Ensuring Excellence: Reconceptualizing Quality Assurance, Risk Management, and Utilization Review

Abstract

A new conceptualization of the related activities QA, RM, and UR may allow an organization to ensure appropriate, proficient, and satisfactory care and to ameliorate the consequences of bad outcomes. Three processes incorporated into the conceptualization are essential to ensuring excellence, as are specific attributes of the care process. The difference in initiation of activities (reactive versus proactive) is part of the model; relationships among the essential activities and processes and between reactive and proactive activities are suggested; and viewing data sources or collection as separate from the processes and activities is suggested. Areas for development and research within the conceptualization that are inadequately understood include data sources and analysis methods useful for the processes needed, evaluation of the consequences of different reactive activities, and the usefulness of TQI activities for setting goals or standards and for changing behavior. Implementing such an approach to ensuring excellence would be a challenge. It is hoped that this formulation will assist in communication among those working to ensure excellence; promote analysis of whether current organizational structures for ensuring excellence and for cost containment are creating redundance, competition, or gaps in needed activities; broaden the perception of the possible and/or appropriate scope of some activities, such as the inclusion of proactive preventive care and the provision of special high-risk programs; and assist in the identification of areas of needed research and development.