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Provider and Facility Reference Manual

Section 10 - Health Care Quality Improvement

Mission Statement

Blue Cross Blue Shield recognizes the need for a comprehensive and culturally sensitive Health Care Quality Improvement Program. The Program is initiated and carried out in a manner designed to meet the goals and objectives of the corporation and all regulatory requirements.

Program Goal Statement

The focus of the Quality Improvement program is to continuously assess and improve the care delivered by our participating practitioners/providers and the service delivered by Blue Cross Blue Shield staff to its members. The organization has the responsibility of designing, measuring, assessing and continually improving its performance. The result is enhanced health and well-being of the populations we serve.

Program Objectives

  • Assist in the corporate mission and vision
  • Integrate quality improvement activities into corporate strategic plans and goals
  • Initiate and monitor activities to identify quality/safety of care, access and service issues
  • Identify best practices through review of structure, processes, outcomes and benchmarks
  • Report quality assessment information and make recommendations regarding participation of practitioners/providers according to the approved credentialing process
  • Develop, implement, and evaluate interventions to improve the quality and safety of care and services
  • Distribute quality improvement activity findings as part of a Quality Improvement Process (QIP) or Problem Solving Process (PSP)
  • Sponsor and support interdepartmental quality improvement activities (including QIPs for case management and action plans for improved member service)
  • Promote a high standard of care through analysis of clinical practices
  • Adopt national (or regional, if more stringent) standards, criteria, and benchmarks for health care quality improvement activities 
  • Serve as a resource to practitioners/providers, supplying consultation and education relating to implementation of the quality improvement programs
  • Educate practitioners/providers and members toward improving health and health care
  • Meet and exceed all requirements for regulatory and accreditation oversight (CMS, NYSDOH/DFS, NCQA, and BCBSA)
  • Identify areas of the health care provided to our members that require improvement and take corrective action


The scope of the Health Care Quality Improvement Program is comprehensive. It includes all Blue Cross Blue Shield members for all operating areas, as well as practitioners and providers who participate in the network. This includes Commercial (HMO, POS, PPO, Federal Employees Program/FEP), EPO, Medicare Advantage, ASO, Essential Plan and Exchange/Qualified Health Plan products and oversight of Child Health Plus and Medicaid managed care. The Health Care Quality Improvement Program includes organization-wide activities, a focus on trend analysis, and development of interventions that improve the quality of care and service provided to members. The activities include clinical, service, and patient experience.

The Health Care Quality Improvement Program monitors and evaluates a wide variety of clinical and service topics that include, but are not limited to, those listed below:

  • Health Promotion
  • Preventive Care
  • Disease Management
  • Case Management
  • Population Health Management
  • Utilization Management (including appropriate utilization of services)
  • Patient Safety
  • Behavioral Health Management
  • Culturally and Linguistically Appropriate Services
  • Complaint management for access to care or quality of care issues
  • Medical policy
  • Pharmacy Management
  • Continuity and Coordination of Care



The ultimate accountability for the Health Care Quality Improvement Program rests with the Board of Directors of Blue Cross Blue Shield.

The authority and responsibilities for administration and implementation of the Health Care Quality Improvement Program are vested in the Senior Medical Director and Vice President, Health Management. The Corporate Quality Management Committee regularly submit reports to the Board of Directors of Blue Cross Blue Shield.

QI Committee Structure

In order to assure that the Health Care Quality Improvement Program is implemented appropriately, key critical responsibilities related to a successful Quality Improvement Program are the shared responsibility of a variety of the committees and subcommittees across the organization.

In support of this shared responsibility the committees, subcommittees, ad hoc committees, etc. will analyze health care related data from monitoring activities, software program output and formal studies, as appropriate.

These committees consider a variety of actions in relation to data as well as a number of other activities that are defined in corporate policies.

These committees include Corporate Quality Management Committee, Corporate Credentials Committee, Pharmacy and Therapeutics Committee, Medical Management Clinical Committee, Vendor Process Management, Mental Health and Substance Use Disorder Parity Compliance Committee and the Behavioral Health Advisory Board Committee.

Monitoring and Evaluation

Results are used to compare with other local plans and regional averages, to revise goals and to target areas of improvement.

Healthcare Effectiveness Data and Information Set (HEDIS)

Measures are primarily clinical in nature, collected annually, audited by an approved contracted vendor, and submitted to NCQA, CMS and the Blue Cross Blue Shield Association.

Consumer Assessment of Health Plan Study (CAHPS) survey provides a measurement of how well the plan/practitioners met members' expectations.

Quality Assurance Reporting Requirements (QARR) is a set of measures for Commercial HMO, Qualified Health Plans (Marketplace), and Medicaid/Child Health Plus populations based on HEDIS-like data, that are collected annually and sent to the NYSDOH.

Medicare Touchpoint Measures (MTM) reflect non-clinical service issues (accuracy and timeliness of enrollment, claims and inquiries) and reported semi-annually to the Blue Cross Blue Shield Association.

Medicare Star Rating is consistent with CMS’ Quality Strategy of optimizing health outcomes by improving quality and transforming the health care system. CMS uses a Five Star Quality Rating System on a scale of 1 to 5, with 5 stars being the highest score a plan can receive and 1 star being the lowest. CMS publishes star ratings in the fall each year and the five-star rating system provides Medicare beneficiaries and their families a way to compare plan performance and quality.

Quality Rating System (QRS) and Qualified Health Plan (QHP) Enrollee Experience Survey is a measure set comprised of clinical quality measures, including National Committee for Quality Assurance (NCQA), HEDIS and a Pharmacy Quality Alliance (PQA) measure. The measure set also includes survey-based measures based on questions from the QHP Enrollee Survey that captures member experience and plan efficiency, affordability and management. The quality ratings Five Star rating scale is similar to Medicare Star Rating.

Population Health Management Strategy

A variety of clinically based programs are in place for addressing the needs of members across the continuum of care. These include health management programs to address the needs of members with complex health care needs, those with physical or developmental disabilities, multiple chronic conditions and severe mental illness. These programs are designed to meet the care needs of the member population through identification, participation, engagement, and targeted interventions aimed at active engagements in health care services. The goal is to maintain or improve the physical and psychosocial well-being of individuals to address health disparities through cost-effective and tailored health solutions.


Delegated entities are required to meet specific regulatory standards including NCQA, NYSDOH, and CMS standards. Delegated entities are evaluated annually and key QI and UM documents are reviewed and approved (program descriptions, policies, work plan and annual evaluations). Joint Oversight Team meetings are conducted to ensure contractual obligations are met, document, and follow up on operational issues, and review and evaluate reports based on performance metrics.

Annual Evaluation of QI Program

In order to continuously improve the quality and effectiveness of the Health Care Quality Improvement Program, an annual evaluation of the QI program is written and submitted to the Senior Medical Director, Vice President Health Management, Quality Management Committee and the Board of Directors of Blue Cross Blue Shield. 

QI Work Plan

The QI work plan is a working document that reflects ongoing progress on QI activities and updates are noted throughout the year as priorities, needs, and goals of the organization change. A mid-year update is presented to the Quality Management Committee and to the Board of Directors of Blue Cross Blue Shield.