Data skills key, say HPR advisors
The advisory board members of Hospital Peer Review (HPR) have diverse backgrounds that span the spectrum of the health care quality profession. Their wide variety of experiences seemed ideal to add perspective to where the health care industry stands today, and what roles hospital quality professionals will play in the future. In October 1995, we asked our board members to evaluate the state of the health care quality profession for this special report. All agree that the world of health care will not look the same when HPR celebrates its 25th anniversary, but they have diverse views on what the health care industry will look like after the turn of the century. What follows are their responses to our survey:
What training, education and career experience will be most important for advancement?
During the next five years, it will become increasingly important for quality managers -- regardless of the mix of functions for which they are responsible -- to have a strong background not only also in the collection of data, but the use of information for decision making. The ability to think critically and communicate well will be essential.
As for career experience, a broad background will be of inestimable value, particularly as health care management encompasses the continuum of care. No longer will expertise in a single discipline be enough to ensure career success. The broader one's background -- quality assessment, CQI, case management, risk management, utilization management, inpatient, outpatient, rehabilitation, home health, information systems, etc. -- the greater one's ability to contribute to the improvement of health care.
-- Ruth Loncar, MBA
Director of Outcomes Management
Adventist Health System/West
Roseville, CA
Education in the field of health care information and technology is necessary. Many health care professionals could use additional education in the field of health care data and the technology that supports it. As the health care industry uses more comparative data, it will be important to keep up with not only the data, but also the technology that supports it.
-- Judy Homa-Lowry
Director of Quality Improvement
The Delta Group
Greenville, SC
Exposure to nontraditional thinking may be the most important learning activity for health care leaders over the next five years. This may occur in formal educational programs, in self-directed learning, or in the pressure cooker of everyday work. Learning to be a learner may be the real trick -- learning to learn from our mistakes, for example, both as individuals and as organizations. This is not something many of us do very well yet, but it will be vital to the dynamic environment we will increasingly face over the next few years.
-- E. David Buchanan
Consultant in Improvement and Quality
Nashville, TN
What will the title "case manager" mean to readers of Hospital Peer Review in its 25th anniversary year?
I predict that by the year 2001, the evidence will have become overwhelming that the nonphysician "case manager" improves the quality/cost-effectiveness of patient care of both inpatients and outpatients. I also predict that most of the forward-looking organizations will abandon the title of "case manager," and instead substitute the term "patient care coordinator" because the term "case manager" is misleading and controlling. Physicians almost universally dislike the term because they feel that they are the "case managers," not the nonphysicians. Patients may fear the term because it implies that their access to a physician could be limited.
-- Elgin K. Kennedy, MD
Consultant in Utilization Management, Mage Corp.
Associate Clinical Professor of Medicine
University of California at San Francisco
San Mateo, CA
It may not happen fully by the 25th year, but I predict that the functions of the "case manager," as we have been using that term recently, will be reabsorbed into the process of direct patient care. Providers of primary care used to perform these functions and the present direction of change in both financing and delivery systems again makes a fully integrated process for addressing a wide range of patient needs eminently logical.
-- E. David Buchanan
Will utilization review managers deal strictly with clinical data and analysis when Hospital Peer Review celebrates its 25th Anniversary? Why or why not?
Progressive utilization review managers already are active participants in managing clinical care (rather than just chart review and data analysis). Successful organizations will incorporate utilization and resource management into the performance evaluation of every employee. To make this happen, utilization managers must assume a leadership role in teaching the organization to become an efficient provider of quality health care.
-- Sharon Baschon, RN
Utilization Resource Management Consultant
The Baschon Group
Durham, NC
Simply having data will not be enough. Success also will depend -- as always -- on how well the data are shared, and how well utilization review managers can motivate their constituents to change.
-- Elgin K. Kennedy
Presently, most health care workers and most data analysts tend to think of analysis in terms of rankings and comparisons. In five years, more people will appreciate the power of analyses that describe the performance and behavior of processes and systems over time.
-- E. David Buchanan
Utilization review, at least as it has developed from the 1970s through the 1990s, is an historical aberration in health care and will disappear. The notion of interposing a person or process between the patient and physician is a perversion generated by the uncontrolled cost escalation of the period noted. Structured care methodologies, case managers, and systems placing providers at risk for their resource usage will relegate what we now know as "utilization management" to a very minor role. Those from this profession will evolve into data analysts, retrain to other roles, or retire (to the great relief of both practitioners and patients).
-- Martin D. Merry, MD
Health Care Quality Consultant
Associate Professor of Health Care Management & Policy
University of New Hampshire
Exeter, NH
In the year 2001, will the quality of health care be more or less important than the cost of health care?
Over the next five years, increasing pressures from managed care to further reduce costs will inevitably lead some providers to lower quality standards to unacceptable levels. Providers will become more aware that quality review is necessary to assure not only quality care for patients but also a level playing field for providers as they compete on price. Further, as patients' choice of provider is increasingly limited, quality will become more significant. As quality becomes more important to patients/employees/ insureds, payers will reflect this change.
-- Harold H. Simpson, JD
Principal
Simpson & Graham, PA
Little Rock, AR
Cost will continue to be paramount to the provider and the payer. Quality will be most important to the patient. . . . Quality will be defined differently. Instead of how nice the doctor's nurse was, or how much better the cough is, patients will be measuring quality by how far they had to drive, how long they had to wait, or how many days away from work it took to run through the health care circuit.
-- Paula Swain, RN, MSN, CPHQ
President
Paula Swain Seminars and Quality Consulting
St. Petersburg, FL
When Hospital Peer Review celebrates its 25th anniversary, the quality of health care will be more important than the cost of health care. Currently, the cost of health care is the predominant focus of the marketplace. However, as competition results in cost parity, quality will become the differentiating factor. We already see this beginning to occur in some marketplaces, such as Cleveland, as it relates to both clinical quality outcomes and service quality. Also, there appears to be a growing awareness among both payers and consumers that improved quality outcomes actually result in decreased costs.
-- Ruth Loncar
It is abundantly clear today that costs are more important than quality, at least to health care payers and to managed care organizations. This is especially true in parts of the country that have developed highly competitive managed care marketplaces. This unfortunate situation will only change when we have scientifically validated quality indicators available nationally, and available to the public, which can routinely and fairly identify the higher-quality health care systems. The HEDIS measures are barely a start. I doubt we will be able to measure the overall quality of a health care system fairly by the year 2001 (but perhaps by 2006?)
-- Elgin K. Kennedy
By the year 2000, there will be considerable movement toward much less variation in clinical outcomes (for example, technical quality will be higher, and with less variation), and people will be much more conscious of plan benefits and service quality. Discussion will focus upon neither quality nor costs; instead, value (quality in the context of cost) will dominate as the basis for decisions regarding health plans.
-- Martin D. Merry
What specific skill will quality professionals need most to prepare for continued managed care growth?
Quality professionals need to have an understanding of the managed care environment through the eyes of managed care agencies instead of the impact of managed care on the hospital. For example, if it is a desire of the managed care agency to comply with the National Committee for Quality Assurance (NCQA) in Washington, DC, it makes sense that the managed care agency will pass those requirements along to its "customers." Therefore, the hospital, clinic, etc., need to be familiar with NCQA regulations and incorporate them into the quality/utilization program.
-- Judy Homa-Lowry
Facilitator skills will help the quality manager bring together clinical, administrative, and financial team members to create an efficient system for providing patient care. Strong communication skills, the ability to manage change in an often-chaotic environment, and common sense are critical. A well-developed sense of humor and an appreciation of the absurd certainly can't hurt.
-- Sharon Baschon
For just about anyone working in health care, the most important personal characteristic for future success will be comfort with change. And the most important skill will be the ability to design and test changes in every conceivable aspect of our organizations, especially in patient care delivery. In order to be ready for a successful career in five years, search now for opportunities to practice change making. Find others who are bored or frustrated with controlling environments, who are curious about new ways of doing things, who understand that the status quo is today's equivalent of the Ancient Mariner's albatross.
-- E. David Buchanan
Now is a good time to act dumb. Ask "Why?" a lot. Seek out people in parts of the hospital you have never seen before. Then be the conduit that ties these outposts together. Make it a passion to see the bottom line from different seats in the hospital.
Become a pro at networking. Hospitals that are using the team approach are discovering that a functional approach for continuum of care includes outpatient services. Inviting a physician's office manager, a community home care and nursing home leader to talk about upcoming projects puts a lot more reality into any planning.
-- Paula Swain
What career tracks will develop over the next five years for quality professionals? For example, will there be a data broker track for staff who will coordinate the myriad information within a hospital? Will the roles of case managers, quality improvement directors and utilization managers be different?
As improvement processes have developed in health care organizations, a distinct space has been created between the actual operation of the process of care and efforts to improve them. This is a major barrier to real and sustained improvement. In the future, the most successful change agents will be those who are able to find ways to move both the responsibility for improvement and the actual functioning of the improvement process back into the day-to-day systems of work. When real improvement is occurring, an external observer should be unable to distinguish the improvement activity from the performance of the work being improved.
-- E. David Buchanan
The lines of responsibility among traditional case managers, utilization managers, and quality managers will continue to blur. This will be driven primarily by two forces -- operational consolidations and the strong link between quality and cost. Quality managers who have excellent data, organization, and communication skills could very well progress into a chief information officer (CIO) role -- advising their facilities on how to access and use the wealth of available data. If the quality manager advances to the CIO position, there will be a need for day-to-day case managers who manage the care of the patient as well as track and trend the results. As more patient care technicians are cross trained to perform non-nursing tasks, nurses could evolve into case managers.
-- Sandy Metzler, MBA, RRA, CPHQ
Director of Resource and Outcomes Management
Columbia-HCA
Nashville, TN
The quality professional needs to be viewed as a necessary and valuable resource for the institution. He or she needs to demonstrate improvement not only in terms of clinical improvement but operational and financial improvement as well. I feel that the role of data broker for all health care institutions is key. Centralizing data, eliminating duplication, eliminating data collection activities that have no current need of purpose for the organization, etc., are critical steps in not only identifying opportunities for savings but also for being able to monitor changes in performance more effectively.
The roles of case managers, quality professionals, and utilization professionals will change in the coming years. I think we may see many of these functions performed by one professional. The professional would have all of these skills. I am also beginning to see hospitals hire quality engineers from outside of health care to assist and direct quality programs. To sum it up, if professionals in these roles are not considered as necessary to the future survival of an organization, they may be eliminated or their responsibilities may be collapsed into other positions.
-- Judy Homa-Lowry
The future is hopeful for those with initiative, creativity and the person who will step out on faith. Roles will be more focused than in previous years. Rather than working in obscurity, writing reports that are not even acknowledged, the quality professional will devise methods of increasing participation, enthusiasm and understanding by using facilitation skills. There is no one else in the hospital who should have more skills in seeing the big picture, using quality methods and communication.
The quality professional may have to define their own role. If that is the case, start feathering your nest and pick the roles that you like best. Get specialty education and make yourself indispensable. For example, carve out the responsibility of producing booklets for managers to continue to train staff on. Offer to get quality projects started when they are suggested. Become the quality shadow of a friendly physician and make him be your mouthpiece for issues that data show to be significant. Get in league with the managed care company that uses the hospital the most. Find out what their objectives are for quality and utilization, support them and trade information on their member's practices.
-- Paula Swain
Quality and utilization managers of the future may find themselves working for a physician group, in an outpatient clinic, long-term, and home care settings, rather than in an acute care hospital. . . . Successful quality and utilization managers will be those who can meet the needs of each of the different components, without losing sight of the overall organizational objectives. The opportunities are almost limitless for those who are not confined by rigid boundaries. Quality and utilization managers who are unable to move away from the single-provider, single-department focus may find themselves without jobs in the next several years.
-- Sharon Baschon
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