Gateway Health

Daniel I. Weaver

It’s no secret that technology changes lives. From the way people interact, travel, access information, work, play, or entertain, technology’s impact on life is undeniable. With U.S. healthcare costing trillions each year, related advancements manifest at a pace that dizzies even the most innovative leaders. Attempting to navigate such a rapidly evolving landscape without a sound Quality Management System (QMS) can mire health plans at the bottom of various Quality Rating Systems (QRS) with detrimental revenue implications. A QMS isn’t important for a high-performing healthcare program; it’s imperative.

Quality Rating Systems are designed to ensure that health plans provide enrollees with high-quality care through effective clinical programs, comprehensive provider network management, and rich benefit structures that exceed enrollee needs and ensure satisfaction. These rating systems are commonly tied to quality bonus payments, pay for performance structures, or revenue withholds, all of which perpetuate investment in value-based contracting, programs, technologies, and vendor relationships. Considering that many health plans cover multiple lines of business (such as commercial, Medicare, or Medicaid) and have more than one Medicare contract, plans need more than a dependable QMS; they need a transformational QMS. And every great QMS starts with people.

"The people, processes, and technologies wrapped in today’s QMS depend on innovators to develop the next generation of QMS solutions that can catapult us to the top of our Quality Rating System rankings as industry leaders, not adopters"

“Teamwork makes the dream work.” John Maxwell coined that phrase, which I’ve bestowed on more than one unsuspecting collaboration. Most folks don’t know the rest of the quote, “But a vision becomes a nightmare when the leader has a big dream and a bad team.” Not every QRS is created equally, with some containing dozens of measurements across preventive care, member experience, satisfaction, drug adherence, and operations. Depending on a health plan’s geographical footprint, a typical annual “playbook” might include more than a hundred unique programs and require interdependencies across multiple departments. Successful execution is rooted in exemplary program management and strong matrixed partnerships. People. People are the backbone of every viable QMS, and until we appropriately value, recognize, support, and develop the people behind the science, we cannot realize the full potential of technological solutions. But people alone don’t define a QMS; their communication and daily operations fuel success.

As a teenager in the 1990’s, I recall being asked if I was down with OPP. That question didn’t care about optimizing processes and procedures, but an effective operating model enables QMS integrity. Many emerging healthcare technologies focus on streamlining process flows and desktop level procedures to achieve overarching process improvement because inconsistency poses one of the most challenging industry barriers. Disparate data sources, unpredictable formats, disjointed technologies, retrospectively altered technical specifications…these, and multiple other irregularities force healthcare solutioning toward standardization. That consistency is even more important to internal processes and procedures. Ineffective inter-departmental communication can produce outdated or inaccurate data, incite sub-optimal service experiences for enrollees and providers, and compromise the integrity of deliverables to government agencies and vendor partners. Solutions constantly flood the healthcare space to mitigate these risks. However, adopting an emerging solution only delays inevitable regression without innovation.

I’m an Irish whisky guy. I’ll never forget the annual O’Leary reunions where my family gathered in emerald green around the baby grand piano hoisting their spirits of choice and singing in nostalgic bliss. Irish whiskey, fine wine, bourbon, whatever your poison, they improve over time. The aging process continuously improves the quality of the product by introducing unique hints of flavor or allowing maturation. The most effective QMS, one that won’t just bandage an immediate need and evaporate into irrelevance a few years after adoption, has to employ a culture of continuous improvement. Applied unilaterally to the technology, interfaces, processes, procedures, and people development, continuous improvement serves as the natural maturation process for a transformational QMS. New drugs enter the market every day. Research facilities identify ways to radically change long-standing medical procedures or debunk industry standards with dependable regularity. New technologies mobilize life-changing medicine, address enrollee barriers to seeking preventive care, and supplement health and wellness engagement programs, and as these technologies revolutionize the industry, health plans must adapt and integrate for survival. It’s equally important to ensure that new solutions are mapped into audit protocols to inform future improvement opportunities. Considering the constant change and influx of solutions requires executive direction.

At a recent Quality Improvement conference, I was asked to describe my Medicare Stars Rating team’s organizational structure, and I joked that it all started with the Overlord. Needless to say, the term Overlord was reiterated many times during the subsequent 24 hours, like a term of endearment. A good QMS may not need an overlord, but it certainly requires a concise Strategic Vision that must generate from and be regularly reinforced by the organization’s Executive Leadership team. You’ve probably all heard the expression, “too many cooks in the kitchen.” An effective QMS requires one cook in the form of an organizational strategic vision. Down to the lowest-paid individual contributor in your workflow, everyone involved in the matrix has to march to the same beat. Consider the organization’s strategic vision as the glue that binds everything together, the catalyst that truly makes the whole greater than the sum of its parts.

The healthcare space is one in which technology breeds competition and enables Quality excellence. Achieving desired outcomes is near impossible without an effective QMS, and in an environment that thrives off innovation and welcomes challenging the status quo, the more transformational and agile a QMS, the better for business. Healthcare leadership isn’t looking for “today” solutions; we’re looking for tomorrow’s solutions. The people, processes, and technologies wrapped in today’s QMS depend on innovators to develop the next generation of QMS solutions that can catapult us to the top of our Quality Rating System rankings as industry leaders, not adopters. We depend on technology not only to change the lives of our enrollees but to change the ways that we shape healthcare for the future.