Integrating Quality Management into Case Management: A Reflective Review

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BY VIVIAN GREENWAY, PhD, MSA, BSN, RN, PAHM, CCM, AND SAJINI PAUL, MSN, RN

When defining quality management, one can think of it as overseeing all activities and tasks that must be done to support a desired level of excellence. This includes the determination of quality policies, creating and implementing quality planning and assurance, in addition to quality control and quality improvement. Quality management, typically referred to as QM, is the process of evaluating quality across the whole of an organization and in doing so, identifying process improvements. The process involves setting goals, identifying where these goals are not being met and adjusting where it is relevant. Quality is a concept in which a healthcare professional desires the most optimal outcome for what is being produced. Excellence is a critical component for which all in the healthcare arena should strive to incorporate. This is to ensure the individual being cared for receives the best care possible in the most affordable, economic way. Effective care strives to use the least number of resources by all involved to achieve the desired process. When you think of quality management, it is a process in which a level of excellence in managing care should occur. According to Seelbach & Brannan (2023), the goal of the healthcare system is to provide care from a qualified provider in an appropriate setting for a particular individual which results in the individual receiving the best possible care (i.e., standard of care based on evidence-based medicine).

History

It is important to take a look at QM from a historical lens to see where its origins derived. It would be an arduous task to pinpoint its first inception; however, the following provides a degree of an overview. In viewing quality management from a nursing perspective, the concept of quality improvement was present as early as the 1850s, when Florence Nightingale, the founder of modern nursing, worked diligently to reduce death rates while organizing care for those in the Crimean War (Karimi & Masoudi Alavi, 2015). Known as the “Lady with the Lamp,” Nightingale’s efforts to improve healthcare set a resounding presence in the work force. She was a pioneer, and her work in nursing favored a systemic approach (McDonald, 2001). In addition to the endeavors brought forth by Florence Nightingale, there are other entities that contributed to the history of quality management. One of the most recent initiatives is the National Strategy for Quality Improvement in Health Care, also known as the National Quality Strategy. This strategy was established to address levels of disconnect between healthcare costs and outcomes in the United States. The 2010 Affordable Care Act required the Secretary of Health and Human Services to establish this strategy (ACA, 2024). The National Committee for Quality Assurance (NCQA) began in the early 1990s by measuring and then accrediting health plans. Since 2008, NCQA’s mission has brought them closer to care delivery, and they have also grown to measure the quality of medical providers and practices (NCQA, 2024). All of the entities described have a purpose, which is to improve healthcare as it relates to quality. In addition, there are a plethora of organizations that also address quality management across the continuum of care, and this article focuses on quality improvement aspects from a payer perspective.

Intersecting with Case Management

To achieve excellence in healthcare, quality management should be an integral part of the process. Focusing on individualized care from a qualitative perspective can assist in improving patient outcomes and increase efficiency in care within the healthcare arena. The National Quality Strategy has six priorities: 1) Making care safer by reducing harm caused in delivery of care; 2) Ensuring that each person and family is engaged as partners in their care; 3) Promoting effective communication and coordination of care; 4) Promoting the most effective prevention and treatment practices for the leading causes of mortality; 5) Working with communities to promote wide use of best practices to enable healthy living; 6) Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new healthcare delivery models (CMS, 2024).

Quality management intersects with case management to incorporate several key functions: promoting patient autonomy, enhancing quality of care, optimizing cost effectiveness, personalizing patient-centered care coordination and ensuring the efficiency of resource utilization. There are seven important principles of quality management: customer focus, leadership, engagement of individuals, process approach implementation, continuous improvement, evidence-based decision making and relationship management (Seelbach & Brannan, 2023). In order for the process of QM to evolve, it is imperative that quality managers be rational decision makers while possessing analytical and communication skills.

Day to Day Operations and Opportunities

In a typical health insurance or payer organizational structure, there is usually a quality management department that ensures the organization adheres to certain standards set by a reputable agency like NCQA or Utilization Review Accreditation Commission (URAC). There may also be some regulatory requirements set by state or federal agencies like the Department of Health & Human Services (DHHS), Centers for Medicare & Medicaid Services (CMS), etc. There may be some standards or outcomes that the organization itself wants to achieve as a quality indicator. There may be several departments within an organization that deal with various aspects of quality management. Each department may look at quality differently and may not be aware of how it is perceived by the other. Often this may lead to duplication of work, confusion among associates and additional administrative burden and subsequently increased cost to beneficiaries.

According to John Hopkins Medicine, there are four types of quality improvement metrics: structure, process, outcome, and balance (Quality Improvement | Johns Hopkins Medicine). In the managed care setting, quality improvement can be viewed as referring to the quality of work, for example how well a case manager completed an assessment. Quality improvement can be measured as compliance with regulations, for example compliance with NCQA or CMS guidelines. It can also be viewed as how well an individual achieved certain outcomes, such as reduced mortality rate or improved compliance with medications.

Quality management may be viewed as functions that are siloed into the QM department rather than being integrated into all branches of organization. For example, there are quality aspects that may affect a payer/ insurance arena like case management, utilization management, credentialing department as well as the quality management department. Often it may be difficult to find healthcare professionals who understand the various aspects of work which are incorporated into QM. In order to achieve a better outcome for the individuals being served, this concept must change.

According to Solomons and Spross (2011), barriers to evidence-based practice adoption occur at the individual and institutional levels. The clinical professionals are expected to know quality standards and measurements, but there is no mandatory requirement about keeping up with these standards and requirements during their later years of career. There may also be a lack of or limited incorporation of quality principles or processes into the professional training for healthcare workers. Having searched professional nursing schools and their curricula for graduate-level training and a common theme, it is noted is that courses/certifications dedicated to QM are limited (University of Phoenix and Walden University: BSN courses).

Certification renewals for each state can vary, especially for mandatory continuing education requirements. In the health insurance industry, healthcare professionals may lack the resources and support needed to interpret the requirements that govern their practice. As previously discussed, there are a plethora of regulations and standards that may play a role in how they will be scored in the quality metrics. A lack of uniformity in the standards set by different regulatory agencies itself may be confusing to professionals. A young professional who may be well trained in the delivery of clinical care may lack the basic knowledge or understanding of quality metrics or regulatory requirements that affect their practice. This in turn will require organizations to hire and provide onsite training to the professionals regarding quality management principles and requirements. Typically, what has been experienced in the past involves professionals becoming overwhelmed with paramount information and may choose to leave the QM work environment. Others who continue to stay may feel frustration, burnout and job dissatisfaction. It is imperative that all is done to eradicate barriers and ensure retention is placed at the forefront.

Strategies

It is noted that quality management should be integrated into all aspects of healthcare organization rather than isolated into a department function. According to Comfere, Matulis and O’Horo (2020), “educating clinicians in effective quality improvement techniques is critical to the future of healthcare.” Training and education of professionals about the principles and framework of quality management should start as early as possible in their career journey. It is advisable to incorporate regular in-service education and succession planning for professionals involved in quality management and case management, especially updating the guidelines and regulatory changes. Succession planning is an important aspect as it will assist in preparing upcoming young healthcare professionals to learn and glean from those who have already paved the way. Healthcare education should be utilized to promote QM as a part of its curriculum and interpersonal collaboration efforts (Seelbach & Brannan, 2023).

Advantages of managed care as it relates to quality management include being able to collaborate with various healthcare disciplines to move the process across the continuum. Organizations may also need to adopt more creative and innovative ways to keep up with the ever-changing aspects of quality management. In their experience at Mayo Clinic, the authors describe adopting a blended approach to QM (Comfere, Matulis and O’Horo, 2020). Even though in its early stage, a recent trend in healthcare industry involves augmented intelligence (AI). AI tools can be used to improve patient outcomes by enhancing the knowledge and competencies of clinicians (Simmon-Fields, 2024). In our experience, AI tools may not replace the clinical expertise and critical thinking in its entirety, but organizations may leverage this innovative technology to overcome the confusion caused by constant regulatory changes.

Summary

In conclusion, quality management and case management cannot be compartmentalized to only one healthcare establishment or department. The traditional way of looking at QM and CM may not fit all; therefore, the organizations need to evolve and find innovative ways to incorporate QM in their workflow. This process change needs to start from a grassroots level of training and education to all aspects of the establishment. A primary focus of QM in healthcare is continuous improvement for individuals involved in the process. Quality management should continue to focus on delivering quality outcomes and ensuring patient safety while meeting standards which are essential for high-quality care. It should also strive to ensure compliance standards are met. As efforts to improve in the field of healthcare continue, there is an identified need to ensure those attempts are expanded for years to come.

References

Affordable care act (ACA). Retrieved from website on 3.24.2024. https://www.healthcare.gov/glossary/affordable-care-act/

Centers for Medicare & Medicaid Services. CMS national quality strategy. Retrieved from website on 2/18/24. https://www.cms.gov/medicare/quality/meaningful-measures-initiative/cms-quality-strategy#:~:text=The%20CMS%20National%20Quality%20Strategy%20focuses%20on%20a%20person%2Dcentric,Medicare%20Advantage%2C%20Medicaid%20and%20Children’s

Comfere, N. I., Matulis, J.C. 3rd, O’Horo, J.C. Quality improvement and healthcare: The Mayo Clinic quality academy experience. J Clin Tuberc Other Mycobact Dis. 2020 Jun 13;20:100170. doi: 10.1016/j.jctube.2020.100170. Erratum in: J Clin Tuberc Other Mycobact Dis. 2021 May 06;24:100242. doi: 10.1016/j.jctube.2021.100242. PMID: 32596515; PMCID: PMC7306605.

Johns Hopkins Medicine (2024). Quality improvement. www.hopkinsmedicine.org/nursing/center-nursing-inquiry/nursing-inquiry/quality-improvement#QI-Definition

Karimi, H., Masoudi Alavi, N. Florence Nightingale: The mother of nursing. Nurs Midwifery Stud. 2015 Jun;4(2):e29475. doi: 10.17795/nmsjournal29475. Epub 2015 Jun 27. PMID: 26339672; PMCID: PMC4557413.

McDonald, L. Florence Nightingale and the early origins of evidence-based nursing. Evid Based Nurs. 2001; Jul; 4(3); 68-9. [PubMed]

NCQA. About NCQA. Retrieved from website on 2/18/24. https://www.ncqa.org/about-ncqa/.

Seelbach, CL; Brannan, GD. Quality Management [Updated 2023, Mar 6] In: StatPearls [Internet], Treasure Island (FL): StatPearls Publishing; 2024 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557505/

Simmons-Fields, L. (2024). Leveraging augmented intelligence to support population health initiatives. CMSA Today. WWW.CMSA.Org, Issue( 4)15-16

Solomons, N. M., & Spross, J. A. (2011). Evidence-based practice barriers and facilitators from a continuous quality improvement perspective: An integrative review. Journal of Nursing Management – Wiley Online Library https://onlinelibrary.wiley.com/doi/10.1111/j.1365-2834.2010.01144.x

Vivian Greenway, PhD, MSA, BSN, RN, PAHM, CCM, has over 30 years of clinical experience in the acute care and managed care environment with emphasis on clinical education and quality management. Over the years, she has worked in leadership and project management positions within healthcare specializing in management of health promotion, disease management and provider education activities. In her current role, she organizes and coordinates activities to ensure full compliance with regulatory and licensing agencies and employer groups relative to medical management activities, including accreditation site surveys and regulatory reviews.

Dr. Greenway was the recipient of the 2023 Distinguished Alumni for Nursing Excellence award at Oakland University’s 35th Annual Nightingale Awards. The award is presented to a nurse who is a graduate of the School of Nursing and is making meaningful contributions to the field as well as demonstrating the high standards of clinical competence and leadership characteristics emphasized by the university. She currently serves on the Board of Directors for CMSA National.

In the current position as manager of quality and accreditation for a health plan, Sajini Paul, RN, MSN, focuses on accreditation activities and quality improvement initiatives for the health plan. Paul works with case management, utilization management and credentialing departments to ensure quality standards are met based on the NCQA guidelines and other regulatory requirements.

Paul has over 20 years of nursing as clinical staff, charge nurse, preceptor and nursing educator. Clinical specialties include medical surgical, telemetry, long term critical care and intensive care unit. She has also worked in quality management for health systems as a sepsis coordinator, stroke coordinator and performance improvement coordinator.

She completed her bachelor’s in nursing from India and completed her RN from Tennessee, United States. She obtained her masters in nursing informatics from Walden University.

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