The changes in reimbursement practices by third party payers have caused the quality of patient care to become a bigger issue than it ever was before. Because of these changes, hospitals are compelled to find ways to provide high quality care at lower costs. Health care providers are frequently finding themselves trying to balance the demand to meet consumer expectations of quality care with the administrative and third party payer mandates for cost containment (Christensen & Bender, 1994). In this age of consumerism, the patient is more knowledgeable about the high cost of health care and therefore has lofty expectations of the care provided. “Despite a climate of cost restraint, health care institutions are under pressure to provide quality care to everyone who seeks it. These pressures directly impact nursing and the delivery of care to patients” (Christensen & Bender, 1994). Both internal and external efforts are centering on the assurance that the provision of quality care is not compromised by the hospital’s accentuation on managed care and cost containment, and that accurate information is communicated to the health care consumer. Health care providers are therefore held accountable for the quality of the care they render.

          The delivery of cost effective, quality patient care demands that the health care disciplines providing patient care have the knowledge, skills, clinical judgement, and attention to detail necessary to meet the expectations and needs of not only the health care consumer but those of the hospital and the third party payer as well. The bedside case manager possesses all of these qualifications, and the use of a bedside case management system by the hospital helps to ensure that the health care consumer, the hospital, and the third party payer are all satisfied. Zander (1988) writes, “More than any other principal, the case manager must be a central caregiver to ensure cost/quality outcomes”. Bedside case management helps the hospital control costs, ensures better utilization of resources, and provides a method for continuous quality improvement of patient care and health care services. According the Rawsky (1996), “Case management plays an integral role in the institution’s continuous quality improvement process. This provides a framework for better care delivery and improved patient outcomes”.

          Bedside case management takes the focus of quality improvement from individual departments and centralizes it as an overall evaluation process that examines every aspect of patient care (Bair et al, 1989). This is important since regulatory agencies, such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Health Care Financing Administration (HCFA), no longer look at each hospital department separately but rather, look for a multidisciplinary approach to patient care that is focused on patient outcomes in combination with continuous quality improvement activities (Cohen & Cesta, 1994). JCAHO jointly reviews the activities of the various hospital departments responsible for each patient care need by evaluating the shared interventions, interactions, and problem-solving techniques utilized between those departments. This move toward a more collaborative approach to quality improvement activities places the responsibility for the delivery of quality care directly on each individual hospital employee (Christensen & Bender, 1994).

          One of the major theories behind continuous quality improvement is collaboration (Vautier & Carey, 1994). Because collaboration is the foundation for a successful bedside case management program, continuous quality improvement and bedside case management work well together. Bedside case management provides for and promotes patient care systems which cross departmental lines. As discussed in an earlier chapter, bedside case management ensures that all health care disciplines: are involved in the care of the patient; contribute to the case management plan; provide input for critical pathway development; and participate in patient care system evaluation and improvements. Johnson & Proffitt (1995) write, “Much like case management, the CQI process emphasizes the collaborative work of interdisciplinary teams which analyze the process, develop and implement solutions”. Wojner (1997) indicates, “With so many different practice disciplines targeting improvement in the same area, the probability of successful care enhancement is greater than achieved through single-discipline quality efforts”.

          The underlying philosophies of bedside case management and continuous quality improvement are very similar (Johnson & Proffitt, 1995). Continuous quality improvement and bedside case management also have comparable goals and outcomes. Bedside case management, like continuous quality improvement, has been developed to improve the quality of patient care and the delivery of health care services by:

·     Focusing on operational improvement.

·     Having a patient-centered approach to care.

·     Instituting a collaborative effort among the various health care disciplines.

          Both bedside case management and continuous quality improvement are consumer-focused; both put emphasis on having practice standards and evaluation of those standards; both articulate the need for concurrent patient care system evaluation; and both provide a means by which tactics to improve patient care systems are developed. Roberts-DeGennaro (1993) writes, “An evaluation can provide the best guide to correcting or improving the provision of services. In addition, evaluation can document any unintended consequences of the services”.

          “CQI includes the following components: (a) identifying the individual steps that make up a health care process or flow charting; (b) statistical analysis of data regarding the process; (c) identifying root causes of problems; (d) selecting a solution; and (e) evaluating the change to ensure the problem has been corrected” (Johnson & Proffitt, 1995). Bedside case management is similar in that it (a) identifies practice standards for meeting patient outcomes (critical pathways); (b) provides a means for problem (variance) identification; (c) incorporates evaluation of variance causation; (d) employs strategies to correct the variance; and (e) re-evaluates to ensure that the variance has been resolved and that no further actions are needed to get the patient back on track. Bedside case management, with critical pathways and variance analysis, can be used in the continuous quality improvement process to meet quality improvement goals. By analyzing variance patterns and reviewing them with the various health care disciplines involved in the care of the patient, resolutions can be reached. Because critical pathways map out the procedures utilized across all departments for the provision of patient care and provide a means for evaluating outcomes through variance analysis; they seem to be appropriate continuous quality improvement tools. Cohen and Cesta (1994) note, “Clearly, the measurement of clinical outcomes has been part of the process of identifying new definitions of quality within health care”.

          Bedside case management and continuous quality improvement work together to assess and refine the quality of care provided to the patient. To facilitate this, data collection tools are developed by outlining the important timing-related outcomes that indicate patient progression along the critical pathway. These outcomes become known as the patient care standard outcome indicators, and a level of compliance is established for each indicator. With the development of data collection tools, health care discipline specific actions that must transpire to guarantee the patient’s progression along the critical pathway are also defined. These health care discipline specific actions are identified as practice standard indicators, and anticipated compliance is fixed for each of these indicators.

          Once the data collection tools are developed, data collection from the critical pathway is undertaken to ascertain whether the predicted patient outcomes were achieved. The critical pathway is surveyed, and variances from the practice standard indicators and the expected patient care standard outcome indicators, including the point in the care at which the variances occurred, are identified and documented. As discussed in a previous chapter, variances are anything that occurs, positive or negative, which modifies the expected patient outcomes of the critical pathway. After the data is collected from the critical pathway, it is compiled and analyzed, and the percentage of actual compliance is determined for each patient care standard outcome and practice standard indicator. This method of data compilation and analysis promotes objective data comparison which, in turn, identifies opportunities for the improvement of patient care and/or helps to establish the overall effectiveness of the multi-disciplinary patient care interventions that have been incorporated into the critical pathway. Once opportunities and/or interventions to improve patient care are determined from the data analysis, an action plan is developed and executed. A synopsis of all of the actions that have been implemented to improve the quality of patient care is then documented, and the dates for follow-up evaluations are also set.

          Bedside case management and continuous quality improvement work in unison, sharing common principles and goals, to assure that the patient receives the highest quality care possible. Responsibility for quality patient care is placed on each and every health care discipline involved in caring for the patient. Patient care is evaluated as a united effort by a multidisciplinary team rather than as individual departments providing patient care services independent of one another. Bedside case management and continuous quality improvement work together to meet regulatory agency requirements and to support mandated patient care cost containment measures while at the same time keeping the quality in managed care.

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Christensen, P., Bender, L. (1994). Models of nursing care in a changing environment: Current challenges and future directions. Orthopaedic Nursing, 13(2), 64-69.

Cohen, E., Cesta, T. (1994). Case management in the acute care setting a model for health care reform. Journal of Case Management, 3(3), 110-115.

Johnson, K., Proffitt, N. (1995). A decentralized model for case management. Nursing Economics, 13(3), 142-151.

Rawsky, E. (1996). Building a case management model in a small community hospital. Nursing Management, 27(2), 49-51.

Roberts-DeGennaro, M. (1993). Generalist model of case management practice. Journal of Case Management, 2(3), 106-111.

Vautier, A., Carey, S. (1994). A collaborative case management program: The Crawford Long Hospital of Emory University model. Nursing Administration Quarterly, 18(4), 1-9.

Wojner, A. (1997). Outcomes management: From theory to practice. Critical Care Nursing Quarterly, 19(4), 1-15.