BUSI 511 Healthcare Administrations
Quality Improvements in Healthcare
Group 1
Stanley Barnes, Joshua-Paul Johnian, Lexie McCosh, & Karalyn Williams
21 March 2022
Respectfully submitted to: Dr. Bullock
Quality Improvements in Healthcare
The United States health care delivery system employs much different unique coverage
opportunities for most individuals within the population. Specific coverage opportunities are
also provided by the government for the disabled, chronically ill, elderly, and the poor (Shi &
Singh, 2019, p. 5). However, despite the availability of insurance coverage and governmental aid
27 million individuals are still without any coverage, leaving most to pay for care out of pocket,
or simply go without (Shi & Singh, 201, p. 9)
Individuals in the United States population with coverage from private insurance companies, or
government provided insurance still have difficulties finding a physician to care for them or lack
access to proper care at all within their communities (Shi & Singh, 2019, p. 12). Despite
coverage challenges, the United States health care system is a global leader when compared to
most developed countries due to high technological medical advances. This is evidenced by the
tenacity and dedication the United States heath care system has to its population based on the
quick development and distribution of the COVID-19 vaccine (Hepburn, 2020). Research has
shown many avenues in which the United States health care delivery system can improve, and
further explanation of those studies are discussed.
Quality improvement in health care, has been one of the largest topics of debate from the
1960's to the present. Throughout every generation each debate sought to make helpful changes
that reflect the growing demands of the nation's health care needs. By implementing different
analytical processes, to see where improvements can be made, the evolution of health care
continues to address needed improvements as well as how each development will be measured,
controlled, analyzed and enriched.
Primarily, when executing a prospective improvement, it is the responsibility of legislators,
scientists, researchers and the common welfare to address and explore accurate results. As the
U.S. continues to address the role of our evolving healthcare system all quality improvements
must be measured by quality outcomes that provide results that are beneficial and initiate change
that can be embraced by all people. From top level executives to pioneering researchers and from
political leaders to civil rights organizers their combined efforts have focused our nation on
health care improvements and change. The current U.S. health care system has numerous
benefits, but there are also many disadvantages as well.
Therefore for the U.S. health care system to accommodate the needs of people, and excel, there
must be quality improvement within the health care system in order to provide for the entire
population.
Historically, the US health care system has not developed a central governing body as in other
developed countries. In part, this lack of oversight is due to the way the U.S health care manages
financing, and reimbursement for medical services, since the present health care system is both
privately and publicly funded. Presently, health care financing accounts for 55% of the total US
health care expenses while the government finances the remaining 45% (Shi & Singh, 2019).
When addressing potential places of health care reform proponents of organizational change
support a centralized health care governing agency, and system, to manage costs and simply
services. Despite the present U.S. health care systems lack of a central authority both federal and
state governments provide an essential role ensuring standards and policies are in place that help
set fair prices attributed to medical services within the public sector (Shi & Singh, 2019). This
research paper will explore, in depth, the many ways government agencies, private corporations,
medical professionals and individual’s partner with quality initiatives to create innovative
approaches designed to improve the overall quality of health care as our nation ages, grows and
adapts with the changing times.
The United States health care system is unique compared to other developed countries, which
have universal health insurance programs for all of their population (Shi & Singh, 2019, p.1). As
medical costs increased, and quality measures lagged, behind other developed nations, legislation
was enacted to increase coverage while managing medical expenses. In 2010 the passing of the
Affordable Care Act was the first major health care reform since the expansion of the Medicare
program and sought to increase medical coverage for some of the population while not
addressing full universal coverage to the entire population (Shi & Singh, 2019, p. 2).
The passage of the ACA has made a significant impact in the way that individuals were finally
able to receive some form of health care with twelve million individuals, with the United States
population, receiving health care coverage through ACA's first open enrollment (Shi & Singh,
2019, p. 9). Out of those twelve million people, ten million were able to receive some form of aid
to be able to pay for that said insurance, decreasing the burden that it could have on that
individual and their families (Shi & Singh, 2019, p. 9).
An additional dynamic of the U.S. health care system is the provision of medical care for the
armed services and retired veterans and while this care is mostly expense free for participants,
through a system called Tricare, it creates another layer of medical care that is uniquely funded
and provides care for individuals who are actively serving in a military function or capacity. (Shi
& Singh, 2019, p. 4). As with any developed nation the United States also attempts to provide
medical care for special populations, including the vulnerable, poor health, certain minority
groups, certain immigration statuses, the poor, and the uninsured, are who all able to receive
public health insurance known as Medicaid and Medicare (Shi & Singh, 2019, p.5). With so
many diverse medical care needs, and potential gaps in coverage, the U.S. government instituted
sweeping medical reforms in the 1960's with two programs of Medicaid and Medicare in an
attempt to provide a safety net when it comes to providing care to those who are financially
limited (Shi & Singh, 2019, p. 5).
Today, Medicare is primarily used for individuals, within the United States, that are elderly,
facing end-stage renal disease or who are disabled (Shi & Singh, 2019, p. 5). For such
individuals to qualify for this healthcare benefit they must be considered at a federally
determined poverty level, or below, or unable to work due to the ailments or age. Likewise,
Medicaid's primary mission is to provide coverage for low-income individuals, children, as well
as cover the elderly and disabled (Shi & Singh, 2019, p. 5-6). Although each of these
government programs seek to narrow gaps in health care ongoing imbalances still exist as
evidenced by some physicians who will not accept new patients that are newly covered under
Medicaid, which results in these individuals having to wait until their symptoms have developed
and must receive emergency care (Shi & Singh, 2019, p. 12).
Statistics have shown medical care, for those that cannot afford, it will likely cause a decrease in
quality of life and a decrease in the amount of life an individual has left. With there are several
health options of available coverage, the United States has to offer, there are is still an
astounding 27 million individuals that lack any form of health coverage which highlights the
need for further reforms and renewed focus on quality outcomes (Shi & Singh, 201, p. 9). In
other countries such as Canada, United Kingdom, and Germany health care is managed through a
centralized agency whereas in the United States the same medical services are distributed among
many different entities (Shi & Singh, 2019, p.10) with the United States' approach to health care
being funded both privately and publicly. With the diversity of healthcare options, within the
U.S., individuals also inherit an abundance of different choices from types of payments,
insurance and even delivery mechanism (Shi & Singh, 2019, p.10).
Therefore, the U.S. health care patch-work approach also affords individuals a choice when it
comes to their health care coverage and self-determination. With individualized healthcare
individuals are able to understand what they are going to pay, why and what the short or long
term treatments are available. Despite, private insurance companies, that contract primarily
through employers, may result in decreased health care options (Shi & Singh, 2019, p. 4) the U.S
approach to health care remains diverse.
Since the U.S. medical system has many contributors there is an increased possibility of
competing outcomes, which can affect quality improvements, as evidenced in the tug of war
between private providers and government managed care. Another way this conflict of interest is
demonstrated is evidenced between private physicians and insurance providers who seek to be
reimbursed maximum dollars, for services, provided, as the government seeks to establish flat
rates for care to contain costs which could come to the detriment of the patient. (Shi & Singh,
2019, p.15).
While there many competing challenges within the U.S. health care system there are also
pioneering successes that have an instant impact on medical care and direct patient satisfaction
primarily through technology (Shi & Singh, 2019, p. 10). An example of how technology has
positively influenced health care is evidenced by access to MRIs, CT scans, and decreased
healing time of the patient after procedures or treatments (Shi & Singh, 2019, p. 119). However,
patient driven desire to seek new technology, and specialized care, has added another financial
weight on the overall cost of health care since cost and costs attributed to training are essential
components to effectively utilize these advancements (Shi & Singh, 2019, p. 121). While many
of these factors impact the cost of care, and make overall health care costs rise significantly, the
U.S. health care system remains the global leader in specialty treatments when compared to care
provided for than overall population, whereas other developed countries are the exact opposite
(Shi & Singh, 2019, p. 10).
Whereas any nation's ability to tackle the complex needs and demands for health care can be
daunting there are additional historical, and cultural, challenges that provide further examination
so as to properly effect positive quality outcomes. For example government- provided health
coverage, Medicaid, does not adequately pay providers for their work (Shi & Singh, 2019, p.
137).
As a result of this reimbursement flaw many providers do not readily accept Medicaid and
therefore do not extended medical services to those who have attained such coverage (Shi &
Singh, 2019, p. 12). Due to technological advances, and price inflation, paying for medical care
without insurance coverage is incredibly expensive and results in many individuals within the
United States going without care at all. Historically, and culturally, the United States has
demonstrated evidence of disparities between the health care services given to certain
demographics of Americans (Bailey et al, 2017) and as difficult challenges, such as racial
discrimination in health care, has resulted in a lower quality of life, and poorer quality outcomes
(Bailey et al, 2017). Further evidence of such disparities is evidenced in minority neighborhoods,
with lower-quality facilities, and fewer physicians to provide care (Bailey et al, 2017). Not only
is there evidence that disparities exist amongst health care delivery, but there are also disparities
between mortality rates and life expectancies (Shi & Singh, 2019, p. 254). African-American
women are more likely to die of complications with childbirth than Caucasian women (Sofer,
2018), African Americans are also at a higher risk of premature death due to stroke and heart
disease (Shi & Singh, 2019, p. 254) and within the Hispanic American community AIDS is a
leading cause of death due to lack of primary care and annual checkups (Shi & Singh, 2019, p.
255).
Another often overlooked but no less important demographic lacks in health care coverage are
the mentally ill, homeless and individuals with disabilities and chronic diseases (Shi & Singh,
2019, p. 261-262) and overall, disparity continues within the United States with many
individuals still without health care coverage despite some improvements through the Affordable
Care Act (Shi & Singh, 2019. Establishing health coverage for individuals with chronic diseases,
who need consistent health care the most, continue to have trouble finding coverage due to these
long-term diseases (Shi & Singh, 2019, p. 264) and unfortunately, as the government continues
to contain the costs that it will pay less health care delivery systems will accept Medicare and
Medicaid. Overall, this simply means that a once well placed and balanced governmental aid is
now unable to meet the health care demands for the majority of the vulnerable populations,
which so desperately needs adequate coverage.
While the U.S. healthcare system continues to wrestle with many social and economic challenges
its overall ability to adapt has also positioned it for medical successes as evidenced by the current
global pandemic of Covid-19. In March of 2020 the United States faced a reality the entire
global community was already experiencing with the outbreak of COVID-19. While initial covid
cases appeared limited to specific age demographics, in health care related settings, soon the
entire nation’s medical community would be tasked with managing, slowing and treating this
growing pandemic. From the spring of 2020 to today the ability for our nation's health care
system to overcome medical supply shortages, rapid production of necessary medical equipment,
medical professional's responses for care and the implementation of a vaccine could not have
happened without a system designed to adapt to such unprecedented challenges.
In the Essentials of the U.S. Health Care System Shi and Singh write, "the United States is a
hotbed of research and innovation in medical technology." (Shi & Singh, 2019, p. 10) From the
mass production of respirators to the manufacturing of hand sanitizer, and now the approval and
implementation, of three COVID-19 vaccines the U.S. health care system has established itself
as a global pioneer in the field of medicine. Despite the challenges associated with rising
expenses and continuing debates on market justice versus social justice (in medicine) the United
States' ability to recognize changing social needs also speaks to the systems inherent adaptability
for improvement in quality outcomes.
Matthew Hepburn, writing in the New England Journal of Medicine, stated, " a partnership of the
Department of Health and Human Services (HHS), the Department of Defense (DOD), and the
private sector — aims to accelerate control of the COVID-19 pandemic by advancing
development, manufacturing, and distribution of vaccines, therapeutics, and diagnostics."
(Hepburn, 2020) Within Hepburn's research he identified several key areas, unique to the U.S.
health care system, which enabled us to respond rapidly to the COVID-19 pandemic. In
Hepburn concluded, "The partnership grew out of an acknowledged need to fundamentally
restructure the way the U.S. government typically supports product development and vaccine
distribution." (Hepburn, 2020) While there have been many critics of the national response to
COVID-19 there can be little doubt the objectives outlined by Operation Warp Speed have
succeed in targeting a health crisis by utilizing multiple branches of government, research,
development, medical professionals, substantial financial investments and the role of the private
sector; with such collaboration, and partners, being unique to the U.S. health care system.
When one considers the recent rapid pivot the U.S. health care system was able to accomplish,
despite its many complexities, there should be little surprise such a response was possible due to
our cultural beliefs and history. "Traditionally held American cultural beliefs and values, the
social fabric of the American society, technological advancements, economic constraints,
political opportunism, and ecological forces are the main historical factors that have continued to
shape U.S. health care delivery." (Shi & Singh, 2019, p. 50)
Furthermore, while the U.S. health care system continues to evaluate the value of assessing
quality outcomes, one must remember the concept of health care, in the U.S., is still considered
relatively young: Science had little to do with medicine until around the mid-1800's there were
no medical schools, and doctors learned their trade by a sort of on-the-job training." (M. Beth
Shanholtzer, 2016) While many of these historical challenges create some of natural barriers for
change, today, discovered in our history is also our nation's willingness to tackle health care
reform through legislation and social justice concern. The growth of the hospital system, reforms
in mental health, changes in employment-based medical insurance and eventually the
government role in medical care (through Medicare, Medicaid and the Affordable Care Act)
have all been initiated through social changes and political demands. An example of this is cited
by author's Shi and Singh when they wrote (referring to Medicare and Medicaid), "At the same
time the growing elderly middle class was becoming a politically active force." (Shi & Singh,
2019, p. 65) The United States has continued to adjust medical policy with the expansion of
Medicare Parts, A, B and C as well as the most recent Affordable Care Act, which seeks to
address affordable medical coverage for the uninsured. While ACA and other expansions to
health care have not reached their desired goals such political and social aims continue to
demonstrate the United States ability to adapt to changing and times health care demands.
As the United States continues to demonstrate changes on a macro level such high-level change
creates industry measures to monitor, track and define success. In-part some of the practices are
borrowed from other health care systems and with each modification, and implementation, the
metrics of how our health care system gauges success is also evolving. In times past our health
care system rewarded, through reimbursement, medical care services that were not always based
on positive patient experience or long-term patient outcomes. Therefore, a system designed to
address acute health needs and not focus on preventative care also focused on expensive methods
of care.
While this is still partially present in our approach to health care there are significant signs of
changing attitudes and approaches to this delivery of health care. Tresa Leming-Lee writes,
"Characteristics of the science of improvement include a combination of expert subject
knowledge along with improvement methods, such as a statistical approach to reducing variation,
and the improvement science strategy, and tools, such as control charts used to stabilize the
variation." (Treasa 'Susie'Leming-LeeDNP, 2019) Such examples of developing approaches to
medicine, that encourages an interdisciplinary team collaboration not only focuses on quality
patient outcomes but by minimizing the possibility of medical error, and refining the patient plan
of care, higher medical care success is achieved along with reduced expenses on historically
wasteful trial and error practices.
Another area where medical care is focusing on evidence-based practice, and quality patient
outcomes, is on the front lines of medical care: the emergency department. In Kristyn C.
Huffman's research she finds simple changing in wording with focused attention on concise
information gathering resulted in a higher probably for positive patient outcomes and better
medical care: "This TH question was worded as "Have you been treated for [chief complaint]
before?" The data collection process and results regarding Emergency Severity Index (ESI)
scores, triage times, and nursing compliance rates are reviewed, along with recommendations for
improving communication during triage." (Kristyn C. Huffman DNP, 2018). Despite these
positive indicators there is still much work to be accomplished. Goldman concludes, "The US
healthcare system needs to invest in rapid feedback on quality measures that would enable more
continuous learning. Whilst measurement has been a powerful force in the US system, a closer
connection to evolving national data systems and evidence‐based improvement strategies is
needed." (Goldmann, 2016) And while the pursuit of quality outcomes, and revised medical
measurements, seek to find their place in our historically patch-work medical system we cannot
lose sight of Mathew Hepburn's conclusions on the recent Covid19 efforts, "While no scientific
enterprise could guarantee success by January 2021, but the strategic decisions and choices we've
made, the support the government has provided, and the accomplishments to date make us
optimistic that we will succeed in this unprecedented endeavor." (Hepburn, 2020)
While the U.S. has shown the ability to overcome unprecedented challenges there is still a
necessary shift, in the healthcare industry, that needs to focus on quality management so as to
further developed a primary goal for the overall improvements in the quality of care. It is
estimated the lack of quality controls have also contributed to significant financial errors within
the healthcare system. In the United States, "...medical errors cost the nation approximately
$37.6 billion each year" (Kumar & Shah, 2011) and "medical errors to be the eighth leading
cause of death in the US, with as many as 98,000 people dying each year as a result of medical
errors" (Kumar & Shah, 2011). While financial errors, combined with other layers of billing
complexities and reimbursement processes, highlight additional barriers to improvement it is
evident quality improvement should not only seek to provide positive patient outcomes but also
include a structurally sound health care system. Thankfully, there has been significant
contributions that have aided in achieving these necessary improvements in both the quality-of-
care patients receive and institutional integrity. Perhaps one of the strongest steps forward, in this
pursuit, is evidenced in the incorporation of healthcare facility accreditation. The development of
The National Committee for Quality Assurance established a set of standards in order to measure
performance of managed care organizations, which were often known as managed report cards.
"The report card is voluntary efforts that were begun out of concerns that controlling health care
utilization could adversely affect the quality of care" (Shi & Singh, 2019).
In order to achieve this process a hospital has the responsibility of, "...accreditation requires
meeting a set of norms by a specific date provided a powerful tool to finally introduce long-
awaited changes as it overcame the resistance to introduce them." (Melo, 2016). Quality
improvement through accreditation requires contribution from all and in order to do that
healthcare should focus in on three conditions in order to get employee involvement in quality
improvement. Gadolin & Andersson (2017) describe the three areas as professions, work
structures, and working relationships. Although it might not be easy to achieve as, "...professions
and work structures tend to prevent employees from engaging, working relationships can often
serve to bridge professions and work structures, thereby supporting employee engagement in
healthcare QI work" (Gadolin & Andersson, 2017), it can serve to be effective long term. As
more countries began to focus in on becoming an accredited hospital improvement across all
levels of flow in the hospital could be seen. A study in Australia showed that "...the hospitals that
had applied for accreditation performed better in terms of administration and management,
medical staff organization, organization of nursing services, review systems, physical facilities
and safety, and hospital role definition and planning" (Melo, 2016).
The overall success and standards of the accreditation process has created an environment in
which hospitals tend to perform better and provide more quality care in order to maintain
accreditation. This process has become a desired achievement of most hospitals since it is seen
as, "...accreditation has increasingly been considered as the preferred method to promote
healthcare quality at organizational and service levels, given its wide reputation as a key driver
for healthcare quality and patient safety improvement." (Melo, 2016).
Interviews that were conducted in Melo's (2016) study of the accreditation process gathered the
opinions of those working for a hospital through accreditation. Those involved in the study had
an overall feeling that, "...accreditation led to a shared feeling that everyone inside the hospital
could play an active role in improving the quality of care across the hospital". In a multi complex
field, such as the healthcare industry, professionals from all different levels of care and
leadership must work together in order for a patient to feel as though they are receiving quality
care. Through the accreditation process hospitals and other medical professionals were
encouraged to standardize their quality measures and focus more on the patient safety aspect of
care. In particular the hospital was able to focus in on developing, "...cross-departmental
strategies to prevent patient falls; and second, changes in the hospital's physical infrastructure in
order to improve its accessibility for patients (e.g., through the creation of ramps for wheelchair
access, and changes in the decoration and layout of hallways in the new building in order to
facilitate patients to recognize the floor where they are at)." (Melo, 2016). Many factors can go
into affecting a facilities quality of care, "...the accreditation process itself has features that can
foster quality improvement, the achievement of such improvements is strongly conditioned by
the hospital's baseline level of quality as well as the quality management and patient safety
activities that exist at the time the hospital embarks on accreditation." (Melo, 2016).
As the U.S. health care system looks for areas to reform, the training and role of effective
healthcare management, one such place under scrutiny is the role between the provider and
consumer.
Since medical care is considered private and even sacred the relationship between a patient and
physician, or patient and facility, can be an effective bond for reinforcing quality improvements.
Likewise, reviewing the supplier and consumer relationships between patient and health care
providers will allow hospitals to look at any provided care from a different perspective
(Batalden, 2018). Seeking God's guidance, in Scripture, encourages the Christ-Centered health
care professional to discover a spiritual responsibility to explore new pathways for improved
healthcare the United States.
In 3 John 1:2 we read the apostles encouragement, Dear friend, I pray that you may enjoy good
health and that all may go well with you, even as your soul is getting along well (Holy Bible,
New Living Translation, 1996/2015) as well as, The LORD will guide you continually, watering
your life when you are dry and keeping you healthy, too (Holy Bible, New Living Translation,
1996/2015).
Continuing the focus on taking care of the overall population should remain the main goal for the
United States' health care delivery system, the Christ-Centered health care advocate, social and
market justice minded health care causes, clinicians and financial providers in order to build an
efficient and effective health care system that meets the needs of both the vulnerable and well
provided for. To meet such altruistic goals the concept of Coproduction, within health care, can
be an effective resource since it utilizes direct feedback from patients and health care workers to
implement, create, design, produce, and evaluate relationships and actions of health care
providers that directly contribute to a patient's overall health (Batalden, 2018).
The process of Coproduction encourages interaction between healthcare professionals and the
patients, toward the aim of efficient patient and provider outcomes. If the goal of health care is to
be patient-centric then efficient tools, that support patient health, will be essential in any
successful reforms.
One such tool that is presently used to evaluate patient satisfaction is known as Hospital
Consumer Assessment of Healthcare Providers and Systems (HCAHPS) (Carter & Silverman,
2016). The utilization of this resource, by the Centers of Medicare and Medicaid Services
(CMS), enables the government to calculate performance scores of healthcare providers and
other health care workers (Carter & Silverman, 2016). Once these primary scores are collected
from Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey,
additional statistical data is utilized for research on quality care and overall successful
performances (Carter & Silverman, 2016). This example of Coproduction is one positive
outcome of an evolving U.S. health care system that combines the efforts of Health care
providers, and staff, to attain high quality reporting from patients that feel they are listened too,
respected, shown courtesy and the reassurance a medical healthcare professional is willing to
listen to them about their concerns (Carter & Silverman, 2016). The prospective positive results,
from this Coproduction, is evidenced by patients satisfaction from providers carefully explaining
treatments and procedures that patients may have (Carter & Silverman, 2016) which results in
patient satisfaction and effective continuity of patient care.
In conclusion when exploring the need for quality improvement, reforms areas of positive
growth, with the U.S. healthcare system, the generic and hot –button solutions are often too
simple to explain the many complexities tied to our present health care demands. As evidenced
throughout this paper, quality improvement also extends into services provided, cost, politics,
technology, competing agencies and the goals of a centralization or accreditation processes.
While many special interests providers, medical professionals and legislative goals try to address
efficient medical care the historically familiar and trusted solutions of Medicare and Medicaid
are approaching insolvency.
Recent legislation such as the ACA is one way government is trying to contain the costs while
providing higher standards for quality care and increased patient coverage. However, from
provider to government care and insurers to patients the continued challenge of differing goals
breeds counterproductive elements the slow the necessary reforms in the US health care systems.
For future healthcare reforms to be effective and efficient there will need to be greater
cooperation, merging of overall goals, acceptable outcomes and investment from the public and
private sectors to create a re-imagined health care system that answers the challenges of
diversity, inequalities, cost, coverage and satisfaction. Are these goals within reach? Yes,
through HITECH initiatives we are beginning to see the gaps narrowing however, greater
collaboration, investment and education will need to pave the way long-lasting reform.
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