and contracted health care plan quality improvement initiatives.

HNS maintains a written Quality Management and Improvement (QMI) Plan that describes the QMI Program.  HNS' quality improvement activities emerge from a systematic and organized framework for improvement.  This framework, adopted by HNS leadership, promotes the accountability of HNS for the quality of the services HNS provides, and the accountability of contracted health care providers for the quality, safety and cost-effectiveness of services provided to members.

Scope 

The scope of QMI activities include but are not limited to:

1. Provider credentialing
   

    

2. Provider accessibility and availability
   

    

3. Quality of care and patient safety
   

    

4. Member complaints/grievances
   

    

5. Utilization Management
   

    

6. Clinical Protocols, Guidelines and Policies
   

    

7. Transaction Management (Claims/Payment Processing)
   

    

8. Regulatory Compliance
   

 Program Objectives 

• Establish quality improvement objectives for achieving improvement in the quality of services provided by HNS and contracted health care professionals.
  

   

• Design and maintain the quality improvement structure and processes that support continuous quality improvement, including measurement, trending, analysis, intervention, and re-measurement.
  

   

• Establish service indicators and benchmarks, including performance goals for continuous and/or periodic monitoring and evaluation.
  

   

• Coordinate QMI activities with all other activities and ensure collaboration, coordination, and communication across all HNS departments.
  

   

• Foster collaboration, coordination, and communication related to QMI activities with contracted health care professionals.
  

   

• Promote participation and collaboration with QMI initiatives by contracted health care professionals by encouraging feedback and participation on standing committees and physician advisory boards.
  

   

• Identify opportunities for improvement and barriers to improvement.
  

   

• Measure and assess performance through the collection and analysis of data.
  

   

• Improve aggregation and analysis of data to develop more meaningful opportunities for reporting, education, and improvement.
  

   

• Maintain an ongoing, effective credentialing program that complies with NCQA standards.
  

   

• Maintain an ongoing, effective program to improve quality, safety and cost-effectiveness of care.
  

   

• Monitor access, availability and safety of care and implement corrective action where necessary.
  

   

• Ensure timely, appropriate and responsible transaction management.
  

   

• Ensure complaints and grievances are handled in a respectful, timely and appropriate manner.
  

   

• Ensure the development/adoption of clinical and administrative practice guidelines to promote quality of care and patient safety.
  

   

• Ensure an annual review of the QMI Program and the development of an annual work plan.
  

   

• Ensure an effective QMI Program that results in improved quality of services by HNS and contracted health care professionals.
  

   

• Maintain technical business information systems to support quality management activities and improve them as necessary to meet program needs.
  

   

• Coordinate and comply with requirements of contracted health care plans and applicable government agencies and state and federal laws.

The QMI Program is assessed annually to determine the effectiveness of the program and services provided by HNS and by our contracted health care professionals.