Quality Improvement

We continuously monitor performance on key quality indicators to ensure the highest level of quality care delivery. Our Quality Management Plan is based upon NCQA-sponsored Health Effectiveness Data and Information Set (HEDIS®). In addition to HEDIS®, we:

  • Monitor and improve accessibility (the time it takes for a member to see a provider).
  • Perform periodic audits of our Utilization Management operating procedures and results.
  • Conduct member and provider satisfaction surveys and share the results with our clients and providers.
  • Develop and implement complaints, appeals and grievances policies and procedures.

To support this process, we have developed seven general strategies for continuous quality improvement:

  • Quality Monitoring and Record Review is a retrospective and concurrent methodology that we use to evaluate the effectiveness and appropriateness of care delivery to the members and beneficiaries we serve.
  • Inter-rater Reliability testing is a methodology employed to decrease variation in nurse practice. This training intervention helps the nurse gain knowledge in the pathophysiology of the top presenting symptoms and conditions and gain skill in health history and interviewing techniques.
  • Clinical Review is a process by which we ensure that all clinical content is current, consistent, and evidenced-based.
  • BHO’s Complaint Process is a process by which we identify, investigate, and resolve problems and issues that come to our attention. Complaints are tracked and trended. Analysis is completed to help the organization understand more fully how we can prevent future occurrences, as well as identify when a process is out of control. These complaints/concerns can be initiated by anyone we serve, a partner, or by our staff.
  • External Validation and Review is a methodology by which we ensure that we are achieving the highest standards of care. BHO has established an external review medical advisory panel that reviews our clinical guidelines for their rigor and appropriateness. As previously mentioned, we engage in external validation of our structure, processes, systems, and tools by seeking URAC accreditation.

In addition, our Quality Management Plan is evaluated on a calendar year basis. An annual review is completed, following the close of the previous year and is reviewed for effectiveness throughout the year.

Evaluation of our Quality Program

At the staff level, we conduct call monitoring and record review on all staff. The frequency and intensity of the call monitoring is based on established policy and procedures. In addition, random monitoring occurs by the quality team to validate supervisory assessments and to ensure inter-rater reliability.

At the program level, due diligence visits from regulators and accrediting bodies are performed and encouraged.

Lastly, we engage an unbiased external medical review panel to test the clinical rigor of our guidelines and logic on an annual basis.