Quality Improvement (QI) Program


The purpose of our QI program is to support and guide the company’s day to day operations in effort to continuously improve quality of care by providing a formal structure and process designed to monitor and evaluate the care provided to our members through defined performance and outcome metrics.


ApexHealth is dedicated to meeting members where they are to ensure the highest quality of care and member experience. The Quality Department is responsible for organization wide development, monitoring, and evaluation of all quality and performance related outcomes to make certain these standards are met. Continuous Quality Improvement of healthcare services within QI Department scope include but are not limited to the following topics:

  • Member Concierge
  • Member Satisfaction Surveys
  • Complaints, Grievances, Appeals
  • Quality of Care Concerns
  • Continuity of Care
  • Credentialing
  • Network Management
  • Access and Availability
  • Provider Satisfaction
  • Utilization Management
  • Population Health Programs
  • Clinical Practice Guidelines and Standards of Care
  • Pharmacy Management
  • Health Plan Data and Information Technology

Goals & Objectives

Our goals and objectives at ApexHealth align with the HHS National Quality Strategy (NQS) and the CMS Quality Strategy which consist of three broad aims, six priorities and four foundational principles.

Three Aims:

  • Better Care
  • Healthier People, Healthier Communities
  • Smarter Spending

Six Priorities:

  • Make Care Safer by Reducing Harm Caused in the Delivery of Care
  • Strengthen Person and Family Engagement as Partners in Care
  • Promote Effective Communication and Coordination of Care
  • Promote Effective Prevention and Treatment of Chronic Disease
  • Work with Communities to Promote Best Practices of Healthy Living
  • Make Care Affordable

Four Foundational Principles:

  • Reduce racial and ethnic disparities
  • Promote data sharing across all settings of care
  • Enable local innovations
  • Foster a learning organization

Work Plan

The Quality Department at ApexHealth creates a thorough and complete QI work plan annually.

This dynamic document covers a full year of planned activities and objectives that address:

  • Quality of clinical care
  • Safety of clinical care
  • Quality of service
  • Members’ experience

The minimum level of detail included for each initiative includes:

  • Specific time frame for each activity’s completion
  • Staff responsible for each activity (titles of activity leads)
  • Periodic and ongoing monitoring of issues identified in prior years that are determined to require additional follow up

Annual Evaluation

The Quality Department annually evaluates how well we met our performance goals and objectives for improving quality of care and safety of clinical care and services specified within our QI Program. Those findings are summarized in a written annual report includes the following information:

  • A description of completed and ongoing QI activities that address quality and safety of clinical care and quality of service
  • Charts, graphs, tables displayed to trend measure data performance over time and in comparison, against performance objectives defined within the QI Program Description
  • Evaluation of the overall effectiveness of the QI program and of its progress toward influencing networkwide safe clinical practices based on an assessment of the performance of all aspects of the QI Program; this includes:
    • Adequacy of QI program resources
    • QI Committee and subcommittee structureo Practitioner participation and leadership involvement in the QI program
    • Title and description of each initiative described in the work plan and whether the activity was completed as expected
    • Major accomplishments
    • HEDIS and other health plan data
    • Barriers to achieving objectives
    • Recommended interventions for overcoming issues and barriers
    • Changes or restructuring necessary to optimize the QI program for the subsequent calendar year

Chronic Condition Improvement Program (CCIP)

The QI Program at ApexHealth includes a Chronic Care Condition Program (CCIP) that promotes effective chronic disease management and the improvement of care and health outcomes for all enrollees with chronic conditions. CCIPs are conducted over a three-year period and aim to achieve the following objectives:

  • Includes interventions above and beyond out inherent care coordination role and overall management of enrollees
  • Engage enrollees as partners in their care
  • Increase disease management and preventive services utilization
  • Improve health outcomes
  • Facilitate the development of targeted goals, specific interventions, and quantifiable, measurable outcomes
  • Guard against potential health disparities
  • Produce best practices