Capability Expectations of Physician Organizations

The following checklist is intended to help POs assess their readiness to join PGIP and organizational capacity for process improvement, analysis and reporting. BCBSM's goal is to help POs assimilate the culture of the program and establish needed capacities early on. POs that are able to demonstrate the following prerequisites are more likely to efficiently and effectively engage in the program and ultimately are more likely to have a successful experience in PGIP. This translates into improved care for all patients.

Organizational commitment

The organizational commitment checklist should be completed and submitted along with the PGIP application to establish fundamental capabilities to promote a successful start in the PGIP program.

  • There is full commitment from PO senior leadership to organizational process improvement. This may include evaluating the organizational structure to support PGIP initiatives, allotting financial resources and allotting personnel resources.
  • A PO clinical champion has been identified and assigned. (Note: clinical champion may vary by quality initiative.)
  • The PO is committed to spreading the adoption of evidence-based guidelines within the PO.

Organizational processes

The PGIP Field Operations team will conduct a preliminary site visit to evaluate the overall organization. This will enable the PO to establish a roadmap of the following core capabilities necessary to promote PGIP success:

  • Process improvement activities that identify barriers and work to eliminate, alleviate, or establish a work plan to remedy staffing issues (number of staff, appropriate skills, buy-in, etc.), training needs and other issues or needs specific to their office.
  • An implementation plan that can be applied, in a customized way, to each quality care initiative.
  • A Quality Improvement Committee (or something similar) that meets routinely and regularly addresses PGIP initiatives.
  • Process improvement educational opportunities for PO staff either through the PO, PGIP workgroups or through external resources (as described in initiative plans). Participation among practice units is highly encouraged.
  • A process in place to spread information about PGIP and its initiatives throughout the PO.
  • Advising sessions for individual providers who show opportunities for improvement in a particular area or areas based on his or her individual data report.
  • A substructure (for larger POs), such as regional medical directors or physician champions and administrative leads for change initiatives, so that practice units are actively led by individuals at the local level with whom they have active relationships and contact.

Staffing capabilities

A thorough assessment of the PO's clinical reporting and data staff needs has been conducted. Suggested capabilities include:

  • Data analyst — one who can prepare and analyze individual provider reports; strong data, analytical and technical skills; may or may not be a clinical individual.
  • Quality analyst — one who can analyze, advise and collaborate with providers to help improve quality processes in provider practice; should have clinical background; may not need strong technical and data analytical skills if PO has data analyst; may handle data analyst duties in smaller PO if skilled enough.
  • Project or operations manager* — oversees data analyst and overall data needs of PO; health care experience; technical skills; leadership skills; not necessarily a clinician.
  • RN analysts* — nurses with analytical ability to review data and collaborate with PO providers to improve health care delivery processes.
  • Clinical director — oversees all above individuals; leadership skills; has good rapport and respect of PO providers; exceptional ability to communicate and collaborate; thoroughly understands health care delivery processes; should have a clinical background.

If it is determined that more staff will not be added, the PO should ensure that current staff can manage the process improvement, reporting and analytical duties effectively.

* These positions typically exist in larger POs

Technical capabilities

  • A thorough assessment of information technology tools and infrastructure and data capabilities and needs has been conducted.
  • PO can identify data requirements at both PO and practice unit level.
  • PO and affiliated practice units have access to meaningful data.
  • PO has a central data warehouse.
  • PO and practice units use (or plan to use) patient registry technology.
  • PO and practice units use (or plan to use) electronic prescribing.