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Quality Programs


Hospital Quality

We work collaboratively with our acute care hospitals, specialty hospitals (oncology and behavioral health), and some ambulatory care centers to improve quality and provide safe care. Programs promoting good care such as preventing infections, surgical complications, and incorrect medications exist at all participating hospitals.

Blue Distinction (BDCs) Centers for Specialty Care®

Blue Distinction Specialty Care is a national designation program honoring health care providers who demonstrate expertise in safely, effectively, and cost-efficiently delivering quality specialty care. BDCs are recognized for excellent clinical outcomes and processes in the areas of bariatric (weight-loss) surgery, transplants, cardiac care, maternity care, cancer care, spine surgery, knee and hip replacement, and fertility care.

Provider Quality

We recognize the importance of the member/provider relationship and its significance in delivering high-quality care. We work with primary care providers who use innovative programs that focus on quality-based health care.

Culturally and Linguistically Appropriate Services (CLAS)

CLAS standards are designed to enhance the member/provider/health plan relationship from a cultural and linguistic perspective.

Language Line Services are used to assist with any language barriers that may exist in order to improve understanding and compliance for all parties and ultimately improve the health and care of our members.

Educational programs designed to decrease ethnic disparities are provided to promote culturally competent care. Health plan employees complete annual training on how culture and language barriers affect our members and how to make the member health care experience a positive one, while promoting increased compliance and wellness.

Continuity and Coordination of Care

Continuity and coordination of care between the hospital/urgent care/specialist and the primary care provider ensures safe and appropriate care and can prevent unnecessary treatments and tests for members. Through an annual survey, we assess how well our providers communicate with each other when treating the same member and identify areas of opportunity. Other health care programs and projects (e.g., case management, radiation safety awareness, etc.) also measure and work toward improving coordinated care for our members.

Medical Record Review for Standards

Primary care provider medical records are reviewed and scored against proven record standards. We assist providers to improve information and conversations in the following areas: body mass index (BMI), health care proxy, cultural needs of patients, assessment of depression in an adolescent record, adult vaccines, and substance-use disorders.

Quality Investigations

Whenever a member contacts us with a concern about the care they received from one of our providers, we look into it. We review member medical records to make sure good care was provided and work with providers and facilities to improve on any concerns we find.

After-Hours Access-to-Care Audit

We ensure the provision and maintenance of appropriate access to primary care services, member services, and some specialty services (behavioral health and OB-GYN) for BlueShield members. All credentialed providers and those who notify us of a new office location undergo an on-site review and must meet the plan’s access-to-care standards of compliance by 100%.

We audit our primary care offices (including pediatricians) and behavioral health offices to make sure our members have 24-hour access to care. We follow up with any office not meeting the standards, review our access-to-care policy with them, and require them to submit written documentation on how they are going to meet the standard.

Patient Safety Program

This program supports and promotes clinical safety for our members through collaborative efforts with internal departments and our practitioners, providers, and community organizations. It includes fall prevention in older adults, radiation safety awareness, and medication safety.

Fall prevention in older adults is a population-based, goal- and outcome-oriented initiative that aligns the member, health care delivery system, and planned interventions to decrease the incidence of falls among community members age 65 and older.

We work with our doctors and medical facilities to order X-rays and scans for members only when needed and keep track of testing to prevent unnecessary duplication. The radiation safety program provides ordering doctors with member-specific information regarding accumulated radiation exposure and promotes coordination of care between the primary care doctor, radiologist, and other specialists with the aim to reduce radiation exposure from unneeded tests.

Our pharmacy’s vendor, Express Scripts®, provides information and tools to doctors to help them prescribe medications safely by informing them of potentially serious drug interactions or improper dosing. We encourage members to review their medications with health care providers on a regular basis. Improved medication safety can help reduce hospitalizations and falls in older adults and result in increased overall quality of care for our members.