Utilization of Quality Management in Health Care in Support of Quality Provided Services
Utilization of Quality Management in Health Care in Support of Quality Provided Services The Patient Protection and Affordable Care Act of 2010 established regulations that require the quality improvement in “the delivery of health care services, patient health outcomes, and population health” (The Henry J. Kaiser Family Foundation, 2011, p. 10).
The national quality strategy section of this law further required the Secretary of the Department of Health and Human Services to develop a National Strategy for Quality Improvement in Health Care (the National Quality Strategy) which will stimulate the establishment of quality health care serving the needs of patients, families, and communities by setting priorities in a strategic plan to guide both the providers and payers (U. S. Dept of Health, 2011, Exec. Sum). The requirements further established an Interagency Working Group to help develop the National Quality Strategy.
This group, composed of representatives from 23 Federal Health Care responsible agencies, is to ensure cooperation between both the Federal and private sector.
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This group developed a draft plan which was then provided to over 300 health care industry entities and the general public for comment on the draft principles and priorities. The combined effort came up with a strategic plan that is composed of three aims, six priorities, and ten principles (Working for Quality, 2011, About the National Quality Strategy).
Section III of the National Strategy for Quality Improvement in Health Care will have the greatest impact on a health care organization’s quality management efforts since it addresses ten areas that establish the foundation for several quality improvement measures including payment, public reporting, quality improvement, certification, measurement of care processes and evaluation and feedback (U. S. Dept of Health, 2011, Polices and Infrastructure Needed to Support Priorities).
Additionally, the quality management organization that is established by the health care provider will have to annually review the list of proposed new measures that will be imposed the following year by the Centers for Medicare and Medicaid Services (CMS) to ensure their quality program has effective measures established and in place to comply with new statutory requirements (Working for Quality, 2011, Multi-Stakeholder Group Input on Quality Measures).
Understanding and implementing the quality measures that are imposed by the Patient Protection and Affordable Care Act of 2010 (ACA) will be the foundation for an effective quality management unit within the health care organization. The quality requirements of the Patient Protection and Affordable Care Act will require many health care organizations to examine their existing quality programs in order to adjust them to accommodate the new requirements, or in some cases, will cause the health care organization to implement a new department or unit to ensure that a quality management system is in place in order to comply with the law.
The use of Deming’s fourteen points for management to make improvements in industrial environments is well known and it is only natural that health care providers would turn towards this proven technique to improve health care quality. Total Quality Management techniques have already been implemented in various health care organizations, where over time, they have moved from Quality Assurance (QA), to Quality Improvement (QI), to Quality Management (QM) (which incorporates parts of both QA and QI (Carefoote, n.d. n. p. ). There are ten characteristics of a successful Quality program: Clear Mission Goals, Active Leadership, Defined Structure and Accountability, Coordinated Activities, Effective Planning, Comprehensive Scope of Services, Focus on Improvement, Data Driven Decision Making, Sound Policies and Procedures and Adequate Resources. The QM organization must have a clear mission and goals which are derived from the requirements of the ACA as well as its own objectives and strategies to serve its population.
One of the most important aspects is active leadership, which must flow from the top down to ensure that the quality program meets all of its objectives. This particular characteristic has important implications if the program is to succeed. Leadership, both medical and administrative, must “walk the walk and talk the talk” of a quality program. The surest means to ensure failure of the QM program is for the health care providers (employees) to sense that the health care organization leadership is only giving “lip service” to the program.
This can also be seen with regard to the program’s defined structure and accountability. There must be direct communication between the Leadership (overall responsible) and the day to day workers (who are required to provide the quality care). Coordination must be organization wide such that all departments have buy-in to the quality function to ensure that quality is not just a program but a way of life.
Effective quality planning must articulate all regulatory and accreditation requirements and all objectives of the program. It should include three processes: an annual program description; an annual action plan that delineates the activities critical to achieving the objectives established by the mission and goals, and a method to assess the organization’s performance of the plan. The scope of quality services must be all-inclusive comprised of clinical care and services.
Each must have standards that included monitoring, evaluation, and improvement. Additionally, it must ensure that metrics for health problems of the population, the organization serves, are reviewed on a regular basis. An important element of the QM program is to emphasize continuous process improvement; however, it should be applied throughout the organization and should not solely focus on areas that are below standards.
This can be achieved through the use of the Joint Commission Accreditation of Healthcare Organizations’ ten step monitoring and evaluation process: assignment of responsibility; delineate the scope of care service; identify the important aspects of care and services; identify indicators; establish means to trigger evaluation; collect and organize data; initiate evaluation; take action to improve care and services; assess effectiveness of actions and maintain improvements; communicate results to affected individuals.
Additionally, Health Employer Data and Information Set (HEDIS) performance measures as well as National Quality Forum (NQF) endorsed measures and ACA requirements should be folded into the continuous improvement process. QM decisions must be based on data collected with regard to both service and quality. Quality performance can be determined by comparing results to standards set by the QM program. For example: Did care meet timeliness standards; or did the cost of care exceed the norm for the care given.
This necessitates a close working relationship between the QM organization and the various other departments in the health care organization to ensure that the correct data is being collected to support the ability to make sound data driven decisions. The simplest way to ensure this occurs is to promulgate an organizational Quality Management guidebook (which is annually updated) that meticulously sets out the various procedures and policies of the QM department/unit.
The final cog in this organization is to ensure that it is provided with the staffing, funds and resources to accomplish its objectives (Carefoote, n. d. n. p. , NCQA, 2011, HEDIS and Quality Measurement, Stelmark, n. d. slides 43 and 48). While there are several different programs that require empirical quality measures as evidence of quality care, pay for performance is one of the most common. According to Susan Hart-Hester et al. , (2008): Pay for performance (P4P) programs provide financial incentives to healthcare providers based on quality of care and cost efficiency of services.
P4P measures may include clinical outcomes, cost efficiency, processes related to best practices, use of health information technology (HIT) (e. g. , electronic health records and registries), patient satisfaction, and patient safety (Impact of P4P). Research in 2008 showed that when P4P measures were well defined and looked at a narrow scope of clinical measures, healthcare outcomes improved (Hart-Hester et al. 2008, n. p. ). Here the QM team must work closely with the healthcare provider to ensure that the proper treatment data is being collected to support P4P requirements thus ensuring a quality score.
An interesting point with regard to P4P as discussed by Conrad and Perry (2009) is that outcome based incentives are overshadowed by process based incentives since the provider has more control over the processes; therefore, the incentive is frequently strengthened by adding in a measure of outcome that is expansive enough to cover patient risk factors such that the blended quality measure will overcome the healthcare provider’s inclination to “treat to the test. ” They also state that there is little evidence that supports whether incentives are a more effective measure in improving quality over the use of penalties (p.360). In one study of a Massachusetts healthcare provider, Conrad and Perry stated that process improvement was shown for diabetic care where there was a combination of rewards and withholds (penalties), but there was no way to establish which caused the improvement (p. 362). As an example of how the QM program would work, the following will discuss how empirical quality measures would impact reimbursements for the health care organization by utilizing data standards from the Blue Cross and Blue Shield of Texas Bridges (BCBSTX) to Excellence Diabetes Care Program.
As can be seen in the chart below, specific empirical data must be gathered either by the healthcare provider or a metrics collector from the QM team and then forwarded to BCBSTX to qualify for financial rewards. The data must also be submitted to any one of four Performance Assessment Organizations (Health Care Incentives Improvement Group, IPRO, National Committee on Quality Assurance, and American Board of Internal Medicine) in order to become a Recognized Physician or Organization (Blue Cross Blue Shield of Texas, n.d. n. p. ). It should be noted that BCBSTX uses a combination of outcome based incentives as well as process based incentives to establish quality care. Clinical Measures Threshold Minimum Criteria Maximum Points Poor Control Measures HbA1c Control > 9. 0 < 27. 5% of pts in sample 15 Blood Pressure Control > 140/90 < 40% of pts in sample 15 LDL Control > 130mg/dl < 40% of pts in sample 10 Superior Control Measures HbA1c Superior Control 1 < 7. 0 < 40% of pts in sample 5
HbA1c Superior Control 2 < 8. 0 < 40% of pts in sample 5 Blood Pressure Superior Control < 130/80 > 30% of pts in sample 10 LDL Superior Control < 100mg/dl > 35% of pts in sample 10 Process Measures Ophthalmologic Exam N/A N/A 10 Nephropathy Exam N/A N/A 5 Podiatry Exam N/A N/A 5 Smoking Status and Cessation Advice and Treatment N/A N/A 10 Total Points 100 Percentage of Total Points Needed to Achieve Recognition 60 As long as the health care provider maintains patients within the applicablesample percentage and has an overall percent of 60 or higher, financial rewards and recognition will be obtained for the quality care. Quality Management is not the only instrument that should be in a health care organization’s tool box to improve quality care and support continuous improvement. Lean, Six Sigma, Key Performance Indicators, Return on Investment and Benefit-Cost Analysis are all additional tools that need to be utilized to improve healthcare.
All of these can assist a healthcare organization in finding the specific data needed to support not only the requirements of ACA but help with internal issues of quality improvement. Quality Management, however, should be the governing approach in using these tools. Success in this endeavor requires the commitment of all employees to see quality as a way of life. In a healthcare organization this commitment should be easier than in most other organizations since the personnel already have a commitment to make people’s lives better through medical treatment.
An important fact here is that information flow must be two-way, with information flowing down on big picture issues and the day to day workforce providing input up the chain of organization on how to do things better, for they are the ones that are in the trenches and already know what works and what does not. Yes, there are always better and more efficient ways to provide medical treatment, but what works in New York City might not work in Austin for a variety of reasons. More and more healthcare organizations are moving to P4P and not just because of ACA.
The California P4P program, was established in 2003 and “remains the largest in terms of dollars distributed and while clinical quality metrics have improved by an average of 3 percent annually patient satisfaction surveys have stagnated” (Altarum Institute, 2011, p. 13). It is therefore incumbent on healthcare organizations to be proactive and incorporate a distinct QM organization that crosses all department lines and works closely with each sub unit to ensure that both quality care and quality improvement are addressed and measured accurately relying heavily on sound empirical data.