Click here for the Proceedings from the 1998 Quality Summit in Puerto Rico

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American Board of Quality Assurance and Utilization Review Physicians
National Association for Healthcare Quality
Managed care magazine
AMERICAN JOURNAL OF MANAGED CARE (PEER REVIEWED
GLOSSARY OF TERMS IN MANAGED CARE
Medline on managed care”>

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Historical Data

• 2000 B.C. The Code of Hammurabbi prescribes rewards and punishment for physicians.

• 1600 B.C. The Oath of Hippocrates directs the behavior of physicians, who do not need others to supervise their profession.

• 1122 B.C During the Chou Dynasty physicians must pass a test to practice.

• 980-1037 In Persia with Avicenna physicians must pass a test in order to practice their Art.

• 1300 University of Paris is the first one to require physicians to possess a license to practice.

• 1518 College of Surgeons auto-regulates the profession.

• 1858 Florence Nightingale attempted to improve medical practice standards during the Crimean War.

• 1910 College of Surgeons accredits 89 out of 692 hospitals.

• 1910 Flexner Report shows that only a few of 160 medical schools provide quality education and provokes the end of diploma mills.

• 1912 E. Codman introduces the first medical audit system.

• 1913 The College of Surgeons proposes its Minimum Standards fo quality for hospital care.

• 1952 The Joint Commission on Accreditation of Hospitals (now of Healthcare Organizations) is founded in Chicago.

• 1953 The JCAH publishes the first Manual of Standards.

• 1972 The Social Security Act creates the PSROs (Professional Standards Review Organizations)

• 1982 The Elam vs College Park Hospital case assigns the final responsibility of care in hospitals on its Governing Board.

• 1975 Yale's John Thompson y Robert Fetter author DRG's (Diagnostic Related Groups)

• 1977 American Board of Quality Assurance and Utilization Review Physician is founded in Pennsylvania.

• 1978 The National Association of Healthcare Professionals is founded.

• 1980 JCAH introduces a chapter on Quality Standards in its Manual of Accreditation of Hospitals.

• 1980 Avedis Donabedian introduces concepts of structure, process and outcome in the art of monitoring patient care.

• 1982 Profesional Review Organizations substitute the PSROs and for the first time Medicare providers must submit medical information for revision.

• 1983 Prospective Payment System is created utilizing DRG's to pay hospitals for patient care.

• @1983 Some health insurance companies begin to reduce benefits for mental health care and for drug abuse care.

• 1985 JCAHO introduces the concept of Continuous Monitoring to monitor care.

• 1989 Total quality Management or Quality Improvement begins as a new paradigm to monitor healthcare services.

  The budget of mental health programs are placed under the newly created Mental Health and Substance Abuse Administration.

• 1990 US Public Health Service contracts with UNISYS Corporation to run a National Practitioner Data Bank.

  Human Genome Proyect begins in the U.S.

• 1990 The Joint Commission for the Accreditation of Healthcare Organizations develops Clinical Indicators to monitor quality of care.

• 1994 The explosion of Managed Care companies and the managed care paradigm begins.

  The National Institute of Mental health completed its National Comorbidity Study at the University of Michigan. It documnets the high prevalence of mental disorders in the U.S.

• 1996 The Domenici-Wellstone bill that eliminates yearly caps in health insurance coverage is signed into law.

• 1998 The Patient Outcomes Research Team study, published in Schizophrenia Bulletin, shows that treatment is still inadequate for this severe mental disorder

• 1999 President Clinton orders that federal employees be given parity in health insurance coverage for mental disorders.

  A landmark event: The Surgeon General publishes “Mental Health: Surgeon General’s Report.”

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  A few Principles of Quality Improvement

  With the advent of systems to monitor quality of care the principles of Quality Assurance were unable to effectively improve patient care because it made providers the sole accountable parties, and it bred fear and anger among health care providers. The change has already begun from Quality Assurance to Quality Improvement theory and practice. The following is a succint view of the differences between the two paradigms of care.

  Quality Assurance---------Total Quality Management
  

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  Quality Improvement tools

  Flow Charts
  Pareto Charts
  Cause and Effect Diagram
  Run chart
  Scatter diagram
  Control charts
  Histograms
  

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  What to look at when you are concerned about quality of patient care:

  The structure of the system
  The processes of care
  The outcomes of care

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  The elements in a process

  Providers are to consumers like inputs are to outputs
  where a "Thing" or service being passed along.

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  When you want to study a process to improve quality of care you may use the FOCUS PDCA nemotechnia

  FOCUS---------PDCA
  Find a process to improve
  Organize a team that knows the process
  Clarify current knowledge of the process
  Understand sources of variations
  Select mode of process improvement
  plan the improvement and continuous data collection
  Do the collection and analysis of data
  Check and study the results
  Act to hold the gain and continue to improve the process
  

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  NCQA is dedicated to evaluate the performance of MCOs (managed care companies). What are NCQA's standards?
  The 50 standards for quality health plans fall into one of the following six categories:
  • Quality Improvement:
    Does the Plan fully examine the quality of care given to its members?
    How well does the Plan coordinate all parts of its delivery system?
    What steps does it take to make sure members have access to care in a reasonable amount of time?
    What improvements in care and service can the Plan demonstrate?

  • Physician Credentials:
    Does the Plan meet specific NCQA requirements for investigating the training and experience of all physicians in its network?
    Does the Plan look for any history of malpractice or fraud?
    Does the Plan keep track of all physicians' performance and use that information for their periodic evaluations?

  • Members' Rights and Responsibilities:
    How clearly does the Plan inform members about how to access health services, how to choose a physician or change physicians, and how to make a complaint?
    How responsive is the Plan to members' satisfaction ratings and complaints?

  • Preventive Health Services:
    Does the Plan encourage members to have preventive tests and immunizations? Does the Plan make sure that its physicians are encouraging and delivering preventive services?

  • Utilization Management:
    Does the Plan use a reasonable and consistent process when deciding what health services are appropriate for individuals' needs?
    When the Plan denies payment for services, does it respond to member and physician appeals?

  • Medical Records:
    How consistently do the medical records kept by the Plan's physicians meet NCQA standards for quality care?
    For instance, do the records show that physicians follow up on patients' abnormal test findings?

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    FROM QUALITY ASSURANCE TO QUALITY MANAGEMENT

    LIMITATIONS OF QUALITY ASSURANCE PARADIGM

    MAY NOT EFFECTIVELY IMPROVE CARE
    PROVIDERS HELD ACCOUNTABLE
    BREEDS FEAR AND ANGER

    TRADITIONAL MANAGEMENT TOTAL QUALITY MANAGEMENT

    Management driven | Customer driven
    Strongly centralized | Strongly decentralized
    Multiple managerial levels | Few managerial levels
    Strictly hierarchical | Cross-functional teams
    Autocratic |Participatory
    Highly regulatory |Highly deregulatory
    People focused |Process focused
    Relies on inspection | Relies on prevention
    Unproductive, wasteful |Effective, efficient

    QUALITY IMPROVEMENT TERMINOLOGY

    CUSTOMER
    PROCESS
    PROJECTS
    VARIATIONS
    SCIENTIFIC METHOD
    QUALITY COUNCIL
    STEERING TEAMS

    EVENTS IN A PROCESS

    INPUT---------->TRANSFORMATION------------->OUTPUT

    ELEMENTS OF A PROCESS

    SUPPLIERS | CUSTOMERS
    INPUTS | OUTPUTS
    *>>>>>>>>>>>>>
    THING BEING PASSED ALONG

    SCIENTIFIC METHOD

    OBSERVATION-->HYPOTHESIS-->TEST-->CONCLUSION-->OBSERVATION

    QUALITY IMPROVEMENT TOOLS

    FLOW CHARTS
    PARETO CHARTS
    CAUSE AND EFFECT DIAGRAMS
    RUN CHART
    SCATTER DIAGRAM
    HISTOGRAMS
    CONTROL CHART

    FOCUS - PDCA

    Find a process to improve
    Organize a team that knows the process
    Clarify current knowledge of the process
    Understand sources of variation
    Select process improvement
    Plan the improvement and continue data collection
    Do the improvement, data collection and analysis
    Check and study results
    Act to hold the gain and to continue to improve the process

    STRESS MANAGEMENT

    COMMUNICATION
    EMPATHY
    TEAM EFFECTIVENESS

    ANALYSIS OF TEAM EFFECTIVENESS

    DEGREE OF MUTUAL TRUST
    DEGREE OF MUTUAL SUPPORT
    COMMUNICATION
    TEAM OBJECTIVES
    HANDLING CONFLICTS
    USE OF MEMBER RESOURCES
    CONTROL METHODS
    ENVIRONMENT

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    On a philosophical tangent. Survival of the fittest Main page