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Quality Improvement Organizations

Essay by   •  March 8, 2012  •  Research Paper  •  1,123 Words (5 Pages)  •  1,671 Views

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As the health care system continues to grow, American health care organizations began to gain a competitive edge and started to adopt total quality management (TQM) in order to eliminate waste, ultimately improving efficiency and reducing variation. External quality improvement is defined as "the evaluation of a health care organization's performance or a physician by an outside or external body." Some of these external review systems can be assigned on a mandatory basis, while others are solely voluntary in nature. At the same time, some systems are confidential whereas some are open to public scrutiny. Ultimately, their goals are to review, assess, and give rank to health care organizations based on standards and measurements; some resulting to significant financial gains or losses. Specifically, the National Committee for Quality Assurance (NCQA), Utilization Review Accreditation Commission (URAC), and the Joint Commission are organizations that assess quality and can make the decision or gains or losses in these health care organizations (Varkey, 2010).

The National Committee for Quality Assurance is a nonprofit organization that is committed to improving the quality of health care. Founded in 1990, it has been the main outline in implementing progression within all health care systems. Doing this, helps to raise the issue of the quality in health care as a first priority of the national agenda. By working with large employers, policy makers, doctors, and patients to help build a consensus based on the importance of health quality, the NCQA will decide what exactly is important, how it can be measured and then finding ways to promote improvement. Programs and services of NCQA mirror a clear-cut formula when measuring improvement: Measure, Analyze. Improve. Repeat (About NCQA, 2011). An example a tool would be HEDIS. It is created to allow consumers and purchasers with information needed to be able to depend on the comparison of health insurance plans. Health issuers measure include, breast cancer screening, childhood immunization status, childhood and adult BMI assessment, antidepressant medication management, controlling of high blood pressure, asthma medication use and comprehensive diabetes care. Included, is a survey which measures satisfaction within its members with its care in certain areas such as quickly getting needed care, claims processing and customer service (What is HEDIS, 2011).

The NCQA measures quality care in the form of statistics that follow the quality of care given based on health care plans. These numbers have been improving for the past five years. Doctors have learned a variety of new ways to practice, health care procedures have been enhanced, and patients receiving treatment have become more engaged. All of these improvements have transformed into lives being saved. For example, as extra individuals receive beta blockers after a heart attack, the chance of experiencing a second heart attack have dropped up to 40% (About NCQA, 2011).

As the health care industry continued to grow there was need utilization review (UR). UR is a procedure that determines whether or not health care services are medically necessary for an insured individual or a particular patient. As a result, URAC was formed. At first, their mission was to utilize UR programs to improve accountability and quality, but in years to come, their mission expanded to cover a much greater range or services. URAC is a nonprofit organization which is renowned as a leader in endorsing health care quality through measurement programs, education and accreditation. URAC proposes a variety of benchmarking programs which are offered to keep up with the constant changes occurring in the health care system, and gives their own symbol of excellence to verify a promise to accountability and quality. URAC's mission is to, "To promote continuous improvement in the quality and efficiency of health care management through processes of

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