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Quality Improvement Plan

Health Maintenance Organization (HMO)

An HMO is a US based healthcare organization that offers or arranges managed health care for people with health insurances, individuals, and also self-funded health care benefits plans. The organization works in liaison with other US based health care providers and facilities on a prepaid basis. The federal state of the US established and implemented the HMO Act of 1973 which requires all employers who have an employee capacity of 25 and above must provide the employees with a federally certified HMO option. This was to replace the traditional health care options that the employers could originally offer the employees. The HMO, unlike the traditional health care options, could ensure that the customer receives quality health care from qualified health care professionals as per the restrictions and guidelines of the organization. Notably, HMO provides emergency health care to its clients regardless of their status of the client's contracted health care provider (Sultz, & Young, 2006).

Despite HMO being an organization that is meant to improve the quality of health care being delivered by insurers, healthcare facilities, and providers, the organization also has failed in some areas a thing that requires potential improvement. The process of accessing the HMO services is long as the customer must have consent from a primary care physician (PCP). According to the HMO guidelines, the PCP must be a doctor. In most cases, a qualified doctor's consent takes time as the physician must test the patient so that he/she can be able to write a report to the HMO. The prolonged process forces the HMO clients to avoid adhering to present thus their personal physicians, pediatricians, and family doctors as their PCP for easy authorization. According to research, the HMO is supposed to help members benefit from reduced healthcare costs a thing that is not the case. Before the customers go through the entire process to access health care, they end up incurring cost just like in the case that the HMO was not in charge. Even in some instances, the customer has to bear part charges while the insuring company incurs the rest, in most cases, such situations are inconveniencing especially on the part of the customer.

For improvement to be a reality at the HMO, the organization needs two major components of data. The first data should demonstrate and highlight the services that the organization is providing. The second data component should contain adequate details of how the services should be delivered. This is in terms of when, where by whom and to whom the services are provided. With this type of data, it is possible to analyze the organization's policies and operations and also the feelings and opinions of the recipients and service providers so that any improvement can be adjusted (Sollecito, & Johnson, 2013).

To collect performance information at the HMO, the following three data collection tools can be used. They include; questionnaire forms, interview schedules, and observations (Ryan, 2011). The type of information that every tool shall collect depends on the source of information of the category of the participant. The reason is that for the data to be informative and inclusive, information must be gathered from all parties involved or directly engaged with the HMO. These parties include; customers, HMO employees, insurances companies, employers, and also health care professionals. For instance, in the case where a customer is engaged in an interview schedule, the type of questions that the client shall be asked are different from the questions that an insurer or a healthcare professional can be asked. On aver all, the type of information that the tools shall collect includes organizational policies and service delivery procedures, and how the services benefit the customers and other parties involved. Also, the tools shall gather opinions, ideas and feelings about HMO services from parties involved as well as how they feel that the organization can be improved to offer better services.

The tools of data collection have their benefits and challenges. For the interview schedules, the tool is beneficial in the sense that it allows a one-on-one engagement. This means that the questioning can take different forms depending on the answers received from the participants. It is also a perfect way of getting a clear picture of the situation from those directly affected because it allows an adequate chance for elaborate explanation. However, the process requires enough time, and it is an expensive operation to conduct. The questionnaires on their part are beneficial in the sense that they allow the participant ample time to think and respond. Thus, they provide the investigating team with well thought out and accurate answers. However, they possess a major weakness in the sense that the participants might fail to respond to the questions thus leaving the investigating team with inadequate information. Also, in the case where the participant does not understand the question, the participant lacks the opportunity to ask for clarification. An observation tool is a beneficial tool because it allows the investigating team to have a clear picture of the real situation on the ground. The reason is because the information is not provided by any party but rather the observations that the observers see the customers, insurers, employers, and the healthcare professional. However, the tool possesses a weakness in the sense that in the case where the observers are not keen, they can provide the investigating team with the inaccurate information thus misleading the entire improvement operation.

The data tools are similar in the sense that they provide similar information and to the same reporting center. This means that they have similar aims and purpose. However, the tools are different because the mode of providing the information is entirely different. For the interviews, the participants face the interviewer face to face and respond to questions asks. On the other hand, for the questionnaires, the respondent is granted a question forms to write the answers on the question form at his own time. For the observation, the observers take a keen look at the situation and make a report.

After gathering data with the help of collective data tools, there are other different tools that can be applied in the displaying and measuring of the quality improvement data obtained. Some of these tools include a balanced scorecard and a flow chart (Ryan, 2011). A balanced scorecard is a display board that comprises all the organizational information which includes policies, procedures, and objectives. The organization is able to learn of its growth with the recordings on the displayed board. Flow charts contain information about any changes or decisions made during the process and the impact they have on the organization.

The balanced scorecard is beneficial because it helps the organization always to work towards the accomplishment of goals which helps in making improvement for the purpose of accomplishing goals. However, the balanced scorecard is disadvantageous because it is vulnerable to human error because it is done manually. The chart flow is beneficial because it helps in keeping the organization on focus and committed to the changes and decisions made. However, if the changes and decisions made were wrong, the chart flow can be misleading.

The balanced scorecard and flow charts are similar in the sense that they are all meant to help in the improvement of quality in the organization. On the other hand, the two are different in the sense that they work different, and they also display different kind of data. However, the two are helpful to the health care organization as they jointly collaborate to detect and monitor operations so that quality improvement can be a reality.

References

Ryan, T. P. (2011). Statistical methods for quality improvement. Hoboken, NJ: Wiley.

Sollecito, W. A., & Johnson, J. K. (2013). Mclaughlin and Kaluzny's Continuous quality improvement in health care. Burlington, MA: Jones & Bartlett Learning.

Sultz, H. A., & Young, K. M. (2006). Healthcare, USA: Understanding its organization and delivery. Sudbury, Mass: Jones and Bartlett.