プロバイダーマニュアル

QUALITY MANAGEMENT PROGRAM PURPOSE AND SCOPE

目的

The purpose of Carelon’s Quality Management Program is to provide a blueprint for planning and deploying quality management throughout the entire organization as well as the provider network. Quality Management includes quality assurance, performance improvement, quality improvement planning activities for clinical care and quality of service.

The Carelon Quality Management Program is based on the principles of Total Quality Management/Continuous Quality Improvement (TQM/CQI), including:

• 改善の機会は無限であるという認識
• 改善はデータ駆動型
• 消費者、プロバイダー、郡の意見への依存
• 臨床的および非臨床的有効性の継続的な測定と再測定
• そのような測定に基づくプログラムによる改善の実施
• 有効性の再測定と継続的な開発および必要に応じた改善の実施

範囲と目標

品質管理プログラムの焦点は、行動医療とサービスの品質に関連するデータの積極的な収集、分析、および報告です。これには、すべての受益者、プロバイダー、および組織向けのさまざまな配信システムのすべてのコンポーネントにわたる体系的な改善努力の開発と実装が含まれます。

The Quality Management Program will use data to identify areas of concern, schedule appropriate follow-up activities, monitor progress and evaluate the effectiveness of corrective action plans. The results will be communicated to the Pennsylvania HealthChoices appropriate programs, Governing Boards, the Pennsylvania Department of Human Services, the Carelon Corporate Quality Council, the Quality Management / Utilization Management Committees (QM/UMCs), consumers, providers and other stakeholders.