1. Do not pay for medically unnecessary, experimental or inefficient care when better practices exist in the community - We must begin to identify the latter.

2. Train staff well (for example, in Six Sigma, below) and do this as job enrichment

3. Pay fairly: it is better to pay the specialist when they reduce hospitalization then to reduce their pay only to see them generate additional, more expensive work.  EG, we are seeing false + imaging leading to unnecessary heart caths.  (This calls for incentive realignment).

4. Get documentation only when it is required; train the doctor's office to tell us, accurately what their assessment is, even if preliminary; and, succinctly, why the patient needs a dear procedure.

5. Use peer reviewed guidelines for which there has been buy in by the provider community.

6. Educate physicians and their staffs.

7. Don't sweat the small stuff (e.g., why review a 99213 after an auto-auth unless it is to check par status and eligibility that any clerk, well trained, can do)

8. Identify cases before they are a crisis or at least pay attention when they appear and reappear.

9. Get PCPs involved in all admissions, follow-up care and get timely follow-ups.

10. Install case management
www.healthleaders.com/index.ez?viewStory=4041

The Origins of the Quality-of-Care Debate- Part Four of Six
(paraphrased) from Blumenthal, D.
New Eng J Med. October 10, 1996;335 (15):1146-1149.

• Wennberg and Gittelsohn20 among others brought clinical epidemiology to our attention in quality management (QM), making its first contribution in identifying the wide variation in the processes and outcomes of care among patients who received routine treatment for the same health care problems in different places and health care settings.21,22,23 However, variation may create the impression that much medical practice lacks scientific foundation. This has "emboldened purchasers and policy makers to challenge physicians' claims that they know authoritatively what constitutes optimal health care.23" But, it has also created opportunities for learning about and improving daily work. While an activity as complex as medical practice is inevitable, the "challenge is to identify the variations that produce the best outcomes. From this standpoint, failure to learn from the variation would be a far more serious indictment of the profession than the variation itself.23"
• Clinical epidemiology can help us understand better how such variation affects outcomes. For example, consider the quality improvement (QI) opportunity in evaluating the timing of prophylactic administration of antibiotics and the risk of surgical-wound infection.24
• "Our tools for measuring outcomes were primitive, however.25 At the same time, sociologists and psychometricians had developed better methods of assessing not only patients' functioning, but also their values and preferences for various functional states.26,27 Outcomes research has created new measures of quality that will change clinical practice, especially the treatment of chronic illnesses, in which improved functioning is a primary objective. This is already apparent with regard to such conditions or procedures as back pain,28 benign prostatic hypertrophy,29 and hysterectomy.30 "
• Progress in information systems, computer technology, and communication techniques is very relevant to QI/QM, especially given the complexity of health care and its systems. Advances In management information systems (MIS) have made it "cheaper, easier, and faster for researchers, clinicians, and managers to accumulate and analyze multiple types of data - including billing data, data on encounters with patients, and data from automated medical records, now increasingly common. Even more important, the spread of computer technology into physicians' offices through desktop equipment and the Internet has created opportunities to gather new and timely information about providers' performance and the clinical choices available to them and their patients.31 This information ranges from advice about drugs and their side effects to consultation with specialists in distant places."
• "For years, advanced industrial organizations have used methods adapted from psychology, statistics, and operations research to avert predictable human errors, eliminate unnecessary and harmful variation, and improve the production of goods and services.33 Despite skepticism on the part of physicians, there is reason to believe that such techniques may be useful not only in preventing error, but also in managing chronic diseases, such as asthma,34 hypertension,35 and other illnesses.36"
• For physicians to retain control of their own work, they must harness information science-medical informatics-to the extent that it enters their practice lives. This will have the side-benefit of helping them "resist untested, radical efforts to reduce the costs of care because they pose threats to quality.
• Furthermore, it can be argued that it is essential to be involved making integrated processes of care work well as this will, inevitably affect clinical decision making if not satisfaction of the practitioner.37 "Earlier in this series, we noted that various definitions of quality were legitimate and reasonable, depending on one's position in the health care system. Physicians tend to see quality in terms of the excellence of the services they provide ("doing the right things right") and the quality of their interactions with patients. Organizations and health plans emphasize the optimal functioning of systems when they define quality of care. The changing nature of medical services is forcing physicians also to pay increasing attention to systems of care, for such systems are increasingly important to both technical excellence and optimal interaction with patients. This is a challenge for which few physicians are prepared.

First, as discovered by the American automobile industry in the 1980s and 1990s, errors represent the largest component of the cost of producing an automobile. Organizations can categorize costs into the following 3 categories:
I. Process cost - The cost to run one iteration of a process, whether that be producing an X-ray, conducting a surgery, caring for a patient with acute MI. Process cost consumes approximately 67% of the total cost of a process.
II. Cost of Quality (COQ) - The cost incurred to assure quality is maintained at an acceptable level. Typically, every process includes several steps, like inspection, to make sure that the process performs as intended. For example, nurses check, then recheck, to assure that the medication they are preparing to administer to patients will not result in an allergic reaction. Case managers invest up to 90% of their time inspecting care to assure that care paths are followed according to protocol. All of these steps, and their underlying costs, are COQ investments; COQ typically consumes 14% of total cost.
III. Cost of Poor Quality (COPQ) - The cost incurred to correct processes that fail to perform as intended. Almost all processes contain some rework, "work-arounds," and unexplained redundancy, not to mention the cost of malpractice and risk management. COPQ consumes approximately 20% of total cost. Therefore, as one calculates COQ and COPQ, the cost structure would consume about 34%

Measure, Monitor and Manage (3m)