PCPI- Physician Consortium for Performance Improvement
It is a national, physician-led initiative dedicated to improving patient health and safety by:
1) Identifying and developing evidence-based clinical performance measures and measurement resources that enhance the quality of patient care and foster accountability
2) Promoting the implementation of effective and relevant clinical performance improvement activities.
3) Advancing the science of clinical performance measurement and improvement NQF- National Quality forum
It is a not-for-profit, nonpartisan, membership-based organization that works to catalyze improvements in healthcare. NQF measures and standards serve as a critically important foundation for initiatives to enhance
…show more content…
Physicians retain separate offices and finances. Often a central site is established to house administrative services and some or all ancillary services.
PHO- Physician-Hospital Organization
It is a union formed between physicians and hospitals to help healthcare service providers attain market share, improve bargaining power and reduce administrative costs. These entities sell their services to managed care organizations, or directly to organizational employers.
IPA- Independent Physician Association
It is a legal entity organized and directed by physicians in private practice to negotiate contracts with insurance companies on their behalf. Participating physicians are usually paid on a capitated or modified fee-for-service basis and may also continue to care for patients not covered by the insurers with whom the IPA contracts. Perhaps the most significant function of an IPA is to exert influence on behalf of its members to counterbalance the leverage of health care insurers.
EPO-Exclusive Provider Organization
It is a managed care plan where services are covered only if you go to doctors, specialists, or hospitals in the plan’s network (except in an emergency).
COB-Coordination of
…show more content…
A variation in the calculation of ALOS can be to consider only length of stay during the period under analysis. It is useful to be able to predict an individual's expected length of stay or to model length of stay to determine factors that affect it.
ADC-Average Daily Census
This refers to the average number of patients in the facility per day. It is derived by dividing the number of patient days for the year by the number of days the facility was open during the year. LTAC-Long-term acute care
It is type of facility specializing in treating patients requiring extended hospitalization. Traditionally, LTACHs provide care for patients receiving prolonged mechanical ventilation. LTACHs have a diverse set of characteristics which influence the ways in which they operate. Physically, LTACHs exist in two models, hospital within hospital or free-standing. Hospital within hospital LTACHs are physically located inside of a short term acute care hospital and often look similar to a separated unit of the hospital. Free-standing LTACHs are LTACHs in separate buildings from short term acute care hospitals. LTACHs can be non-profit or for profit. They also can be associated with a health care system, post-acute care system, or a system of
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
The health care organization with which I am familiar and involved is Kaiser Permanente where I work as an Emergency Room Registered Nurse and later promoted to management. Kaiser Permanente was founded in 1945, is the nation’s largest not-for-profit health plan, serving 9.1 million members, with headquarters in Oakland, California. At Kaiser Permanente, physicians are responsible for medical decisions, continuously developing and refining medical practices to ensure that care is delivered in the most effective manner possible. Kaiser Permanente combines a nonprofit insurance plan with its own hospitals and clinics, is the kind of holistic health system that President Obama’s health care law encourages. It still operates in a half-dozen states from Maryland to Hawaii and is looking to expand...
What is managed care? According to the Oxford English Dictionary, managed care is “a system of health care in which patients agree to visit only certain doctors and hospitals, and in which the cost of treatment is monitored by a managing company.” Managed care is a variety of techniques designed to reduce the cost of providing health benefits and advance the quality of care. In the United States alone, there are various managed care programs, that are ranged from more restrictive to less restrictive. As stated in the National Institutes of Health, the future of managed care is uncertain. It is enthralling to note that in spite of the advances in healthcare systems, such as our hospital’s ability to provide patients with lower cost, managed
When one examines managed health care and the hospitals that provide the care, a degree of variation is found in the treatment and care of their patients. This variation can be between hospitals or even between physicians within a health care network. For managed care companies the variation may be beneficial. This may provide them with opportunities to save money when it comes to paying for their policy holder’s care, however this large variation may also be detrimental to the insurance company. This would fall into the category of management of utilization, if hospitals and managed care organizations can control treatment utilization, they can control premium costs for both themselves and their customers (Rodwin 1996). If health care organizations can implement prevention as a way to warrant good health with their consumers, insurance companies can also illuminate unnecessary health care. These are just a few examples of how the health care industry can help benefit their patients, but that does not mean every issue involving physician over utilization or quality of care is erased because there is a management mechanism set in place.
For patients requiring longer acute care than what is generally given at an inpatient acute care hospital, The Long Term Acute Care Hospital is an option. To be admitted to an LTACH, patients are required to have “medically complex situations with a mean length of stay > 25 days” (Munoz-Price, 2009, p. 438 ). Examples of patients with complex acute care needs are those with multiple comorbidities who need mechanical ventilator weaning, administration of intravenous antibiotics, and those with complex wound care (Munoz-Price, 2009, p. 438). According to Landon Horton, CNO of Select Specialty Hospital in Fort Smith, Arkansas, “The services provided by LTACH facilities allow the patients to get home who would not otherwise, have a higher level of functioning at discharge, and increase their quality of life” (personal communication, March 7, 2014).
The Centers for Medicare and Medicaid Services (CMS) have recently begun requiring hospitals to report to the public how they are doing on patient care. Brown, Donaldson and Storer Brown (2008) introduce and explain how facilities can use quartile dashboards to transform large amounts of data into easy to read and understandable tool to be used for reporting as well as to determine areas in need of improvement. By looking at a sample dashboard for an inpatient rehab unit a greater understanding of dashboards and their benefits can be seen. The sample dashboard includes four general areas, including nurse sensitive service line/unit specific indicators, general indicators, patient satisfaction survey indicators and NDNQI data. The overall performance was found to improve over time. There were areas with greater improvement such as length of stay, than others including RN care hours and pressure ulcers. The areas of pressure ulcers and falls did worse the final quarter and can be grouped under the general heading of patient centered nursing care. The area of patient satisfaction saw a steady improvement over the first three quarters only to report the worst numbers the final quarter. A facility then takes the data gathered and uses it to form nursing plan...
The overall goal of performance management is to ensure that an organization and its subsystems (processes, departments, teams, etc.), are optimally working together to achieve the results desired by the organization. Performance management has a wide variety of applications including measuring the leader performance, such as, staff performance, business performance, or in health care, health outcome performance measures. To manage and measure performance of leaders are directed to the organizational strategic goals and mission. The primary reason to measure and manage performance of leaders is to drive quality improvement. The Clinical performance of a leader are derived from evidence-based clinical guidelines and measurement allows an evaluation of an important outcome of care for patients, and it is a proxy to understand the effectiveness of the underlying systems of care. Just as there are evidence-based care guidelines for many conditions, there also are established measures that indicate how leaders has effectively guidelines and has translated to
At its most fundamental core, quality improvement of healthcare services and resources requires disciplined attention to the measurement, monitoring, and reporting of system performance (Drake, Harris, Watson, & Pohlner, 2011; Jones, 2010; Kennedy, Caselli, & Berry, 2011). Research points to performance measurement as a significant factor in enabling strategic planning processes and achievement of performance goals (Tapinos, Dyson & Meadows, 2005). Thus, without a system of measurement that accounts for the performance behaviors of healthcare professionals, managers and administrative employees, quality improvement remains a visionary abstraction (de Waal, 2004).
In conclusion, managed care integrates the functions of financing, insurance, delivery, and payment within an organization. It also exercises formal control over utilization. Managed care is viewed as accepting the lowest competitive bid for services rendered. Today, HMOs and PPOs are the most common and widely used models for managed care. Although managed care is here to stay, it requires revision in some areas. Challenges that are to be faced include double agentry, fidelity, confidentiality, honesty, and vulnerability. With the help and guidance of health information professionals, managed care will continue to escalade and become better for all.
practice, physicians share patient duties and the physical office space. This is the second most
The rapid growth of managed care is the response to limited financial resources and the demand for healthcare services to be affordable. Economic viability is a crucial aspect of health care. Managed care plans were developed to provided health care services, but also to be a method to collect payment for services. There are different types of managed care plans. For example, health maintenance organization (HMO), preferred provider organization (PPO), and point-of-service (POS) plans. For brevity of this paper the HMO managed care system will be discussed along with the relevance of the role of the advance practitioner practicing in HMO setting.
... is an abstract model that proposes an exploratory plan for health services and evaluating quality of health care. In accordance with the model, information about quality of care can be obtained from three categories: structure, process, and outcomes. In addition, not long ago The Joint Commission include outcomes in its accreditation valuations (Sultz, & Young, 2011, p. 378).
Unfortunately, this era also witnessed tumor in the medical community as the American Medical Association (AMA) greatly opposed the prepaid plans of the early 1900s while favoring the indemnity- type insurance that reimbursed policyholders. Therefore with the pioneers of prepaid services encountering daring degrees of oppositions, a strategy to discourage such opposition led to the development of the early Independent practice associations (IPA) model HMO (Fox & Kongstvedt, 2015; Kongstvedt, 2009).
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
The importance of Evidence-Based Practice is to ensure the best possible care is provided for patients. Evidence-Based Practice functions by measuring the effectiveness of a treatment and differentiating findings between high-quality and low-quality. It also helps with health development and improves the reliability and facilitates students to become reflecti...