Exemplary Quality Improvement Programs in HMOs

Abstract

This descriptive, exploratory project considers the key features of six health maintenance organizations (HMOs) perceived to be exemplary in their quality improvement (QI) efforts. Twelve experts in HMO QI identified 31 exemplary programs, broadly defined as QI efforts that exceed regulatory standards through commitment of resources, comprehensiveness, innovativeness, and methodologic sophistication. Six of the HMOs were selected for study, of which five (and an alternate site) underwent review and site visits conducted in mid-1992. The QI programs all used methods of continuous quality improvement (CQI) for developing new mechanisms for addressing problem areas and monitoring and adjusting new interventions. The HMOs have formal methods for developing and monitoring standards of care and rely heavily on clinician input. All the HMOs recognize both the importance and limitations of using outcomes measurement; quality studies continue to rely more on evaluation of key processes known to influence outcomes. It is not known how representative these six QI programs are of the average HMO QI program. However, findings suggest that the programs meet, and often exceed, published national quality standards. In addition, the key features of the QI programs were often present in all six, or at least a majority, of the HMOs—suggesting that a set of features does exist that could be considered exemplary. This information should be useful to designers, implementers, buyers, and regulators of managed care organizations to help safeguard quality. In addition, it should be determined whether these key features produce outcomes of the same perceived caliber. In HMOs with exemplary QIprograms, published standards don’t seem to drive QI activities—they seem instead to be met naturally as innovation and continuous improvement take place.