Providers

The QIS adopts evidence and approves clinical criteria on an annual basis. The specific functions and responsibilities of the committee are as follows:

• Provide regular clinical measurement oversight
• Identify and monitor key quality indicators that measure performance against clinical practice guidelines, external benchmarks and internal targets (HEDIS)
• Assist with review of clinical aspects of the Quality Improvement (QI) program, work plan, and the Care Management program Recommend new opportunities or changes in current programs and interventions to improve clinical care and service
• Assist with development, review and maintenance of clinical policies and procedures
• Review and analyze potential quality of care issues if required
• Review, assess, and recommend internal utilization management practices
• Approve the criteria used to review authorization decisions at least annually
• Review and approve the Utilization Management (UM) program description
• Evaluate utilization functions including the assessment and analysis of utilization statistics, management guidelines, referral trends, ambulatory treatment patterns, inpatient monitoring processes and the effectiveness of discharge planning programs

Committee Structure

The membership is comprised of the following:

• Chief Medical Officer
• Vice President of Quality
• Medical Director
• Vice President of Health Services
• Vice President of Pharmacy Services
• VP Government Programs
• Vice President of Network Development
• Director Quality Improvement and Clinical Analytics
• Director, Customer Advocacy
• Director Medicaid Operations
• Director Medicare
• Director Grievance and Appeals
• BSWH Quality Alliance Physician Representative
• Specialty Care representatives
• Primary Care representatives

Quorum

The committee meets monthly and the quorum defined as more than one half of the committee membership.
Meetings may be held without a quorum, but voting may not take place.