There are many forces driving Managed Care Organizations (MCO’s) that requires close attention to the quality of care given to patients and the patient outcome results from services provided. MCO’s have evolved from employing the traditional Quality Assurance (QA) mechanisms in evaluating patient care outcomes and have ushered in the era of Quality Management (QM). Healthcare is an ever-changing flux environment that is seeking to provide quality care in a cost effective manner to achieve the best patient outcomes. This paper will define both QA and QM models and discuss the differences of each to understand what is driving the quality evolution in Managed Care.
Quality Management
QM is a philosophy that relates to the policies and practices …show more content…
Codman in the 1900s that practiced surgery at Massachusetts General Hospital (Kongstvedt, 2013). Dr Codman was one of the first advocates for systematic performance assessment and included evaluation of care provided to his own patients (Kongstvedt, 2013). The onset of computers in the 1960s and 1970s brought the introduction of large administrative data sets these computer generated reports helped investigators in the analyses of practice variations (Kongstvedt, 2013). According to Kongstvedt, (2013), in this same time period, Avedias Donabedian developed three criteria for assessment of quality that are still used today, including structure, process and outcome (Kongstvedt, 2013). Structured criteria measures Healthcare performance that focuses on the situation in which care and services are provided (Kongstvedt, 2013). This criterion is used in accreditation by federal and state regulations that govern items to include board certification of physicians, licensure of facilities, safety compliance issues, and medical record storage (Kongstvedt, 2013). These measures provide proof that the MCO’s are capable to provide services it proposes to offer and mandated periodic reviews and reporting mechanisms verify these measures (Kongstvedt, …show more content…
The QI model includes the continuous improvement model that addresses understanding the customer need, identify processes and outcomes to meet those needs, assess performance, define indicators to measure performance and monitor performance to meet the expectations of the customers (Kongstvedt, 2013). Understanding the customer’s needs is the basis of all quality management programs and health care systems are putting this initiative at the forefront. Many times in Healthcare, the customers needs have been understood from reactive understanding, which usually comes in the form of complaints. Most MCOs have a formal process to survey their members to obtain satisfaction with care and services performed in the network (Kongstvedt, 2013). All initiatives are part of the bigger piece of managed care, as we know it
Quality Management
QM is a philosophy that relates to the policies and practices …show more content…
Codman in the 1900s that practiced surgery at Massachusetts General Hospital (Kongstvedt, 2013). Dr Codman was one of the first advocates for systematic performance assessment and included evaluation of care provided to his own patients (Kongstvedt, 2013). The onset of computers in the 1960s and 1970s brought the introduction of large administrative data sets these computer generated reports helped investigators in the analyses of practice variations (Kongstvedt, 2013). According to Kongstvedt, (2013), in this same time period, Avedias Donabedian developed three criteria for assessment of quality that are still used today, including structure, process and outcome (Kongstvedt, 2013). Structured criteria measures Healthcare performance that focuses on the situation in which care and services are provided (Kongstvedt, 2013). This criterion is used in accreditation by federal and state regulations that govern items to include board certification of physicians, licensure of facilities, safety compliance issues, and medical record storage (Kongstvedt, 2013). These measures provide proof that the MCO’s are capable to provide services it proposes to offer and mandated periodic reviews and reporting mechanisms verify these measures (Kongstvedt, …show more content…
The QI model includes the continuous improvement model that addresses understanding the customer need, identify processes and outcomes to meet those needs, assess performance, define indicators to measure performance and monitor performance to meet the expectations of the customers (Kongstvedt, 2013). Understanding the customer’s needs is the basis of all quality management programs and health care systems are putting this initiative at the forefront. Many times in Healthcare, the customers needs have been understood from reactive understanding, which usually comes in the form of complaints. Most MCOs have a formal process to survey their members to obtain satisfaction with care and services performed in the network (Kongstvedt, 2013). All initiatives are part of the bigger piece of managed care, as we know it