Healthcare Quality Review and Inspections (CMS)

Healthcare Quality

The healthcare quality department is in charge of the creation of hospital policy and procedures. Healthcare professionals within the department are responsible for ensuring that all of the processes in a hospital operate smoothly and consistently for every patient no matter what his or her initial visit was. They are charged with maintaining high quality standards in patient care through the implementation of policies and procedural changes. Hospital policy and procedures must be legally binding in order to protect the legal rights of patients and allow hospitals to participate in Medicare and Medicaid programs. Hospital staff may also be held responsible for errors and omissions in policy and procedure manuals are not followed in a timely manner.

History of Healthcare Quality

There has been a proliferation of professionals in the healthcare industry over the past 100 years who have devoted their careers to developing quality guidance documents for health systems throughout the United States. In the beginning, healthcare professionals provided guidance to hospitals on how to provide for their patients. Over time, they developed processes for quality assurance in the health systems. Today, they provide even more detailed guidance, developing and reviewing medical diagnosis, therapeutic procedures, and outcomes.

Methods of Clinical Guidance

Although the methods used by healthcare professionals may vary, they generally follow at least two common paths.

The first path follows the scientific evidence in support of the treatment options chosen by the health system. For example, when deciding whether or not to use invasive interventions, doctors evaluate the available scientific evidence and the effectiveness of such interventions in the individual patient. If scientific evidence does not support a course of treatment, doctors often rely on expert testimony as the basis for their treatment decisions.

The second path follows clinical practice guidelines created by the healthcare system itself. These clinical practice guidelines specify which procedures should be performed, which patients should receive those procedures, and that medical personnel should perform them. For example, an acute care hospital might follow the guidelines established by the Centers For Medicare and Medicaid Services (CMS), which set standards for how hospitals measure the effectiveness of their care. The CMS determines which procedures are necessary and which are unnecessary and then implements those guidelines.

Quality Assurance As described above, the healthcare quality is dependent upon the accuracy and validity of the data used to make clinical practice decisions. This includes assessing what is known about a patient’s likely course of the illness. The data used to make these assessments are called quality indicators or quality parameters. Many quality assurance programs focus on ensuring that quality parameters are accurately determined and reported. Other programs focus on ensuring that these parameters are appropriately monitored and adjusted so that they provide feedback to the staff that helps improve their own quality of care.

Another important function of the Healthcare Quality Department is quality review and inspection. The goal of this department is to reduce risks to the public’s health and safety through the inspection of health care provision facilities. For example, if patient X comes in complaining of discomfort from a particular procedure, but a nurse is unable to correctly identify the problem, the Healthcare Quality Department will conduct an inspection to determine whether the procedure was appropriately performed. When problems are found, corrective action may be recommended.

Clinical Quality Review and Inspections are designed to ensure that medical treatments are given according to recognized standards. This includes determining whether a patient received the recommended treatment; whether procedures were correctly administered; and whether errors were made in administering medications or in completing treatments. By providing feedback to practitioners, the Quality Department can suggest modifications that will help reduce risks to patients and allow them to receive the best possible care. An example of a clinical practice guideline might state that if X-ray technicians do not identify and remove foreign objects during a breast examination, then the technicians should be trained to recognize the objects and make appropriate adjustments without further delay.

Ensuring that clinical procedures are performed properly is important to maintaining the quality and the safety of healthcare provided to all patients. The CMS strives to work with all Healthcare Providers to make sure that all patients receive the highest quality healthcare while keeping facilities in compliance with all applicable legal and regulatory requirements. In order to be certified by the Healthcare Quality Commission, organizations must meet a series of criteria, which includes providing training to staff on legal and regulatory issues, ensuring adequate staff health and fitness levels, meeting standards for service and patient care, maintaining quality and standards of care, developing and implementing guidelines for patient safety and satisfaction, and maintaining effective communications with patients. Each of these areas is essential for the safe and efficient management of healthcare.