Quality Management Program

The Funds has established a Quality Committee, which meets on a regular basis, and comprises members drawn from among the Funds’ staff and outside experts. The Committee has defined quality measurement criteria and monitors quality indices associated with the various programs.

The overall goals of the program are to:

• Provide a continuous, systematic, and comprehensive approach to managing the quality of care provided to beneficiaries;

• Assure that Trustees and staff members are aware of patterns and trends in provider performance, and that staff members follow through and resolve concerns about the quality of care;

• Assure that clinicians and other providers serving Funds’ beneficiaries have appropriate credentials, knowledge, experience and training to enable them to provide high quality, cost effective care;

• Conduct peer review studies and evaluations in a systematic, fair, and accurate manner to attempt to detect poor quality services;

• Provide a systematic linkage of services to risk management, utilization review, care management, and other appropriate quality-related activities; and

• Develop basic information to serve as a benchmark for quality assurance and as a basis for comparison of outcomes over time and across programs.

A summary of selected quality-related Funds initiatives follow:

• Maintain/increase annual influenza immunization rates.
• Increase proportion of beneficiaries immunized for pneumonia.
• Promote health and wellness among the beneficiaries.
• Promote beneficiary health and awareness of diabetes; reduce diabetic complications through beneficiary education and outreach activities.
• Assess beneficiary functional health status and satisfaction by conducting a biennial beneficiary survey and identify opportunities to improve health care access and quality for beneficiaries.
• Maintain integrated population-based database to monitor medical and prescription drug claims.
• Minimize adverse drug events; alert providers about prescribing patterns that may be inappropriate for elderly patients.
• Advise practicing physicians about FDA drug safety alerts relevant to the Funds’ population.
• Ensure cooperating providers meet basic licensure and competency criteria.
• Monitor care for events that may be indicators of quality issues, such as hospital readmissions.
• Monitor timeliness and quality of services provided by the Funds’ Call Center to beneficiaries and providers.