Health Care Quality and Performance

The Performance and Federal Reporting unit within Quality has a primary focus on quality metrics and mandatory reporting requirements.  Our function is to provide guidance and monitoring of SoonerCare, SoonerCare Choice and SoonerSelect programs, as well as other Medicaid waivers such as the Institutions for Mental Diseases (IMD) Waiver for Serious Mental Illness/Substance Use Disorders (SMI/SUD) and Long-Term Services & Supports (LTSS) waivers.

This includes but is not limited to standardized metrics within the  CMS Core Set Measures and surveys from the Consumers Assessment of Healthcare Providers & Systems (CAHPS).

To facilitate this, our unit works with external partners such as the Centers for Medicare & Medicaid Services (CMS), other sister state agencies and an External Quality Review Organization, as well as coordinating with internal departments to fulfill reporting requirements and to help the agency make data-driven decisions. 

QUALITY ASSURANCE

The Quality Assurance (QA) team, in accordance with the Centers for Medicare and Medicaid Services (CMS) regulations, follows a continuous quality improvement process to ensure the health, safety and welfare of SoonerCare members. Through an ongoing process of discovery, remediation and improvement, the QA team monitors (a) level of care determinations; (b) provider qualifications; and (c) SoonerCare member health, safety and welfare. 

The QA Department encourages our members and providers to provide feedback about our activities and the information we share, what is meaningful and relevant, and how we can continue to improve SoonerCare. Email feedback to Quality@okhca.org.

If you have issues or concerns with SoonerCare or its providers, please contact the SoonerCare helpline at 800-987-7767. 
 

QUALITY IMPROVEMENT ORGANIZATION (QIO)

The QIO program is led by CMS, which is a program dedicated to improving the quality of health care.  Signed into law in 1982 with Title XI of the Social Security Act, it has the following core functions:

• Using data to track health care quality improvements.
• Protecting the integrity of federal funding, ensuring that services and goods paid are reasonable and necessary and provided in the most appropriate setting.
• Protecting beneficiaries

QIO organizations are independent organizations that work directly with health care providers to ensure health care is qualitative, safe and efficient. The QA team oversees the QIO organization’s activities that include:

• Utilization review.
• Quality of care review.
• Diagnosis-Related Group (DRG) validation services.
   

QUALITY IMPROVEMENT

Quality Improvement (QI) is improvement strategies designed to advance the quality of care for SoonerCare members through input from members, providers, collaborative work groups and other stakeholders who advise and share best practices, interventions, program services and contribute to the development of improvement projects.

The goal of OHCA’s Quality Improvement Unit includes the Quintuple Aim:

• Improve health outcomes for SoonerCare members.
• Improve member experience.
• Decrease the cost of care per capita.
• Improve provider experience.
• Advance health equity.

The QI department supports the Quintuple Aim by increasing operational excellence through unit-specific dashboards, robust data management, surveys, the Plan Do Study Act (PDSA) improvement tool, and monitoring data trends. QI continuously promotes fiscal responsibility by controlling costs and utilization management.
 

PATIENT-CENTERED MEDICAL HOME (PCMH)

The QA/QI department oversees the PCMH program for the SoonerCare Choice members. PCMH is a model of health care delivery with an approach to delivering high-quality, cost-effective primary care that puts the patient at the center. The main concepts for a PCMH are:

• Team-based care and group practice organization.
• Knowing and managing your patient population.
• Patient-centered access and continuity.
• Care management and support.
• Care coordination and transitions of care.
• Measurement of performance and quality improvement.

SoonerSelect (SS) Quality provides oversight of the managed care process, reviews the Contracted Entity (CE) reports, establishes criteria and indicators of quality, and gives feedback for better results.  The SS Quality unit works closely with the EQRO to support the conduct of all CMS mandatory activities such as validation of performance improvement projects (PIPs), quality assurance and performance improvement plans, compliance reviews and some optional ones. The team meets with all dental and health/CSP CEs regularly to receive and provide feedback on managed care quality related activities. The overarching goal is to improve the health outcomes of SoonerSelect members through high standards and continuous improvement of managed care. 

The Health Improvement Unit at the Oklahoma Health Care Authority leads efforts to improve health outcomes for SoonerCare members by advancing policies, supporting programs and building partnerships that address both medical needs and the broader life factors that influence health. These include access to safe housing, transportation, nutritious food, education, supportive social environments and the like.

The unit plays a key role in implementing evidence-based health initiatives, testing the efficacy of health models, working with managed care organizations to monitor progress, reviewing data and ensuring that enhanced services are effectively reaching our members. Through strategic partnerships with a variety of  organizations, the unit  works to expand access to trusted, culturally responsive care, empowering families and improving outcomes.

Oklahoma is proud to be one of 15 states chosen to receive the Transforming Maternal Health (TMaH) Cooperative Agreements, a national initiative funded  by the Centers for Medicare & Medicaid Services. This funding agreement will support innovative strategies to improve health outcomes for mothers and babies. Through strengthened partnerships, expanded community supports and enhanced coordination of care, Oklahoma aims to ensure that more families receive the quality, respectful and person-centered care they deserve before, during and after pregnancy.

The Strategic Team focuses on:

1. Strategic Planning and Monitoring:

• Setting Goals: The team uses Traction as its strategic planning tool. The unit facilitates the agency’s goals and  ensures goals are accomplished through monitoring and reporting.
• Managing Projects: The team uses quality and performance improvement resources like "Plan, Do, Study, Act" (PDSA) and "Lean Six Sigma" to ensure project outcomes are attained.
  • PDSA:  Tests of improvement are planned, implemented, studied and incorporated into processes if they are successful.
  • Lean Six Sigma: Techniques that are applied to discover and fix  problems in  the agency’s processes so things work more effectively and efficiently.

2. Strategic Innovation:

• Improving Processes: Evaluate and document current state. Define and implement future state.
• Always Getting Better: Use data and information to innovate and improve
• Building a Culture of Improvement: Build a culture of continuous improvement by working closely with business units across the agency.

The overall purpose of the Office of Data Governance and Analytics unit is to provide consistent, comprehensive, timely and relevant information to Oklahoma Health Care Authority’s internal and external stakeholders while ensuring that data is proactively managed for the benefit of the organization.