Study Guide: Quality Management

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1 Study Guide: Quality Management Outline: Below is a brief outline of the course. Introduction The goal is to reduce the outcome variability of key processes, thus reducing waste, increasing efficiency and increasing overall customer satisfaction and profitability. A basic understanding of statistical measurements is very important in any successful quality management program. Practices must appropriately measure variability before they can manage and reduce it. o Total Quality Management (TQM) TQM seeks to integrate an organization s functions with respect to meeting customer needs and organizational objectives. TQM prescribes to the principal of Do the right thing, the first and every time, and Quality is a constantly moving target. o Continuous Quality Improvement (CQI) CQI is similar in many aspects to TQM. However, it has historically been more popular in healthcare settings. It is focuses on:! Quality planning: What does the customer want or need?! Quality measurement and control: Were the processes done well?! Quality improvement: How can we improve the services or products? o Six Sigma The roots of Six Sigma are heavily grounded in the manufacturing industries. Six Sigma was primarily pioneered by Motorola in the mid 1980s. The goal of Six Sigma performance is to reduce the number of errors (or variances) to an extremely low number (six standard deviations from the mean). This level of error reduction reduces the defects per million to less than one. 1 Measuring Data o The goal of quality management is to reduce variability in a key process. Therefore, measurement is very important. Numerous quality tools including histograms and Pareto charts are available to help you analyze and improve quality. You can access the American Society for Quality s website to review these in more detail. Flowcharting o In this course, we will focus on flowcharting in more detail. o Flowcharting is a fundamental quality improvement method. A flow chart is a pictorial representation of the various steps involved in a process. It is an exact

2 way of describing a process and goes beyond simply listing the steps. The flow chart allows for decisions and intermediate results to occur throughout the entire process. It also allows for different paths to be taken at different steps. o Flow charts provide stakeholders with an easily identifiable, common language by using various shapes and lines, each with a distinct meaning. Clinical Pathways o Clinical pathways are frequently used to improve healthcare delivery and ensure patient safety. A clinical pathway is a guideline of a care or treatment plan for a specific condition. A clinical pathway also outlines preventative and self care for patients with this condition. Define and Develop Clinical Pathway Structures A structured approach to patient care lends itself well to a clinical pathway. The purpose is to encapsulate a care or treatment plan for a specific condition or preventative care for patients in a particular situation or condition. It identifies care activities and the caregiver workflow needed for a patient with a specific condition or disease. It can be adjusted for the particular patient s needs. o A clinical pathway may also be used for: Identifying a standard of care for patients with a particular problem or condition that considers risk adjustments based on a patient s psychological health and social factors, family/genetic history, age, race and gender. Treating illnesses or managing health and wellness. o A clinical pathway consists of a template, which is a diagram of network structure or a flow chart identifying recommended alternative paths of care based on intermediate goals and outcomes. Network diagram paths can lead to final outcomes that identify the conclusion of the care path (e.g. discharge from the hospital), or paths may be ongoing. 2 A care activity may consist of: Text identifying care to be given A goal An order or appointment to be automatically scheduled A protocol defined elsewhere in the system Another clinical pathway Keys for Successful Clinical Pathways

3 o Successful clinical pathways focus on satisfying customer s expectations, identifying problems, building commitment, and promoting open decision making among workers. They also provide the identification of an issue having significant monetary, clinical or outcome impact if improved or modified. o In order to be successfully implemented, the development of the pathway must account for the practice patterns of physicians and other members of the healthcare provider team. The entire care team must be allowed input to ensure buy in and improve adherence to the pathway. o The pathway should be written in short, easy-to-understand sentences. o Measure the effect of the pathway on outcomes, cost and patient satisfaction. o Incentives do not have to be monetary. Recognition and demonstrated appreciation for a job well done can serve as good incentives. o Consider clinical flexibility. When necessary, physicians need to be able to circumvent the guideline in a way that is not too time consuming or inconvenient. Monitor the frequency of divergences from the clinical pathway and review repeated episodes to determine if the pathway needs to be revised or expanded. o Monitor compliance and provide performance measures to encourage discussion of best practices. Credentialing and Certification To be successful in the credentialing process, it is essential to: Be organized Invest in a computerized tracking system Know the rules Invest in staff and training Be proactive and persistent External credentialing/certification organizations Most small- to medium-sized medical groups have a system of internal controls and quality-assurance programs centered on clinical practices and do not necessarily seek credentialing from outside organizations. However, many larger groups seek the expertise of an independent credentialing verification organization (CVO) to validate internal processes, screen potential providers, and provide the group with verification of credentials. Accreditation 3

4 The two most recognized accreditation organizations are the Accreditation Association for Ambulatory Health Care (AAAHC) and the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). AAAHC focuses on medical groups and JCAHO focuses primarily on hospitals. However, because many hospitals employ physicians or own medical groups, physicians are often required to meet JCAHO criteria for the hospital to pass the hospital accreditation. Each of these organizations has very thorough and extensive processes to earn accreditation. The evaluation is based on clinical quality, documentation, confidentiality, patient safety, practice protocols, error prevention and physician certification. Both organizations provide the practice and/or hospital with detailed information on the requirements. Criteria from AAAHC and JCAHO can be used as a roadmap for internal quality assurance efforts. Peer Review All healthcare organizations require peer review for initial and periodic renewal of privileges. For hospital credentialing, peers are asked to evaluate potential candidates on both personal and professional criteria. If patient or staff complaints are received about a practitioner, peer review may again be invoked. Examples of concerns include clinical skills, decision-making ability, reliability and medical necessity. Informal evaluation systems are based on: Patient complaints Patient attitudes Professional work patterns Peer review is also used in Quality Assurance Committee meetings. These meetings use measures to access clinical outcomes and processes. These meetings typically include an examination of random or specific patient medical records. Health plans, state medical boards or outside agencies investigating fraud or abuse allegations or malpractice situations can request or demand external, independent reviews. Credentialing The Centers for Medicare & Medicaid (CMS) website details Medicare and Medicaid licensure and credentialing processes. Websites for payers explain the process and have online applications on their websites. The websites have sections that allow 4

5 practice representatives to enroll their physicians, nurse practitioners and physician assistants as providers. Medicaid Credentialing Each state has its own Medicaid program that includes specific instructions on becoming a contracted provider, filing claims and navigating the state s unique appeals process. States may have multiple programs (traditional Medicaid and Medicaid managed care organizations, as example) that may require multiple provider numbers and separate contracts. Medicare Credentialing Medicare provider enrollment is online. The application is standardized and the progress can be tracked online. Individual providers must reassign their benefits to the group in order for the group to receive payments for their services. You must treat Medicare patients the same as other patients from a financial and business perspective. Detailed instructions are available in the online Medicare provider manuals and through the contracted vendors (designated intermediaries) who adjudicate claims and administer payments for Medicare. You will need to determine the intermediary payer for your state and follow its credentialing, provider enrollment and claims-filing processes. Third-party Credentialing Third-party payers are straightforward in terms of credentialing. In fact, as the industry has moved away from closed panels in favor of open networks, most of the focus has been on financial arrangements, customer service and meeting certain minimum clinical standards (e.g., childhood immunizations, mammograms). As part of the credentialing process, your provider must: 5 Have a license to practice medicine Have the requisite malpractice insurance Be willing to accept new patients Agree to the fee schedule/contract terms and conditions stated in the provider manual Have call arrangements for after-hours and emergency care

6 Commercial carriers may have additional requirements such as proof of CPR and advanced life support training, tuberculin skin testing, letters of reference from peers or hospital privileges. Although third-party payers may accept the tax identification as part of the claimsfiling process, claims will be rejected without an National Provider Identifier (NPI) number for the provider and for the group, if the group is receiving payment for the provider s services. Be aware that even if you file claims with payers as a convenience for your patients when you are not contracted as a provider, you are not automatically under contract. You may get paid at a lower out-of-network rate, your services may not be covered or the payment may go directly to the patient. Your group should file claims electronically. You can do this directly with the payer or through an intermediary, an electronic data interchange (EDI). The intermediary services can be free of charge without fees for each transaction. They may have specific filing requirements or work only with designated practice management software. Internal Focus and Priorities When considering what is required for certification and credentialing, the practice must look at its medical specialty service area, budget and market conditions. In other words, what does the practice need to do to optimize its revenue cycle and provide the appropriate level of patient care? Many groups do not invest enough in staff, systems or time to be completely successful. To ensure a minimum level of success, the group should: 6 Make sure your equipment meets industry standards. If a portion of your revenue is attributed to laboratory, radiology, outpatient surgery, or procedures, you must have licenses and certification up to industry standards and current regulations. You must also have a quality-assurance program to track maintenance and compliance on a real-time and ongoing basis. Make sure that clinical support staff have the appropriate licenses and training and their scope of practice is closely monitored. Verification of licensure and training should be confirmed annually. Keep a detailed list of credentialing requirements including expirations and renewal criteria. The practice should establish a reminder system for renewing credentials in a timely manner. It is critical to maintain and renew licensure, malpractice coverage, and certification before it expires.

7 Maintenance of board certification and proof of continuing education are often requirements for medical license renewal. Research possible rate reductions for malpractice insurance coverage from completing risk management or other certification training programs. Benchmarking The purpose of benchmarking is to collect and measure data from your practice, and to compare and contrast it to similar practices. For example, a cardiology practice can benchmark itself against other cardiology practices or a practice can benchmark its own physicians against one another. Benchmarking can also be used to compare and contrast the historical trends of a given practice. Almost any item in a practice can be benchmarked, such as salaries, collections, and days in accounts receivable, encounters and number of staff per provider relative value units (RVUs). The Value of Benchmarking Benchmarking can be used to improve a practice, determine appropriate salaries, and determine the appropriate number of physicians for the number and types of cases. Practices typically benchmark productivity to ensure that physicians are working up to their potential. Benchmarks can be used to determine compensation, recruiting needs, business growth opportunities and productivity. Productivity can be measured by RVUs, encounters and/or revenue. HEDIS (Health Effectiveness Data Information Set) History 7 In 1979, the National Committee for Quality Assurance (NCQA) was established. In 1991, NCQA began accrediting health plans. In 1990, NCQA integrated the Health Effectiveness Data Information Set (HEDIS) as an audit compliance program as part of health plan accreditation to assess the plan s information systems and performance for quality indicators. Today more than 90 percent of health plans operating in the United States recognize and utilize HEDIS for tracking and monitoring performance across their provider network.

8 HEDIS is an area of focus for medical groups today as they seek to improve the care they deliver. Most health plans compare their providers to this national database as part of the payfor-performance determinations. Knowledge of HEDIS indicators helps: To improve the quality of care being delivered to the group s patients. To understand how the group compares to HEDIS standards. Realistically, a group cannot focus on all the measures nor may all measures apply to the types of care and services the physicians provide. Typically, a practice will identify the top five or six HEDIS indicators. Once this is done, the practice can decide how to improve or maintain levels as deemed appropriate. Finally, the group tracks this data for trends and determines if its efforts are resulting in improvement. Patient Charts Quality Assurance Group practices have quality assurance programs conducted by an organized internal review committee. Typically, the reviews include acceptable performance in specific and randomly selected patient cases. Quality assurance programs vary substantially according to practice type, size, and the interest of the physicians. Practices closely associated with a hospital that share the same medical records are more likely to have a formal quality assurance program than a freestanding group practice. Although accreditation is voluntary in the ambulatory practices, clinics may elect to be accredited because the accreditation process helps the group evaluate their performance and establishes internal audit standards. To ensure accurate documentation and completeness of the patient chart, the following should be included: Demographics, insurance and financial information Legal agreements and consents Problem and medication lists and immunizations Health history and assessments Patient-reported data Clinical orders and diagnostic testing Chief complaints and diagnoses Clinical course of treatment and patient education Procedures, surgeries and encounters 8

9 Clinical Pathways With the growing influence of insurance companies and a demand for improved patient outcomes and cost containment, clinical pathways can be a useful tool for improving the delivery of healthcare and the management of high-risk patients. Group practices can achieve success with clinical pathways by collaborating with insurance companies on treatment plans. The treatment plans, which can be negotiated and agreed upon by physicians, payers and insurance companies, help meet the objectives of patient care and cost containment. It may be necessary to review patient care with the plan s medical director, case manager, care coordinator or utilization review team in order to deviate from the agreed upon clinical pathway. Patient Satisfaction Ensuring a good patient experience is critical to the success of your organization. Patients vote with their feet, and unhappy patients will seek their medical care elsewhere. Word of mouth is an excellent way to get patient referrals, so keeping your customers satisfied is critical. The quality of patient service is often related to malpractice risk. One way to determine patients opinions of the service quality is to measure their satisfaction and meeting patient expectations. In addition, some practices directly tie patient satisfaction to physician compensation. Practices also use positive patient satisfaction results to negotiate third-party contracts. As healthcare moves to more accountability and value-based care, the patient s perceptions and expectations will become exceedingly important. Any of the following can be used to determine patient satisfaction: o Surveys o Informal patient discussions o Patient complaint reports o Patient focus groups o Patient advisory groups A specific practice division or an outside vendor can be contracted to collect data and analyze patient satisfaction. Individuals with responsibility for compliance should get copies of the reports and then address service-related issues, especially those that are consistently reported. Policies and procedures should be in place for addressing patient suggestions and for improving procedures. In addition, patient complaints should be directly linked to quality improvement initiatives. 9

10 Patient satisfaction data should be trended and compared to the previous year and quarters. Are improvements resulting in higher satisfaction scores? If not, did the improvement address the right problem? Customer Service Programs Customer service programs should be a part of employee orientation and incorporated into the organization s culture and corporate mission. An ongoing employee customer service recognition program can be effective. Physicians and staff could receive awards (pins, ribbons, or certificates) for exceptional customer service. These should be presented at physician and staff meetings. In larger organizations, service excellence luncheons for award recipients can also be a part of the recognition program. Accounts Receivable (AR) Benchmarking By monitoring the number of days in accounts receivable, the management can determine the efficiency of the business office staff and identify delays in payment. If the business office is writing or adjusting off too many charges, the reduced number of days in AR can provide a red flag and signal the need for further investigation with an internal audit. The aging of the accounts receivable is also a useful benchmark. It helps a practice determine how quickly charges are getting paid. It can help detect breakdowns in the claims submission and patient payment systems and identify where attention needs to be focused. If very old, accounts receivable should be written off if they are determined to be uncollectible and repeated attempts to collect the funds have been unsuccessful. Management of denials is also an important benchmark. Monitoring the percentage of denials is especially useful when trended against historical data. Changes in the number and type of denials can be caused by either the billing software or insurance carrier. These discrepancies should always be investigated to determine the root cause. Staff should monitor for changes in plan requirements, coding and precertification processes that will impact claims processing or reimbursement. Pay for Performance (P4P) P4P provides financial incentives for meeting pre-established targets for delivering healthcare. These targets relate to quality and efficiency. This is an alternative arrangement to fee-for-service payments. Many pilot P4P programs are underway, and evidence-based programs will drive future funding and payment mechanisms. In larger organizations, this process might be managed by a Department of Clinical Effectiveness. Electronic medical records, registries and population health software will help administrators facilitate the data gathering process. 10

11 Electronic Health Records (EHR) Meaningful Use of EHRs The American Recovery and Reinvestment Act (ARRA) of 2009 contains provisions affecting healthcare. In an effort to increase the adoption rate of EHRs in physician practices and improve the use of technology for patient care, the legislation includes financial incentives for eligible physicians that use qualified EHRs. In order to demonstrate the meaningful use of their EHR and receive payment, practices are required to attest to meeting program objectives. The Centers for Medicare & Medicaid Services (CMS) has released the final rule on Stage 2 of meaningful use requirements. There are final 17 core objectives as well as six menu-selected objectives, five of which are new. ARRA details the future changes that will occur in transitioning to stage 2 of this program, now delayed until Objectives: Describe a quality improvement tool to develop a clinical pathway. Identify quality management programs. Review the peer review process for clinical staff. Identify patient satisfaction and customer service programs. Identify and maintain benchmarks for establishing practice performance standards. Give examples of internal processes and systems to participate in pay-for-performance programs to enhance healthcare quality. Identify programs for staff, business and equipment credentialing and licensure. 11

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