Quality Improvement, Billing & Revenue cycle

Week 8

Key areas for Service delivery

•Clinical Services (Medical care )•Management of services (Efficient

and effective service)•Administration of billing and

reimbursement (core task for organization)• Financing of Services( Manage costs

and revenue streams)

Revenue raised by GovernmentPetrochemical, oil & Gas

InvestmentsTourism etc.

Daman (Government established insurance company)

supply Employer Health insurance & Theqa for Emiratis

Government facilities to provide Healthcare services

ALSO Private providers & mixed i.e Cleveland Clinic

Tiered insurance based healthcare provided for UAE

residents

Ministry of Finance sets budgets for

Ministry of Health

HAAD Licensing and approvals SEHA operational management

of healthcare facilities

ECONOMY

Revenue cycle• DefinitionHealth care revenue cycle management consists of the tools, methodologies and techniques that medical institutions use to review patients' financial situation, issue invoices and collect payments from the federal and state governments, insurance companies and other organizations.

Read more: http://www.ehow.com/facts_6937338_revenue-cycle-management-healthcare_.html#ixzz2jB8nywDU

Revenue cycle

What is quality?• We want to provide the best service we can • We want to do this in the most efficient and effective way• We want to maximize revenue • We want to minimize medical errors• Offer best services for staff and patients• We want to have good management and successful planning• We want accreditation to benchmark good service• Reduce coding and billing errors to maximize revenue streams• We want a process of evaluation to get information on which

we plan our services• We want clinical staff to practice evidence based clinical

practice• We want planning based on information and clear objectives

Objectives – need to be:

• Specific- focus on key things•Measurable – we can measure i.e patients • Attainable – We can do it• Realistic – this is able to be achieved• Time limited – has a time limit• Evaluated – How effective were we?• Risk assessed- threats to success identified

to reduce risk

Example• Objective 1 – We want to increase by 10% revenue from the

pharmacy within the next 6 months.

• By having a set of objectives staff can see what they have to do, they also can be reviewed by their contribution to them

• If we involve clinical and administrative staff in setting the objectives they will be more effective and linked to the clinical practice

• Accurate patient information is key to planning, evaluation and objective setting!

Quality improvement key principles

• Understanding the problems based on the information available

• Understanding the processes and the systems within the organization particularly the patient pathway – and where it can be simplified

• Analyze the demand, capacity and work flow of the services• Choose tools to bring about change – effective planning,

leadership, clinical engagement and staff and patient participation in the process

• Evaluating and measuring the impact of change• Use of Key Performance Indicators ( KPI)

Planning process

Patient pathway

Revenue cycle

Clinical

Administration

Management

Finance

Budgeting

Quality

Plan, Do, Study, Act

Health Information

7 core elements• Data and measurements for improvements (shared objectives

based on information).• Understanding the processes ( seeing where issues are)• Improving reliability (reduction od medical errors by mapping

clinical pathways)• Demand, capacity and flow• Enthusing, involving and engaging staff (Staff are part of the

solution not the problem)• Patient involvement and feedback • Integration of clinical, revenue and objectives within financial

and strategic planning

Total quality managementStrategic• Set the vision and the objectives• Overview of the data and

information to make decisions

Operational• Implement the objectives and

ensure data is accurate.• Reporting on implementation

Financial/admin• Monitoring KPI in the budget,

and revenue. • Monitoring costs• Revenue cycle and denials

reporting

Clinical• Reduction of medical errors• Clinical and non clinical data

management• Evidence based clinical practice

Bench marking & accreditation

Task

• In twos or threes look at providers here in Abu Dhabi and what standards they work to and what accreditation they have