Health Care Quality Management As It Applies To Managed Care Term Paper

Length: 10 pages Sources: 1+ Subject: Healthcare Type: Term Paper Paper: #98569284 Related Topics: Healthcare Policy, Healthcare Management, Quality Assurance, Health Care Provider
Excerpt from Term Paper :

Health Care Quality Management as it Applies to Managed Care

In the current age of improved answerability for quality of care, every healthcare expert should be conversant in the theory and paraphernalia of quality management) Quality Management-QM is an all-embracing attitude that pervades the management infrastructure, rules and customs of an establishment. It characteristically comprises of five fundamental doctrines -- undivided attention on the customer/supplier relationships; a stress on functional and care systems and the avoidance of mistakes; the use of decision making by the help of data; the willing participation of leaders and empowerment of the workforce; and an importance on persistently enhancing achievement in every spheres. (Carefoote, 1998) Managed care systems have come to be an important type of health care supply and funding in the United States.

Earlier, managed care comprised of health maintenance organization -- HMOs. The meaning of a managed care system thereafter broadened to contain nearly any type of healthcare insurance that restricts the person insuring the preference of health care providers and the person's capability to refer him to expert doctors. (Morgan, 1996) Managed care builds a business atmosphere wherein rivalry needs minute consideration to quality. Even though the health care business might profit from answers taken from other industries, managed care accords exclusive attention to non-financial, indefinable reasons. Sufficient cost-utility analysis should account for such reasons instead of depending on fake numerical values. (Reinke, 1995) The imperative for managed care delivery systems has been functioning by the wishes to restrict the expenses of health care. Companies and procurers of public sectors have shifted their attention to health plans to check spiraling expenses. (Rivera; Lee, 1999)

Managed Care put a significant effect on every feature of health care. (McLaughlin; Kaluzny, 1998) Of late the number of Americans getting health care by some type of managed care establishments has gone up in a big way. (Quality Measurement and Improvement in Managed Care) In excess of 50% of every U.S. workers and their insured family members have joined such programs and Medicaid and Medicare are speedily going ahead in that route. The first effect of managed care has been the falling of costs in the range of 30 to 60% in important markets, coupled with the opening of particular checks and measures like advance endorsement for optional methods and restrictions on duration of admission in the hospitals, privatization and merger of healthcare units with an attention on limited functioning results, wrath of doctors and doubtfulness; patients anxiety regarding quality; and bosses content with the sluggish progression of best incentives meant for their staff. (McLaughlin; Kaluzny, 1998)

The forthcoming confrontation to managed care is its capability to shift from merely the management of availability and the lowering of premiums to the substantive management of care with the complete identification of the intricacies of the care process. This changeover needs a reassessment of persistent quality improvement within the background of managed care. (McLaughlin; Kaluzny, 1998) Complete quality management is thus an objective which needs most important corporate dedication to execute and keep going. The ideal outcomes in the case of a quality management program will be attained while every element is bonded together in an all-inclusive program. To accomplish that, a substantial expense in workforce and instruments is needed. Since the advantages of maintaining a program comes to be extensively understood and welcomed, increasingly managed care insurers and providers will take up these or identical standards. (Dunn, 1990)

The issue is "How are you aware that patients are receiving superior-quality and enough care?" will not be able to be given a solution by the insurers who do not have a similar type of program. (Dunn, 1990) Since managed care permeates our health care atmosphere, efforts must be taken to make sure the quality of care is provided. An effective quality program possess the features as follows: Attaining increased quality is the duty of everybody and it is pertinent that the medical and administrative leadership take up the important job of making...


Responsibility for quality requires at the topmost levels in the organization. Whereas the main answerability is held by the Board of Directors, it is usually passed on to the medical and administrative leaders for the routine functions. Every managed care departments has a crossing point with the quality aspect to render quality an endeavor spanning throughout the company. Planning is crucial to guaranteeing that important goals are achieved and also every legal aspect and affiliation obligations have been complied with. (Carefoote, 1998)

The extent of quality program takes into account the medical care as well as the service. Medical care points out to the direct delivery of care by the doctors and the institutional providers like hospitals, long-term care services, home health units and so forth. Service quality means the existence, convenience and adequacy of services to the members. A complete program has medical as well as service quality securitization, assessment and betterment. Important to the achievement of the program is the capability to pull out and investigate the data, which relate to facilities and quality data. To make sure reliable, consistent customs in the company, the organization requires a procedure to interact specific program rules and methods. Ultimately, in the absence of sufficient resources, the organization can be deficient of attaining its goals. During the procedure of planning, the organization can be deficient of making sure resources are enough to fulfill the requirements of the program. (Carefoote, 1998)

Total Quality Management -TQM as well as managed care thus admits the vibrant characteristics of medical procedures and the potential and accountability of the two institutions and medicos to enhance their processes. The two are steady with endeavors to find out and carry out the ideal methods. (McLaughlin; Kaluzny, 1998) Berwick and associates in their pioneering achievement took the results of the National Demonstration Project on Quality Improvement in Healthcare and reasoned that TQM would effectively be employed in health care institutions. Margulies and Adams gave an example of a lot of contributors who have been fruitful as regards organizational betterment, interferences in an operating room, nursing facilities, division, and city hospital-clinical point and gave a positive investigation regarding the probabilities of achievement. His evaluation of the writings backs the encouraging outcomes of team building, management development, action research, clarification of functions, and organizational alterations in a broad range of health organizations. (Friedman; White, 1999)

But the basic dissimilarities must not be shrouded. Constant development must change its hub from preventing needless deviations to ease quick organizational training and institutionalizing mass customization into the process of health services. We all know that the ideal care takes into account disparities in each of us at both physical and emotional levels. In our capacity in attaining mass customization, lies the long-standing prospect of health care and not with the mass production or continuous improvement. It is hard to accomplish, though all health care are trying for it and mass customization is the endpoint. There are complications in the health care atmosphere that must be tackled. There is a truth that the technique of health care is a difficult, multistage process described as having at least three stages like analysis, cure and aftercare; At each phase for any given disease entity the fraction of art to science in the current state of-the-art may vary broadly; diverse forms of techniques react differently to dissimilar ratios of art to science; regrettably, we have not yet been able to efficiently modify the delivery method and its related methods of payment and organization to the state of knowledge for an exact disease at a particular stage of care delivery. (McLaughlin; Kaluzny, 1998)

These four features account for many of the troubles in successfully using any one-delivery method with its organization and payment systems to the total delivery of health care. Each instance offers a challenge to the art and science of medicine in analysis, in cure and in aftercare. These phases may be quite different in the degree to which the selected method has a powerful scientific foundation. The diagnosis may be quite instinctive, while the cure, if properly identified, may be quite simple, as is the choice of aftercare. (McLaughlin; Kaluzny, 1998) The main part of delivering patient care in a managed care atmosphere is the proficient organization of patient care delivery. Competent organization ropes particular patient effects that are appreciated within economically accountable and resourceful time frames. When both the order and the quantity of capital used are observed, constructive results are reached by proper use of resources. (Morgan, 1996)

Hospitals, in reaction to the requirement to advance competence, have applied domestic hard works to manage costs. The techniques that are used are the implementation of utilization review -UR processes, staff restructuring, personnel reductions, and case management. UR is made use of to evaluate the power of care the patient is getting. In particular, UR seeks to make sure that the care is both essential and proper. The objective of unit staff…

Sources Used in Documents:


Booth, Maureen. (January 6, 1997). "Protecting Quality under Medicaid Managed Care" Online Journal of Issues in Nursing. Available from Accessed on 28 November, 2004

Carefoote, Roberta L. (1998) "Managed Care and Quality Management" Available from Accessed on 28 November, 2004

Dunn R. (September, 1990) "Managed care: quality management differentiates the product" Top Health Rec Manage. Volume: 11; No: 1; pp: 25-31 Available from; db=PubMed& list_uids=10106985& dopt=Abstract Accessed on 28 November, 2004

Friedman, Leonard H; White, David B. (Autumn, 1999) "What Is Quality, Who Wants It, and Why?" Managed Care Quarterly. Available from Accessed on 28 November, 2004
Gold, Marsha; Wooldridge, Judith. (Summer, 1995) "Surveying consumer satisfaction to assess managed-care quality: current practices - New Initiatives and Approaches in Health Care Quality" Health Care financing Review. Available from Accessed on 28 November, 2004
Kelly, Diane L. "Applying Quality Management in Healthcare: A Process for Improvement." Available from Accessed on 28 November, 2004
McLaughlin, Curtis P; Kaluzny, Arnold D. (February 1998) "Managed Care: The Challenge Ahead" OR/MS Today. Available from Accessed on 28 November, 2004
"Quality Measurement and Improvement in Managed Care" Available from Accessed on 28 November, 2004
Rivera, Lourdes; Lee, Peter. (Jan 20, 1999) "Making Sense of Managed Care Quality Information" Available from Accessed on 28 November, 2004

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