Just in time for National Healthcare Quality Week!
CareNational specializes in the Medical Management segment of healthcare, meaning four primary areas: Case Management, Utilization Management, Quality Management, and Reimbursement Management. We pride ourselves in our expertise in these areas, as we are able to provide our clients and candidates with an informed perspective and truly consultative approach. However, while we are definitively more knowledgeable than other generalized staffing firms and recruiting agencies, we do not physically perform these tasks nor do we directly oversee these departments, so we need your help.
In Shakespeare’s Romeo & Juliet (Act II, Scene II) Juliet famously asks Romeo: “What’s in a name? That which we call a rose, by any other name would smell as sweet.”
Operating coast to coast, and working with both various types of payer and provider organizations, we have encountered a plethora of different terminology and titles for what are essentially comparable departments, functions, and individual roles. Some, such as ‘Licensed Vocational Nurse’ vs ‘Licensed Practical Nurse’ vary state to state, while other terms, such as ‘Medical Management’ vs ‘Healthcare Services’, seem to vary based on organizational preferences. We wanted to look at each of our 4 niche segments and discuss the various titles, terms, and subsets of the discipline to see what you, the reader, had encountered in your education and experience.
Of all of CareNational’s core focus areas, Quality Management is in many ways the most complex and multi-faceted of the Medical Management disciplines, so I will need your help on this, dear reader. On the surface, the mission seems simple and serves as a consistent philosophy across the wide variety of supporting roles: ensure the quality of patient care. However when navigating the variety of position functions, tools, and organizational structures internal to Quality Management, it becomes significantly more hazy. Additionally, many of the foundational elements are based on the general business concept of quality management that has four main components: quality planning, quality control, quality assurance, and quality improvement. So how does that translate to healthcare?
In healthcare, as in business operations, the first three components (quality planning, quality control, quality assurance) might be wrapped together under the general term ‘Quality Management’, as they each play a role in ensuring the product (or in healthcare, the service) meets minimum established standards. However, there has been a shift in emphasis to that forth component (Quality Improvement), particularly in healthcare. The fundamental basis of this philosophical move is to change the goal from meeting minimum standards, to exceeding those standards. Many organizations have even removed the ceiling on the QI process and instituted programs that are constantly looking to make improvements, often referred to as Continuous Quality Improvement or CQI. Other programs seek to create QI as a common goal of all staff and leaders, not just the responsibility of one department and incorporate constant improvement into the initial quality planning stage. This is sometimes referred to as Total Quality Management or TQM.
Depending on the history of the organization, and to what degree they have embraced or emphasized ideas like CQI and TQM, they may call it a ‘Quality Management’ department or a ‘Quality Improvement’ division. I should note that the term ‘Performance Improvement’ is sometimes used as synonymous with ‘Quality Improvement’ but not always. In its most accurate sense it should be referring to improving strictly performance based measures and metrics, discussed in more detail below. But first, what does quality mean in healthcare?
“The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”
-The Institute of Medicine (IOM) Definition of “Quality of Care”
So how does a fairly simple ideological goal become so convoluted, at least to this blog author? While quality is a straightforward idea, it can often be subjective to the point of view of the consumer. In order to create and improve on healthcare quality goals, a variety of measures and processes are used to collect and analyze relevant data. Quality measures are mechanisms that enable the user to quantify the quality of healthcare processes, outcomes, patient perceptions, and organizational systems by comparing it to an evidence-based criterion. Quality measures may also relate directly to one or more quality goals for healthcare: safe, effective, patient-centered, timely, efficient, and equitable. Essentially it is the application of a scientific, statistical, and analytical approach to establish baseline quality goals and institute programs to initiate and measure improvements from there.
Performance measurement is the quantitative assessment of both healthcare process measures and outcome measures for which an individual physician, practitioner, or health care organization may be accountable. A performance indicator is a quantitative expression that describes whether, or how often, a process of care or outcome of care occurs. Process measures assess the activities carried out by health care professionals to deliver services, often guided by evidence-based clinical guidelines. Outcome measures examine discrete, patient-focused endpoints such as readmission, length of stay, morbidity and mortality. The simplest performance measure is a numerator/denominator equation that measures compliance where the Numerator represents the number of times that the care was provided and the Denominator represents the number of times a provider had the opportunity to provide an element of recommended care to a patient.
These quality measurement indicators are critical because payers want information on clinical performance to make contract decisions as well as to track return on payments to health care providers. Health care providers need information about performance to develop high-quality, cost-efficient systems to deliver care. Researchers and regulatory agencies need information from clinical performance measures to develop and implement policy. There are a wide variety of common programs and tools in use today. Some focus on collecting measures and comparing to standard baseline, whereas others use those results to give ratings or incentives to health pans. There are too many to create a comprehensive list or to go into detail on each, but here are a few of the most common:
HEDIS – The Healthcare Effectiveness Data and Information Set, developed by the National Committee for Quality Assurance (NCQA), consists of 75 measures across 8 domains of care. It’s used by many health plans to compare to other plans and improve care. Measures are vetted by stakeholders and tested for reliability, feasibility, and validity and can vary from year to year.
CAHPS – The Consumer Assessment of Healthcare Providers and Systems is the health plan survey endorsed by the National Quality Foundation (NQF) which includes standardized questionnaires and optional supplemental items for both commercial plans and Medicaid / Medicare plans and programs.
P4P – The Pay for Performance program gives financial incentives to clinicians for better health outcomes. Also known as value-based purchasing, this payment model rewards physicians, hospitals, medical groups, and other healthcare providers for meeting certain performance measures for quality and efficiency. It penalizes caregivers for poor outcomes, medical errors, or increased costs.
STAR Ratings – A Medicare evaluation system that gives an overall score of the plan’s quality and performance on many different topics that emphasize patient care and satisfaction, using national clinical and service quality measures, health outcomes, and patient feedback.
These are just a few of the most common programs that are tied to Quality Management measures. They are generally familiar to most Medical Management professionals, not just those Certified Professionals in Healthcare Quality (CPHQ). In recognition of the upcoming 2015 HEDIS season, we will be expanding on that program in a detailed series of articles.
As stated initially, CareNational specializes in recruitment and career search consultation in these specialized areas, but we do not perform these functions ourselves. So how did we do? Did we accurately identify the most common job titles related to these functions and duties? Did we miss anything or get anything wrong? Please let us know! What titles does your organization use? What terms have you seen throughout your career? We want to hear from the experts: that’s you!
Please comment below with your thoughts and experiences. You can also contact us via email at firstname.lastname@example.org or call us toll free at 800-974-4828.