EXEMPLARY QUALITY IMPROVEMENT PROGRAMS IN HMOS

Background: This descriptive, exploratory project considers the key fe atures of six health maintenance organizations (HMOs) perceived to be exemplary in their quality improvement (QI) efforts. Methods: Twelve e xperts in HMO, QI identified 31 exemplary programs, broadly defined as QI efforts that exceed regulatory standards through commitment of res ources, comprehensiveness, innovativeness; and methodologic sophistica tion. Six of the HMOs were selected for study, of which five (and an a lternate site) underwent review and site visits conducted in mid-1992. Findings: The QI programs all used methods of continuous quality impr ovement (CQI) for developing new mechanisms for addressing problem are as and monitoring and adjusting new interventions. The HMOs have forma l methods for developing and monitoring standards of care and rely hea vily on clinician input. All the HMOs recognize both the importance an d limitations of using outcomes measurement; quality studies continue to rely more on evaluation of key processes known to influence outcome s. Discussion: It is not known how representative these six QI program s 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 inform ation should be useful to designers, implementers, buyers, and regulat ors of managed care organizations to help safeguard quality. in additi on, it should be determined whether these key features produce outcome s of the same perceived caliber.