Payment for Healthcare Services Assignment

Payment for Healthcare Services Assignment

in t r O d u c t i O n Just like the case with leadership, a single chapter on quality only scratches the surface. However, quality, safety, patient experience, and value must be included in a strategic plan. Payment for healthcare services has shifted to emphasize shared risk (between payers and providers), value (higher quality for a lower cost), and financial consequences for hospital- acquired conditions (infections, readmissions, and medical errors). Healthcare executives must be able to speak the language to clinicians and know when to involve them in the planning process. This chapter will address the fundamentals of quality management and the shift to pay-for-performance (P4P) programs.

 

Avedis Donabedian, a physician considered the father of quality assurance in healthcare, defined quality as a reflection of the goals and values currently adhered to in the medical care system and the society in which it exists (Donabedian 1966). This definition signi- fies that no one common criterion exists on which to measure healthcare quality. For this reason, he introduced the Donabedian framework, a model for evaluating the quality of medical care according to three criteria: structure, process, and outcomes.

 

Structure includes the environment in which healthcare is delivered (e.g., for-profit or not-for-profit, health system or freestanding hospital), the instruments and equipment that providers use, administrative processes, the qualifications of the medical staff, and the fiscal organization of the institution. Access to care may also be considered part of the structure.

 

Process considers how care is delivered. For example, healthcare quality could be evaluated according to the appropriateness and completeness of information obtained through a review of a patient’s clinical history, physical examinations, and diagnostic tests. Other components of quality could include the provider’s explanation of a patient’s diag- nosis and recommended therapy and the physician’s technical competence in performing diagnostic and therapeutic procedures, including surgery. Still other components include evidence of preventive management in health and illness; coordination and continuity of

outcomes.

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Harrison, Jeffrey P.. Essentials of Strategic Planning in Healthcare, Third Edition, Health Administration Press, 2020. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=6349384. Created from apus on 2022-03-25 01:06:10.

 

C h a p t e r 1 2 : Q u a l i t y , S a f e t y , P a t i e n t E x p e r i e n c e , a n d V a l u e 2 5 9

 

care; and acceptability of the care to the patient (Donabedian 1966). The use of the latest research on evidence-based practice is another process indicator. By studying the process indicators of quality, healthcare organizations can assess whether medicine was practiced appropriately and whether it addressed the patient’s needs.

 

Outcomes, the most discussed measure of quality, include recovery, restoration of function, and survival. National organizations such as the Centers for Medicare & Med- icaid Services (CMS), the Joint Commission, and the National Association for Healthcare Quality typically publish, using national standards, the outcome measures that hospitals are expected to report. Some of the most important outcomes are mortality, safety of care, readmissions, and patient experience. The so-called triple aim approach, as presented by the Institute of Healthcare Improvement (IHI), focuses on the outcomes of improving the patient experience of care, the health of populations, and reducing the per capita cost of healthcare (Tinker 2018).

 

To provide the best quality of care, health organizations need to meet the three quality criteria: structure, process, and outcomes. As described above, each criterion influ- ences the others. For example, a patient with a broken bone needs access to a qualified physician and an appropriate facility for treatment, and the care the individual receives should meet preestablished standards. A positive outcome of healing with no complications after treatment is expected but should also be measured. If that outcome is not achieved, then the organization needs to examine its structure (qualifications and experience of the physician and facility) and its processes (whether standards were followed). If any one of these criteria is lacking, the others are negatively affected, and the organization has failed to provide optimum quality of care.

 

d e f i n i n g Q u a L i t y

 

The most widely accepted definition of healthcare quality comes from the Institute of Medicine (IOM). In its landmark book Crossing the Quality Chasm, the institute says that quality is “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (IOM 2001). The IOM goes on to identify the key characteristics of quality care: safe, effective, patient centered, timely, efficient, and equitable. These features are designed to guide organizations, providers, and administrators around the priorities of quality and safety. Spath (2017) points out that patient safety is a key component of quality management in and of itself. Patient safety has been defined by the Agency for Healthcare Research and Quality (AHRQ 2020) as “freedom from accidental or preventable injuries produced by medical care.”

 

Even with these definitions, quality tends to be subjective and is open to individual interpretation. This subjectivity makes measuring quality no easy task. While scholars agree on some of the underlying problems affecting quality in healthcare, they differ dramatically

 

 

Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com

 

Harrison, Jeffrey P.. Essentials of Strategic Planning in Healthcare, Third Edition, Health Administration Press, 2020. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=6349384. Created from apus on 2022-03-25 01:06:10.

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