The National Committee for Quality Assurance (NCQA) has been accrediting MCOs since 1991. All of the information that NCQA gathers from the standardized performance guidelines report card go into the Healthcare Effectiveness Data and Information Set (HEDIS). HEDIS is a popular tool utilized to evaluate the quality of a health care plan (chap. 9). Presently NCQA accredits the most health care plans including EPO, HMOs, POS, and PPOs. NCQA uses HEDIS and CAHPS measures to evaluate and assess clinical performances to help keep the accreditation standards high. The evaluation of their compliance with NCQA standards determines if a plan's status will be recognized as excellent (highest accreditation), commendable (well-established), accredited
Nerenz, D. R. & Neil, N. (2001). Performance measures for health care systems. Commissioned paper for the center for Health management research. [PDF document]. Retrieved from Systemswww.hret.org/chmr/resources/cp19b.pdf
To guarantee that its members receive appropriate, high level quality care in a cost-effective manner, each managed care organization (MCO) tailors its networks according to the characteristics of the providers, consumers, and competitors in a specific market. Other considerations for creating the network are the managed care organization's own goals for quality, accessibility, cost savings, and member satisfaction. Strategic planning for networks is a continuing process. In addition to an initial evaluation of its markets and goals, the managed care organization must periodically reevaluate its target markets and objectives. After reviewing the markets, then the organization must modify its network strategies accordingly to remain competitive in the rapidly changing healthcare industry. Coventry Health Care, Inc and its affiliated companies recognize the importance of developing and managing an adequate network of qualified providers to serve the need of customers and enrolled members (Coventry Health Care Intranet, Creasy and Spath, http://cvtynet/ ). "A central goal of managed care is containing the costs of delivering care, but the wide variety of organizations typically lumped together under the umbrella of managed care pursue this goal using combination of numerous strategies that vary from market to market and from organization to organization" (Baker , 2000, p.2).
Introduction “Health informatics is the science that underlies the academic investigation and practical application of computing and communications technology to healthcare, health education and biomedical research” (UofV, 2012). This broad area of inquiry incorporates the design and optimization of information systems that support clinical practice, public health and research; understanding and optimizing the way in which biomedical data and information systems are used for decision-making; and using communications and computing technology to better educate healthcare providers, researchers and consumers. Although there are many benefits of bringing in electronic health systems there are glaring issues that associate with these systems. The
The current focus on new healthcare models is a reaction to long-standing concerns around quality, cost, and efficiency. Accountable Care Organizations model focus on integrated healthcare to promote accountability and improve outcomes for the health of a defined population. The goal of integrated healthcare is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors (CMS, 2014). The following paper will analyze an ACO’s ability to change healthcare in the United States.
Merwin, E & Thornlow, D. (2009). Managing to improve quality: the relationship between accreditation standards, safety practices, and patient outcomes. Health Care Managment Review, 34(3), 262-272. DOI: 10.1097/HMR.0b013e3181a16bce
Managed care dominates health care in the United States. It is any health care delivery system that combines the functions of health insurance and the actual delivery of care, where costs and utilization of services are controlled by methods such as gatekeeping, case management, and utilization review. Different types of managed care plans came into development by three major factors. These factors include choice of providers, different ways of arranging the delivery of services, and payment and risk sharing. Types of managed care organizations include Health Maintenance Organizations (HMOs) which consist of five common models that differ according to how the HMO is related to the participating physicians, Preferred Provider Organizations (PPOs), Exclusive Provider Organizations (EPO), and Point of Service Plans (POS). `The information management system in a managed care organization is determined by the structure of the organization' (Peden,1998, p.90). The goal of a managed care system is to provide subscribers and dependants with needed health care services at the lowest possible cost. Certain managed care plans also focus on prevention by trying to keep members healthy.
Healthcare services should be provided to all people without discriminations of any nature. Professionals in the healthcare sector should ensure that while attending to patients, they act in accordance to the medical laws. Agencies regulating the healthcare industry ensure that all the health professionals act in accordance to the medical laws and people have access to high quality medical attention.
Conditions of Participation was created to ensure all facilities participating in Medicare follow a set of regulations that protect the safety of Medicare recipients. In 1986 revisions were made to reinforce accreditation and certification procedures. Participating hospitals that are accredited by the Joint Commission on Accreditation of Healthcare Organizations or American Osteopathic Association have been deemed to meeting Conditions of Participation requirements on the wellbeing of Medicare Recipients. The Joint Commission on Accreditation of Healthcare Organizations also requires that the facilities are licensed by their state. (Lohr, 1990, p.
Medicare suppliers must be accredited by the Joint Commission (JC) or by a state regulated survey, which is performed by selected state agencies on behalf of the Centers for Medicare and Medicaid (CMS). As of July 2010 the CMS monitor and provide guidelines which the Joint Commission incorporates into its review processes. Accreditation consists of a in depth review of a hospital's physical plant, patient care , medical staffing and services based on quality factors and standards produced by CMS, as well as conditions of participation requirements under the Title 42, Part 482, of the United States Code.
Quality and quality improvement are important to any healthcare organization because these principles allows organizations to fulfill their missions more effectively. Defining what quality is may differ depending on whom is asking the question, as differing participates may have differing ideas about what quality means and why it is important. Being that quality is what unites patients and healthcare organizations, we can see the importance of quality and the need for strong policies and practices that improve patient care and their experience while receiving that care. Giannini (2015) states that this dualistic approach to quality utilizes separate measurements, conformance quality that measures patient outcomes against a set standard and
The NHS Outcomes Framework has five standard domains which is set out to improve the quality and outcome of care and services that is being delivered to the patients and service users (National Quality Board, 2011). As such, this project plan is focused on domain 2 as it has been mentioned before, is based on improving the quality of people with long term conditions. Nurses will give cardiac discharge advice to patients on self care, thus identifying how to improve and manage their condition so that they can continue with their normal lifestyle. Furthermore patients will be advised on how to overcome stress and depression which will help them in maintaining the activities of living (DoH, 2013).
The standards of the Joint Commission are a foundation for an objective evaluation process the may help healthcare organizations measure, assess and improve performance. These standards are focused on organizational functions that are key for providing safe high quality care services. The Joint Commission’s standards set goal expectations of reasonable, achievable and surveyable performance of an organization. Only new standards that are relative to patient safety or care quality, have positive impact on healthcare outcomes, and can be accurately measured are added. Input from healthcare professionals, providers, experts, consumers and government agencies develop these standards.
...n of Healthcare Organizations (JCAHO), and the American Medical Accreditation Program (AMAP), just to name a couple. Each of the accrediting bodies is unique in terms of their mission, activities, compositions of their boards, and organizational histories, and each develops their own accreditation process and programs and sets their own accreditation standards. . "Accreditation of a health care facility or program is a symbol of quality, similar to the Good Housekeeping Seal of Approval that indicates to the public that the organization or program has met certain standards." (Goode, 2001) The accreditation proves that healthcare facility underwent the accreditation process and met all of the necessary requirements to become qualified. Accreditation has been generally viewed as a desirable process to establish standards and work toward achieving higher quality care.
Introduction Cost-effectiveness analysis (CEA) is a form of economic analysis that compares the relative costs and outcomes/effects of two or more scenarios. The CEA is typically expressed as a ratio, where the denominator is a gain in health using a natural unit of measurement (years of life, cases of flu prevented, etc.). and the numerator is the cost associated with that health gain. Most clinical studies express gains in health in terms of disease-specific measures, such as number of heart attacks avoided or cases of influenza prevented. Although this is useful for particular treatments related to those health conditions, those measures do not allow for comparison across diseases.
Understanding quality measurement is essential in improving quality. Teams need to be able to understand whether the changes being made are actually leading to improved care and improved outcomes. For data to have an impact on an improvement initiative, providers and staff must understand it, trust it, and use it. Health care organization must understand the measurement of quality provided by the Institute of Medicine (patient outcomes, patient satisfaction, compliance, efficiency, safe, timely, patient centered, and equitable. An organization cannot improve its performance if it does not know how it is performing. Measuring quality improvements is essential as it reflects the quality of care given by the providers and that by comparing performance