WHA's Quality Improvement Program

Western Health Advantages (WHA's) Quality Improvement (QI) Program provides a framework for WHA to continuously identify and make improvements in all settings in which care is delivered to members. QI Program activities can address a variety of issues such as improving clinical quality, maximizing safe clinical practices, and enhancing member and provider satisfaction.

WHA's QI Program strives to ensure that services provided to WHA members conform to the standards and requirements set forth by regulatory and accrediting agencies such as the National Committee for Quality Assurance (NCQA) and the California's Department of Managed Health Care (DMHC).

Goals of WHA's Quality Improvement Program

The goals and objectives of WHA's QI Program focus on providing an environment that enhances the relationship between patient and physician while providing affordable and compassionate care to its members. WHA's QI Program goals are to ensure:

• The quality of clinical care and service members receive from participating health care providers is continuously improved
• Member and provider satisfaction is enhanced
• Nationally recognized quality standards and regulatory requirements are met
• Safe clinical practices are maximized
• Member and provider concerns are thoroughly addressed in a timely and appropriate manner
• Efforts are made to improve the quality of service that providers and members receive
• Coordination of care for members and between providers is optimal

• Collaborative activities are promoted and encouraged among other insurers, employer groups, medical providers and behavioral health providers and contracted medical groups/IPAs.

WHA's QI Program Structure

WHA's Board of Directors has overall responsibility for the QI Program and annually the Board approves the Program and the QI activities to be undertaken. WHA's Quality Improvement Committee (QIC) is responsible for overseeing the implementation of the Program. QIC is made up of physicians and non-physician managers from WHA's contracted medical groups/IPAs, WHA's Chief Medical Officer/Medical Director, WHA's Assistant Medical Director, and key management staff from various departments throughout the organization. The QIC sets priorities, evaluates, and monitors quality improvement initiatives, makes policy recommendations, and assists in the development of collaborative QI activities. Practitioners from WHA's provider groups also participate in the Utilization Management Committee, Credentialing Committee and WHA's Pharmacy and Therapeutics Committee all of which are subcommittees of the QIC.

WHA's QI Program Scope

WHA monitors, measures, and analyzes the key aspects of care and service. It then uses this information to create specific quality improvement initiatives and other interventions for improvement. The areas of focus include but are not limited to the following:

• Access to care
• Availability of services
• Assessment of member and provider satisfaction
• HEDIS® and CAHPS® results
• Utilization trends
• Continuity and coordination of care
• Care management, Wellness and Preventive Health services
• Provider credentialing
• Patient safety

WHA's QI Initiatives

Each year WHA identifies QI opportunities that have the potential for improving care and/or service for WHA members and providers. The QI opportunities selected for interventions are ranked by importance to insure regulatory/accreditation requirements are met and that the opportunity selected affects the largest number of WHA members and/or it is of highest significance to members and/or providers. QI projects are typically the result of issues raised by members through WHA's satisfaction surveys or through members and/or provider complaints and grievances. Many of WHA's QI initiatives are carried out in collaboration with WHA's contracted providers.

For Additional Information

For further information or questions regarding WHA's QI Program or to find out more contact WHA's Member Services department at (916) 563-2250 or toll free at (888) 563-2250, Monday through Friday between
8 a.m. and 5 p.m.

Health Plan Report Cards

A report card on WHA's performance on key health care and service measures is available on the State of California's Office of the Patient Advocate's (OPA) website at www.opa.ca.gov/report_card/.

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