Introduction Southside HMO serves 495,000 members throughout the eastern region of the United States. Servicing this amount of members means that the company is providing quality health care. Given this amount of volume it is understandable that there will be concerns at times raised from both our providers and the membership. It is essential that all issues and concerns be addressed in a professional, ethical and timely fashion while maintaining the standard of care that our company has built its reputation on.
It has been brought my attention that some of our Sunnyside Hospital affiliated members have filed complaints that their primary care physician issued referrals to designated specialists are not being approved. There are also complaints
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It is also key that we identify if the cause for the issues are a result of a localized facility issue or if it is actually system wide. This task will be accomplished with a client survey or phone call at which time our staff will assure our membership that their health and concerns are our top priority. Going forward it is my recommendation that all future incoming complaints be acknowledged within 24 hours with a statement informing the complainant that their concern will be reviewed and investigated with a formal response or resolution completed within 30 days. It is also understood that depending on the complexity of the complaint an additional 30 days may be required or expedited. In this instance this can only occur with supervisor review and approval.
The providers of Sunnyside Hospital will be contacted next in the form of a series of town hall meetings if hospital space is available or mailers. It is essential that we reassure our participating providers that their service is invaluable and patient care is our priority. We need to be sure that the providers have confidence in the service that our company supplies. We will also reassure the providers that we value their expertise in providing comprehensive patient care and it is our role at Southside HMO to coordinate that care while maintaining costs at an affordable level for
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This educational plan will also be shared with our members and providers by the use of mailers, posters, and inserts.
It is my recommendation that performance measures be instituted as a means to know how to better service both the members and providers. These measures will maintain and ensure the following (Kongstvedt, 2013): Transparency and accountability Quality improvement Education and engagement of consumers Patient safety Research
Summary
With the implementation of the above guidelines, initiatives and protocols we will continue to provide quality health care for our members and assist our providers with the tools needed to give their patients the care required. Our company will continue to be in compliance with all quality management initiatives. Ultimately, our members and providers need to feel our company is not about the bottom line but the people it serves by providing quality
Our vision is to be the hospital of choice for patients, employees, physicians, volunteers, and the community.
A physician-hospital organization (PHO) consists of 15 hospitals – with 2,247 staffed beds – and approximately 500 physicians. The PHO operates in a very large section of south Georgia, including the cities of Valdosta, Tifton, Thomasville, Moultrie, and Waycross. The PHOs’ physician members represent approximately 90 percent of all physicians practicing in the region.
RECOMMENDATION There is “an inherent conflict between best care and financial performance”. The CEO states that “Finances are not, and never have been, our primary concern.” However, the business must address its decreasing profitability to be able to continue to survive. This will become even more urgent if the reduced government spending that the CEO foresees happens. The organizational culture is high quality care, high-performance and non-profit which must be taken into account in any solution. The healthcare business has a clear focus and is very successful at continually improving its patient care and processes. While clinical performance improvements have resulted in revenue losses for the Intermountain healthcare business the Intermountain health plan, SelectHealth, and other health plans that buy Intermountain health care services have benefitted. Intermountain needs to translate these benefits into additional profits to support its main business, healthcare. Its skill at providing this care should translate into significant market advantage for SelectHealth and for Intermountain when selling
Kaiser Permanente is a managed care facility that provides services across the health care continuum. Over the years the organization has continually made efforts toward improvements since it was first founded in 1945. These improvements generate a series of successes that set Kaiser apart from similar organizations. But, just as any health care delivery system, Kaiser has faced challenges in the past, present and may continue to do so in the future. In this paper I will explain what attributes to the success of Kaiser Permanente and some of the challenges they face.
McLaughlin, C.P., & Kaluzny, A.D. (2006). Continuous Quality Improvement in Health Care, Third Edition, Jones & Bartlett Publishers, Sudbury, MA.
(MCOs) operating. The hospital group is the state’s largest not-for-profit organization and boasts an impressive performance plan, serving the healthcare needs of approximately 8 million citizens in Virginia. Moreover, Chesapeake Health Plans was the first organization to successfully attempt to request and obtain the highest level of accreditation from the National Committee of Quality Assurance (NCQA). Furthermore, Chesapeake health plans are structured to provide medical plans that cover services under the HMO’s, PPO’s, POS, and Medicare HMO’s. Chesapeake health plans attributes a considerable portion of their net service revenue generated to their effective HMO health plans, which realized a 46% of total revenue, while their Medicare HMO produced an impressive 39% of total revenue. Furthermore, their Preferred Provider Plan (PPO) generated 10%, and the Point of Service Plan (POS) saw a 5% figure. This case study financial analysis will effectively assess Chesapeake Health Plans: HMO financial performance, focusing on a competitive analysis, a cash flow analysis, clear profitability ratios, liquidity ratios, debt management ratios, asset management ratios, operating indicator analysis, a comprehensive financial assessment of Chesapeake’s financial state, as well as effective fiscal recommendations for their organization.
Quality management is essential to the success of the quality improvement of the health care industry. “Management uses management and planning tools to organize the decision making process and create a hierarchy when faced with competing priorities “( Ransom, et al., 2008). Quality measures should have these goals: effective, safe, efficient, patient-centered, equitable, and timely care (Quality Measures, Center for Medicare & Medicaid Services, 2011).
In the late summer of August 2005 the Gulf Coast was preparing for a hurricane that no one ever imagined would be such a detriment to the beloved town of New Orleans, LA. Hurricane Katrina was a category five hurricane, according to the Saffir-Simpson Hurricane Scale. On August 29, 2005 Katrina made land fall as a category three hurricane with wind speeds around one hundred and forty miles per hour. Evacuation efforts in the state of Louisiana were non-existent for many families including the local hospitals and nursing homes. The hospitals became shelters for the surrounding nursing home facilities, current patients, the staff, families of the staff, and even pets. One of the most unethical debates from this disaster occurred in a local hospital where patients were given lethal doses of drugs and euthanized by Dr. Anna Pou. The conditions at Memorial Hospital were anything but ideal, but no person is obligated to decide who survives and who perishes.
This quality improvement discussion will review the purpose of quality management in health care industry and why it is needed. Included in this QI report will be an explanation of the
If a patient or carer wants to complain I would see if I could deal with it personally. If I was unable to resolve the issue, I would advise them to call or email PALS the hospital complaints department.
al., 2012). Trying to get the leadership motivated with adapting to TQM was a challenge in the beginning. The enthusiasm of top leaders has caused the TQM process to become effective. Although Health care has a complex adaptive system, leadership is crucial in implementing an improvement system (Sollecito & Johnson, 2013). The strengths of the TQM process were the support of the chamber of commerce, implementation of a quality improvement plan, adapting a successful way to measure improvement and development of cost effective techniques (McLaughlin, et. al., 2012). Corporate headquarters was totally involved in the TQM program with the CEO John Kausch as an active member of the Total Quality Council of the Pensacola, Area Chamber of Commerce (McLaughlin, et. al., 2012)
Nurses are constantly challenged by changes which occur in their practice environment and are under the influence of internal or external factors. Due to the increased complexity of the health system, nowadays nurses are faced with ethical and legal decisions and often come across dilemmas regarding patient care. From this perspective a good question to be raised would be whether or not nurses have the necessary background, knowledge and skills to make appropriate legal and ethical decisions. Even though most nursing programs cover the ethical and moral issues in health care, it is questionable if new nurses have the depth of knowledge and understanding of these issues and apply them in their practice
Glickman, S., Baggett, K., Krubert, C., Peterson. E., & Schulman, K. (2007). Promoting quality: the health-care organization from a management perspective. International Journal for Quality in Health Care.
Any patient or family complaint should be immediately addressed by the employee who receives it. If it is an outside call, every attempt should be made to identify what unit or department they have the concern with and to forward that call to the individual within that department who is best able to assist the caller. Often these issues are just a miscommunication or an unmet need that can quickly be remedied. An example of a complaint that can be quickly remedied is a need for a prescription refill,
Everyday, healthcare professionals are faced with ethical dilemmas in their workplace. These ethical dilemmas need to be addressed in order to provide the best care for the patient. Healthcare professionals have to weigh their own personal beliefs, professional beliefs, ethical understandings, and several other factors to decide what the best care for their patient might be. This is illustrated in Mrs. Smith’s case. Mrs. Smith is an 85 year old who has suffered from a large stroke that extends to both of her brains hemispheres which has left her unconscious. She only has some brain stem reflexes and requires a ventilator for support. She is unable to communicate how she wishes to proceed with her healthcare. Mrs. Smith’s children, Sara and Frank have different views regarding their mother’s plan of care. The decision that needs to be made is whether to prolong Mrs. Smith’s life, as Sara would like to do, or stop all treatments and care, as Frank feels his mother would want. In the healthcare field, there are situations similar to this case that happen daily where moral and ethical judgment is necessary to guide the decision that would be best for the patient. The purpose of this paper is to explore and discuss, compare and contrast the personal and professional values, ethical principles, and legal issues regarding Mrs. Smith’s quality of life and further plan of care.