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Quality Improvement Program
Ped-I-Care has accepted the responsibility of providing quality health care to Children with Special Health Care Needs (CSHCN). It is the intention of Ped-I-Care to continually improve the quality of services provided to Ped-I-Care members. Achieving this goal requires establishing standards and performance goals for the delivery of care, measuring performance outcomes, and initiating appropriate interventions to improve the system of care and health related outcomes.
In order to ensure services meet the community standard and to discover ways the system can be improved, Ped-I-Care has developed a Quality Improvement Program (QIP). The QIP functions under the supervision of the Quality and Utilization Management Committee (QUMC), composed mainly of physicians who have special training and expertise in Pediatrics.
The complete plan is available upon written request, but is summarized in here. Certain quality criteria have been identified for providers who participate in the Ped-I-Care Network. These include credentialing of providers and use of additional provider contracting requirements, which ensure member access and quality care. PCP requirements include access standards for patients including taking call and scheduling of timely appointments. Requirements related to medical records, confidentiality and patient treatment are included in all contracts and/or this manual.
Ped-I-Care visits each provider at least once every two years to review a sample of medical records of members. The charts are reviewed by a Quality Improvement (QI) Nurse to evaluate the measures described below. The results of the site visit are summarized in a letter sent to the provider. In addition, providers will receive annual reports on the quality outcomes for the Ped-I-Care program as a whole.
Ped-I-Care evaluates the following quality indicators:
- Access to appropriate care - including wait times for scheduling appointments and inoffice waiting time, as well as access to primary care physicians through an after hours call system
- Mortality
- Health status indicators:
- Immunization (percent of members at age two (2) years who have completed the basic immunization series)
- Well-child health care utilization (percent of children who are in compliance with the supervision standards established in the guidelines for Health Supervision of Children and Youth developed by the American Academy of Pediatrics)
- Other health care services utilization
- Family requests for reassignment of Primary Care Physicians
- Member or family perspectives of care, including complaints and grievances
- Percent of members or families who report positive perceptions of care
- Personnel/provider satisfaction including turn-over rates, physician disenrollment, and satisfaction with payment and authorization systems
- Compliance with medical record documentation requirements
Data from claims, as well as patient and provider satisfaction surveys also will be reviewed.
In addition to this data driven approach to quality, Ped-I-Care has developed indicators that, when identified, indicate a need for an individual case review of the circumstances and contributing factors. Events that trigger an individualized chart review include conditions such as hospital admission for diabetic coma, bleeding/perforation or intestinal gangrene.
Providers will have their Ped-I-Care charts reviewed every two years and will receive feedback summarizing the review of these charts. The chart reviews will be completed using a tool developed from the guidelines for medical records in the Provider Manual. Site visits will be scheduled in advance at the convenience of the provider. The site visit will include a survey of the facility to ensure the practice employs appropriate safety, access and confidentiality measures.
