Hurst, K. (2008), "Editorial", International Journal of Health Care Quality Assurance, Vol. 21 No. 3. https://doi.org/10.1108/ijhcqa.2008.06221caa.001
Emerald Group Publishing Limited
Copyright © 2008, Emerald Group Publishing Limited
Article Type: Editorial From: International Journal of Health Care Quality Assurance, Volume 21, Issue 3.
A steady flow of efficiency and effectiveness-focussed managed care articles in recent months prompts us to launch our third special issue. Managed care services are one-stop healthcare provider networks, such as health maintenance and preferred provider organisations (HMO and PPO). They look after patients usually for a fixed annual premium in return for loyalty and willingness to participate in prevention programmes as well as treatment and care. Financial control and service quality are equally important in these organisations. They also lean heavily towards practice regulation and shared risk taking. Even if managed care regulators keep service quality on the front burner and finances are not allowed to dominate then is there a risk that quality assurance (QA) gets lost in the managed care milieu? Like all healthcare services questions are posed regularly, which fall nicely into Maxwell’s six quality dimensions: access, relevance, effectiveness, fairness, acceptability, efficiency and economy. For example, under fairness we might ask if services equitably distributed? In short, the QA issues are immense and even our special issue may not be able to do the topic justice.
The sub-plots are the ways managed care organisations achieve efficiency (doing things right) and effectiveness (doing the right things). Articles are not run-of-the-mill (if managed care can be described as such) rather our authors have pushed back the frontiers and consequently generate new insights. For starters, Kristina Guo, one of our regular contributors and guest editors, provides a clear managed care account. Her article is not only an excellent scene-setter but also explains and critiques US managed care organisation quality assurance approaches and the list is impressive. She concentrates on five case studies best-practice organisations that underline the complexity and issues facing quality assurance managers and practitioners if not all stakeholders. It is clear from her article that service quality differences among US managed care organisations are staggering. Even the basics are problematic for example, if there are no standard quality definitions then measuring and more importantly benchmarking is harder. Nevertheless, if quality assurance managers and practitioners wish to learn from the best managed care services then Kristina’s article is an excellent starting point.
John Parnaby and Denis Towill follow-up an earlier seamless healthcare publication (Volume 19, Issue 4) which was written by Denis. We invited them to address supply chains in a managed care context since, theoretically, these organisations should be doing this well or at least exhibit several seamless care attributes. The authors explore traditional health service and managed care seamless care similarities and differences; notably organisational structures and process common to both ‘learning’ organisations. Perhaps the main difference is that traditional health service functional silos, epitomised by separate queuing (often for long waits in the past), in contrast to free-flowing managed care pipelines. The authors describe and illustrate several analytical and problem-solving approaches to overcome hold-ups in both service types.
Setting the Patwardhan duo’s business process re-engineering (BPR) critique in managed care context is perhaps ambitious but it has to be done. Readers may recall that BPR and patient-focused care were hot topics in the 1990s. Even if these management approaches do not enjoy resurgence then it is still worthwhile to look at the interfaces between managed care and other quality improvement processes in a BPR context. However, readers will need some legerdemain to think about BPR-TQM-CQI with their managed care hats on. Nevertheless, it is not unreasonable to explore BPR’s error-trapping and service improvement function in these ways. The authors raise important questions for quality improving healthcare organisations. For example, is BPR’s incremental approach better than TQM’s holistic style? They conclude that BPR is not for everyone and care needed to check if it is the right approach to service improvement?
Zillur Rahman and M.N. Qureshi’s case study describing India’s main private healthcare company offers opportunities to look behind the scenes of an entrepreneurial organisation. Among other things the company’s staff developed the country’s first HMO. Readers will get a clear impression that LIFENET broke India’s healthcare service mould. What also strikes the reader is the company’s strong, dual-pronged quality improvement strategy, which incorporates internal (i.e. employees and other stakeholders) and external (i.e. the patient) customer service improvements. Strong links are made between balancing quality and profit issues about which the authors are honest and up-front as the company faces major competition. Nevertheless, QA programmes seem to have contributed to the company’s success.
Laurent Boyer and colleagues’ article is an intriguing French managed care before-and-after study of services for patients with diabetes mellitus. Their clinically and economically-based structure, process and output/outcome measures are impressive. In common with other managed care programmes the aim was to control healthcare costs, improve quality by strengthening inter-professional collaboration and practitioners’ adherence to evidence-based practice guidelines. Diabetes mellitus proves to be an excellent choice not least because it is, as the authors remind us, one of the more worrying chronic diseases owing to rising incidence and its connection to obesity growth in the population. Their managed care programme focussed on follow-up services, notably prevention and screening. Findings show that initial service improvements were not sustained probably because non-managed care services caught up. Modest hospital savings emerged, on the other hand, which is encouraging as healthcare moves to primary and community care. The study raised important managed care and broader healthcare policy issues for any country.
Revital Gross et al. also look at managed care disease and service specific programmes. We are delighted to publish this article for broader reasons. First, regular readers know that Israeli healthcare articles are always innovative. Second, and a point that underlines the first, the article is based on an extensive managed care qualitative study. Like Guo’s article, the authors select case studies that succeeded or failed. They examine managed care in a quality spiral context notably examining internal and external success or failure factors that fall into one of the following themes: time allocation; leadership and management; inter-professional collaboration; internal and external rewards from managers and patients respectively and information systems. Interesting and novel findings emerge; that is, one theme’s success and failures cannot be disentangled from another. That is, none can be labelled as an overriding success factor (or vice versa).
Finally, George Rust and his medical colleagues write an elegantly simple article about improving healthcare efficiency and effectiveness in one of Atlanta’s safety-net primary care services. Again, diabetes mellitus is the clinical focus while the managerial hub is redesigning point-of-care-testing to remove all but one discretionary (which run the risk of inadvertent omission) diagnostic, treatment and care steps; consequently, improving outputs and outcomes considerably. A qualitative and quantitative before-and-after research design allowed the researchers to tease out important efficiency and effectiveness issues. Two important findings emerge: service variations exist and service changes may not be sustainable when funding is constrained. Nevertheless, the article epitomises service efficiency and effectiveness from which readers will learn a great deal.