Goal
The primary goal of the Blue Cross and Blue Shield of New Mexico (BCBSNM) Quality Improvement (QI) Program is to improve our members’ health status and outcomes. This is accomplished by deploying meaningful quality improvement activities and interventions that are implemented across all care settings. BCBSNM aims to improve the quality of care and services delivered to our members, your patients.
Scope
The Quality Improvement/Quality Management (QI/QM) Program encompasses all clinical care and services that are furnished to our members, inclusive of medical, behavioral, and long-term care services.
The scope of the QI Program includes the process and outcomes of;
- Medical, behavioral and long-term care services
- Ancillary services
- Pharmacy services
- Dental, transportation and vendor services
- Member services and experience, patient safety and efficient use of resources and adequacy of resources
The QI/QM program is comprehensive and includes mechanisms to evaluate outcome effectiveness, the ongoing identification of, monitoring, and evaluation of, all that impacts the safety, accessibility, availability, continuity and quality of care and services provided to our members. BCBSNM is committed to the delivery of high quality of medical, behavioral and long-term care regardless of our members ethnic, cultural, religious beliefs or language.
BCBSNM continuously evaluates the effectiveness of the QI Program by measuring improvements against state targets, nationally applied and internally established standards and benchmarks. BCBSNM has met most its quality goals in 2022 and continues to maintain its accreditation through the National Committee for Quality Assurance (NCQA) for the Medicaid line of business.
Several key points in the evaluation of the 2022 QI Program includes:
- Member complaints and appeals
- Continuity of Medical and Behavioral Care
- Healthcare Effectives Data and Information Set (HEDIS®)
- Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey data
- Provider and practitioner safety and care practices
- Clinical practice guidelines
- Clinical quality initiatives
- Member and provider experience
- Clinical performance data
- Health care utilization and complex disease management
BCBSNM met the following 2022 QI Program achievements and goals:
- Achieved seven of ten established benchmarks for select New Mexico Human Services Department (HSD) performance measures
- Achieved Full Compliance with New Mexico External Quality Review Organization standards for annual audit of QI Performance Measure Program quality initiatives, interventions, and performance improvement projects
- Steadily improved compliance with HSD requirements for Critical Incidents processing and reporting; met and exceeded internal and external goals for timeliness and accuracy
- Met audit requirements of the HEDIS® annual medical records abstraction project
Participation in QI/QM
Contracted providers and practitioners in the Blue Cross Community Centennial network are required to cooperate with all QI activities, as well as allow the use of provider and/or practitioner performance data, to ensure the success of the QI/QM Program. If you are interested in learning more about Blue Cross Community Centennial QI/QM Program or to request a printed copy, please email qualityinquiry@bcbsnm.com.
HEDIS is a registered trademark of the National Committee for Quality Assurance.
CAHPS is a registered trademark of the Agency for Healthcare Research and Quality.