Quality Improvement

Optima Health, through its commitment to excellence, has developed a comprehensive program directed toward improving the quality of care, safety, and appropriate utilization of services for our members. The Quality Improvement program is designed to implement, monitor, evaluate, and improve processes within the scope of our health plan on a continual basis in order to improve the health of our members every day.

Quality Improvement Highlights

Clinical Guidelines Update

The guidelines are based on published national guidelines, literature review, and the expert consensus of clinical practitioners. They reflect current recommendations for screening, diagnostic testing, and treatment. These guidelines are published by Sentara Health Plans, Inc. (SHP) as recommendations for the clinical management of specific conditions. Clinical data in a particular case may necessitate or permit deviation from these guidelines. The SHP guidelines are institutionally endorsed recommendations and are not intended as a substitute for clinical judgment. Copies of clinical guidelines are available via mail, email, fax, or online. Please contact Quality Improvement Department at 1-844-620-1015.

Optima Health QI Program

The Optima Health QI program is a comprehensive document or a set of documents that serves our culturally diverse membership. It describes, in plain language, the QI program’s governance, scope, goals, measurable objectives, structure, responsibilities, annual work plan and annual evaluation.

Quality Improvement Program includes:

  • The QI program’s functional areas and their responsibilities.
  • Reporting relationships of QI Department staff and the QI Committee.
  • Resources and analytical support.
  • Delegated QI activities, if the organization delegates QI activities.
  • Collaborative QI activities
  • Outlines Optima Health’s efforts to monitor and improve behavioral healthcare.
  • The role of the designated physician in the QI program, which includes participating in or advising the QI Committee or a subcommittee that reports to the QI Committee
  • Defines the role, function and reporting relationships of the QI Committee and subcommittees, including committees associated with oversight of delegated activities (e.g. clinical subcommittees, ad hoc tasks forces, or multidisciplinary work groups or subcommittees).
  • Outlines the organization’s approach to address the cultural and linguistic needs of its membership. The QI program description might include objectives or other objectives the organization deems appropriate:
    • To reduce health care disparities in clinical areas.
    • To improve cultural competency in materials and communications.
    • To improve network adequacy to meet the needs of underserved groups.
    • To improve other areas of needs the organization deems appropriate.
  • Includes a dynamic work plan that reflects ongoing progress on QI activities throughout the year and addresses:
    • Yearly planned QI activities and objectives for improving:
      • Quality of clinical care.
      • Safety of clinical care.
      • Quality of service.
      • Members’ experience.
    • Time frame for each activity’s completion.
    • Staff members responsible for each activity.
    • Monitoring of previously identified issues.
    • Annual evaluation of the QI program. effectiveness is measured by comparing the performance measure outcomes
      • The performance measures are based on nationally recognized goals and/or internal goals based on the plan population.
      • These measures are evaluated annually and measured against national averages.

For more information about Quality Improvement at Optima Health please contact the Quality Improvement Department at 757-252-8400 or toll-free 1-844-620-1015. NCQA’s website (ncqa.org) contains information to help consumers, employers and others make more informed health care choices.

Hard copies of these items are available upon your request by contacting the Quality Improvement Department at 757-252-8400 or toll-free 1-844-620-1015.


National Committee for Quality Assurance (NCQA) (2019). 2018 Standards and Guidelines for the Accreditation of Health Plans. QI 1- QI 2 pp.59-77.(ncqa.org)


Initiatives to improve the quality of care:

Member Satisfaction

Annual satisfaction surveys are conducted to measure the satisfaction of our members with the various aspects of the health plan, the care they receive, and their access to physicians.

Complaints and Concerns

The quality improvement program thanks our members for notifying us of any complaint or concern. We view these as an opportunity to improve the services we provide by tracking and analyzing the information received.

Other Documents