Respond to all of the following questions and be sure to respond to two of your other classmates’ postings:
1. What are the steps in the quality improvement model and how is benchmarking involved? 2. What are the stages in which data quality errors found in a health record most commonly occur? 3. What is the definition of risk management? 4. What are the parts of an effective risk management program? 5. What is utilization review and why is it important in healthcare? 6. What is the process of utilization review? Please paper should be 400-500 words and in an essay format, strictly on topic, original with real scholar references to support your answers.
NO PHARGIARISM PLEASE! This is the Chapter reading for this assignment:
Read Chapter 7 in Today’s Health Information Management. INTRODUCTION
Quality health care “means doing the right thing at the right time, in the right way, for the right person, and getting the best possible results.”1 The term quality, by definition, can mean excellence, status, or grade; thus, it can be measured and quantified. The patient, and perhaps the patient’s family, may interpret quality health care differently from the way that health care providers interpret it. Therefore, it is important to determine—if possible—what is “right” and what is “wrong” with regard to quality health care. The study and analysis of health care are important to maintain a level of quality that is satisfactory to all parties involved. As a result of the current focus on patient safety, and in an attempt to reduce deaths and complications, providing the best quality health care while maintaining cost controls has become a challenge to all involved. Current quality initiatives are multifaceted and include government-directed, private sectorsupported, and consumer-driven projects.
This chapter explores the historical development of health care quality including a review of the important pioneers and the tools they developed. Their work has been studied, refined, and widely used in a variety of applications related to performance-improvement activities. Risk management is discussed, with emphasis on the importance of coordination with quality activities. The evolution of utilization management is also reviewed, with a focus on its relationship to quality management.
In addition, this chapter explores current trends in data collection and storage, and their application to improvements in quality care and patient safety. Current events are identified that influence and provide direction to legislative support and funding. This chapter also provides multiple tips and tools for both personal and institutional use.
Data quality refers to the high grade, superiority, or excellence of data. Data quality is intertwined with the concept of quality patient care; it refers to data that can demonstrate and represent in an objective sense the delivery of quality patient care. When the data collected are reflective of the care provided, one can reach conclusions about the quality of care the patient received.
The concept of studying the quality of patient care has been a part of the health care field for almost 100 years. Individual surgeons, such as A. E. Codman, pioneered the practice of monitoring surgical outcomes in patients and documenting physician errors concerning specific patients. These physicians began the practice of conducting morbidity and mortality conferences as a means to improve patient care. Building on the prior work of individual surgeons, the American College of Surgeons (ACS) created the Hospital Standardization Program in 1918. This program served as the genesis for the accreditation movement of the 20th century, which included the concept of quality patient care and the formation of the Joint Commission on Accreditation of Hospitals (JCAH) in 1951. The ACS transferred the Hospital Standardization Program to the JCAH in 1953.
Efforts to improve the quality of patient care have varied during the 20th century, beginning with the establishment of formalized mechanisms to measure patient care against established criteria. A timeline illustrating these efforts is shown in Figure 7-1. These mechanisms focused on an organization’s reaction to individual events and the mistakes of individual health care providers. A variety of quality efforts followed, including ones developed in other industries that were adapted to the health care environment. The concepts of total quality management, defined as the organization-wide approach to quality improvement, and continuous quality improvement, defined as the systematic, team-based approach to process and performance improvement, introduced the team-based approach to quality health care. These newer efforts moved the focus from individual events and health care providers to an organization’s systems and their potential for improvement.
Figure 7-1 | Quality management timeline
Accompanying the change in focus were new terms such as quality management, quality assurance, process improvement, and performance improvement. Quality management generally means that every aspect of health care quality may be subject to managerial oversight. Quality assurance refers to those actions taken to establish, protect, promote, and improve the quality of health care. Process improvement refers to the improvement of processes involved in the delivery of health care. Performance improvement refers to the improvement of performance as it relates to patient care. Regardless of the names applied and their respective approaches, most health care organizations in the 21st century are bound by the requirements of various accrediting and regulatory bodies to engage in some function that focuses on the quality of patient care.2
In order to measure patient care for quality purposes, one must first possess data. The data crucial to supporting any quality initiative are the data found in the patient health record. These data must be reliable with respect to quality. Data errors can be made during many stages, such as when data are entered into the record (the documentation process), when data are retrieved from the record (the abstracting process), when data are manipulated (the coding process), when data are processed (the indexing and registry processes), and when data are used (the interpreting process). At each stage, the data must be both consistent and accurate. Furthermore, good quality data are the result of coordinated efforts to ensure integrity at each stage. A recent focus on the legibility of handwritten data, the appropriate use of abbreviations, and their relationship to medication errors has increased pressure from accrediting agencies to improve the quality of data as a means to improve patient safety.
Quality health care management is the result of the dedication of a variety of professionals working in all levels of employment and in all aspects of health care. These professionals are supported by governmental offices at the federal, state, and local levels that define what data they require to be reported to them. When data definitions are not specified by the agency or organization requiring a report, the responsibility to define the data falls to the team or group that is responsible for collecting and disseminating the data. Fundamental to the collection and dissemination of data is the application of the appropriate collection format and reporting tools. However, before data collection can begin, there must be consensus on the perimeters of the data to be collected. The team or group should also select an assessment model, such as quality circles, PDSA, or FOCUS PDCA. Quality circles are small groups of workers who perform similar work that meet regularly to analyze and solve work-related problems and to recommend solutions to management. These groups are also known as Kaizen teams, a Japanese term meaning to generate or implement employee ideas.3 PDSA (Plan, Do, Study, Act), also known as PDCA (Plan-Do- Check-Act),4 is illustrated in Figure 7-2. FOCUS PDCA5 involves finding a process to improve, organizing a team that knows the process, clarifying the current knowledge of the process, understanding the causes of special variation, and selecting the process improvement. Figure 7-3 illustrates the FOCUS PDCA approach.
Essentially, these assessment models provide groups with guidance about how to organize the process. These models were developed largely as a result of the manufacturing industry quality movement of the 1950s and 1960s led by W. Edwards Deming, J. M. Juran, and Philip Crosby. In the 1960s, these models were applied to the health care sector by Avedis Donabedian, who separated the quality of health care measures into three distinct categories: structure, process, and outcomes.6 In the 1970s, when the Joint Commission on Accreditation of Healthcare Organizations, now known as the Joint Commission, and the Health Care Financing Administration (HCFA), now known as Centers for Medicare and Medicaid Services (CMS), began to mandate quality initiatives, health care looked to the successes of the manufacturing industry for direction and ideas.
Figure 7-2 | Plan, do, study (or check), and act assessment model
Figure 7-3 | FOCUS assessment model
The quest for quality, and the tools necessary to achieve it, eventually led to the development of the Malcolm Baldrige National Quality Award. The U.S. Congress created this award in 1987,7 which led to the creation of a new public-private partnership. Principal support for the award comes from the Foundation for the Malcolm Baldrige National Quality Award. The U.S. president announces the award annually. The award initially recognized the manufacturing and service sectors, including both large and small businesses, but it was expanded in 1999 to include the education and health care sectors; several health care organizations have applied for and received this award since then. In 2006, the program expanded even further to consider nonprofit and governmental organizations in the application process. The seven categories in which participants are judged for the Malcolm Baldrige Award are listed in Table 7-1. The focus of the evaluation centers on total quality management with emphasis on sustaining results.
Table 7-1 | Health Care Criteria in the Malcolm Baldrige Award
Customer and market focus
Measurement, analysis, and knowledge management
Source: Malcolm Baldrige National Quality Award, http://www.quality.nist.gov Courtesy of The National Institute of Standards and Technology (NIST).
Early pioneers who applied the Malcolm Baldrige concepts found it difficult at times to achieve effective implementation and/or sustain improvement. In an effort to achieve the greatest possible savings from the improvement projects, the Juran Institute, working with Motorola, developed a methodology called Six Sigma.8 Six Sigma is defined as the measurement of quality to a level of near perfection or without defects. General Electric (GE) and Allied Signal (now Honeywell) also contributed to the development and popularity of the methodology. Part of its success is attributed to the organization of training and leadership. High-level executives are trained and appointed as “champions” to drive the program, and employees receive training and support to become certified internal experts. The amount of training one receives results in different belt levels: black belts are technical personnel who are trained to apply the statistically based methodology. Master black belts coach black belts and coordinate projects. The project team members are referred to as green belts and also receive basic process-improvement training.
The Six Sigma Improvement Methodology is similar to that of PDCA and FOCUS PDSA, but it uses five steps, known as (D)MAIC: Define, Measure, Analyze, Improve, and Control. Many components of the health care industry have applied the Six Sigma improvement methodology toward the elimination of errors rather than the correction of defects (as it has been applied in industry). The approach is similar and both ultimately strive for perfection. In light of the fact that one error can be of catastrophic consequence if it involves a sentinel event or even death, the concept of near perfection in the Six Sigma standards is important for all applications of health care delivery.
Federal Efforts Whereas the quest for quality led to the development of the Baldrige Award and Six Sigma, efforts at the federal level resulted in the formation of the Agency for Health Care Policy and Research (AHCPR) in 1989. Later changed to the Agency for Healthcare Research and Quality (AHRQ) as part of the Healthcare Research and Quality Act of 1999, this body is a scientific research agency located within the Public Health Service (PHS) of the U.S. Department of Health and Human Services. AHRQ focuses on quality of care research and acts as a “science partner” between the public and private sectors to improve the quality and safety of patient care. Over time, the agency has changed its focus from developing and supporting clinical practice guidelines to developing evidence-based guidelines. AHRQ’s mission is to develop scientific evidence that enables health care decision makers to reach more informed health care choices. The agency assumes the responsibility to conduct, support, and disseminate scientific research designed to improve the outcomes, quality, and safety of health care. The agency is also committed to supporting efforts to reduce health care costs, broaden access to services, and improve the efficiency and effectiveness of the ways health care services are organized, delivered, and financed.
AHRQ has achieved numerous accomplishments since its inception. These accomplishments range in focus from the Medical Expenditure Panel Survey (MEPS), the Healthcare Cost and Utilization Project (HCUP), and the Consumer Assessment of Healthcare Plans Survey (CAHPS), to the grant component of AHRQ’s Translation of Research into Practice (TRIP) activity and the Quality/Safety of Patient Care program. The latter program encompasses both the Patient Safety Health Care Information program and the Health Care Information Technology program. Each of the programs listed here provides valuable information to the agency. For example, the Medical Expenditure Panel Survey (MEPS) serves as the only national source for annual data on how Americans use and pay for medical care. The survey collects detailed information from families on access, use, expense, insurance coverage, and quality. This information provides public and private sector decision makers with important data to analyze changes in behavior and the market. The Healthcare Cost and Utilization Project (HCUP) also provides information regarding the cost and use of health care resources but focuses on how health care is used by the consumer. HCUP is a family of databases containing routinely collected information that is translated into a uniform format to facilitate comparison. The Consumer Assessment of Health Plans (CAHP) uses surveys to collect data from beneficiaries about their health care plans. The grant component, Translation of Research into Practice (TRIP), provides the financial support to initiate or improve programs where identified. Patient safety research is also an important element of these activities and includes a significant effort directed toward promoting information technology, particularly in small and rural communities where health information technology has been limited due to cost and availability. Other research efforts for patient safety are focused on reducing medical errors and improving pharmaceutical outcomes through the Centers of Excellence for Research and Therapeutics (CERT) program.
AHRQ has provided grants to increase the use of health information technology, including electronic health records.
As a result of the growing concern for the increased use of health information technology (HIT) to improve the quality of health care and control costs, AHRQ awarded $139 million in contracts and grants in 2004 to promote the use of health information technology. The goals of the AHRQ projects are listed in Table 7-2. Grants were awarded to providers, hospitals, and health care systems, including rural health care settings, critical access hospitals, hospitals and programs for children, as well as university hospitals in urban areas. The locations were spread throughout the country from coast to coast, border to border, and included Alaska and Hawaii. Many grant recipients sought to develop HIT infrastructure and data-sharing capacity among clinical provider organizations. Other grant recipients sought to improve existing systems that were considered outdated, or to install technology where it had not previously existed, such as pharmacy dispensing systems, bar coding, patient scheduling, and decision-support systems. Some grants went toward the construction of a fully integrated electronic health record (EHR), such as one effort by the Tulare District Hospital Rural Health Consortium. Some universities received grants to employ technology for disease-specific projects, such as the Trial of Decision Support to Improve Diabetes Outcomes at Case Western Reserve University; others sought to develop cancer care management programs, such as the Technology Exchange for Cancer Health Network (TECH-Net) established by the University of Tennessee; and others worked to automate tracking of adverse events, such as the Automated Adverse Drug Events Detection and Intervention System established by Duke University. Still other grants focused on promoting statewide and regional networks for health information exchange, sometimes referred to as regional health information organizations (RHIOs). The goal of these projects is to develop a health information exchange that connects the systems of various local health care providers so they can better coordinate care and enable clinicians to obtain patient information at the point of care.9 More information concerning the work of RHIOs is found in Chapter 10, “Database Management.”
Table 7-2 | Goals of the AHRQ Projects
Improve patient safety by reducing medical errors
Increase health information sharing between providers, labs, pharmacies, and patients
Help patients transition between health care settings
Reduce duplicative and unnecessary testing
Increase our knowledge and understanding of the clinical, safety, quality, financial, and organizational values and benefits of HIT
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Among its accomplishments of the 21st century, the AHRQ has begun certifying patient safety organizations (PSOs). These organizations were created pursuant to the Patient Safety and Quality Improvement Act of 2005 and are designed to serve as independent entities that collect, analyze, and aggregate information about patient safety. They use this data to identify the underlying causes of lapses in patient safety. PSOs gather data through the voluntary reporting of health care providers and organizations according to the terms of the Patient Safety and Quality Improvement Final Rule (Safety Rule).
A second 21st century accomplishment of the AHRQ involves the creation of the National Strategy for Quality Improvement in Health Care (National Quality Strategy). Created pursuant to the Patient Protection and Affordable Care Act, the National Quality Strategy aims to improve the overall quality of patient care, reduce costs, and improve patient health. AHRQ developed the National Quality Strategy using evidence-based results of medical research and input from a wide range of stakeholders across the health care system.
A similar effort at the federal level to improve quality patient care initiated in the U.S. Department of Health and Human Services and resulted in creation of the Center for Medicare and Medicaid Innovation. Also created pursuant to the Patient Protection and Affordable Care Act, the Center is designed to test innovative care and payment models and encourage adoption of practices that reduce costs, while simultaneously delivering highquality patient care at lower cost.
The U.S. President connects the use of electronic health records with improvement in quality patient care.
One of the most significant efforts to focus attention on the importance of advancing health information technology as a means to improve the quality of patient care was made by U.S. President George W. Bush. In his State of the Union Address on January 20, 2004, he stated, “By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care.”10 He acted on this statement shortly thereafter, establishing a national coordinator for health information technology within the U.S. Department of Health and Human Services. This coordinator announced that a 10-year plan would be developed to outline the steps necessary to transform the delivery of health care by adopting health information technology in both the public and private sectors. Included in these steps are the EHR and a national health information infrastructure (NHII), topics that are addressed in further detail in Chapter 10, “Database Management,” and Chapter 11, “Information Systems and Technology.”
Private Efforts Concern for improving the quality of health care also moved others to action. The Institute of Medicine, a private nonprofit organization that provides health policy advice under a congressional charter granted to the National Academy of Sciences, conducted an in-depth analysis of the U.S. health care system and issued a report in 2001. This report, Crossing the Quality Chasm: A New Health System for the 21st Century,11 identified a significant number of changes that had affected the delivery of health care services, specifically the shift from care of acute illnesses to care of chronic illnesses. The report recognized that current health care systems are more devoted to dealing with acute, episodic conditions, and are poorly organized to meet the challenges of continuity of care. The report challenged all health care constituencies—health professionals, federal and state policy makers, purchasers of health care, regulators, organization managers and governing boards, and consumers—to commit to a national statement of purpose and adopt a shared vision of six specific aims for improvement.
The report did not include a specific “blueprint” or standard for the future because it encouraged imagination and innovation to drive the effort. Specific recommendations included a set of guiding principles known as the Ten Steps for Redesign, the establishment of the Health Care Quality Innovation Fund to initiate the process of change, and development of care processes for common health conditions—most of them chronic—that afflict great numbers of people. This report served as a driving force behind the funding of grants through AHRQ and the other programs that have already been identified.
The National Committee for Quality Assurance (NCQA) is another organization involved in improving health care quality. Established in 1990, this organization focuses on the managed care industry. It began accrediting these organizations in 1991 in an effort to provide standardized information about them. Its Managed Care Organization (MCO) program is voluntary, and approximately 50 percent of the current HMOs in this country have undergone review by NCQA. Earning the accreditation status is important to many HMOs, because some large employers refuse to conduct business with health plans that have not been accredited by NCQA. In addition, more than 30 states recognize the accreditation for regulatory requirements and do not conduct separate reviews.
In 1992, NCQA assumed responsibility for management of the Health Plan Employer Data and Information Set (HEDIS), a tool used by many health plans to measure performance of care and service. Purchasers and consumers use the data to compare the performances of managed health care plans. Because more than 60 measures are present in the data set, containing a high degree of specificity, performance comparisons are considered very reliable and comprehensive. The NCQA has designed an audit process that utilizes certified auditors to assure data integrity and validity. HEDIS data are frequently the source of health plan “report cards” that are published in magazines and newspapers. Included in HEDIS is the CAHPS 3.0H survey that measures members’ satisfaction with their care in areas such as claims processing, customer service, and receiving needed care quickly. The data are also used by the plans to help identify opportunities for improvement. A sample of HEDIS measures is shown in Table 7-3.
Table 7-3 | Sample HEDIS Measures, Addressing a Broad Range of Important Topics
Asthma medication use
Controlling high blood pressure
Antidepressant medication management
Smoking cessation programs
Beta-blocker treatment after a heart attack
Source: Information compiled from the National Association for Healthcare Quality (NAHQ), http://www.nahq.org.
Courtesy of the National Association for Healthcare Quality.
The NCQA also operates recognition programs for individual physicians and medical groups. These programs are voluntary, and physicians may apply through NCQA. Doctors who qualify must meet widely accepted evidence-based standards of care. One program includes a Diabetes Physician Recognition Program that was developed in conjunction with the American Diabetes Association. This program recognizes physicians who keep their patients’ blood sugar and blood pressure at acceptable levels and routinely perform eye and foot examination. The Heart/Stroke Recognition Program (HSRP) is a partnership with the American Heart Association/American Stroke Association and recognizes doctors and practices that control their patients’ blood pressure and cholesterol levels, prescribe antithrombotics such as aspirin, and provide advice for smokers looking to quit.
Table 7-4 | NCQA Accrediting Domains for Accountable Care Organizations
ACO structure and operations
The organization clearly defines its organizational structure, demonstrates capability to manage resources and aligns provider incentives through payment arrangements and other mechanisms to promote the delivery of efficient and effective care.
Access to needed providers
The organization has sufficient numbers and types of practitioners and provides timely access to culturally competent health care.
Patient-centered primary care
The primary-care practices within the organization act as medical homes for patients.
The organization collects, integrates and uses data from various sources for care management, performance reporting, and identifying patients for population health programs. The organization provides resources to patients and practitioners to support care management activities.
Care coordination and transitions
The organization facilitates timely exchange of information between providers, patients, and their caregivers to promote safe transitions.
Patient rights and responsibilities
The organization informs patients about the role of the ACO and its services. It is transparent about its clinical performance and any performance-based financial incentives offered to practitioners.
Performance reporting and quality improvement
The organization measures and publicly reports performance on clinical quality of care, patient experience, and cost measures. The organization identifies opportunities for improvement and brings together providers and stakeholders to collaborate on improvement initiatives.
Source: National Committee on Quality Assurance, www.ncqa.org.
Courtesy of the National Committee on Quality Assurance.
In 2011, NCQA began accrediting accountable care organizations, an entity created pursuant to the Affordable Care Act of 2010. An accountable care organization (ACO) refers to a group of providers and suppliers of services (e.g., hospitals, physicians, and others involved in patient care) that work together to coordinate care for the patients who receive Medicare health benefits. An ACO is designed to focus on preventive care, coordinate care among providers to reduce error and duplication of services, involve patients in their health care, and contain costs. The accreditation domains to be applied by NCQA to accountable care organizations are listed in Table 7-4.
The organization that brings all of the professionals involved in quality health care management together is the National Association for Healthcare Quality (NAHQ). This organization is based on the idea that quality health care professionals drive the delivery of vital data for effective decision making in health care systems. Organized in 1975 as the National Association for Quality Assurance Professionals (NAQAP) to represent these health care workers, the organization provides educational, research, and certification programs to its membership. Members include a wide range of professionals who focus on quality management, quality improvement, case/care/disease/utilization management, and risk management. The membership is composed of all levels of employment from all types of health care settings. Members achieve certification through examination and earn the credential of Certified Professional in Healthcare Quality (CPHQ); the examination recognizes professional and academic achievement. The organization also promotes networking and mentoring through educational meetings and publications. Membership includes physicians, nurses, health information management professionals, health care management professionals, information systems management professionals, social workers, and physical and occupational therapists, all with a common focus on improving the outcomes of health care.
Equally important as selecting a methodology is using assessment tools effectively. Several tools are often employed, including idea generation, data gathering and organizing techniques, cause analysis, and data display methods. While each tool is applicable in many environments, they apply especially well in the context of data quality because they assist in identifying progress, relationships, and the presence or absence of trends. This process of identification leads to a determination of the presence, absence, or level of quality. One useful resource for quality assessment tools is the Web site of the American Society for Quality (http:// www.asq.com), where instructions and samples are available.
When new ideas are needed to address an issue or problem, brainstorming and benchmarking are often employed. Brainstorming refers to an idea-generating tool in which ideas are offered on a particular topic, in an unrestrained manner, by all members of a group within a short period of time. Brainstorming can be structured or unstructured, and it generally employs guidelines to assure that ideas are not criticized and that all ideas are accepted during the process. Benchmarking refers to the structured process of comparing outcomes or work practices generated by one group or organization against those of an acknowledged superior performer as a means of improving performance.
Once ideas are generated, the challenge lies in organizing them into a fashion in which they can be processed or analyzed. Organizational tools frequently used include affinity diagrams, nominal group techniques, Gantt charts, and PERT. An affinity diagram refers to a diagram that organizes infor