National Committee for Quality Assurance (NCQA) Accreditation
NCQA Accreditation is a comprehensive evaluation of health plans clinical measures and consumer experience measures. Standards are developed with the help of health plans, providers, insurance customers, unions, regulatory agencies and consumer groups. NCQA's Health Plan Accreditation is considered the industry's gold standard. NCQA Accreditation measures five areas of performance: Staying Healthy, Getting Better, Living with Illness, Access and Service, and Qualified Providers. To see how SWHP Providers measured up, click the link below, then choose "Health Plan Report Card" and search for "Scott and White" to see our ratings.
Healthcare Effectiveness Data and Information Set (HEDIS®)
HEDIS® is a registered trademark of NCQA. SWHP uses HEDIS® to measure clinical quality performance and evaluate areas of care: preventive services, treatment of acute illness, management of chronic illnesses, and patient experience with services provided (as measured through the CAHPS, a standardized survey used by all plans).
Purpose and Scope of the QI Program
The purpose of the quality improvement program is to ensure SWHP is providing the highest quality care that is easy to access and affordable to our members regardless of plan type, age, race/ethnicity or health status. SWHP supports and tries to reach "Triple Aim" goals: improving Member's affordability, quality and experience of care. SWHP Quality programs and improvement projects are designed to improve member outcomes through systematic ongoing measurement, provider/member/health plan care coordination, and continuous evaluation of results.
The scope of the QI Program is to monitor, evaluate and improve:
- • The quality and safety of clinical care
- • The quality of service provided by SWHP
- • The quality of practitioners and providers
- • Affordable and accessible health care and wellness
- • The overall Member experience
SWHP strives for personal differentiation. No matter the product, the Member is our focus. SWHP has many examples of helping our members navigate the maze of healthcare, as well as thoughtful interventions that have improved the health outcomes of our Members. SWHP's close connection to both our Members and our provider community places us in a unique position to act as an effective member advocate. As a regional health plan, we have exceptional opportunities to finance health care in a way that is intrinsically superior by aligning incentives, identifying gaps in health care delivery, and facilitating smooth and seamless coordination of care throughout the health care continuum.
QI Program Goals - Objectives
Improve Member Health Outcomes - through staying healthy and management of chronic conditions such as the following: Diabetes, Asthma, Coronary Artery Disease, Hypertension, Chronic Obstructive Pulmonary Disease (COPD), Behavioral/Mental Health, Children's' and Women's' Health
Improve Medical Safety - by fostering a supportive environment that helps providers to improve the safety of their practice, monitoring SWHP Pharmacy medication safety, monitoring medication errors, and providing Members with information that improves their knowledge about clinical safety in their own care.
Increase Member Satisfaction - by prompt identification and resolution of dissatisfaction with administrative or medical processes. Evaluate processes for improvement. SWHP conducts the CAHPS survey to measure Member Satisfaction annually. This survey is use to identify opportunities for improvement.
Meet the Cultural and Linguistic Needs of the Member – by identifying language and other cultural/social needs of SWHP Members. We meet those needs by providing bilingual services, translated materials, cultural diversity education, training for SWHP staff and a network of diverse and multilingual providers. SWHP regularly monitors Member demographic data and Member feedback to adjust the provider network and services to reflect the Member's needs.
Provide Affordable Care - through reducing the variations in clinical care, preventing overuse, underuse or misuse of services, redirection of care to the most appropriate place, and through continued improvement of all SWHP processes to optimize care and reduce unnecessary care.
Organizational Effectiveness – strive to achieve statistically significant improvements in all quality measurements to meet or exceed regional or national averages set forth by National Committee Quality Assurance, Centers for Medicare and Medicaid (CMS), Texas Department of Insurance (TDI) and Texas Health and Human Services Commission (HHSC) or other accepted quality Standards.