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Quality in Healthcare
Quality in Healthcare
There are two things we can focus on when we talk about quality:
Quality Assurance
Quality Assurance
&
&
Quality Improvement
Quality Improvement
While they may seem the same, QA and QI are very different!
Quality Assurance
Quality Assurance
QA = Maintain
You reach a certain level that is exceptable
Than you try not to slip below it
Example: Benchmark
Quality Improvement
Quality Improvement
QI = Continuous
Make changes that increase quality
You always seek to improve upon past performance
Example: Exceed the Benchmark and move the average
Quality Assurance
Quality Assurance
Individual focused
Perfection myth
Solo practitioners
Peer review ignored
Errors punished
Quality Improvement
Quality Improvement
Systems focused
Fallibility recognized
Teamwork
Peer review valued
Errors seen as opportunities for learning
Quality Improvement seeks to:
Quality Improvement seeks to:
Standardize processes
Structure to reduce variation
Achieve predictable results
Improve outcomes for patients, healthcare systems, and organizations
Quality in Healthcare
Quality in Healthcare
How do we deploy finite resources to maximize financial impact and document care quality?
How do we navigate the complexity of financial reporting, while avoiding the pursuit of unnecessary and wasteful gap closure activities?
What are we trying to accomplish?
What are we trying to accomplish?
How will we know that a change is an improvement?
How will we know that a change is an improvement?
What changes can we make that will result in improvement?
What changes can we make that will result in improvement?
HEDIS DATA:
HEDIS DATA:
HEDIS is a comprehensive set of standardized performance measures designed to provide purchasers and consumers with the information they need for reliable comparison of health plan performance.
HEDIS is a comprehensive set of standardized performance measures designed to provide purchasers and consumers with the information they need for reliable comparison of health plan performance.
Administrative Data
Administrative Data
Consists of claim or encounter data submitted to the health plan
Hybrid Data
Hybrid Data
Requires reviews of a random sample of member medical records
To abstract data for services rendered but that were not reported to the health plan through claims/encounter data
How can I improve my HEDIS SCORE
How can I improve my HEDIS SCORE
1. Submit claim encounter for each and every service rendered
2. Make sure that chart documentation reflects all services billed
3. Bill (or report by encounter submission) for all delivered services, regardless of contract status
4. Ensure that all claim/encounter data is submitted in an accurate and timely manner
5. Consider including CPT II codes to provide additional details and reduce medical record requests
TWO Big Questions to Ask
TWO Big Questions to Ask
How do we deploy finite resources to maximize financial impact and document care quality?
How do we navigate the complexity of financial reporting, while avoiding the pursuit of unnecessary and wasteful gap closure activities?
Today’s health plans need to employ a Data-Driven Triad:
Today’s health plans need to employ a Data-Driven Triad:
Gap identification
Gap identification
Strategic intervention
Strategic intervention
Dynamic recalibration
Dynamic recalibration
Close Quality gaps with those aimed at Documentation and Coding
Close Quality gaps with those aimed at Documentation and Coding
to
Produce a coordinated road map that is:
Produce a coordinated road map that is:
More efficient for the plan
More efficient for the plan
Less disruptive to providers
Less disruptive to providers
More respectful of the members
More respectful of the members
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