Quality & safety

1. Quality management and improvement includes quality improvement program structure and operations. Health services contracting, availability of practitioners, accessibility of services, member satisfaction, population health management, clinical practice guidelines, continuity and coordination of medical care and between medical and behavioral health care, quality improvement for clinical care and service, medical record documentation, and delegation of QI activities.
2. Utilization management includes utilization management structure, clinical criteria for UM decisions, communication services, appropriate professionals, timeliness of UM decisions and notification to members and practitioners, clinical information, denial notices, policies for appeals and the handling of appeals, evaluation of new technology, satisfaction with the UM process, if applicable triage and referral for behavioral health care, and if appropriate delegation of UM.
3. Member rights and responsibilities includes a statement of members’ rights and responsibilities, distribution of this statement to members and practitioners, policies for complaints and appeals, subscriber information, physician and hospital directories, privacy and confidentiality, marketing information and delegation of members’ rights and responsibilities.
4. Credentialing and re-credentialing includes credentialing policies and committee, initial credentialing verification, application and attestation, initial sanction information, recredentialing verification, recredentialing cycle length, ongoing monitoring, notification to authorities and practitioner appeal rights, assessment of organizational providers and delegation of credentialing.
5. Member connections includes health risk appraisals, interactive consumer health tools, functionality of claims processing, pharmacy benefit, and personalized information on health plan services, innovations in member services, health information line, encouraging wellness and prevention and delegation of MEM.
6. Preventive health is the process of adopting Clinical Practice Guidelines (CPG) and educating members and providers to provide care to detect and treat preventable illnesses early or avoid them altogether.
7. Healthcare Effectiveness Data Information Set (HEDIS^®) is a set of clinical quality measures the health plan reports annually. These measures are comparable across health plans and must be audited before reporting to ensure rates are an accurate representation of the care received by our health plan members. Each year a subset of these measures is used to give the health plan a score from one to five stars.
8. Consumer Assessment of Healthcare Providers and Systems Satisfaction CAHPS^® is a survey of our members that helps us learn what we can do to improve your experience with the health plan and in-network providers.

MercyCare Health Plans and its board of directors are committed to using health plan resources and information systems to help our network of physicians continually improve the health care services our members receive. We always work to promote and achieve excellence in all areas of service through continuous quality initiatives. In doing so, MercyCare annually develops a quality improvement program description, population health management strategy, quality and population health management activities evaluation, and work plan to provide a detailed review of how we evaluate overall effectiveness of our quality improvement program. We constantly evaluate how we can improve health care delivery, accessibility and member satisfaction with our health plans.

To request a copy of our quality improvement program descriptions and evaluations, please call or email customer service at 800.895.2421 or mcare@mhemail.org

The safety of our members is of utmost importance to MercyCare Health Plans. We want our members to feel confident in accessing services through any of our network hospitals. One way to identify how effective a hospital is at providing care, and the quality and safety of the care provided is by accessing CheckPoint. All of MercyCare’s network hospitals participate in CheckPoint. CheckPoint was developed by the Wisconsin Hospital Association (WHA) and is used to provide reliable data to consumers. Some of the measures reported on CheckPoint are related to:

• Heart attacks
• Heart failure
• Pneumonia
• Surgical infection prevention
• Medical errors

You can access CheckPoint at wicheckpoint.org.

Good communication is a vital part of patient safety. It is important for members and health care providers to effectively communicate with each other. Effective communication reduces the risk of errors and promotes better health outcomes. MercyCare recommends you ask the following questions when you see your doctor:

1. What is my main problem?
2. What do I need to do?

The Agency for Healthcare Research and Quality’s (AHRQ) website, ahrq.gov, has information regarding the importance of taking an active role in your own health care by asking the right questions. Please reference this website for additional information on this initiative and what questions to ask.

Electronic medical records are a timely and patient-centered form of communication between practitioners. They allow practitioners to communicate and exchange data accurately and effectively, and eliminate the risk of handwritten medical abbreviations. Mercy Health System has made a commitment to implementing electronic medical records throughout its facilities.

Our member rights and responsibilities document is also a good tool to promote communication and in turn, safety. MercyCare developed this document to be respectful of members’ rights and also to educate members on what is expected of them. Members and providers both should be aware of these rights and responsibilities.
Review document

The Leapfrog Group
The Leapfrog Group is a voluntary program aimed at mobilizing employer purchasing power to alert America’s health industry that big leaps in health care safety, quality and customer value will be recognized and rewarded. Among other initiatives, Leapfrog works with its employer members to encourage transparency and easy access to health care information as well as rewards for hospitals that have a proven record of high-quality care.
leapfroggroup.org

Wisconsin Collaborative for Healthcare Quality
Wisconsin Collaborative for Healthcare Quality is a voluntary consortium of organizations learning and working together to improve the quality and cost-effectiveness of health care for the people of Wisconsin.
wchq.org

The Agency for Healthcare Research and Quality (AHRQ)
The Agency for Healthcare Research and Quality (AHRQ) funds this site that is comprised of a collection of patient safety information and resources titled AHRQ Patient Safety Network. This site offers weekly updates of patient safety literature, news, tools, etc.
psnet.ahrq.gov

The HQA is national public private collaboration that represents hospitals, consumer representative, physician and nursing organizations, employer and payers, oversite organizations, and government agencies. HQA is committed to making meaningful and easy to understand information about hospital performance accessible to the public.
hospitalqualityalliance.org

One of the collaboration efforts of HQA is Hospital Compare, (hospitalcompare.hhs.gov) which allows you compare the care delivered at different hospitals.