Risk And Quality Management Assessment Summary Essays Examples

Introduction

Risk management is a significant aspect in any organization. It is also an important and significant process when handling healthcare organizations. It is important to understand the risks and quality issues in healthcare industry. Having this understanding will enable the managers to have plans that will allow them to have strategies to manage the risks. It will also enable the managers to set quality standards that will be followed in the entire organization. This paper will focus on quality and risk status of Blue Cross Blue Shield of Georgia (BCBSGA).

Background information

Blue Cross Blue Shield of Georgia is a Managed Care Organization whose main task is to provide insurance plans for individuals’ families. The insurance plans can be used for dental, health or life. It has been in operation in Georgia for more than 70 years. They have been providing quality health benefits for the members who have registered for their plans. The health plan options include BlueChoice Preferred Provider Organization (PPO) which fits members who do not have primary health care provider. The members do not have to have an in-network provider in order to get their healthcare services. Another choice alternative is Blue Open Access Point-of-Service (POS). It fits members seeking for lower premiums with the same type of flexibility that is experienced in BlueChoice PPO network. In this option, the members will not be required to have a preferred primary care provider neither do they have to choose a referral. In addition, the members have access to network providers that are found in the whole country. Another choice offered is the BlueChoice Dental. It is an option which covers fundamental dental issues and services like crowning, root canals and dentures. The last option that is offered is that of Term Life Insurance which an insurance provision for individuals is. The premium range from $15000-$100000.

Purpose of risk and quality management

For a long time, individuals and organizations have looked for ways in which they can reduce and eliminate risks. Programs have been set to help in the management of organizational risks. These programs have helped organizations reduce the losses that can be encountered on the event of risks coming to reality. Quality management is continuous process that enables organizations to deliver products and services that meet the standards that have been set. It is in the quest to ensure that the products and services that are offered meet the requirements of the clients that quality management processes are undertaken. The two processes, risk and quality management are proactive methods through which organizations are sustained. They help them to reduce losses in case there are negative events that occur. They improve the services and the products that are offered. The programs that have been developed to ensure that the organizations are in order have been designed to provide checks and balances for the organization. This aspect will ensure that there are policies, accreditation, and standards in place that will be followed. With the presence of quality and risk assessment, organizations will be able to grow. Without the presence of the risk and quality plans, organizations would incur a lot of losses, would lose clients and competent employees. It is the same case with Blue Cross Blue Shield of Georgia. Without the use of quality and risk management processes, they will lose revenue, clients, and staff.

Key concepts

Quality and risk management enhancement are the key components for any organization. Some of the risk and quality management key concepts in the Blue Cross Blue Shield of Georgia include the need to integrate the quality and risk aspect to the organization core mandate. The core mandate in this case is the mission and vision of the organization. There is also a council that includes the top management of the organization that will help in coming up with policies that will be followed in the management of the risks and quality aspects (Kongstvedt, 2012). There is also another important factor where personnel will be trained so that they understand their roles in risk and quality management in the entire organization. Another concept is selection of a procedure that will be used in mitigating and improving the risks that have been identified. Another concept is the formation of process teams which will be concerned with the processes that will be tasked with mitigating the risk. Also, there is the application of the most recent techniques and processes in the management and enhancement of the risks identified.

Steps that will be used to identify and management the risks

It is important for Blue Cross Blue to view the risks identified in form of processes as they will have priorities and goals that will enable them to manage the risks. There are five steps that will be used in the management of the risks. The first step is the identification of the exposures of the losses that might occur. The second step will be the identification of the alternative risk techniques that might be useful in the entire process. After this, the best risk technique and approach will be chosen over the others. The fourth step will be implementation of the technique that has been identified. The last step will be to monitor the step that has been implemented and have improvement in case there will be the need to have improvements.

Typical risks in the organization

There are risks that affect a health insurance organization. The risks will affect the organization negatively, in several was. One of the risks that might affect Blue Cross Blue Shield of Georgia is the violation of the Health Insurance Portability and Accountability Act (HIPAA). If the privacy of the patients is compromised, there are legal consequences that might be faced by the insurance firm. Another risks is Insurance Fraud where medical providers bill for services which were not rendered. In the end, the providers might file a case against the insurance firm. The risk will lead to loss of customers, accreditation, and revenue. Another risk is that of dispute in regard to the contract with the healthcare organization. It will occur if there is failure to renew contracts with some organizations. With this risk, there is likely negative impact where individuals will lose trust with the insurance firm.

Internal and external factors that affect quality

There are internal and external factors that are known to influence the outcome of quality in an organization. One of the external quality factors is that of Health Reform/Affordable Care Act. It is a risk external factor that affects organizations in the United States. It has made the accessibility of health insurance possible for anyone. It was fought by insurance companies because of the negative impact it would bring to the business. The negative impact is that if the organization does not follow the Act, they will lead to complaints from individuals. They will lose revenue and clients. There is also the aspect of contractual agreements. These agreements might be breached by individuals and will lead to losses if there are disputes that will be filed by the organizations which have been faulted. The negative impact is the loss of reliability and revenue. The loss of revenue is because of the lack of trust as clients will flock away.

Goals of the organization

There is a need to have short-term and long-term goals for an organization to grow. They are integrated in the mission statement of an organization. The goal of Blue Cross Blue Shield of Georgia is to provide better care to the members. Also, they will ensure that they add value to the services that are provided. The goal undergoes continuous improvement because of the changes that are experienced due to changes in the government policy and regulations. The organization struggles to ensure that there is affordable coverage for the low-income group so that everyone has a cover. Another long term goal is the improvement of healthcare in the community they serve (Nicolay et al., 2012).
Some of the short-term goal is to increase membership, have other alternative plans for members and have leadership improvement for the individual members of the insurance.

Policies

Some of the policies that need to be implemented in the organization include raising awareness of the management of the organization. There is also a need to have compliance of Affordable Care Act 2010. Another policy is to have compliance of all employees to the HIPAA.

Relationship between risk and quality management

The two processes are related in that they have the same tools that are used in the management of the procedures set. There is the use of research, analysis and practice which are common in both entities.

References

Kongstvedt, P. (2012). Essentials of managed health care. Jones & Bartlett Publishers.
Nicolay, C. R., Purkayastha, S., Greenhalgh, A., Benn, J., Chaturvedi, S., Phillips, N., & Darzi, A. (2012). Systematic review of the application of quality improvement methodologies from the manufacturing industry to surgical healthcare. British Journal of Surgery, 99(3), 324-335.