Potential Quality Issues FAQs

How are PQI’s identified?

A potential quality issue is a suspected deviation from provider performance, clinical care, or outcome of care which requires further investigation to determine if an actual quality of care concern or opportunity for improvement exists. PHC identifies PQIs through the systematic review of a variety of data sources, including but not limited to:

  • ​Complaints, grievances, and appeals
  • Utilization review
  • Claims and encounter data
  • Care coordination
  • Medical record audits
  • Facility site reviews
  • Referrals from other health plan staff, providers, and members of the community

 

What happens when a quality issue is identified?
  • ​A Registered Nurse conducts the initial review and further investigation. Medical records are obtained if necessary.

  • Cases are referred to a physician reviewer if a potential quality issue exists.

  • Provider of concern is asked for input and a final determination is made by the physician reviewer or sent to a specialist for review.

  • Due to the nature or complexity of the case, it can be referred to the Peer Review Committee (PRC) for final determination.  The PRC is comprised of PHC network providers who represent multiple disciplines.

Who can refer a PQI?
  • ​Health plan staff

  • Health plan members

  • Any contracted or non-contracted provider and staff

  • Any member of the community

When should a PQI be referred?

​Any time there is a suspected quality of care concern; some examples may include:

  • A delay in obtaining a referral

  • Long wait time in the office at the time of an appointment

  • Rudeness from providers or staff members

  • Possible inadequate assessment of an adult or child

  • Complication in the delivery of a child

  • Unexpected death of an adult or child

How can a PQI be referred?

You can use the PQI Referral Form by clicking here.

Contact us for additional information.

 

Southern Region: (707) 863-4620
Northern Region: (530) 999-6828

Fax: (707) 863-4316

Email: PQI@partnershiphp.org