1. QI Program Structure (QI 1)
- Does the organization have a written description of its QI program that is reviewed and updated annually?
- Is the organization's governing body accountable for the QI program?
- Is behavioral health specifically addressed in the QI program?
- Does a QI Committee oversee the QI program?
- Are the roles, structures and functions of the QI Committee and other committees described in the QI program description?
- Is there an annual QI work plan?
2. QI Program Operations (QI 2)
- Does the QI committee meet regularly and take action on quality improvement activities?
- Is there documentation of QI committee meetings?
- Are practitioners involved in the planning, design, implementation and review of the QI program?
- Are the organization’s practitioners and members informed about its QI program?
- Is there a plan for collecting and providing information on provider and practitioner safety and quality?
3. Accessibility of Services (QI 3)
- Does the organization have standards to assure access to medical care, including routine primary care, urgent care, and after-hours care?
- Can members who need behavioral health care obtain it when they need it?
- Does the organization measure its performance in these areas?
4. Member Satisfaction (QI 4)
- Does the organization evaluate member complaints and appeals to assess member satisfaction?
- Does the organization analyze results of member satisfaction surveys?
- Does the organization take steps to improve performance in these areas?
5. Disease Management (QI 5)
- Does the organization offer programs and services to members with chronic health conditions, such as diabetes?
- Are members systematically identified and informed about the programs?
- Are member participation and program effectiveness measured?
- Are practitioners made aware of and educated about these programs?
- Are interventions based on stratification of severity or other clinical criteria?
6. Clinical Practice Guidelines (QI 6)
- Does the organization establish practice guidelines for its practitioners to follow?
- Is there a clinical basis to the guidelines?
- Are the guidelines reviewed at least every two years?
- Are the guidelines distributed to appropriate practitioners?
- Does the organization measure its performance against the guidelines annually?
7. Continuity and Coordination of Medical Care (QI 7)
- Does the organization monitor the continuity and coordination of care between practitioners; for example, between a primary care physician and a specialist?
- Does the organization measure its performance in these areas and make improvements when needed?
- Does the organization or practitioner notify members affected by the termination of a primary care practitioner?
8. Continuity and Coordination Between Medical and Behavioral Health Care (QI 8)
- Does the organization monitor the coordination of general medical care and behavioral health care?
- Does the organization collaborate with its behavioral health specialists in collecting and analyzing data and implementing actions to improve the coordination of behavioral health with general medical care?
9. Clinical Quality Improvements (QI 9)
- Does the organization identify, monitor and work to improve clinical issues relevant to its members.
10. Effectiveness of the QI Program (QI 10)
- Does the organization demonstrate meaningful improvement in the quality of clinical care and service it renders to its members?
11. Delegation of QI (QI 11)
- If the organization delegates QI activity, has it worked with the delegated party to develop a mutually agreed-upon document that outlines responsibilities, delegated activities, and evaluation processes?
- Has the organization evaluated whether or not the delegated party can perform the activities?
- Does the organization approve the delegated party’s QI work plan and review its performance annually?