Quality Improvement Program

Our Mission

To provide accountability for the quality of health care delivery and service. This is accomplished through the commitment of the board of directors, the physician quality and the health plan quality improvement committees to develop and carry out a quality assurance plan that has a systematic approach to assessing, measuring, defining and resolving medical care, including behavioral health and service issues.

Our Philosophy

The Plan believes that the only way to achieve continuous quality improvement is to have its entire organization embrace a well-defined quality improvement program and annual work plan in their day-to-day activities.

What Is A Quality Improvement Program?

The organized method for monitoring, evaluating and improving the quality, safety and appropriateness of health care, including behavioral health care, which encompasses mental health and substance use disorders, services to members through related activities and studies is known as a quality improvement (QI) program.

QI encompasses the entire delivery system, including, but not limited to, hospital care, ambulatory care, ancillary services, emergency services, behavioral health services (including mental health and substance use disorders), preventive services, vision services, pharmacy, dental services, home health care, hospice care and extended care facilities. This is done by assessing and working to improve medical care systems, processes, and outcomes, and are monitored for both quality and utilization activities. Both over-utilization and under-utilization are addressed; this includes monitoring for fraud, waste, and abuse.

Another important piece of QI is our distribution of information to members to improve their knowledge about the prevention of illness or chronic illness as it relates to their own health care. This may be done by improvement interventions as identified.

Quality is Important to Us

Our Quality Improvement Program is guided by our accrediting body, the National Committee for Quality Assurance, or NCQA . With the standards that guide Health Plans, Sanford Health Plan follows guidelines that align with federal and most state government regulations. Rates are based on the plans' combined HEDIS®, CAHPS®, and NCQA® Accreditation standards scores. To see our latest rating, click here.

Provider and Member interventions are guided by a review of measures through the following:

• HEDIS®

  • HEDIS (Healthcare Effectiveness Data and Information Set) is a set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare health care quality. Quality improvement activities, health management programs and practitioner profiling efforts have all used HEDIS as a core measurement set.

  CAHPS®

  • CAHPS® (Consumer Assessment of Healthcare Providers and Systems) is another way to measure how your care and experiences are measured. Patient and Member Experience is your view of the healthcare system, including your care from us, your health plan, and from doctors, nurses, and staff in hospitals, physician practices, and other healthcare facilities. If you receive a survey in the first quarter of the year, we want to hear from you! We use the survey results to help guide where improvements need to be made and to not change and hear what you like.

• Medicare Stars

  • Our Medicare Advantage programs are compared to other Medicare Advantage programs by CMS (Center for Medicare and Medicaid), a government agency, and include Medicare CAHPS, Part C and Part D CMS Display and Star Measures. Medicare Stars is a rating system that includes an overall rating between 1 and 5 Stars. Star ratings are calculated each year and may change from one year to the next. To see our latest Medicare Star rating, click here.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

Confidentiality

Sanford Health Plan complies with all applicable federal requirements, including HIPAA, state and NCQA regulations regarding privacy, security, breach notification and confidentiality. Any Plan employee or any participating practitioner or provider engaging in QI activities must uphold the established principles of patient/physician confidentiality and individual privacy. All QI worksheets, study results and other related materials will remain confidential. Reference to practitioners and providers as well as members will be by number or symbol only. Committee members will not release any information regarding a provider or member, unless it is required by law or is necessary to coordinate health care services or secure the health or safety of a member. Such instances will be documented and actions will be in accordance with federal and state laws and regulations.