dards of quality in terms of both processes and outcomes of care

  • Subject to formal accreditation processes that include use of standard quality measures Health Plan Employer Data and Information Set (HEDIS) and member survey data Consumer Assessment of Health Plans (CAHPS)

  • Responsible for implementing clinical guidelines and designing disease management programs

  • Able to use a variety of financial and other incentive systems to alter clinician behavior

Medical Groups:

  • Able to enforce clinical guidelines and policies

  • Able to select group members on the basis of compatible practice styles

  • Able to maintain medical records systems, registries, and other sorts of data systems used to measure quality of care

  • Able to design and implement compensation systems that reward quality

From the perspective of the purchaser, responsibility for assessing and improving quality of care has largely been delegated to health plans and hospitals. For health plans, requirements for National Committee for Quality Assurance accreditation and comparison using HEDIS measures and CAHPS results represent methods by which purchasers attempt to improve quality of care. For hospitals, more recent initiatives by the Leapfrog Group and other purchasers have focused on technologies such as electronic order entry for pharmacies or the “volume-outcome relationship” to improve quality in inpatient settings. Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accreditation requires that a “cultural assessment” be conducted in the context of patient and family education to ensure that social, ethnic, cultural, and emotional factors are considered in providing patient care (JCAHO, 1999). Medical groups have not been as directly engaged as agents for quality improvement, except perhaps in examples like the Buyers Health Care Action Group in the Minneapolis/ St. Paul area, where a “direct contracting” model has been used to try to manage both cost and quality (Buyers Health Care Action Group, 2002).

When these types of organizations engage in quality improvement activities, it is generally presumed that they have the necessary clinical, administrative, and patient demographic information to create effective programs and monitor outcomes. Health plans working to improve breast cancer screening rates, for example, are presumed to have information that will enable them to identify women over the age of 50 who either have or have not had a mammogram during a certain time period. Hospitals working to improve use of beta-blockers after acute myocardial infarction are

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