• Does the plan have a written description of its QI program that is reviewed and updated annually?
• Is the plan's governing body accountable for the QI program?
• Is behavioral health specifically addressed in the QI program?
• Does a QI Committee oversee the QI program?
• Are the roles, structures and functions of the QI Committee and other committees described in the QI program description?
• Is there an annual QI work plan?

2.    QI Program Operations (QI 2)

• Does the QI committee meet regularly and take action on quality improvement activities?
• Is there documentation of QI committee meetings?
• Are practitioners involved in the planning, design, implementation and review of the QI program?
• Are the plan’s practitioners and members informed about its QI program?
• Is there a plan for collecting and providing information on provider and practitioner safety and quality?

3.    Health Services Contracting (QI 3)

• Are participating practitioners and providers required to cooperate with QI activities, provide access to their medical records and protect the confidentiality of member information?
• Do contracts with practitioners and providers assure their free communication with patients about treatment?
• Do contracts with specialty groups require timely notification to members about termination of a specialist or specialty group?

4.    Availability of Practitioners (QI 4)

• Are plan practitioners located throughout its service area?
• In creating its provider network, does the plan consider special needs of its members? For example, are there multilingual practitioners?
• Does the plan take steps to ensure that there are sufficient numbers of practitioners available to its members?
• Does the plan measure its performance in these areas and make improvements when needed?

5.    Accessibility of Services (QI 5)

• Does the plan have standards to assure access to medical care, including routine primary care, emergency care, and after-hours care?
• Can members who need behavioral health care obtain it when they need it?
• Does the plan measure its performance in these areas?

6.    Member Satisfaction (QI 6)

• Does the plan evaluate member complaints and appeals to assess member satisfaction?
• Does the plan analyze results of member satisfaction surveys?
• Does the plan take steps to improve performance in these areas?

7.    Complex Case Management (QI 7)

• Are members with complex conditions systematically identified and referred for case management?
• Does the plan have case management systems that are based on sound evidence?
• Does the plan have case management systems that ensure appropriate documentation and follow-up?
• Does the case management system have processes for initial assessment and ongoing management of members in its program?
• Does the plan measure performance and member satisfaction of its program and take action on opportunities when necessary?

8.    Disease Management (QI 8)

• Does the plan offer programs and services to members with chronic health conditions, such as diabetes?
• Are members systematically identified and informed about the programs?
• Are member participation and program effectiveness measured?
• Are practitioners made aware of and educated about these programs?
• Are interventions based on stratification of severity or other clinical criteria?

9.    Clinical Practice Guidelines (QI 9)

• Does the plan establish practice guidelines for its practitioners to follow?
• Is there a clinical basis to the guidelines?
• Are the guidelines reviewed at least every two years?
• Are the guidelines distributed to appropriate practitioners?
• Does the plan measure its performance against the guidelines annually?

10.    Continuity and Coordination of Medical Care (QI 10)

• Does the plan monitor the continuity and coordination of care between practitioners; for example, between a primary care physician and a specialist?
• Does the plan measure its performance in these areas and make improvements when needed?
• Does the plan or practitioner notify members affected by the termination of a primary care practitioner?
• Under certain circumstances, can members continue to see a practitioner whose contract is terminated?

11.    Continuity and Coordination Between Medical and Behavioral Health Care (QI 11)

• Does the plan monitor the coordination of general medical care and behavioral health care?
• Does the plan collaborate with its behavioral health specialists in collecting and analyzing data and implementing actions to improve the coordination of behavioral health with general medical care?

2.    Clinical Quality Improvements (QI 12)

• Does the plan measure and demonstrate improvement in the quality of clinical care?
• Des the plan demonstrate at least three clinical care improvements, including one in behavioral health?

13.    Service Quality Improvements (QI 13)

• Does the plan measure and demonstrate improvement in the quality of service?
• Does the plan demonstrate at least two quality of service improvements?

14.    Standards for Medical Record Documentation (QI 14)

• Does the plan establish and distribute medical record policies that address confidentiality, documentation standards, record keeping and availability?
• Does the plan have methods to improve medical record keeping where appropriate?

15.    Delegation of QI Activity (QI 15)

• If the plan delegates QI activity, has it worked with the delegated party to develop a mutually agreed-upon document that outlines responsibilities, delegated activities, and evaluation processes?
• Has the plan evaluated whether or not the delegated party can perform the activities?
  Does the plan approve the delegated party’s QI work plan and review its performance annually?