Quality Improvement Program
At Blue Shield of California Promise Health Plan, we are guided by our mission and values, which encourage innovation and enable us to be a catalyst for constructive and transformational change. Blue Shield Promise’s Quality Improvement Program (QIP) is committed to promoting continuous and coordinated care in a patient-centered environment that recognizes the positive relationship between health education, a culture of wellness, an emphasis on prevention, and affordable healthcare.
Blue Shield Promise holds National Committee for Quality Assurance (NCQA) Health Plan Accreditation for its Medicaid line of business.
The goal of the program is to ensure that we meet our promise of providing high quality care and service to our members. The program objectively and systematically monitors and evaluates the quality, appropriateness, and care and service outcome delivered to our members. The program provides mechanisms that pursue opportunities for improvement and problem resolution, and it measures many different parts of the care and services we offer. A formal evaluation of the Quality Improvement Program is performed annually. You can request the evaluation results by calling our Provider Services:
Phone: (800) 468-9935, 6 a.m. to 6:30 p.m., Monday through Friday.
QIP focus areas
Specific key elements of focus for the Quality Improvement Department may include but are not limited to:
- Provider accessibility and availability
- Provider satisfaction
- Provider credentialing
- Clinical practice guidelines
- Under- and over-utilization
- Adverse outcomes/sentinel events
- Medical record-keeping practices
- Healthcare Effectiveness Data and Information Set (HEDIS®) measurements
- Facility site reviews
- Member satisfaction and grievances
- Timeliness of handling claims
- High-risk and high-volume services
The performance of the program is measured via the following:
- Studies to ensure that appointments are available
- Studies to ensure that after-hours services are available
- Studies to measure how long patients wait in the office for an appointment
- Facility site reviews, including access for members with disabilities
- Member satisfaction surveys
- Provider satisfaction surveys
- Analyses of clinical metrics and outcomes
- Behavioral health
- Child and adolescent care
- Cancer screenings
- Management of chronic conditions
- Prenatal and postpartum care
See more information on related policies and guidelines:
Access to care standards
Facility site review policy and procedures (PDF, 11.8 MB)
Initial health appointment guidelines
Member experience and CAHPS ratings
The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) is an annual standardized survey conducted between February and May to assess members’ experiences with their provider and health plan. Patients are randomly selected for the survey. Blue Shield Promise uses the results to improve our members’ experience.
Over half of the questions in the survey are related to the provider and clinic staff. Blue Shield Promise offers an online course for providers and clinic staff with best practices to improve CAHPS scores.
How to get better CAHPS ratings
Improving member access and availability is a top priority. Blue Shield Promise offers this tip sheet for ideas to improve access to care.
Read about access to care best practices (PDF, 97 KB)
View recent CAHPS ratings for San Diego (PDF, 149 KB)
CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).
Programs and services
To achieve the Quality Improvement Program goals, Blue Shield Promise has developed multiple programs to assist its members in managing their health conditions and maintaining active and healthy lifestyles. These programs utilize clinical practice guidelines and include:
- Population health management programs
- Healthy Start Comprehensive Prenatal and Postpartum Program
- Asthma Program
- Congestive Heart Failure Program
- Coronary Heart Disease Program
Quality Improvement Program annual evaluation results
View 2022 Quality Improvement Program evaluation results for Medi-Cal LA (PDF, 27 KB)
View 2022 Quality Improvement Program evaluation results for Medi-Cal SD (PDF, 25 KB)
Medical care solutions
Review medical care solutions for Blue Shield Promise plans.
Utilization management and clinical practice guidelines
Utilization management (UM) and clinical practice guidelines define healthcare standards applicable to members and providers.
Population Health Management
Our Disease Management Program provides education, care coordination, and support for members with certain chronic conditions.
Cultural Awareness and Linguistics Program
Blue Shield Promise ensures that all our members have access to translation services that help them access programs and care in their language of choice.
Access to care standards
Learn the guidelines Blue Shield of California Promise Health Plan uses to ensure our members have proper access to care.
Physician’s facility site review policy and procedures
See policies for site accessibility, fire safety and prevention, non-medical emergency procedures, medical equipment maintenance, and staff qualification requirements.