A FRAMEWORK FOR CONTINUOUS
There are four core principles underlying successful quality improvement programs. The
1 identifying, documenting, and embedding precisely measurable claims best practices
and best-practice behavioral expectations into the organizational culture.
2 implementing a consistent, metrics-based approach to measuring best-practice
adherence at all organizational levels. This includes establishing measurable
relationships between best-practice non-adherence and financial outcomes.
3 Analyzing the data that matters. Be sure to find the pain points and their respective root
causes throughout the organization.
4 Strengthening performance by executing continuous quality improvement processes
that consistently drive measurable gains in knowledge, skills, and behaviors.
best practices in real-time based on their
baseline knowledge, practices, and behaviors. This leads to a fundamental challenge: how to constructively manage the
performance variance introduced by differing skill set and knowledge.
Early Adherence Measurement
Now consider our second cornerstone
of the overall framework, “implementing
a consistent, metrics-based approach to
measuring best practice adherence at all
organizational levels.” It is often prudent
to introduce a carefully crafted best-practices compliance questionnaire, which
will enable an organization to:
E Accurately translate best practices
into a measurement tool that allows
for the capture of job performance and
behavioral attributes in a discrete data
E Identify tasks and decision points where
the highest frequency of errors occur.
E Assess the economic impact of task,
analysis, and decision errors at the most
Generating insightful reports will also
enable supervisors to develop improvement plans and deliver meaningful, objective feedback to direct reports. Once a
questionnaire has been drafted, a review
protocol supporting continuous quality improvement objectives should be
developed. It may include both a central
review process and a field review process.
E A sound central review process ensures
steady state measurements for evaluating
the program’s impact on financial performance are in place.
E A continuously calibrated field review
process forms a foundation for depart-mental/unit /claims handler quality issue
identification and analysis. This ensures
that claims supervisors have the requisite
tools to develop and execute sustainable
quality improvement plans.
This is a key step toward enabling your
supervisors to more effectively manage
their teams and create a sustainable culture of continuous improvement that
empowers individual claims handlers.
Keep in mind, however, there will be hurdles to overcome, such as:
E Calibrating your organization to your
best practices and behavioral expectations.
E Errors result from sub-optimal decisions made by individuals, but performance data is not always adequately individualized.
E Aggregate quality improvement requires
improvement in knowledge, skills and
desk level behavior from each individual.
E Claims supervisors are not traditionally
well-versed or experienced in data analysis and quality improvement techniques.
E Gaps can occur in addressing performance issues as a result of supervisory
knowledge and skill deficits, as well as
inconsistent improvement planning and
Motivating Your Troops
Supervisors must also look at empowering staffs from a common sense
perspective. Specifying ideal practices
is one thing; encouraging adherence is
another. Ideally, behavior change comes
about because the claims manager offers a viable incentive to improve or