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. Partnership 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 Partnership network providers who represent multiple disciplines.
When should a PQI be referred?
Any time there is a suspected quality of care concern; some examples may include:
How can a PQI be referred?
Contact us for additional information.
