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Clinical Quality Management

Provider Type

  • Physicians 
  • Hospitals
  • Ancillary

The Health Net Prison Health Care Provider Network (PHCPN) Clinical Quality Management (CQM) program monitors quality of care delivered by participating providers and manages potential quality issues (PQIs) as identified. It encompasses all medical and behavioral health providers contracting with Network Providers, LLC (NPLLC). The CQM program includes the measurement of adherence to nationally recognized clinical standards and the implementation of actions to improve quality of care. The scope of the program includes:

  • Monitoring and evaluating care provided in all health care delivery settings, including behavioral health services and the behavioral aspects of health care in coordination with other medical conditions
  • Clinical quality and safety of care
  • Hospital quality comparison reports
  • Provider access and availability for patient
  • Medical record and documentation standards
  • Provider qualifications and selection
  • Monitoring continuity and coordination of care

Health Net PHCPN has developed quality management systems that extend across the entire continuum of care. All program components are judged on their measurable effect on the patient population. The Health Net PHCPN CQM program is designed to function at the corporate and regional (statewide) level, linked by CQM committees and reporting structures.

Health Net PHCPN does not delegate its comprehensive CQM program or oversight responsibilities to participating providers, hospitals or ancillary providers. Participating providers, hospitals and ancillary providers are required to comply with the standards and requirements set forth in this operations manual and the NPLLC network contract.

Information about the Health Net PHCPN CQM program goals, processes and outcomes as they relate to patient care is available to providers on request through the PHCPN Provider Services Center.

The Health Net Quality Improvement Committee (HNQIC) systematically manages continuous improvement of the quality of services delivered to patients. The committee evaluates input from other Health Net Quality Improvement (QI) committees to determine what QI activities are undertaken. The committee monitors and supports these activities, including implementation of meaningful, strong, system-wide interventions to improve performance when opportunities for improvement are identified. The HNQIC reports directly to the Health Net board of directors.

The following committees report to the HNQIC:

  • Credentialing/Peer Review Committee
  • Specialty Network Committee
  • Clinical Quality Management (CQM) Workgroup

Credentialing/Peer Review Committee

The Credentialing/Peer Review Committee verifies and reviews practitioners and organizational providers who contract with Network Providers, LLC (NPLLC) to render professional services to patients for training, licensure, competency, and qualifications that meet established standards for credentialing and re-credentialing. The Credentialing Committee ensures NPLLC's credentialing and re-credentialing criteria for participation in the Prison Health Care Provider Network (PHCPN) are met and maintained. The HNQIC delegates authority and responsibility for credentialing and re-credentialing peer reviews to this committee. This committee is also responsible for peer review activities and decisions regarding clinical quality management. The committee provides a forum for instituting corrective action as necessary, and assesses the effectiveness of these interventions through systematic follow-up, for both inpatient and outpatient care.

The Credentialing/Peer Committee reports quarterly to the HNQIC and provides a quarterly summary of activities to the Health Net board of directors. Membership includes practicing medical directors or practitioners (representing primary and specialty disciplines) from each Health Net of California region (northern, central and southern California).

Specialty Committee

The Specialty Committee sets standards for the NPLLC-participating Transplantation Performance Centers and Bariatric Performance Centers, guides patients to specialty network providers, monitors performance, issues requests for corrective action plans (CAPs) and reports to HNQIC. This committee meets six times per year and reports quarterly to HNQIC.

Clinical Quality Management Committee

The Health Net PHCPN CQM committee is designed to monitor and evaluate the quality of health care on a continuous and systematic basis. The CQM committee also supports the identification and pursuit of opportunities to improve clinical health outcomes, safety and access. The CQM committee consists of a small core of CQM staff, including a consulting physician and ad-hoc members pertinent to the report topic. At each meeting, there is focused discussion on report findings, barriers and interventions for the purpose of making and implementing decisions regarding CQM activities. This committee meets at least quarterly and reports significant findings to the Peer Review Committee when identified.

Health Net's Prison Health Care Provider Network (PHCPN) Clinical Quality Management (CQM) program is designed to monitor and evaluate the adequacy and appropriateness of health care on a continuous and systematic basis. The CQM program also supports the identification and pursuit of opportunities to improve health outcomes. The purpose and goals of the CQM program are:

  • Support Health Net's PHCPN strategic business plan to promote safe quality health care and satisfy requirements for continuous clinical quality management

  • Provide an integrated structure that links knowledge and processes together throughout the organization to assess and improve the quality and safety of clinical care provided to patients 

  • Establish, implement and continually evaluate the effectiveness of a written clinical quality management plan. Ensure data collection and reporting systems to provide information. Analyze hospital inpatient clinical quality measures and take action to maintain or improve clinical services to patients

  • Promote systems and business operations that provide and protect the confidentiality, privacy and security of patient and provider information in accordance with state and federal requirements and accreditation guidelines

  • Meet the requirements of regulatory agencies and accreditation, including the Centers for Medicare and Medicaid Services (CMS) and the National Committee for Quality Assurance (NCQA)

  • Monitor clinical practices to promote outcomes for patients through improved provider relationships and through the promotion of evidence-based health care

  • Anticipate, understand and respond to customer needs, be customer-driven and dedicated to a standard of excellence in all customer relationships

The Health Net PHCPN CQM program includes a written program description and an annually revised CQM work plan that defines the activities and planned improvements for the year. The annual work plan is developed following an evaluation of the previous year's activities and accomplishments. The Health Net Quality Improvement Committee (HNQIC) and the Health Net board of directors approves and monitors the annual Health Net PHCPN program and the CQM work plan. The board of directors receives quarterly reports regarding Medical Affairs and Quality Management.

The Health Net Prison Health Care Provider Network (PHCPN) Clinical Quality Management (CQM) program participates in various quality improvement initiatives, including:

  • The Industry Collaboration Effort (ICE), comprising CQM representatives from the major health plans in California

  • Leapfrog Group to improve patient safety through various "leaps" in health care practices and standards

  • California Cooperative Healthcare Reporting Initiative (CCHRI), a collaborative of health care purchasers, plans and providers. CCHRI sponsors a variety of data collection and quality improvement activities

  • California Quality Collaborative (CQC), a collaborative program sponsored by various health plans, California Association of Physician Groups (CAPG) and coordinated by Pacific Business Group on Health (PBGH). The program seeks to improve clinical care and service for all Californians by providing strategies at the point of care. Current CQC projects include training sessions for providers that focus on clinical performance in chronic care, enhancing the patient experience through effective physician-patient communication, and maximizing the implementation of large-scale information technology (IT) projects to benefit care. Specifically, the performance improvement curricula teach the principles of the Wagner chronic disease model; how to implement a population care registry; and leadership and change management skills. Best practices are also communicated through other provider education opportunities, such as teleconferences, meetings and other regular communications 

  • The Health Net PHCPN CQM program continues its support of the California Hospital Assessment Reporting Taskforce (CHART) efforts to provide standardized hospital quality information regarding California hospitals. Through CHART, Health Net and other coalition stakeholders created a statewide process to standardize hospital performance measures. CHART's single set of measures reduces hospitals' burden of compliance while providing hospitals with clean, benchmarked, risk-adjusted data for QI purposes. Submitted data from participating hospitals represents over 80 percent of California's inpatient admissions. This data is made publicly available through a reporting tool and can be viewed through CalHospitalCompare.org or through the Health Net Hospital Comparison Report

Health Net and Network Providers, LLC (NPLLC) requires that all targeted, participating hospitals annually submit the Leapfrog Group Patient Safety Survey.

This data is reported publicly through the Hospital Comparison Report on Health Net's California Correctional Health Care Services (CCHCS) provider website through Health Net's relationship with HealthShare/WebMD. This Internet-based decision support tool enables CCHCS to receive an independent analysis of area hospitals, including their clinical outcomes, patient volume and charges for a particular procedure or medical condition. Health Net's relationship with HealthShare/WebMD brings monthly updates to its online Hospital Comparison Report so that the most current hospital quality information is available to CCHCS utilization management staff, NPLLC participating providers and Clinical Quality Management (CQM) associates.

Providers may rank the importance of a number of variables, including:

  • Number of Patients - References the number of times the hospital has treated this condition or administered this therapy and, accordingly, the hospital's depth of experience
  • Mortality Rate - Indicates the number of deaths while undergoing a specific treatment. For certain conditions, the mortality rate is likely to be a key consideration
  • Complication Rate - Identifies the most common complications associated with the procedure or medical condition, and shows the complication rates for each hospital being compared
  • Average Length of Stay - Indicates how long, on average, someone is hospitalized for a certain procedure or medical condition
  • Cost - Displays the average hospital charges per procedure. Most health plans have contracts with hospitals that specify the rate the health plan pays for hospital services. While the average hospital charges may not directly impact what CCHCS must pay, hospital charges eventually have an impact on rates  

In compliance with regulatory requirements, Network Providers, LLC (NPLLC) monitors and evaluates potential quality issues (PQIs) involving California Correctional Health Care Services (CCHCS) patient. Providers should use the Potential Quality Issue (PQI) Referral form to fax reports of potential or suspected deviation from standards of care that cannot be justified without additional review or investigation.

The participation of the NPLLC providers in the Health Net Prison Health Care Provider Network (PHCPN) Clinical Quality Management (CQM) program is integral to success. All participating providers have agreed to provide patient data upon request and respond to queries from the Health Net PHCPN CQM program clinical staff to facilitate a quality-of-care review.

Last Updated: 01/17/2020