Quality indicators

The Centers for Medicare & Medicaid Services (CMS) is a federal agency within the U.S. Department of Health and Human Services. The CMS uses Clinical Quality Measures, or CQMs to ensure that health care systems deliver effective, safe, efficient, patient-centered, equitable, and timely care. Clinical quality measures, or CQMs, are tools that help measure and track the quality of health care services provided. These measures use data associated with providers’ ability to deliver high-quality care or relate to long term goals for quality health care. CQMs measure many aspects of patient care including:

• health outcomes
• clinical processes
• patient safety
• efficient use of health care resources
• care coordination
• patient engagements
• population and public health
• adherence to clinical guidelines

The Utilization Review Accreditation Commission (URAC) believes that effective case management puts the consumer at the center of all health care decisions and is an essential driver to ensuring that consumers get the right care, in the right setting, at the right time. URAC’s Case Management accreditation allows for the application of case management standards across all health care settings such as medical and social case management, behavioral health providers, hospital case management, disability and workers’ compensation case management, and emerging practices.

URAC’s case management standards cover:

• Scope of services standard; types of clients served, delivery model for case management services, qualifications for case management staff.
• Case management staff standard; guidelines for caseload, availability of physician for consultation, a process for training and education of case managers.
• Case management process standard; criteria for identifying clients for case management services, disclosure to clients the nature or the case management relationship, documentation of consent, policies to document patient assessments, policy for resolving disagreements, criteria for discharge.
• Organizational ethics and confidentiality standard; policy and procedure to protect confidentiality, promotion of autonomy of decision making, patient input into the case management plan, respecting rights of patient to refuse treatment or services.
• Complaints standard; policies and procedures for patients and providers to submit a complaint.

NCQA’s Case Management Accreditation is a comprehensive, evidence-based accreditation program dedicated to quality improvement that can be used for case management programs in provider, payer or community-based organizations.
NCQA’s Case Management Accreditation:

• Directly addresses how case management services are delivered, not just the organization’s internal administrative processes.
• Gets right to the core of care coordination and quality of care.
• Is designed for a wide variety of organizations. It is appropriate for health plans, providers, population health management organizations, and community-based case management organizations.
• focuses on ensuring the organization has a process to ensure safe transitions.

The standards address how case management programs:

• Identify people who are in need of case management services;
• Target the right services to people and monitor their care and needs over time.
• Develop personalized, patient-centered care plans;
• Monitor people to ensure care plan goals are reached and to make adjustments as needed;
• Manage communication among providers and share information effectively as people move between care settings, especially when there are transitions from institutional settings;
• Build in consumer protections to ensure people have access to knowledgeable, well-qualified case management staff;
• Keep personal health information safe and secure.

NCQA standards also call for case management program staff to stay up to date on the latest evidence and care management techniques and work towards continuous improvement in patient outcomes and satisfaction.

AHRQ’s mission is to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable, and to work with the U.S. Department of Health and Human Services (HHS) and other partners to make sure that the evidence is understood and used.
AHRQ’s priority areas of focus are:

• Improve health care quality by accelerating implementation of patient centered outcomes research
• Increase accessibility to health care
• Improve health care affordability, efficiency, and cost transparency
• Make health care safer:

          -Prevent healthcare associated infections
          -Accelerate patient safety improvement in hospitals
          -Reduce harm associated with obstetrical care
          -Improve safety and reduce medical liability
          -Accelerate patient safety improvements in nursing homes

resources:
http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/ClinicalQualityMeasures.html
http://www.ncqa.org/Programs/Accreditation/CaseManagementCM.aspx
http://www.qualityforum.org
http://www.ahrq.gov/about/index.html