Nursing 557: Quality improvement in healthcare project
Quality improvement in health care consists of a system of continuous acts within the system that result to improvement in the overall system and the status of the specific targeted group of people (Ogrinc et al.,2015). According to the Institute of Medicine (IOM) quality improvement is the actual relationship between the improvement of healthcare services and the outcome of the patients (Larson et al.,2016). Based on the desired outcome of the newly developed system especially one pertaining to the improvement of data collection and storage within care facilities; there are some principles to be considered in order to ensure a successful quality improvement project; focusing on being part of the health team, focusing on the patients, focus on patient data collection and usage, and review of quality improvement systems as systems and processes.
Before the initiation of quality improvement, the organization has to consider its current system and the mode of service delivery. A healthcare service delivery system may be small such as the family planning or immunization clinic or a huge facility that provide all services to the public. Quality improvement may become achieved in various forms even though the optimum achievement is dependent on individualization to meet specific needs of the organization and that of the patients. Activities within the project are categorized mainly into two; the actions to be carried out and the procedure of performing them. One of the commonly used tools is the process mapping, which helps understand the organization better and the processes within the system as well.
One of the measures of quality improvement in health is the assessment of the patient’s needs achievement and expectations. Some of the common services in QI that are designed to achieve patient satisfaction and improved outcome include; patient safety, provision of patient centered care, improvement of patient access to services, evidence based care provision, coordination of care with other systems and collaborations, patient engagement, and cultural competencies (Dandoy et al.,2017). Team work and inter-professional collaboration in healthcare is very effective in QI when; creativity is required to provide solutions, whenever the system is complex, to improve contributions from different personnel, and provide various staff commitment.
Laws and regulations
The False Claims Act is a federal law that regulates and hinders any person or organization from filing a false claim or record over any form of healthcare program. The false claims act was enacted in 1863 by a congress concerned that suppliers of goods to the union army during the civil war were defrauding the army. The healthcare program is basically a federal law that is responsible for the provision of health services to the public either directly or indirectly through the insurance companies (Krause 2017 p56). The healthcare organization is either funded by the government or the private sector and is responsible for ensuring that their services are acquired by all members. The act is responsible for the determining those who are eligible for care and payment according to the federal regulations and those who are not. It enables the prevention of false acquisition either knowingly or unknowingly based on the fact that all the claims are false. Some individuals and organizations may choose to commit fraud with known intentions for their own monetary gains.
Some states in the US have adopted the state laws from the federal law that helps cover increased cases of fraud in the healthcare facilities. One of them is the Michigan Medicaid False Claims Act (MMFCA) (Salcido & Rubin 2016 p19). The act is responsible for the management of care provisions by the Medicaid Acts and thus prevents any fraud and kickback conspiracies that may be organized against the program. Some of the common occurrences within the False Claims Act are the billing services for care that is not yet provided or accounted for, sometimes the same care service may be paid for more than once which is also fraud, and the cases of making false records for health services so that they can be paid for even if they do not exist.
Breaking the federal claim law can result to extensive financial penalties depending on the offense committed. Anyone can commit medical fraud ranging from solo ventures to widespread activities by an institution or group. For every false claim or fraud committed the penalty associated is payment of the actual amount stolen in three times and the addition payment of $5500 to $11000 which is a lot of money for any care services. For the state policies such as MMFCA, the consequences can be imprisonment or payment of a fine of approximately $50,000 or in extreme cases both may apply (Kennedy 2019 p45). Under the criminal FCA, 18 U.S.C Section 287, individuals or entities may face criminal charges for submitting false, fictitious, or fraudulent claims. Any person who receives a claim with their right knowledge and decide to remain silent even with their knowledge that it might be wrong may be eligible for the payment of triple the amount or sometimes even with imprisonment.
Although the federal claims act is mainly in support of the hospital and health institutions that provide care, there are other roles that are played by the act. It helps protect the employees who take charge in reporting and providing witness for the cases that have been paid as a result of fraud. Mainly the people who get sentenced or the organizations may choose to take action against the people who report them and that may lead to severe consequences even for those who reported. The employees are protected from cases of harassment and discrimination or suspension for reporting any cases of fraud. Additionally, the employees who report the cases may be paid more in salary plus other incentives and interests. In the case where they lose their jobs because of their acts of honesty, they are reinstated and also receive all forms of compensation for the losses they incurred. Apart from the MMFCA, there are two other forms of federal claims act, the Federal Civil Claims Act of the social security act and the Federal Civil False Claims Act of the United States Code.
References
Dandoy, C. E., Hilden, J. M., Billett, A. L., & Mueller, B. U. (2017). Quality Improvement and Patient Safety Resources. In Patient Safety and Quality in Pediatric Hematology/Oncology and Stem Cell Transplantation (pp. 361-368). Springer, Cham.
Kennedy, P. (2019). Lies and Statistics: Statistical Sampling in Liability Determinations Under the False Claims Act. Stanford Law Review, 71(5).
Krause, J. H. (2017). Reflections on Certification, Interpretation, and the Quest for Fraud That Counts under the False Claims Act. U. Ill. L. Rev., 1811.
Larson, D. B., Donnelly, L. F., Podberesky, D. J., Merrow, A. C., Sharpe Jr, R. E., & Kruskal, J. B. (2016). Peer feedback, learning, and improvement: answering the call of the Institute of Medicine report on diagnostic error. Radiology, 283(1), 231-241.
Ogrinc, G., Davies, L., Goodman, D., Batalden, P., Davidoff, F., & Stevens, D. (2015). SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process. The Journal of Continuing Education in Nursing, 46(11), 501-507.
Salcido, R., & Rubin, E. (2016). What Extrapolation Could Mean for Your Practice: A Legal Overview of Statistical Sampling in Overpayment and False Claims Act Cases. Chest, 149(6), 1566-1570.
