Quality Assurance is the same as quality management and includes quality assessment and corrective actions taken to remedy any deficiencies identified through the assessment process. See QA Programs in class 2. A method of review which occurs after health care has been provided and sometimes after reimbursement has been issued. This type of review is used to review situations in which it is believed there may have been inadequate data on which to base a decision about Utilization Management programs, possibly choose to vary reimbursement as a result of the review, or to monitor expenditures in areas which were not selected for intensive review. Total Quality Management is a managerial innovation and calls for continuous and relentless improvement in the total process that provides care, not simply in the improved actions of individual professionals.
Improvement is based on both outcomes and process.
TQM places primary emphasis for problem characterization on the system rather than the individual. The extent to which the members of a covered group use a program or obtain a particular service, or category of procedures, over a given period of time. Usually expressed as the number of services used per year or per 100 or 1,000 persons eligible for the service. Many insurance plans and all HMOs require that UR procedures are followed prior to all inpatient and some outpatient and emergency care or they will not pay for services rendered. See UM and UR in class 2.