Case management goes global
Case management goes global
QI efforts gathering steam overseas
If you think case managers in the United States have it rough, consider working in a country where the concept of case management is so new that hospital administrators are at a loss to explain it to physicians and staff, and where less than 10 years ago, no one had any idea what medical procedures actually cost.
That’s the situation in Great Britain, where only now are health care professionals beginning to address quality improvement in a systematic way. The situation is similar in other Western nations, most of which are struggling toward privatization of their nationalized health care systems, says Janet L. Maronde, RN, CPHQ, executive director of the Health Quality and Certification Board of the National Association for Healthcare Quality in San Gabriel, CA. The board, which oversees the Certified Professional in Healthcare Quality (CPHQ) credential, has been monitoring these nations closely as it seeks to expand its influence abroad.
Driving the newfound interest in health care quality overseas are many of the same factors U.S. hospitals began dealing with years ago, Maronde adds. These include the rise in health care costs, the aging of the global population, and a recession that forced governments to seek new alternatives to their health care "safety nets."
"Each country is adapting its own system, and the systems are all different," Maronde says. But many of the challenges they face are similar, and probably familiar to old hands in case management in the U.S. "In terms of physicians listening to anyone other than themselves, [most countries] are back where we were in the 1970s," Maronde says. "Or actually worse, because case managers in most countries are usually female, and that can be a big issue. There are still places where you just don’t have females telling males what to do."
In many countries, it’s a challenge simply to explain what case management is, much less actually implement it. "Case management is budding, but it’s still pretty much in its infancy everywhere," Maronde says. "Right now, it’s just barely starting to show its head. Quality improvement is somewhat more established."
However, things are changing quickly, particularly in Great Britain, largely because of the Labour Party’s recent victory in national elections. In a white paper released in December 1997, the new government laid out a plan to reform the British health care system, stressing cost containment. It also stressed the concept of "clinical governance," under which medical staff for the first time would assume responsibility for monitoring the quality of services they provide, says Nancy Dixon, MA, CPHQ, FNAHQ, FIQA, FAQMC, a consultant in health care quality at Healthcare Quality Quest Ltd. in Romsey, Hampshire, UK. Before returning to Great Britain a few years ago, Dixon worked for five years at the Oak Brook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations.
"Up to now, all of the medical staff functions and med staff/board relationships that we’ve been used to for decades in the U.S. health care system simply don’t exist here," she says. "Each doctor does what he wishes."
Although case management in the UK is still nascent, other quality improvement efforts have already gained a foothold, Dixon says. Most notably, the government-run National Health Service has established a number of centers designed specifically to compile and disseminate benchmarking data. And some larger hospitals have begun engaging the services of large consulting companies to help establish a plan for process re-engineering.
"The goal of much of this is to begin identifying care which does not benefit patients and stop doing it, or minimize the time to which such care is actually being used," Dixon says. "And at the same time practice what is shown by research or expert opinion to be the best practice. It’s a drive to raise the standard, to minimize the variation in clinical practice among different geographic areas something which has been identified as a problem here."
It’s been a slow and difficult process, however, given that until 1989, no one knew what health care cost per patient in the UK, Dixon says. The National Health Service simply gave lump sums of money to different regions using a population-based formula. The money was then distributed to health care organizations in those regions "in a very bureaucratic fashion," Dixon says. "And the organizations spent the money as they saw fit. So no one really knew what it cost to care for a patient with a myocardial infarction, or a child with asthma. Or anything. All of those are recent developments, and costing is still pretty basic."
Even so, clinical pathways are becoming well-established in the UK as a means of identifying best practices. They’re also winning favor because they help to reduce the clinical fragmentation that has characterized the British system in the past. "Probably the biggest motivation in the UK is to try first of all to get a multidisciplinary approach to care thoroughly integrated in day-to-day practice," she says. "Five or more years ago, care was very fragmented by profession."
Underlying all this, of course, is the desire to reduce costs, although health care professionals in the UK hesitate to admit it out loud, Dixon says. "This is still a country that’s quite sensitive to how you describe things," she says. "But in the end, it’s about reducing length of stay."
For more information about case management abroad, contact the following:
Nancy Dixon, MA, CPHQ, consultant in healthcare quality, Healthcare Quality Quest Ltd., Shelley Farm, Shelley Lane, Ower, Romsey, Hampshire, SO51, 6AS, UK. Telephone: 44-1703-814024.
Janet L. Maronde, RN, CPHQ, executive director, Healthcare Quality Certification Board, National Association for Healthcare Quality, P.O. Box 1880, San Gabriel, CA 91778. Telephone: (818) 286-8074.
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