A review of the quality assessment process within managed health care

Abstract

The research study was conducted in an HIV Disease Management Programme within a Managed Health Care Organisation in Gauteng, South Africa. This Managed Health Care Organisation provides Managed Care services to Medical Scheme beneficiaries who have been exposed to HIV/AIDS by registering them onto the HIV Disease Management Programme (DMP). This is to ensure adequate clinical care, education and support are provided to the affected beneficiaries to promote their quality of life, whilst managing the financial risk of the Medical Scheme. The study focused on the non-clinical aspect of the HIV Disease Management Programme, namely the Quality Assessment function. The Quality Assessment process evaluates the quality of the Managed Care services rendered to the enrolled beneficiaries and Service Providers by the employees of the Managed Care Organisation. The objectives of this study were the following: ➢ To examine the current Quality Assessment process sampling activities from a service quality perspective, identify best practice, and recommend improvements; ➢ To ascertain if the Quality Assessment Questionnaire (the process input) contains the correct quality parameters to identify the critical errors to be addressed; and ➢ To determine if the monthly Quality Assessment reports (the process output) contain the essential quality elements and tools to effectively demonstrate the quality of the services rendered. The research methods used in this research study included both qualitative and quantitative methods. The research identified international and national best practice related to the Quality Assessment process, specifically in the South African Managed Care environment. The research methodology is within the ambit of an archival research.