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Group Health

2009 – 2012 Quality Plan and Program Description

2012 Update

Approval Schedule

Quality Oversight Team (QOT): February 1, 2012 Executive Leadership Team (ELT): February 7, 2012

Quality Committee of the Board (QCOB): February 22, 2012

Table of Contents

Introduction………………………………………………………………………………..

Vision for Quality…………………………………………………………..…………….

Alignment with Group Health’s Strategic Plan……………………….…………….

Reflections Regarding Achievement of 2011 Quality Goals……….…………….

2012 Quality Hypothesis and Goals…………………………………….…………….

2012 Quality Framework and Action Plan…………………………….…………….

Quality Program Description……………………………………………..……………

Quality Improvement Planning Process……………………………….……………..

Quality Program Implementation……………………………………….......................

Evaluation of the Quality Program………………………………………....................

Confidentiality……………………………………………………………....……………

Quality Program Structure and Accountability……………………………………..

Attachment 1: Quality Assessment and Improvement Structure………………..

Attachment 2: Group Practice Division Quality Committees……….....................

Attachment 3: Health Plan Division Performance Management System………

Attachment 4: Credentialing Committee Membership…………………………...

Attachment 5: Enterprise Quality Department…………………………………….

Attachment 6: Quality Resources at Group Health………………………………..

Attachment 7: Quality Improvement Focus – Medicaid Population…………… 31

2012 Quality Plan version, January 4, 2012

Introduction The 2009 - 2012 Quality Plan summarizes the history of quality improvement at Group Health Cooperative that is fueled with the spirit of innovation in service to our members. We continue to lead our improvement work on the basis of evidence-based medicine. We do this by leveraging information technology to improve the patient care process and experience and applying research to clinical practice. This assists us in defining the ideal model for care delivery for the range of patient health status, from wellness to chronic disease management. As highlighted in the 2011 Quality Program Evaluation, Group Health continued its position as one of the best and most innovative health care organizations in the country. This was demonstrated by retaining our highest level of accreditation for NCQA, retaining the top rating on quality care measures in the Puget Sound Health Alliance, being one of nine Medicare plans in the nation that received the highest 5 star rating and numerous other clinical quality and service recognition awards. Looking forward in this ever-changing health care environment, we continue to remain confident of our ability to meet the coming challenges. Group Health members are experiencing the results of our focused efforts to provide care that is high quality, safe, and easy to access. In 2011 we maintained our emphasis on assuring consistent processes were in place to meet critical quality, care experience and affordability goals but met with significant challenges. The lack of reliable and consistently available clinical data negatively impacted our ability to successfully improve some of our processes and tools for optimal success. While our underlying financial state is strong, losses during 2011 require a disciplined examination of root causes and a continued focus on making our care processes efficient and effective to make our excellence affordable for all members.

Vision for Quality Our vision for quality remains unchanged and predicated on our continued belief that Group Health’s approach to care delivery means better clinical outcomes for our members. Our integrated approach to care delivery and financing continues to distinguish us from other health care providers and health plans in this market. While our medical group remains central to our ability to provide quality care and service at a lower cost, we continue to work toward a future that ensures high quality care for our members regardless of where they receive it. Our future means that all our members will consistently say that Group Health provides:

 The best care, information, expert advice, and support

 Outstanding service every time

 Value that exceeds needs and expectations

We believe in using the best available scientific evidence in our decision-making, tools, and practices. We believe in the importance of providing consistent care in our processes, reducing unwarranted variation and building reliable clinical information systems to support care delivery. We believe that care ought to be patient centered, providing timely, expert information to patients that allows them to make better care decisions. We also believe that a productive relationship between physician, practice team, and patient is key to better health care outcomes, safer care, and a better care experience for the patient. These beliefs are the key components of the Planned Care Model (Wagner, et. al., MacColl Institute for Healthcare Innovation), Group Health’s model for care delivery that guides the implementation of our vision for quality. We know that when the key components of the model are

supported by leaders and organized around a patient-centered, integrated system of care, we will achieve health outcomes that out-perform our competitors. Group Health is uniquely positioned to achieve our quality vision thanks to the excellence of our providers, our ability to efficiently and effectively organize care around patient populations, and our use of technology to support personalized care. We continue to leverage our investments in Epic and MyGroupHealth and other clinical information systems to make the right thing the easy thing to do, with activated patients and clinicians. Three major tactics support patient centered care:

1. Opportunistic Care: The most efficient approach toward delivering comprehensive care is to anticipate all of a patient needs and deliver them at the time of scheduled services. We will continue to build point of service tools, including those for patients, with information that allows clinical teams the ability to address needed preventive and scheduled chronic care services for the patient at the time of the visit. Our goal is that the majority of our patients finish their visit with us with all their clinical needs having been recognized.

2. Patient Activation and Outreach: We will continue to invest in improving and developing tools to activate

patients to act to improve their health through reminder systems (birthday letters, IVR, MyGroupHealth reminders) and our Health Profile (health assessment tool) that identify all of the opportunities to improve both preventive and chronic illness care. We will continue to support opportunities for patient self management including the use of specific tools for shared decision making for preference based care interventions.

3. Feedback: Performance improves only when metrics are well defined and available for ongoing visual

inspection. We will continue to improve the completeness and timeliness of performance reporting, including the use of tools that support patient-centered rather than disease oriented performance. We will continue to evolve the incentive system in primary care across the Enterprise to support clinical excellence by moving away from an emphasis on productivity towards service and clinical quality (patient centered) outcomes among provider panels and clinic populations.

Alignment with Group Health’s Strategic Plan refresh The five-year strategic plan introduced in early 2008 set forth a compelling map to attain our vision of “affordable excellence” for our patients. The executive leadership team has completed the refresh of the 2008-2012 plan that extends to 2015. The plan calls for continued deployment of the four interrelated focus areas and associated goals with a slight change in emphasis from affordable excellence to “making excellence affordable”. The current plan outlines the path to achieve the following goals by 2015: Quality

 Rank among the top 25 national NCQA-accredited plans for both Group Health Cooperative (GHC) and Group Health Options (GHO) commercial plan performance.

 Maintain Centers for Medicare and Medicaid Services (CMS) quality rating of at least 5 stars for Medicare Advantage HMO plan and improve rating for PPO plan.

 Maintain Centers for Medicare and Medicaid Services (CMS) quality rating of at least 5 stars for Medicare Advantage.

 Maintain position as the highest-ranked group practice in the Puget Sounds Health Alliance “Community Check-Up”

Affordability  Achieve a 3 percent net margin each year  Maintain 120 days cash on hand

Profitable growth:  Grow enrollment to 932,000 insured members by year-end 2015  Target profitable lines of business

People  Achieve 90th percentile Gallup grand mean score for health care organizations.

Reflections Regarding Achievement of 2011 Quality Goals The Quality goal set for 2011 was to reduce defects, defined as deviations from the standard, by 50 percent. Customer requirements determine which standards are deemed critical. The hypothesis stated that by reducing defects, quality and performance would improve. In the last few years, this practical application with an emphasis on improving processes to improving quality has been widely accepted and utilized throughout Group Health. In addition to defect reduction for processes that support clinical care outcomes, numerous other processes in areas such as marketing, membership, customer service responses, claims administration, and contracting had the same goal of reducing defects by 50 percent resulting in process improvements throughout all areas of the organization. Using this framework, a key Quality goal was to reduce the NNAT clinical quality defects by 50% to assure our continued progression in NCQA rankings as well as achievement of Medicare 5 Star performance for our Medicare Advantage population. Reflections of our experience including root causes for our failure to improve our clinical performance as defined by HEDIS NNAT include the following: Measurement limitations: We have had an absence of relevant performance data that has seriously impeded our ability to proceed with key interventions. Without reliable data, key clinical tools, new tool development, timely and accurate reporting/feedback to teams, improvement in performance was significantly impacted. The enterprise quality dashboard was improved in 2011 with fewer measures. However, while we made progress in the use of monitoring and breakthrough metrics with use of control charts, there remains lack of a consistent understanding of how to think of goals and targets. While checking is occurring, we do not have a reliable process for escalating issues where performance is below target that leads to sufficient countermeasures to meet our targets. This has resulted in a loss of consistent operational excellence throughout the Enterprise wide Delivery Systems. Lean as the quality improvement process: While we recognize the importance of both standardizing and improving our key processes, we may have lost some consistency in 2011 for the application of defect metrics as applied to key processes. More focus is needed to define the key improvement processes and work to reduce the defects that contribute towards the achievement of the quality goals outlined in the strategic plan. We have continued to be challenged with too much work in progress that impedes our ability to be effective and focused. While reducing defects of key processes has been widely adopted and will assure our ability to achieve the quality goals, reducing defects by fifty percent is felt to have less meaning as a quality goal itself. Provider Activation Across the Enterprise: Our ability to fully realize the work of our practitioners and clinical teams has been impacted by both the lack of reliable measurement systems and tools as well as multiple priorities for clinical teams. In the Group Practice, standard work within the Medical Home Model lost ground and was not followed consistently. In the Network, the strategy for activating contracted providers and teams has been started but not yet fully realized or robust to be effective and incentives are still in development but not yet implemented. Patient Activation and Outreach There were successful improvements in the area of outreach and activation of patients across the Enterprise while recognizing this is insufficient. Opportunities exist to optimize our current efforts with letters and IVR (interactive

voice recognition), coordinating activation with standard work, analyzing outreach efforts to nimbly respond to targeted populations and leveraging other methods such as optimal use of My GroupHealth. Successes in 2011 We made progress and had some key successes in the following: Care Management (EDHI work)

 Continued improvement of care management transition work with improvements in use of urgent and emergency care and reduction of admission rates

Deployment of two key improvement initiatives:  Successful implementation of new “Meaningful Use” requirements  Successful implementation of the Medicare 5 Star project team and interventions to improve metrics using

established goals, clear accountabilities, definition of roles and a cross functional team with consistent checking, monitoring and adjustment of workplan to achieve a 5 Star rating.

Patient Safety  Gains in patient safety with leadership alignment in goals, consistent messaging for patient safety across

operational areas, improved reporting, and integration into standard work with identification of system-wide improvement efforts in process.

Reducing Clinical Variation  Improvement in work on shared decision making and high end imaging with integration of both into standard

work across several Consultative Specialties. Expanding Capacity in the Contracted Network

 Development and beginning implementation of a Practice Consultancy model to drive improvement in the contracted Network.

2012 Quality Hypothesis and Goals Reflections and adjustments by the Executive Leadership Team through the Strategic Deployment Process have reiterated the imperative that we increase our focus on integrating and coordinating multiple improvements and deploy the work through the eyes of the patient to ensure their care needs and experience exceed their expectations. The goals for 2012 and hypothesis for achieving these are: 2012 Quality Goals:

 Maintain 5 Star performance for Medicare 5 Star quality program for GHC (based on 2012 quality performance)

 Achieve the top 40 in NCQA in 2013 (based on 2012 quality performance)  Achieve the top 15 in NCQA for GHC Medicare in 2013 (based on 2012 quality performance)

Hypotheses for achieving these goals are:

 The clinical NNAT gap can be closed by increasing patient and provider activation, opportunistically addressing the identified care gaps during each touch and by giving timely feedback to an engaged provider/care team showing performance and results.

 By focusing on the four critical areas identified as root causes, we have confidence that this will reduce the HEDIS NNAT and improve the perception of the member experienced as measured by the CAHPS survey.

 By decreasing defects by 50% in the relevant key processes, we will achieve the 2012 HEDIS goals and maintain Medicare 5 Star rating for GHC.

 The implementation of the key strategies outlined in the Quality Workplan will meet the 2012 Quality goals and “lift” performance for clinical and service quality in GHO.

2012 Quality Framework and Action Plan Per our 2011 Quality Plan, we will continue our work to ensure that key characteristics to improve quality are being pursued throughout all of our operations. The attributes of a successful, sustainable quality improvement program that we will continue to pursue and monitor include:

 Identification of customer requirements and the key processes that support meeting them  Development of standard work that is sufficient to meet all of the requirements  Measurement of adherence to standards (defects in standard work processes)  Establishment of in-process and outcome metrics, and a regular tracking of performance  Use of visual controls to make the work and gaps visible  Evidence that progress towards goals are checked  Adjustments to a plan that are supported by data  Implementation of countermeasures

Building upon the successes and reflections from 2011, it will be critical that we continue to drive improvement within the current work while extending improvement efforts into new areas that leverage learnings and increase the rate of improvement. Fundamental to this work is the ability to continue to build reliable, consistent processes of care which include: Drive Operational Excellence:

Drive operational excellence by re-establishment of basic components of the Management System and further implementation of these;  Continue to concentrate efforts on the stabilization and continuous improvement of Medical Home and care

management transition work  Continue implementation of the consultative specialty improvement work  Integrate improvements across the spectrum of care including services such as Home Care, Consulting Nurse

Services, Anticoagulation Management Services, Urgent Care, etc.

Increase execution of patient centric strategies for prevention and chronic disease management:  Re-establishment of a reliable and consistent measurement feedback system for clinical and service

performance and process for monitoring timely data production.  Sustain and improve accomplishments to implement use of shared decision-making tools for preference

sensitive conditions in the Group Practice and spread use of methods within the Contracted Network.  Continued development and deployment of patient-centered information technology tools and reminder systems

to improve opportunistic care and outreach, and increase patient activation across the enterprise (e.g., Health Profile, outreach letters and targeted reminders, use of MyGroupHealth, optimal use of Epic and potential use of Enterprise wide clinical system)

Continue to expand our capacity to intervene in our contracted network

 Further execution of a clinical integration strategy that would provide an innovative solution to how Group Health relates to external provider groups

 Fully implement the use of incentives to improve quality in our contracted Network.  Ensure appropriate quality monitoring and feedback with our contracted hospitals

Enhance our culture of Patient Safety:

 Continue to engage operational leaders in leading improvement work to increase the reliability of clinical processes and foster a just culture.

 Re-design our reporting processes including a consistent approach for analysis and problem solving to generate timely system improvements

 Promote transparent communication amongst team members that promotes safe care  Engage in efforts to activate patients in roles that facilitate a patient safety culture.

In 2012, we will continue to monitor progress toward our goals using measures that are relevant to our customers and that can be benchmarked against other health care systems both locally and nationally. The HEDIS (Healthcare Effectiveness Data Information Set), CAHPS (Consumer Assessment of Healthcare Providers and Systems) and Medicare 5 Star quality measures are a core part of that performance measurement, target-setting, and monitoring process. Attention to the purchaser’s expectations, through eValue8, supported by the National Business Coalition on Health (NBCH), and interactions with our key purchaser groups will continue to carry Group Health forward in demonstrating its leadership in value-based purchasing.

These measures are comprehensive, covering a broad set of domains in clinical quality, care experience, and affordability. They allow us to continue to measure our progress and compare our results against other local and national health plans.

All quality improvement metrics in support of the Quality Plan goal will be monitored by the Quality Dashboard as approved by the Executive Leadership Team (ELT). The Group Health management system includes periodic reviews and adjustment processes to ensure achievement of goals and results. When planned actions are not executed, as scheduled or expected outcomes are not achieved, countermeasures will be developed and activated.

Quality goals and progress toward those goals remain the accountability of the Quality Oversight Team and Executive Leadership Team, and ultimately, the Board of Trustees, who have delegated responsibility for oversight to the Quality Committee of the Board. The membership and accountabilities of these groups are described in the Quality Program Description.

QUALITY PROGRAM DESCRIPTION

Program Objective and Scope A comprehensive Quality Program1 is essential to meeting organizational goals, carrying out its vision and promoting our approach to care delivery. The process for monitoring, evaluating and improving quality is designed in concert with the purpose and strategic plan of Group Health Cooperative. Two key components of the process include:

 Involvement of medical and behavioral health care professionals in the analysis of data to identify opportunities for improvement, and

 The use of data2 to assist with the delivery of high quality healthcare, ongoing monitoring and

evaluation of important aspects of care and service, and continuous improvement of systems and processes.

Under the direction of the Group Health Cooperative Medical Director and GHC President/CEO, the Quality Program is designed to promote high quality, safe medical and behavioral health care, and superior service to Group Health (GH) and Group Health Options, Inc. (GHO) enrollees and other patients who receive services within Group Health in a caring, personalized manner that is respectful of member and individual member values and choices. The Group Health Medical Director and GHC President/CEO delegate substantial responsibility for the quality program to the Associate Medical Director for Quality & Informatics and VP Clinical Excellence who co-chair the Quality Oversight Team (QOT), the QI Committee for the organization. They are the designated leaders with substantial involvement in the QI program and is responsible for quality management and improvement activities. The quality assessment and improvement programs and outcomes are reviewed and approved annually by the Executive Leadership Team (ELT) and the Quality Committee of the Board (QCOB), as delegated by the GH Board of Trustees. Group Health assumes accountability, through its Quality Program, for continuous quality improvement for all of our members for all product and plans, including Group Health Cooperative and Group Health Options Commercial, Medicare, and Medicaid lines of business. Using the principles of population-based care for organizing our improvement activities, Group Health addresses member needs in a patient-centered manner while simultaneously acknowledging special needs of our members, in particular, our culturally and linguistically diverse members and those with complex health needs. A key approach in building our ongoing capacity to serve our culturally and linguistically diverse members is the collection and analysis of race, ethnicity, and language data and linking this data to clinical and patient satisfaction metrics to identify and reduce health care disparities. Group Health’s complex case management program, as described in the Care Management Program Description, is designed to help members with multiple chronic conditions by providing resources and support to address these complex health needs. Special attention is paid to our obligations for oversight and monitoring of the Behavioral Health Care quality improvement program and for specific vulnerable populations of our membership such as those in our Healthy Options program.

1 The scope of the Group Health Cooperative quality program includes medical and behavioral health care, service, and care management in the owned and operated facilities and the contracted network, as well as patient safety and staff effectiveness. 2 Data sources include claims, encounter data, enrollment data, complaints and inquiries, utilization management data, and HEDIS data.

The scope of our Quality Program includes oversight, monitoring and improvement of behavioral health care for members. The medical director for Behavioral Health Services (BHS), a PhD psychologist, is the designated behavioral health care practitioner most involved in the behavioral health aspects of the QI program. He is a member of the Quality Oversight Team (QOT), BHS Leadership Team (BHSLT) and Primary Care Leadership Team, assuring accountability and ongoing engagement in the Quality Improvement Program. The BHSLT is the organization’s committee for improving quality for behavioral health services. Key tasks for BHSLT include setting the department’s quality agenda and providing input into organization and divisional quality plans. This oversight includes monitoring, planning, and taking actions to improve key aspects of quality including HEDIS performance, access, continuity and coordination of care, confidentiality, patient satisfaction, referral and triage functions, under/over utilization, use of new technology, and patient safety. (see BHSLT committee description). Behavioral health representation or input is solicited for multiple quality committees to ensure these important aspects of care are considered; e.g., Patient Safety, Care Management Committee, MTAC, Pharmacy and Therapeutics, and relevant clinical practice guideline teams. The scope of Group Health’s Quality Program also includes specific quality improvement activities and measurements directed at Group Health’s Healthy Options population to ensure that the clinical and service performance standards set by the State of Washington Health and Recovery Services Administration (HRSA) and the Centers for Medicare and Medicaid Services (CMS) are met or exceeded for this important and vulnerable population. (see Attachment 7) The organization, with oversight by ELT and QOT, provides a number of structures to address the monitoring and improvement work of clinical quality, service quality, patient safety, and utilization/ care management in both medical and behavioral health care provided to Group Health and Group Health Options enrollees.

Quality Improvement Planning Process Group Health sees its commitment to improving the performance of our health care system performance as a key strategy—contributing to overall organizational success and viability. The diagram below illustrates the quality improvement planning process relies heavily on ongoing performance monitoring and assessment to identify potential organizational quality improvement priorities.

Sources for Potential Quality Improvement Activities:

 Strategic Goal Deployment (organizational priorities)  Quality Plan/Quality Performance Measures  Local gaps/improvement opportunities that support system wide priorities  Legal/Regulatory Requirements and feedback regarding opportunities identified  New Customer/Market requirements or expectations (to incorporate in quality planning)

Care Delivery System Leadership & Quality

Councils

 Performance monitoring and analysis of QI activities/quality performance; identify potential gaps/ concerns.

 Identify improvement opportunities and plan strategies/toolkits to use.

 Coordinate with centralized quality support resources.

 Provide status reports to QOT (linked checking).  Share best practices.

QOT

(Quality Oversight Team)

Quality Department

 Inform the strategic plan re: recommended organizational Quality priorities and performance goals and targets.

 Oversee the Quality Program, including the Care Management Program and Group Health Options, to assure it meets regulatory and accreditation requirements/standards; provide regular reports to ELT.

 Monitor performance indicators.  Identify areas without systems to support

continuous improvement or gaps in performance.

 Ensure reconciliation of issues as needed for quality issues/ recommendations that have operational and/or dollar impact.

 Approve the Quality Program (Quality Program Description, Plan, and Evaluation).

 Oversight of Quality program and performance (i.e., Quality A3 and dashboard measures).

 Make resource decisions for strategic priorities, including the Quality Program.

 Set the Quality Agenda (Quality Vision, Priorities, and Performance Targets).

Board of Trustees and Quality Committee of

the Board

 Approval of Quality source documents.  High level oversight of Quality program and

performance.  Advise the Board of Trustees on strategic

planning and resource allocation issues related to achieving and maintaining quality goals.

(*Arrows indicate opportunities for interaction)

ELT

(Executive Leadership Team)

Quality Program Implementation Implementation of our quality program now emphasizes lean principles in quality improvement. We have historically focused on outcomes alone – meeting our customer requirements for clinical quality and safety, care experience and affordability without regard to how we achieved those results. This model has left us with significant limitations in our ability to accelerate sustainable improvements – while heroism has produced some important gains, it is not a sustainable model for the organization, and does not spread from site to site reliably. In 2012 we will continue to augment our work to ensure that key characteristics to improve quality are present in all of our operations. The attributes of successful, sustainable quality improvement that we will monitor include:

 Identification of customer requirements and the key processes that support meeting them.  Development of standard work that is sufficient to meet all of the requirements.  Measurement of adherence to standards (defects in standard work processes).  Establishment of in-process and outcome metrics, and regular tracking of performance.  Use of visual controls to make the work and gaps visible.  Evidence that progress towards goals is checked.  Adjustments to plan that are supported by data.  Implementation of counter measures.

Professionals from a variety of expert groups, including medical directors, front line physicians, consultant specialists, nursing staff, quality improvement staff, operational managers and others come together as a team that works with a high level of objectivity and integrity and utilizes sophisticated quality management tools and approaches. They analyze data to identify improvement opportunities, understand and identify variation in the care and service provided to members, and establish and develop system-wide approaches to meet agreed-upon quality outcomes. To the greatest extent possible, quality improvement efforts are encouraged and supported at the local level. Health care and administrative teams are charged with reviewing performance according to the agreed-upon measures and goals, analyzing and agreeing upon the areas that require the most improvement and designing strategies to close performance gaps. These teams are supported in performing rapid-cycle continuous improvement activities. Performance data and expert consulting resources are available to assist local teams. This local level work is directly linked with the organizational goals that are agreed upon by the Executive Leadership Team. The teams are asked to share their progress on a quarterly basis to the Quality Oversight Team and to each other so that cross-organizational learning can take place. The expected results are to provide high quality care and service that is patient-centered and supports to practitioners with the tools and support needed to provide excellent care and service. Group Health continues to focus on providing high quality care and service to members while controlling costs through proven medical management strategies. This focus requires continued emphasis on ensuring that each activity of our business adds value to the delivery of care and service. Central to this effort are: the development and implementation of evidence-based guidelines, medical management strategies, and population –based care programs; support for physicians with information about their patients; centralized systems, where applicable, that provide patient-centered reminder systems; and information systems that provide valid and reliable data for ongoing assessment and feedback.

Evaluation of the Quality Program The Quality Program at GH is formally evaluated annually by the Executive Leadership Team (ELT) and the Quality Committee of the Board (QCOB), as delegated by the GH Board of Trustees. The intent of the evaluation process is to determine whether areas identified as needing improvement have been appropriately addressed, established indicators adequately assess the performance of the organization’s quality of care and service, and objectives are being effectively and efficiently accomplished. The evaluation includes an assessment of the overall effectiveness of the QI program, including progress toward influencing safe clinical practices throughout the delivery system, as well as monitoring other aspects of the program, such as practitioner availability, over and under utilization, and complaints and appeals.

Confidentiality Respect and recognition of the sensitivity of quality assessment and improvement information is of primary importance. Quality assessment information is available only to duly authorized personnel. Quality assessment information is considered confidential and is protected from discovery/disclosure based on local, state, and federal statutes. Group Health operates a State of Washington Department of Health approved Coordinated Quality Improvement Program (RCW 43.70.510). This voluntary program provides protection of information and documents created through quality assessment and improvement efforts.

Quality Program Structure and Accountability The overall organizational structure is depicted in Attachment 1. Attachments 2-5 represent the organization’s quality structures.

The Quality Division provides oversight for the enterprise Quality function by supporting processes, practices, and improvements. Quality is one of the four focus areas of Group Health’s Business Plan and is led by the Executive Vice President of the Group Practice Division who is the Quality pacesetter. The Quality pacesetter sets the tempo for Quality as a business strategy and engages managers and staff in meeting the targets established. The Quality pacesetter is responsible for removing barriers that stand in the way of continuous improvement, breaking down silos between functions, resolving conflicts, representing customers, and ensuring that Group Health is making progress toward goals.

The delivery system is accountable for quality improvement. Two divisions represent the delivery system: the Group Practice Division and the Health Plan Division. The Group Practice Division encompasses the majority of Group Health’s owned and operated clinical services. These include a hospital, 25 primary care medical centers, 6 specialty care units, 7 behavioral health clinics, and numerous other clinical sites providing vision, speech, hearing, and retail services. The Health Plan Division has oversight of all contracted network care and many care management functions.

The following serves as a description of the various committee and leadership structures at GH which are designed to promote and support excellent quality of care and service.

The following committees and groups provide oversight of the quality improvement work throughout GH:

COMMITTEE OR GROUP DESCRIPTION COMPOSITION OF GROUP Quality Committee of the Board (QCOB meets at least 4 times per year) Purpose: The Quality Committee of the Group Health Cooperative Board of Trustees is established by action of the Board of Trustees for the primary purpose of acting on behalf of the Board in overseeing implementation of Group Health’s Quality Plan and Program, and monitoring the organization’s performance to ensure goals and standards established for the delivery of care and services to Group Health members and patients are met. Tasks:  Approve the Group Health Cooperative Quality Plan and Program

Description and the annual Quality Program Evaluation.  Review the annual professional liability report and make

recommendations regarding the functioning of the system to increase the rate of improvement.

 Annually review and approve the Group Health Central Hospital Quality Management Plan and Patient Safety and Quality of Care report.

 Perform the functions of the governing body of Central Hospital, under the delegated authority of the Board of Trustees.

 Perform the functions of the governing body of Group Health Cooperative-owned ambulatory surgery centers, under the delegated authority of the Board of Trustees.

 Oversee and review the activities of the credentialing and privileging processes for practitioners and providers.

 5 members of the Board of Trustees  Group Health Management

Representatives (non-voting members of QCOB; attend as requested by QCOB)

COMMITTEE OR GROUP DESCRIPTION COMPOSITION OF GROUP Quality Committee of the Board (con’t)  Monitor defined performance measures to gauge success in achieving

and maintaining targeted standards of quality care and service.  Monitor patient, member, and employee satisfaction with Group

Health’s care delivery system, the health plan, and business operations.

 Ensure that management has identified and is taking corrective or improvement actions to address performance deficiencies.

 Provide policy oversight for those policies designated and assigned by the Board.

 Regularly report to the Board regarding the execution of the committee’s duties and responsibilities.

Executive Leadership Team (ELT– meets weekly) Purpose: Sets organizational strategy and provides senior leadership oversight to organizational performance and improvement activities. ELT is responsible for overseeing the development and implementation of a system-wide quality agenda that supports achievement of the organization’s strategies, and for monitoring performance and progress of the quality program. Group Health Options, Inc. (GHO) delegates to Group Health Cooperative responsibility for its quality program, including the responsibility for overseeing the implementation and monitoring the performance of its quality program. Group Health Cooperative performs that delegated responsibility through the work of the Executive Leadership Team and Quality Oversight Team and is accountable to GHO executive management for assuring the quality program meets all the necessary requirements as outlined in the GHO- GHC delegation agreements. Tasks:  Set the quality agenda (quality vision, priorities, and performance

targets) and approve the GH Quality Plan and Program Description.  Monitor performance indicators.  Make recommendations to the Quality Committee of the Board

regarding: a. resource allocation for strategic performance improvement

support; b. annual assessment of the success of the quality program; c. approval of quality indicators for regular review by the

Quality Committee; and d. sponsorship of the Quality Plan.

 GHC President and CEO  GHP President and Chief Medical

Executive  Exec. VP, Group Practice Division  Exec. VP, Health Plan Division  Exec. VP and Chief Financial and

Administrative Officer  Exec. VP, Public Affairs and

Governance  Exec. VP and General Counsel  Exec. VP, Human Resources  Exec. Medical Director, Group

Practice Division  Exec. Medical Director, Health Plan

Division  Exec. VP, Group Health Permanente  Vice President, Strategic Planning

and Deployment and Chief of Staff

Quality Oversight Team (QOT – meets quarterly) Purpose: QOT is charged by ELT to serve as the QI Committee for the organization. QOT evaluates and monitors organization-wide efforts designed to improve the value of the health care delivered to Group Health patients, considering issues of clinical excellence, care experience and affordability.

 Assoc. Medical Director, Quality & Informatics, chair

 Exec. Medical Director, Health Plan Division

 Exec. Medical Director, Group Practice Division

COMMITTEE OR GROUP DESCRIPTION COMPOSITION OF GROUP Quality Oversight Team (con’t) The charge of the group is to oversee ELT- established goals for quality performance and support the care delivery system in attaining those goals. The delivery system is responsible for the outcomes, with operating divisions deciding local tactics to meet their goals. The Enterprise Quality department informs decisions for improving quality, providing expertise in population management strategies, quality improvement, improving patient safety, supplying timely measurement, and leveraging our informatics infrastructure to support local teams. QOT will provide regular reports to ELT regarding the oversight and evaluation activities conducted by QOT at ELT direction, and regarding any recommendations for the quality agenda. Tasks:  Oversee the broad integrity of the Quality Program for the enterprise.  Incorporate GHO and other lines of business into the GHC oversight

model.  Recommend goals and targets to ELT.  Define and communicate standards, metrics, and targets for assessing

performance.  Require regular reporting of performance, including quantitative and

qualitative analysis.  Identify systemic themes and barriers.  Assess and leverage relational aspects of quality (clinical, safety,

service/access, care management) to ensure both balance and opportunity.

 Escalate issues that require ELT action.

 Exec. Vice President, Group Practice Division  Vice President, Network Svcs. and

Care Management, Health Plan Division

 Medical Director, Group Practice  Vice President, Clinical Excellence,

Quality and Nursing Practice  Vice President, Group Health

Options  Exec. Director, Behavioral Health

Services

The following committees report through the Quality Oversight Team (QOT) and/or ELT:

COMMITTEE OR GROUP DESCRIPTION COMPOSITION OF GROUP Professional Liability Committee (meets monthly) Purpose: The Professional Liability Committee has responsibility for reviewing medical and legal issues that result in litigation against Group Health Cooperative. The Committee authorizes settlements and reviews system issues for quality improvement. Tasks:  Review professional liability claims and litigation.  Authorize settlement amounts.  Research Risk Management issues.  Recommend system changes to improve the quality and safety of care

provided.

 Exec. VP and General Counsel, or Designee

 Exec. Director, Risk Management  Three GHP physicians and one

family practice physician  Medical Director, or Designee  Representation of medical centers in

Spokane, North Idaho, and Puget Sound region

 Vice President, Clinical Excellence, Quality, and Nursing Practice (PhD, RN), or Designee

COMMITTEE OR GROUP DESCRIPTION COMPOSITION OF GROUP Confidentiality and Security Council (meets monthly) Purpose: The Confidentiality and Security Council has a primary role in advising regarding development and ongoing maintenance of privacy policies, the implementation and compliance with privacy policies, and privacy training. The Council serves as an advisor and as an informational body with limited decision making. Tasks:  Review and advise regarding policies, procedures, and training

addressing privacy, confidentiality, security, and collection, use, and disclosure of member/patient information, administrative safeguards, business information, and other Group health information assets.

 Review of summary report information about breaches and breach remediation indentifying trends and actionable items.

 Provide input and review of privacy, confidentiality, and security education, training, awareness content; review effectiveness of training programs.

 Provide a forum for the discussion of issues related to information, use and disclosure, confidentiality, privacy, and security.

 Co-chair - Privacy Officer  Physician co-chair – appointed by

the Medical Director Council members include representatives from:  Risk Management  Human Resources  Medical Staff  Privacy Office  Information Security  Group Health Research Institute  Network Services and Care

Management  Health Information Management  Group Practice

Credentialing and Privileging Committees (C&PCs – meets at least 10 times annually) Purpose: To select, evaluate, and monitor the practitioners and providers (healthcare delivery organizations) who care for GH enrollees. Tasks:  Establish standards/criteria regarding qualifications for GH providers

and practitioners.  Approve/deny the credentials of practitioners and make

recommendations to the Quality Committee regarding appointments, reappointments, privileging, and re-privileging within the GH delivery system.

 Provide oversight of delegated credentialing activities.  Recommend credentialing/privileging policies and procedures to

QCOB.

 Western Washington Credentialing & Privileging Committee

 Eastern WA/North Idaho Credentialing & Privileging Committee

 Central WA Credentialing Committee

*(See Attachment #4 for complete membership)

Care Management Oversight Team (CMOT – meets quarterly) Purpose: The Care Management Oversight Team (CMOT) is delegated by Group Health’s Quality Oversight Team (QOT) to oversee the statewide Care Management program. CMOT specifically:  Acts as the approval body for organizational care management work

plans and policies, including UM policies for denials and appeals, Medical Technology and Assessment Committee (MTAC), and Pharmacy & Therapeutics Committee (P&T).

 Develops the Care Management Program Description and Annual Work Plan.

 Conducts an annual evaluation of the Care Management Work Plan in meeting organizational goals and objectives.

 Monitors the operational status of care management activities across

Core Membership includes:  Exec. Director, Care Management  Exec. Medical Director, Health Plan

Division (or Designee), chair  Exec. Director, Health Plan

Operations  Director of Medical Operations,

Behavioral Health Services  Manager, Quality Performance

Review  Exec. Director, Government

Programs Additional representatives may attend on an ad hoc basis

COMMITTEE OR GROUP DESCRIPTION COMPOSITION OF GROUP Care Management Oversight Team (con’t) the organization to ensure a cross-functional, integrated approach to delivering high-quality care to members.  Oversees and monitors compliance with regulatory and accrediting

bodies.  Provides monitoring for, and recommends direction to, the Clinical

Expense Group (CEG). Tasks: CMOT’s scope is primarily related to improvement and monitoring work, including:  Approval body for organizational care management work plans, such

as case management, pharmacy, etc.  Oversight and approval of systems and programs to ensure

compliance with regulatory and accrediting bodies such as NCQA, TeaMonitor, etc.

 Sponsor of PDCA/improvement work in support of Care Management core work, once stabilized and ready for hand-off by CDOG (Care Delivery Oversight Group).

Patient Safety Committee (PSC – meets approximatel monthly) Purpose: To evaluate patient safety risks and make prioritized recommendations to the enterprise to improve safety; to support the Patient Safety Office in execution of the Patient Safety Work Plan; and, to enhance alignment with patient safety initiatives throughout the enterprise. Tasks:  Review, approve and monitor the Patient Safety Work Plan.  Ensure that Group Health’s improvement activities focus on

nationally agreed upon safety priorities.  Analyze Unusual Occurrence database to identify risk and develop

countermeasures to system issues that impact patient safety.  Synthesize information from feedback systems (e.g. Unusual

Occurrences, Patient Safety WalkRounds, Member Quality of Care Concerns, etc) to identify potential risk and opportunity for improvement.

 Promote the spread of patient safety improvement and lessons learned from Unusual Occurrences across the system.

 Recommend to the delivery system and GHC and GHP Boards appropriate patient safety dashboard measures.

 Ensure that Group Health’s policies and procedures are consistent with Just Culture.

 Recommend safety improvements with both internal and contracted delivery system leaders.

 Ensure alignment of Group Health’s patient safety initiatives with regulatory requirements.

 Develop a member engagement strategy.  Survey Group Health providers and staff perceptions of patient safety

culture.  Provide expert consultation on patient safety science.

 Medical Director, Patient Safety, chair

 Patient Safety Officer  Exec. Director, Risk Management  Chief, Hospital Medical Staff  Director, Hospital Quality &

Compliance  MD, Consultative Specialty

Services  MD, Primary Care  MD, Surgical Services  Director, Infection Control,

Employee Health (RN)  Manager, Medication Safety  Assoc. Director, Lab Services  Nursing Operations Clinical Practice

Specialist (RN)  MCA/Administrator, Group Practice

Division  Director, Clinical Operations,

Behavioral Health (ad hoc member)

COMMITTEE OR GROUP DESCRIPTION COMPOSITION OF GROUP Patient Safety Committee (con’t)  Conduct annual self evaluation: The committee will annually

determine whether it is functioning effectively and plan improvements based on that assessment.

Medication Safety Committee (MSC - meets quarterly) Purpose: To support quality patient care by using a systems-oriented approach in evaluating and promoting the safety of the medication use process. Tasks:  Help build and foster a safety culture within the organization.  Improve and maintain an effective medication unusual occurrence

reporting system.  Review and prioritize the level of patient risk based on trends

identified in the Unusual Occurrence data, Institute of Safe Medication Practice (ISMP), and other external sources.

 Make recommendations towards medication safety improvement efforts with both internal and contracted delivery system leaders.

 Provide expert consultation as it relates to medication safety concerns.

 Review, approve and monitor the Medication Safety work plan.  Ensure alignment with regulatory compliance as it relates to

Medication Safety.

 Physician, Medication Safety (co- chair)

 Manager, Medication Safety (co- chair)

 Medical Center Pharmacy Manager(s)

 Clinical Pharmacist Representative(s)

 Associate Director, Pharmacy Operations

 Manager, Pharmacy Informatics  Pharmacy Technician Ananyst  Manager, Nursing Operations  Patient Safety Officer  Manager, AMB Pharmacy Contact

Center  Coordinator, Transitions of Care  Manager, Specialty Pharmacy

Services  Member from Central Hospital

(vacant)  Consultant Sub-group from Clinical

and Operational areas as determined

Clinical Information Systems Safety Committee (CISSC – meets monthly to quarterly)

Purpose: To develop and implement a comprehensive organizational Clinical Information Systems patient safety program under the leadership of the Chief Medical Information Officer (CMIO). Tasks:  Assess and prioritize patient safety risks through monitoring and

analysis of: a. Unusual Occurrences b. ERT incidences c. EPIC patient safety alerts and concerns d. Liaison activities with Medication Safety and Lab committees.  Make recommendations and coordinate improvement activities in CIS

applications.  Identify and evaluate opportunities for proactive system

developments to improve patient safety in clinical information systems.

 Build and foster a culture of patient safety within the CIS organization.

 Chief Medical Information Officer, chair

 Manager, Pharmacy Informatics  Nursing Operations Clinical Practice

Specialist, RN Director Clinical Services

 Director, EPIC Team  Director, Epic Technical Services  Patient Safety Officer  Medical Director, Clinical

Informatics  Medical Director, Patient Safety  Director, Care Delivery Information

Services  Manager, Clinical Departmental

Systems Consultant members from technical, clinical and operational areas as needed

COMMITTEE OR GROUP DESCRIPTION COMPOSITION OF GROUP Prevention Population Teams (meet either monthly, bi-monthly or quarterly – varies by team) Purpose: These are prevention-based population teams whose overall goal is to promote healthy behaviors, reduce risk of disease, and detect early onset of disease among GH enrollees. The prevention teams include: Tobacco and Alcohol Prevention; Immunizations; Cancer Screening (breast, cervical, colorectal); and, Well Visits. Tasks:  Develop the long-term vision for prevention needs and aims in the

domain of the prevention team.  Develop an annual workplan to evaluate the quality of preventive care

within the scope of the prevention team.  Review and recommend measures for evaluating performance.  Develop a set of options and toolkits for delivery system and clinic

leaders to use to improve uptake of prevention services.  Share accountability for performance improvement in the delivery

system.

 Delivery System Administrator, co- chair

 Delivery System MD, co-chair  Clinical Improvement & Prevention

staff  Other members from Quality,

Delivery System, and Health Plan, depending on unique function of the specific team

Oversight provided by:  Medical Dir., Preventive Care  Director, Clinical Improvement and

Prevention (RN)

Guideline Oversight Group (meets once per month) Purpose: Oversee the development and updating of clinical guidelines to ensure high quality products, efficient use of GHC/GHP resources and timeliness of project completion. Act as a liaison between guideline teams and the Quality Oversight Team (QOT). Tasks:  Evaluate requests for new guidelines and prioritize based on clinical,

business, and customer service factors.  Oversee creation of processes related to clinical guidelines, such as

system for deciding whether to adopt or adapt material from outside source or develop product internally.

 Monitor the progress of guideline projects and problem-solve any barriers to continued progress.

 Review completed projects submitted by guideline teams to ensure high quality of products and consistency of key recommendations with the evidence.

 Oversee preparation of materials on guideline projects to be reviewed by QOT.

 Medical Director, Quality Improvement

 Medical Director, Preventive Care  Medical Director, Clinical

Knowledge Development and Support

 Assistant Medical Director, Preventive Care

 Director, Clinical Improvement and Prevention (RN)  Manager, Clinical Knowledge

Development and Support  Coordinator, Clinical Guideline

Development  Clinical Epidemiologist  Supervisor, Clinical Publication

Behavioral Health Services Leadership Team (BHSLT- meets 2 – 3 times per month) Purpose: Provides senior leadership oversight for behavioral health (BH) care across the GH delivery system and is responsible for all business and quality improvement functions. As the department’s approving quality body, is responsible for orchestrating the department’s quality agenda to support organizational strategies, implementing the quality program, monitoring performance, and making changes as needed. Tasks:  Set the department’s quality agenda and provide input into

organization and divisional quality plans.

 Director, Behavioral Health Services

 Director, Medical Operations  Director, Clinical Operations

COMMITTEE OR GROUP DESCRIPTION COMPOSITION OF GROUP Behavioral Health Services Leadership Team (con’t)

 Monitor, plan and take actions to improve: - HEDIS performance on BH measures - Patient experience of BH care - Access to care - Coordination of care - Patient Safety

 Ensure compliance with accreditation and regulatory standards for BH (e.g., NCQA, State, Medicare).

 Oversee BHS systems and infrastructure (e.g., referral and triage functions, new technology).

 Oversee training and professional development for staff.  Liaison with other departments in the organization to connect

departmental efforts with organizational work (e.g., patient confidentiality, unusual occurrence monitoring).

 Oversee utilization management functions for BHS.  Quality of Care reviews are delegated to the Quality of Care Review

Committee who report findings through the Unusual Occurrences reporting system. This committee meets monthly and results are reported on a quarterly basis to the BHS LT.

The following groups provide support for and promote communication and execution of quality improvement opportunities and initiatives throughout GHC:

COMMITTEE OR GROUP DESCRIPTION COMPOSITION OF GROUP Division Leadership Teams/Quality Councils (meets at least monthly to quarterly) Purpose: Provide division-specific and/or function-specific organizational direction and oversight for quality improvement initiatives. Facilitate and provide direct support for the quality improvement initiatives based on directions derived from the strategic plan A3 deployment, the Quality Committee of the Board and/or the QOT. Tasks:  Monitor the quality indicators [process measures/standards] and

identify and present trends to the attention of QOT when they cross pre-established thresholds, or otherwise warrant attention or action by ELT or the Quality Committee.

 Identify opportunities for improvement and provide direction regarding which issues to target for intervention.

 Review and approve policies that impact quality.  Approve, support/guide performance improvement teams.  Recognize and celebrate performance improvement efforts.

Varies by site, includes key physician and administrative leadership through the following structures:

 Group Practice Division Leadership

Team/Quality Council (Attachment #1, 2)

 Network Services and Care Management Leadership Team/ Quality Council (Attachment 1, 3)

 Health Plan Division (Attachment #3)

COMMITTEE OR GROUP DESCRIPTION COMPOSITION OF GROUP Enterprise Quality Purpose: To support executive leaders in driving process, practice and quality/service improvements across the enterprise while ensuring that initiatives are integrated and coordinated in order to fully leverage our integrated system. Tasks:  Assist with the planning and development of strategies for service

and clinical quality improvement.  Support implementation of quality improvement strategies and

initiatives.  Provide internal expertise through the application of Lean tools to

meet strategic, service line, and local improvement needs.  Provide quality improvement support in the delivery systems.  Support the care management strategy development and

implementation.  Support clinical guideline development and implementation.  Provide organizational health information and education.  Provide training and consultation for service and practice

improvement strategies.  Support the implementation and management of the Group Health

Options quality program.

 See Attachment 5

GH Quality Assessment and Improvement Accountability Structure The key feature of Group Health’s quality assessment and improvement process is the ability to view sub-optimal quality from a broad, systems perspective. We believe that most quality problems are the result of poorly designed systems and processes. An essential activity that is built in to the quality assessment process is to “drill down” to determine whether an individual provider’s apparent problem may be related to an underlying system issue. Performance measures and reporting of progress against targeted measures is widely available to all Group Health staff through the internal web site Connections. Group Health conveys quality information to those who are accountable for assessing and improving care in one of two forms: 1. In the aggregate form. This information is used for population or geographic area assessments

and identification of system problems. 2. In the practitioner-specific form. This information is used for credentialing and performance

evaluation. The structure diagrams on the following pages describe linkages among responsible groups. These linkages are the communication conduits for performance information. Attachment 6 describes the data sources and analytical resources that support the quality program.

ATTACHMENT 1

GHC Quality Assessment and Improvement Structure

Board of Trustees

Quality Committee of the Board

Executive Leadership Team

Quality Oversight Team

Professional Liability

Committee

Confidentiality & Security

Council

Credentialing & Privileging Committees

*Behavioral Health Services

Leadership Team

*Patient Safety Committee

Group Practice Division

[LT/Quality Council]

Health Plan Division

[LT/Quality Council]

 Medical Directors Clinical Review & Policy Cmte. (MDCRP)

 Medical Technology Assessment Cmte. (MTAC)

 Pharmacy & Therapeutics Cmte. (P&T)

 *Care Planning and Improvement Committees (CPICs)

*also has links to Divisional Leadership Teams/Quality Councils

Legend:

GHC

Division

 Privacy Office  Quality of Care Review Cmte.

 Medication Safety Committee

 CIS Safety Committee

 Quality of Care Case Review

*Care Management

Oversight Team.

 Clinical Support Service Line Quality Committees

 Consultative Specialty Quality Committees

 Primary Care/ Behavioral Health Leadership Team

 Network Services and Care Management Leadership Team (NSCMLT)

 Network Services and Care Management Quality Council (NSCM-QC)

ATTACHMENT 2 Group Practice Division Quality Committees

Quality Oversight Team (QOT)

Group Practice Division

Quality Council

Clinical Service Line Committees

Lab/Pathology (Quality)

Pharmacy (Quality)

Hospice (Quality)

Quality of Care Case Review (Patient Safety)

Consultative Specialty Leadership Team/

Quality Council

Radiology QA Committee

Radiation Oncology QA Committee

Olympic View Dyalysis Center QA

Committee

Consultative Specialty Section meetings

Hospital (Quality)

Ambulatory Surgery Centers (Quality)

Primary Care/ Behavioral Health Leadership Team

Home Health (Quality)

Emergency Services/ Urgent Care

(Quality)

Nursing Home Services (Quality)

ATTACHMENT 3 Health Plan Division Performance Management System

< F

u n ct

io n >

at ch

ba ll/

C ap

ac ity

c he

MEDICAL DIRECTOR CLINICAL REVIEW AND POLICY

COMMITTEE

Assures consistent and uniform set of medical policies

Assures and maintains balance between medical policy,

medical efficacy and market/environment Considers new technologies

Maintains, revises and creates medical necessity policy to use in making coverage

decisions

GPD OWNED & OPERATED

1° Care 2° Care 3° Care

NON-OWNED & OPERATED

Provider Relations DA/DMD’s

MEDICAL TECHNOLOGY ASSESSMENT COMMITTEE

Assess the evidence for new and existing technologies and provide

the assessment outcome to MDCRPC

UTILIZATION IMPROVEMENT

GROUP

Utilization management oversight

Assess feasibility of clinical cost initiatives

CARE MANAGEMENT Design Team

Logic Cell Oversight CM Model Oversight

CMIS oversight and standards CM strategy deployment

Content of Care Oversight of CM work & system Improvement & coordination

of CM

GPDLT Group Practice Division

Leadership Team

NSCMLT Network Services/Care

Management Leadership Team

Care Delivery Design and Improvement Structure

ORGANIZE AND DESIGN Determine feasibility of new initiatives

Determine disposition of new initiatives

Develop tactics, strategies, and designs to close performance gaps

Eliminate redundant improvement efforts

Request analytics

DEPLOY AND IMPROVE Run Operations Operationalize improvement initiatives Drive ongoing improvement Strategic input to design teams/ CDOG

QCOB

Q & P

ELT Strategic direction

CMOT Annual organizational

monitoring

Set Quality Agenda

Prioritization of quality initiatives

QOT

Includes regulatory oversight, monitoring of

ongoing operational programs throughout

system, and identification of new

opportunities

CAT Capital

Allocation Team

CEG Clinical Executive

Group

Monitoring Dashboard

Establish Metrics for Care Delivery System Cost, Quality, Access, Member/Pt. Satisfaction, Business Alignment, Purchaser SatisfactionLOAD

Prioritizing enterprise work

Setting strategies

Monitoring performance outcomes

Contracting oversight

Strategic positioning in service delivery markets

PHARMACY & THERAPEUTICS

COMMITTEE

Identify the most cost effective pharmaceutical treatment and

recommend changes to the formulary and prior auth criteria

Evaluate use of new pharmaceuticals or new application of existing

pharmaceuticals

ATTACHMENT 4 Credentialing Committees Membership

Member Specialty Status Member Specialty Status

Central Washington Pope, Brad, MD, chair Family Practice GHP Chou, Valiant, MD Obstetrics/Gynecology Contracted Western Washington

(Seattle C&P)

Thiel, Arthur, MD Orthopaedic Surgery Contracted Bailey, Desiray, MD, chair Anesthesiology GHP Mayuga, Lorena, MD Family Medicine Contracted Dimer, Jane, MD, Obstetrics &

Gynecology GHP

Gibson, Lori, LICSW Behavioral Health Staff Paros, Philip, OD Optometry GHP McLaughlin, Pat Manager, Provider Services Staff Shewey, Linda, Midwifery/ARNP’s GHP Pittman, Michelle Credentialing Specialist Staff Lowe, Marc, MD Urology GHP Runyan, Candice Supervisor, Credentialing Staff Duncan, Stephen, MD Family Practice GHP Ahart, Sharon, MD Pediatrics Contracted Wanderer, Michael, MD, co-chair Family Practice GHP Eastern Washington/North Idaho

Feller, Steve, DPM Podiatry Contracted

Pope, Brad, MD, chair Family Practice GHP Steinfeld, Bradley, PhD Psychology/Behavioral Health

GHP

Barrong, Shawn, MD Obstetrics/Gynecology Contracted Erickson, Michael, PA-C Physician Assistant GHP Gibson, Lori, LICSW Behavioral Health Staff Hsia, Raymond, MD Gastroenterology GHP Schaaf, Tom, MD Family Practice GHP Quality Committee Oversight of

Credentialing & Privileging:

Bergum, Mary, MD Family Practice Contracted Bob Margulis N/A Trustee Juliver, Adam, MD General Surgery Contracted Susan Byington N/A Trustee Brooks, Maureen Manager, Provider Services Staff Harry Harrison, MD N/A Trustee Kenning, Kimberly Credentialing Specialist Staff Dorothy Ruzicki, RN N/A Trustee Runyan, Candice Supervisor, Credentialing Staff Leo Greenawalt N/A Trustee Savres, William, MD Family Practice GHP

ATTACHMENT 5 Enterprise Quality

Vice President of Clinical

Excellence, Quality, and Nursing

Practice

Associate Medical Director, Quality and

Informatics

Director of Nursing

Operations

Clinical Practice

Specialist

Director, Professional Practice &

Development

Clinical Practice & Education Specialist

Clinical Practice & Nursing Education

Specialist

Manager, Nursing Operations Clinical

Information Systems

Administrative Coordinator

Population

Management Coordinator

Quality Performance Review

Manager

Clinical Knowledge Development &

Support Manager

Patient Safety Manager

Screening Programs Manager

Health Information & Promotion Manager

Expert Wound Care Team

(2)

Project Manager

Clinical Practice Specialists

(2)

Director, Clinical Improvement &

Prevention

Director, Content of Care

Content of CareClinical Improvement & Prevention Nursing

Operations

Vice President of Clinical Excellence,

Quality, and Nursing Practice

Program Manager

Administrative Coordinator

Administrative Assistant

Infection Preventionist, BVU

Infection Preventionist, CMB

Infection Preventionist, TAD

Employee Health & Infection Control

Coordinator, EW/NI

Infection Control Analytical Analyst

Infection Control Admin C

Employee Health Administrative Coordinator

Infection Control & Employee Health

Admin B

Employee Health Coordinator

Infection Prevention & Employee Health

Director, Infection Prevention &

Employee Health

ATTACHMENT 6 Quality Resources at Group Health Cooperative

Quality Improvement Activity Resources The resources that Group Health devotes to the Quality Improvement Program and specific quality improvement activities are broad and include staff (employees and consultant staff), data sources, and analytical resources such as statistical expertise and programs. Evaluation of adequate quality resources is determined through evidence that the organization is completing quality improvement activities in a competent and timely manner. This is done through the annual Quality Program Evaluation, as well as ongoing monitoring of performance and progress on the quality workplan by the Quality Oversight Team (QOT) throughout the year. Oversight for Enterprise Quality is provided by a Vice President and an Associate Medical Director, and a total of six medical directors, one in each of the following areas: Informatics, Clinical Improvement, Preventive Care, Clinical Knowledge Support, Continuing Medical Education, and Senior Services. The Preventive Care Department also has an Associate Medical Director and an Assistant Medical Director. Staff (over 200 positions), including 51 in the Clinical Improvement and Prevention department, dedicated to quality improvement activities are present in the following areas:

 Patient Safety  Clinical Knowledge Support  Continuing Medical Education  Clinical Improvement and Prevention  Quality Performance Review  Consulting Services  Credentialing  Member Appeals  Clinical Review Unit  Member Quality of Care Grievances  Behavioral Health Services  Care Management  Pharmacy Administration

In addition, external consultant staff arrangements are made as needed. Data Sources Group Health uses a number of different sources and systems to collect data and generate results for quality indicators, including the following:  Premier membership and billing system – enrollment data  Enterprise Master Files (EMF) – additional consumer and practitioner demographics

 EPIC clinical information system – clinical data from the electronic medical record  EPIC practice management suite – encounter, appointment, admit/discharge/transfer,

and billing information for inpatient and outpatient services received at Group Health facilities on or after 11/1/2009

 LastWord – encounter, appointment, admit/discharge/transfer, and billing information for inpatient and outpatient services received at Group Health facilities prior to 11/1/2009

 Premier claims system – data for institutional and professional services received inside and outside Group Health clinics

 Coop Rx – internal pharmacy claims system  MedImpact – external pharmacy claims system  Laboratory Information System (LIS) – internal laboratory services and results  PAML – selected external laboratory services and results for some members treated

in Spokane area Group Health clinics  CareTracker – care coordination tracking tool  eWatson – customer relationship management tracking system (including complaint

and appeals data)  Patient Experience Survey Results database – results from Group Health’s survey of

patient satisfaction  Cancer Screening Exclusions – Supplemental source of data, identifying members

with valid exclusions from selected screening procedures Data from most of these systems are stored in Group Health’s Data Warehouse, a repository for current and historical clinical, service, financial, utilization, and administrative data. Programmers in Enterprise Information Management (EIM) create programs to extract the data and produce results for key clinical, utilization, and service quality indicators. Data Warehouse and Reporting Resources Group Health maintains a data warehouse repository usable by staff across the organization for analysis and reporting. Part of that maintenance requires pulling data from original source systems such as claims and Epic into warehouse tables “scrubbed” and enhanced with value-added attributes. In addition, for various applications or reporting needs, datamarts are developed with specific information needed for that reporting or by those applications. This team includes the following staff:

 Analyst, Application Systems Programmer III (8 positions) – develop, maintain, and administer data integration (ETL) processes and tools; develop, maintain, and administer ad-hoc and standard reporting applications, dashboards and tools; manage the ongoing loading and optimization of the Data Warehouse

 Manager, Data Integration (1 position) – responsible for the day-to-day load operations of the Data Warehouse; ensures that all data are loaded as required; manages resources for data integration development projects within EIM

 Business Intelligence Analyst (8 positions) – responsible for gathering requirements and source-to-target mapping of data; manage the daily workflow of work by the individual teams

 Analyst, Business Programming I; Analyst, Data Quality (6 positions) – quality assurance/validation of all data loads from the source systems into the data warehouse.

 Data Consultant (2 positions) – logical and physical design of database/data mart structures

 Business Data Analyst (1 position) – staffs a help desk to provide support for reports and resources and completes data warehouse queries and other ad hoc requests for analysis

 Analytical Assistants (2 positions) – provide general support for analytical work and help desk, perform data validation, schedule medical record review visits to non-owned/operated facilities, manage compilation of materials for and staffs the annual HEDIS compliance audit.

 Analyst, Application Systems, Programmer III (1 position) – develop technical infrastructure to produce reports, develop measures, and datamart to support clinical measurement reporting

Measurement and Analytical Resources Group Health dedicates significant staff and information systems to analyzing and reporting the large volume of clinical and service quality data available. This team includes the following staff:

 Senior Measurement Consultants (2 positions) – work with organization leaders to understand issues, questions being asked, and data needed to support decision- making; provide leadership to teams doing the analysis

 Manager (1 position) – as part of support services, that manager leads the annual medical record review process that is part of HEDIS reporting, including hiring of 7-9 temporary reviewers, training, and performing reviews

 Measurement Analyst (4 positions) – perform deep analysis including data profiling, hypothesis testing and statistical analysis for quality related initiatives; provide support analysis to drive clinical and process improvements; provide ad hoc analysis using standard statistical methods; evaluate effectiveness of new programs

In addition, EIM utilizes high-level technical staff from other EIM departments to support new and ongoing work:

 System Architect (1 position) – design, build, and maintain stand-alone application to collect medical record review data

 Database Consultant (1 position) – design complex data mart structures These programmers use a number of applications to produce results and reports for clinical and service quality indicators including:

 VIPS certified HEDIS measure calculation  Informatica PowerCenter (Extract, Translate, & Load “ETL” software

application)

 SAS  Sybase Adaptive Server Enterprise  Microsoft Visual Basic  Microsoft SQL Server  Microsoft Access  Microsoft Excel  Business Objects reporting tools, including Crystal Reports

The Enterprise Information Management department includes a PhD level statistician and three Masters level statistical analysts to provide consultation regarding the statistical relevance of changes in clinical and service performance.

ATTACHMENT 7 Quality Improvement Focus for the Medicaid Population

As stated in the Quality Program Description, the scope of Group Health’s quality program includes specific quality improvement activities and measurements directed at Group Health’s Healthy Options (Medicaid) population. These activities ensure that the clinical, service, and care management performance standards set by the State of Washington Health and Recovery Services Administration (HRSA) and the Centers for Medicare and Medicaid Services (CMS) are met or exceeded for this important and vulnerable population. Group Health provides coverage for Medicaid members in four counties in Washington, serving approximately four percent of Healthy Options enrollees. More than 87 percent of Group Health’s Medicaid members receive care in Group Health owned and operated medical centers. About three percent of Group Health’s membership are Medicaid members, of which more than 80 percent are aged 18 or younger. A process for identification, review, prioritization, and development of performance improvement projects (PIPS) through ongoing monitoring and reporting of clinical measures is in place. Staff in Quality and Planning develops and monitors monthly Healthy Options and Basic Health specific line of business performance on clinical and service measures to identify improvement opportunities. As part of the ongoing quality monitoring process multiple dimensions of quality are assessed for the care and service provided to the Healthy Options members specifically. This comprehensive performance monitoring and assessment includes: Purchaser feedback: The TEAMonitor review is an annual assessment by State agencies (DSHS/HRSA and Healthcare Authority, HCA) reviewing Group Health’s performance for State programs – Medicaid Healthy Options and Basic Health. Ongoing monitoring of corrective action plan items, including those related to the Quality Program, are reviewed and discussed regularly at the TEAMonitor Oversight Group, comprised of representatives from Quality, Health Plan Administration Compliance, Government Programs, and Marketing. The TEAMonitor Oversight Group’s work reports up to the Government Programs Oversight Committee who has broad responsibility for ensuring that government sponsored contract requirements are met. Clinical performance: As previously mentioned, clinical and service measures for Healthy Options and Basic Health specific lines of business are monitored on a monthly basis by Quality and Planning staff to identify improvement opportunities.

Current quality improvement activities focused on this population include:  Children with Special Health Care Needs  Preventive Well Visits  Childhood Immunizations

Service performance: Healthy Options member satisfaction performance through the PES survey is monitored monthly; however, the small denominator sizes of 50-70 make it difficult to identify trends or actionable information. Complaint data provides more useful member feedback related to service performance. Complaints and Appeals are both monitored on a quarterly basis. Care management performance: Components of care management performance that are monitored regularly, either quarterly or annually as appropriate, include: denials; over/under utilization; the Patient Review and Coordination program; and, care coordination/complex case management programs. In addition to the regular and ongoing monitoring of quality performance, the formal annual Quality Program Evaluation includes a specific assessment of performance for the Healthy Option’s (Medicaid) population, and the findings and recommendations are used to inform the Quality Plan for improvement activities for the following year.

2012 Update of Quality Plan and Program Description
Table of Contents
Introduction
Vision for Quality
Alignment with Strategic Plan
Reflections Regarding Achievement of 2011 Quality Goals
2012 Quality Hypothesis and Goals
2012 Quality Framework and Action Plan
Quality Program Description
Quality Improvement Planning Process
Quality Program Implementation
Evaluation of the Quality Program
Confidentiality
Quality Program Structure and Accountability - Committee Descriptions
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