PARTNERSHIP HEALTHPLAN OF CALIFORNIA POLICY / PROCEDURE

Policy/Procedure Number: MPQP1004 (previously QP100104) Lead Department: Health Services ☒External Policy Policy/Procedure Title: Internal Quality Improvement Committee ☐ Internal Policy Next Review Date: 04/19/2018 Original Date: 05/17/2000 Last Review Date: 04/19/2017 Applies to: ☒ Medi-Cal ☐ Employees Reviewing ☒ IQI ☐ P & T ☒ QUAC Entities: ☐ OPERATIONS ☐ EXECUTIVE ☐ COMPLIANCE ☐ DEPARTMENT

Approving ☐ BOARD ☐ COMPLIANCE ☐ FINANCE ☒ PAC Entities: ☐ CEO ☐ COO ☐ CREDENTIALING ☐ DEPT. DIRECTOR/OFFICER Approval Signature: Robert Moore, MD, MPH Approval Date: 04/19/2017

I. RELATED POLICIES: N/A

II. IMPACTED DEPTS: All

III. DEFINITIONS: A. IQI – Internal Quality Improvement Committee B. PAC – Physician Advisory Committee C. UM – Utilization Management D. P&T – Pharmacy and Therapeutic E. Q/UAC – Quality/Utilization Advisory Committee

IV. ATTACHMENTS: A. N/A

V. PURPOSE: The Internal Quality Improvement (IQI) Committee is responsible for advising Partnership HealthPlan of California (PHC) on quality activities at the health plan, with a goal of improving overall quality of care and service for members, providers and internal operations. Since quality activities are implemented through multiple departments, the IQI Committee consists of a multi-departmental team that reviews new or revised policies, delegation reports, activities, and other reports specific to quality improvement and utilization management initiatives. The committee makes recommendations for improvement areas and continuously monitors the progress of the Quality Improvement (QI) and Utilization Management (UM) programs. The committee reports to the Quality/Utilization Advisory Committee (QUAC), which ensures that plan activities comply with all state and regulatory requirements, and, meets current NCQA standards.

VI. POLICY / PROCEDURE: A. COMMITTEE STRUCTURE A.1. Membership: A.1.a. The IQI Committee is comprised of the following PHC staff: (Standing committee members are required to appoint and send a designee if unable to attend)

Page 1 of 4 Policy/Procedure Number: MPQP1004 (previously QP100104) Lead Department: Health Services Policy/Procedure Title: Internal Quality Improvement Committee ☒External Policy ☐Internal Policy Original Date: 05/17/2000 Next Review Date: 04/19/2018 Last Review Date: 04/19/2017 Applies to: ☒ Medi-Cal ☐ Employees

PHC Standing Members Chief Medical Officer (CMO) – Committee Chairman Chief Executive Officer (CEO) Chief Operations Officer (COO) Senior Director, Regulatory Affairs-Compliance Officer Regional Medical Directors Regional Director (Santa Rosa) Senior Director, Health Services Northern Region Director, Health Services Director, Member Services Northern Region Director, Member Services/Provider Relations Director, Operations Excellence/Project Management Office (PMO) Director, Pharmacy Services Senior Director, Provider Relations Director, Quality & Performance Improvement Director, Utilization Management Director, Care Coordination Northern Region Associate Director, Quality, Analytics & PMO Manager, Health Analytics Manager, Grievance and Appeals Resolution Manager, Quality Improvement Programs- Committee Co-chair Senior Health Educator Northern Region Health Educator Supervisor, Member Services

A.1.b. Standing members are responsible for maintaining an annual attendance rate of 75% or greater. Committee members may appoint a designee to attend. A.2. Minutes: Minutes are recorded of all meetings and are maintained according to the Confidentiality policy/procedure. Minutes are submitted through the RAC Inbox monthly and submitted quarterly, by RAC, to the Department of Healthcare Services (DHCS). A.3. Chair: The Chief Medical Officer (CMO) chairs the committee. When absent, the committee Chair will appoint a designee. A.4. Meetings: The Committee meets at least 10 times a year, but does not convene in the months of July or December, with the option to add additional meetings if needed. A.5. Voting: Standing Member(s)/Designee(s) will vote and the committee Chair will acknowledge consensus. B. COMMITTEE RESPONSIBILITIES B.1.Reviews policies and makes recommendations or revisions for effective monitoring and achievement of Quality Improvement objectives. B.2.Monitors quality improvement projects across the organization that impact patient care, focusing on areas such as clinical outcomes, patient experience including access and service, and cost efficiency. B.3.Monitor utilization management activities for both medical and pharmacy management – denials,

Page 2 of 4 Policy/Procedure Number: MPQP1004 (previously QP100104) Lead Department: Health Services Policy/Procedure Title: Internal Quality Improvement Committee ☒External Policy ☐Internal Policy Original Date: 05/17/2000 Next Review Date: 04/19/2018 Last Review Date: 04/19/2017 Applies to: ☒ Medi-Cal ☐ Employees authorizations, appeals, etc. B.4.Review policies and clinical guidelines that relate to health services or service for our members – also includes credentialing; performance improvement initiatives, etc.

Page 3 of 4 Policy/Procedure Number: MPQP1004 (previously QP100104) Lead Department: Health Services Policy/Procedure Title: Internal Quality Improvement Committee ☒External Policy ☐Internal Policy Original Date: 05/17/2000 Next Review Date: 04/19/2018 Last Review Date: 04/19/2017 Applies to: ☒ Medi-Cal ☐ Employees B.5.Review delegation reports for quality, utilization management, credentialing where concerns exists. B.6.Review findings from regulatory audits and monitor progress on corrective action plans. B.7.Review performance metrics (i.e. dashboards and indicator reports) and make recommendations for corrective action for indicators that are below established thresholds; assure appropriate follow-up on corrective actions that relate to quality of care and service concerns. B.8.Makes recommendations for implement the QI and UM Programs, the QI Work Plan and Evaluation; in addition to PHC’s care coordination activities, Cultural and Linguistics Program, and Compliants/Grivances/Appeals. C. COMMITTEE ACCOUNTABILITY C.1.The IQI is accountable to the Q/UAC, and through this body, to the PAC and the PHC Board of Commissioners.

VII. REFERENCES: N/A

VIII. DISTRIBUTION: A. PHC Department Directors B. PHC Provider Manual

IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Committee Chairman

X. REVISION DATES: Medi-Cal 06/20/01; 09/18/02; 09/15/04; 03/15/06; 03/21/07; 02/20/08; 03/18/09; 04/21/10; 09/19/12; 10/16/13; 04/16/14; 04/15/15; 04/20/16; 04/19/17

PREVIOUSLY APPLIED TO: PartnershipAdvantage MPQP1004 – 03/21/2007 to 01/01/2015

Healthy Kids- 3/21/20017 to 12/01/2016 (Healthy Kids program ended 12/01/2016)

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