Use proven business methods to stay competitive in case management

Continuous quality and process improvement aids outcomes, planning

Good case management outcomes are the result of good case management processes. They also are vital to your case management organization's success. Today's climate of increased accountability places even more pressure on case managers to prove their worth and improve their outcomes. The key to doing just that may require case managers to move away from traditional methods of calculating case management outcomes and turn to business processes formerly employed only by quality improvement experts: continuous quality improvement (CQI) and continuous process improvement (CPI).

"In the 1980s, we concentrated on quality assurance. We looked after the fact at what went wrong and did a lot of finger pointing," explains Suzanne K. Powell, RN, BSN, CCM, the director of case management and CQI for Arizona's peer review organization, Health Services Advisory Group in Phoenix. "CQI is not finger pointing, and it's not a Band-Aid or quick-fix approach. CQI is prevention. It is looking at processes and improving them. Quality assurance placed the blame on people. CQI places the blame on the process."

The following environmental forces make understanding and using CQI and CPI methods important for case managers in the 21st century:

o Cost-saving opportunities are dwindling. "We can no longer rely solely on the fact that case managers can dem onstrate that they saved costs," says Powell. "With the increase in contracted rates for medical services and equipment, it's harder to negotiate savings on a case. We have to look for new avenues to prove our worth."

o Case managers must prove their worth in a new direction. "The need to prove our worth as case managers still exists, but we must take our reporting efforts in a new direction," she says. "I believe instead of focusing on cost savings, we must shift to quality of care issues. To survive, we must measure our outcomes, and CQI provides the tools to prove that we are experts at coordination of multilevel medical services."

o Outcomes measurements are requested and required in all aspects of health care.

"We can learn a valuable lesson from the HEDIS [Health Plan Employer Data Information Set]," Powell says. "In the 1980s, health maintenance organizations [HMOs] were each using their own proprietary systems for measuring patient satisfaction. HMOs were quoting satisfaction rates in marketing materials, but there was no way to compare apples to apples.

"HEDIS standardized the process. Now employers and other consumers can look at the patient satisfaction rates of competing HMOs and know that they were measured the same way. That's what case management must do. We must develop standard measurements so that two case management organizations can be compared fairly."

o CQI and CPI processes provide tools to identify and measure case management outcomes and plan or improve case management programs.

"The CPI or CQI process is a systematic approach to evaluating your current delivery system," says Ellen Aliberti, RN, MS, CCM, manager of Medicare programs for MedPartners in La Habra, CA.

"CPI helps you visually identify duplication and fragmentation in your current processes and highlight opportunities for gaining improvement," she says. (For more information on visual representation of processes, see story on flowcharts, p. 130.)

The CQI process is broken down into these four stages, Powell says:

4 Plan the improvement.

4 Do the improvement on a limited scale.

4 Check/study the results of the pilot project.

4 Act to continue improving the process.

Aliberti and Anderson say MedPartners recently used the CPI process to plan five new senior programs. The CPI process included the following seven steps:

1. Identify process to improve. "If it's not broke, don't fix it," Aliberti says. "Not all processes need improvement."

2. Organize a team. "When you plan a team, be sure to include representatives from all of the departments affected by the program or process," she says. "If you leave a department out of the process, it won't work as well. That department won't have buy-in to your program."

3. Establish a mission statement. "A mission statement establishes the ground rules for you to work from," she says.

4. Clarify knowledge of current process. "Understanding your current process helps you identify causes of variation. Once you identify the causes of variation, you can identify areas for improvement." MedPartners sent a survey to its network physicians to identify barriers to participation in a proposed Geriatric Evaluation and Management Clinic.

"After looking at our current process, we noted that there was no formal mechanism to refer members to any of our existing geriatric specialty services," she says.

Survey findings include the following:

4 80% of MedPartners physicians were struggling with time constraints when caring for frail elderly members.

4 70% of MedPartners physicians reported that they lacked resources necessary to care for frail elderly members.

4 Roughly 40% reported that they lacked the knowledge necessary to provide highest quality care for frail elderly members.

"The devil is in the details," Aliberti says. "Data are essential to the CPI process." (For a case study of what can happen when CPI is not part of your planning process, see p. 132.)

5. Understand causes of process variation.

6. Identify strategies for improving process.

7. Develop plan for evaluation of new process. Whether it's called CQI or CPI, both processes involve continuous incremental evaluation, Powell adds.

CQI and CPI teams should have six to eight members, she notes. "If your team becomes too large, you experience too much dissension," she says. "However, you don't want a well-balanced team with members from more than one department. You would probably want to include some financial people and claims people in addition to case managers."

The flowchart is the queen of CQI, she says. It provides the CQI team with a visual representation of the process under study. Flowcharts also are useful for training new case managers. "It helps case mangers visualize where they fit in the system and the actions expected at different stages."

"It's important to have a well-dressed flowchart. Anyone should be able to follow a good flowchart at a glance, see your decision points, and follow your flow even without any knowledge of your process," Powell says.

A good flowchart also helps identify the "CRUD" that often leads to poor outcomes, she says. CRUD stands for complexity, redundancy, unnecessary steps, and delays.

"Check your results for lessons learned," Powell suggests. "Failures are not necessarily bad. We can learn why processes or programs fail and improve them."