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 to improve the health of our members every day.

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.

The Quality Improvement Program includes:

  • The QI program's functional areas and responsibilities
  • Reporting relationships of QI department staff and the QI Committee
  • Resources and analytical support
  • Delegate 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 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 task 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 the organization deems appropriate

The Goals of the Quality Improvement Program are:

  • The QI program's functional areas and their responsibilities
  • 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
  • Include a dynamic work plan that reflects ongoing progress on QI activities throughout the year
  • Yearly planned QI activities and objectives for improving: quality and safety of clinical care, quality of service, and member 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's effectiveness by comparing the performance measure outcomes

For hard copies or 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.

National Committee for Quality Assurance (NCQA) (2019). 2020 Standards and Guidelines for the Accreditation of Health Plans. QI 1- QI 2 pp.79-90. www.ncqa.org