For quality professionals, job number one is jumpstarting healthcare quality initiatives that took a back seat during the height of COVID-19. As hospital staff were stretched thin and supply chains were disrupted—and still are in many places—the Centers for Medicare & Medicaid Services (CMS) even temporarily suspended quality reporting requirements for Medicare quality programs in 2020. 

Now it’s time for healthcare organizations to resurrect their quality assurance (QA) programs. We provide six tips to succeed at a reset.

What is healthcare quality assurance (QA)?

Quality control is about managing products and production—reactively detecting defects and correcting them. In healthcare, the proactive term quality assurance is apt—requiring systematic monitoring and evaluation of the quality and appropriateness of patient care delivered.

The National Committee for Quality Assurance (NCQA) leads the way for payers and other healthcare organizations when it comes to setting quality standards. And because regulators and payers use quality measures to gauge compliance and/or determine reimbursement, healthcare provider organizations require a process to maintain strict control over quality. That’s where quality assurance comes in.

According to the NCQA, quality assurance is process oriented, ongoing, and depends on measuring, monitoring, and providing feedback. It may entail activities such as:

  • Assessing or evaluating quality in your organization as compared with standards or benchmarks
  • Identifying problems or issues with care delivery and designing quality improvement activities to overcome them
  • Monitoring and conducting follow-up or corrective actions to ensure the activities had the desired results
  • Continuous training of staff to maintain high quality standards

What does a healthcare quality assurance program include?

The NCQA outlines four areas that are typically the focus of quality assurance programs:

  1. Structure. Measures of structure evaluate quality according to “scale” in various healthcare settings. For example, clinics and hospitals have different attributes and therefore require varying benchmarks for quality measurement. Consider the differences when examining metrics such as nurse-to-patient ratio or percentage of board-certified physicians as these correlate with quality of care in various settings. 
  2. Process. Process measures examine how well a healthcare organization’s documented processes and procedures are followed, regardless of whether providers or patients are the subject of the metric. For example, process measures might include hand hygiene compliance by physicians, the percentage of patients who received preventive services (e.g., mammograms or immunizations), or the percentage of diabetic patients who had their blood sugar tested. Evidence-based guidelines and best practices are used to develop processes.
  3. Outcomes. Outcomes measures include numbers and percentages such as mortality rates, hospital readmissions, and surgical complications such as hospital-acquired infections. The intent of measuring outcomes is to evaluate something (e.g., the effects of evidence-based care on patients’ health, an organizational system's effectiveness, a provider's’ performance) and incorporate findings into improvement efforts. For provider organizations, achieving outcomes goals affects compliance with accreditors and reimbursement from payers.
  4. Patient experience. Patient experience is the sum of interactions that influence patients’ perceptions of the healthcare they receive. For health systems and providers, it affects factors ranging from workforce satisfaction to reimbursement under value-based payment models. Patient experience measures use process and outcomes measures to gauge care quality. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, for example, asks hospital-discharged patients questions about their recent stay (e.g., communication with physicians, responsiveness of hospital staff, cleanliness and quietness of the environment, discharge information, etc.).   

Designing effective quality assurance programs that promote the best possible patient outcomes requires compliance with hundreds of regulations, policies, and laws at the federal, state, and local levels. In addition, internal strategies support quality healthcare delivery and must be reported to an organization’s governing body (e.g. the board). 

Why is QA important? 

Under value-based payment models, reimbursement is based on healthcare quality and efforts to improve quality. For example, CMS’ Quality Payment Program rewards healthcare organizations for delivering quality, evidence-based care that improves outcomes while containing costs. Under CMS’ Merit-Based Incentive Payment System (MIPS), Medicare payment adjustments (bonuses or penalties) are based on a clinician’s total MIPS score:

  • Quality composes 30% of the MIPS score, with “improvement activities” accounting for another 15% 
  • Cost (30%) and promoting interoperability (25%) make up the rest of the MIPS score 
  • For small-practice clinicians, quality accounts for 40% of the MIPS score, with improvement activities (30%) and cost (30%) making up the remainder

In 2022, clinicians must meet a minimum performance threshold (a MIPS score of at least 75 points) to avoid MIPS penalties. With quality and improvement activities composing almost half of the MIPS score, it’s imperative for healthcare organizations to renew their QA programs.

Further, some payers require public reporting of quality measures, including patient experience scores. For example, CMS requires hospitals subject to Inpatient Prospective Payment System (IPPS) to collect and submit HCAHPS data to receive their full IPPS annual payment update. IPPS hospitals that fail to publicly report the required quality measures (including the HCAHPS survey) may receive a reduced annual payment update.

Six steps to resurrect your healthcare quality assurance program

If your healthcare organization’s quality assurance efforts flagged or focused only on minimal maintenance during the pandemic, now is the time to spark full-on efforts toward continuous improvement. Read our top six tips for a recharge.

1. Assemble a steering committee

The steering committee guides the QA program, establishing processes that improve patient outcomes, reduce errors, and improve the patient experience (and HCAHPS scores). The steering committee evaluates current policies and procedures, reviews relevant regulations, recommends changes and reporting procedures, and sets goals. 

Staff in many departments indirectly impact the patient experience, so be sure to include representatives from several departments—patient account representatives, clinical educators, and legal consultants—as well as clinicians who provide direct patient care. Having a cross-section of employees helps you consider important factors that affect quality and patients’ perception of care. 

2. Identify problem areas 

Identifying problematic processes and procedures is the foundation of healthcare quality assurance. There are several ways to detect known or suspected problems that need attention:

  • Conduct a risk assessment and internal audits to identify potential violations of federal, state, accrediting body and other regulations. By identifying compliance problems, you can take steps to reduce their negative impact on your organization, staff, and patients. For example, conduct internal Health Insurance Portability and Accountability Act (HIPAA) audits according to The Department for Health and Human Services Office for Civil Rights (OCR’s) audit protocol to discover potential violations of the Privacy Rule.
  • Review patient complaints and satisfaction surveys (including HCAHPS scores). Use complaints management software to automate the collection and processing of patient feedback and facilitate reporting.
  • Review incident reports and ask staff about problem areas. Incident reports help staff identify and change the individual or system-level factors contributing to medical errors. Incident management software simplifies the reporting of adverse events and analyzes their root causes.
3. Choose quality metrics that matter (and that you’ll use)

With no universal definition of quality and hundreds of quality measures to choose from, how do you select the right ones? In short, use structure, process, and outcomes metrics based on your organization’s needs, the specific reporting requirements of your payers (including CMS’ quality programs), and your accrediting body (e.g., The Joint Commission). Consider including these five general measurement areas:

  • Mortality
  • Adverse events and incidents
  • Hospital readmission rates
  • Patient experience
  • Timeliness and effectiveness of care

To aid measurement efforts, use a quality management dashboard to track and display metrics. Like your car’s dashboard, healthcare quality management dashboards provide a visual representation of data that guides decision making. When you know how fast you’re driving, you can make informed decisions about altering your speed. Similarly, when you know how many adverse events the ICU had last month, you can decide what corrective actions to take.   

4. Establish a safety and quality culture

Make sure employees understand why QA is essential. Remind them about the importance of patient experience scores and share a few examples of how their actions impact the patient experience and, in turn, HCAHPS survey results and the hospital’s finances.

Nurses, physicians, and other staff need to feel safe reporting incidents and near misses, without fear of punishment. To move away from a shaming/blaming culture that deters incident reporting, adopt “Just Culture,” “Safety II,” or other initiatives that emphasize that most errors are due to flawed systems, not individual negligence. 

5. Implement improvement actions 

Determining the root cause of medical errors and adverse events, and developing protocols to prevent or reduce them, is at the heart of all quality assurance (QA) activities. After you’ve identified problem areas and causes, the next step is to develop an improvement plan and strengthen your policies, processes, and procedures. For example, you may need to provide staff training, update medical equipment, and/or modify your staffing policies (e.g., revisit nurse-to-patient ratios).

6. Evaluate results  

Monitoring your quality metrics tells you whether your corrective actions worked. Did you meet your improvement goals? Have readmissions and adverse events decreased? Have patient experience scores increased? If not, you may need to adjust your improvement plan to achieve your desired results. Improvement management software makes it simple to monitor the progress of your improvement actions.

Share the results of your improvement actions with staff to increase their engagement. Understanding the role they play in quality improvement, and seeing that their input is making a difference, increases their commitment to your quality assurance program.

symplr Quality provides comprehensive quality reporting and monitoring, helping you maintain strict control over the quality measures affecting your reimbursement. 

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