Medicare: New Directions in Quality Assurance Proceedings (1991)

Leo M. Cooney, Jr.

Early in my career, I was given responsibility for overseeing the care provided by more than 100 interns and resident physicians at a large urban teaching hospital. I learned quickly that it was not easy to ensure that professionals will always perform to the best of their abilities. I could see that they were in the right place at the right time. I could review each chart to ensure that each fever was evaluated and each patient with anemia worked up, but too much badgering affected morale and performance. I learned at Boston City Hospital, however, that encouragement, peer pressure, motivation, and pride in a joint effort could result in a very high standard of care.

Now, many years later, I have a different experience with quality-of-care efforts in my dual responsibilities as director of utilization review at another large university hospital and as medical director of a skilled nursing facility. I now find myself spending hours worrying about the quality of records instead of the quality of patient care. Are the "verbal orders" signed, recreational therapy plans reviewed, or 30-day reviews completed? I see the adversarial relationship that has developed between our Peer Review Organization (PRO) and our hospital and medical staff. Numerous charts are photocopied and sent off in entirety because they fail "quality screens." Letters and accusations pass back and forth with virtually no impact on the way in which we practice medicine. The quality review burden on providers is exacerbated by the large number of agencies that review care, including the state health department, Medicaid agency, PROs, and the Joint Commission on Accreditation of Healthcare Organizations, yet these agencies are unable to share information or review in a coordinated fashion.

As I have participated in this Institute of Medicine (IOM) committee for the past two years, I have tried to understand why some review is helpful and effective and other reviews are so intrusive and often counterproduc-

tive. I have concluded that a successful review is one in which you are treated as a professional, are challenged by your peers, and feel that you are a part of the process. Furthermore, there are both a clear understanding of why your work is being reviewed and a general trust in the experience and skills of those reviewing your work. This professional review is an essential component of American medicine, and it is reflected in morbidity and mortality conferences, tissue committees, clinical pathological conferences, and management reviews.

Most of the reviews that are generated by external agencies do not meet with the same level of understanding and cooperation that professional review receives. Most external reviews are designed to identify poor performance, not to elevate the general standard of care. Our present system subjects all providers to an increasingly burdensome and adversarial review to identify a small number of "outlier providers." Unfortunately, once these outlier providers have been identified, our review organizations have not been able to deal with them effectively.

We propose, in this IOM report (IOM, 1990), to move away from an often punitive review of the quality of records and process of care to a more substantive and innovative review of the actual results of care provided. We recognize that this review will be difficult and challenging, but it will conform to the standards of review that health care professionals have used for the past century to determine the effectiveness of various medical, surgical, and preventive maneuvers.

This emphasis on outcome will require cooperation and participation by health care professionals in the outcome process and analysis. Furthermore, we will supply these data to providers and, if necessary, we expect them to adjust their care to improve their results. We have seen how cooperatively and effectively institutions can deal with such problems as operative wound infections, nursery epidemics, and complications resulting from the use of new equipment and procedures. We would like to expand these efforts at continuous quality assurance by identifying those areas in which providers might attempt to improve their results.

We have made a major new assumption in quality review in this report, one that I believe heightens the "professional responsibility" theme of the report. We believe that, because providers must assume responsibility for the final outcomes of care, they must assure that all aspects of the health care system are properly applied. Thus, if one institution finds that a high proportion of its patients with fractured hips, though previously independent, are now immobile or institutionalized, that institution must look at all aspects of care. Whether the problem is poor surgical technique, postoperative care, in-house rehabilitation, discharge planning, or home or nursing home rehabilitation, the provider must identify the problem and address its correction. We have based our new approach on four characteristics of health

care providers: professionalism, responsiveness to outcomes, competitiveness, and pride.

Professionals must assume responsibility for a task and be accountable for all aspects of this effort. This concept recognizes that the health care professional is accountable not only for the care he or she delivers, but also for the continuum of care arranged for that patient, from consulting physicians to home care to skilled nursing facility care. An emphasis on the outcome for care highlights the responsibility of the professional to assure that all aspects of care delivered to his or her patient are of such quality and coordination that the outcome will be as good as possible.

Health care professionals make many decisions throughout each day, decisions that are well-meaning and have substantial impact on the outcome of care. Medical research helps us with many of these decisions, such as giving us data about medical treatment versus observation for asymptomatic urinary tract infections.

There are many other decisions, however, for which traditional medical research has not been helpful. Which elderly patient might benefit from a total hip replacement, and which patient might become confused and experience a decline in health status during the hospitalization? Should patients with fractured hips receive their rehabilitation in an acute hospital, in a rehabilitation hospital, or in a skilled nursing facility? What is the outcome of care in the real world of community hospitals and community practitioners versus those results reported in the literature from university referral centers?

We believe that this information, fed back in an appropriately nonjudgmental manner, will have a positive effect on the way in which we practice care and on the outcome for our patients. Moreover, this emphasis on outcome will point out that exceptional technical care followed by poor rehabilitation is unsatisfactory, in that the health professional has the responsibility for ensuring the best possible final results of care for his or her patient.

Americans are, of course, very competitive, and we should use this characteristic to improve the quality of care. At present, hospitals compare themselves with other hospitals in terms of who has the most high-technology equipment, who is doing heart and liver transplants, and who has the best accommodations and menus. Few data are available to institutions to allow

them truly to know how they are doing. I believe that the natural instincts of the American marketplace will push these institutions to improve the outcomes for their patients with fractured hips, pneumonia, myocardial infarctions, and other medical and surgical conditions. They will do this only when they feel that these outcomes are an accurate reflection of the care that they arrange or provide. Internal steps designed to improve quality of care can and have worked extremely well when providers understand the importance of these maneuvers to improve the outcome for their patients.

Most of us chose the health care professions as our career because of a strong ego. We want patients to come to us and to our institutions because they believe that we will provide the best care available. If we believe that the outcomes reported to us are a true reflection of the results of care given to our patients, we will do all in our power to make those results as positive as possible. We will make these efforts only if we believe in the value and integrity of those reviewing us and in the results they generate. This entire process will have positive outcomes only if professionals buy into it as a cooperative venture, producing results with which all can agree.

In the final analysis, we believe that excellent medical care results from highly motivated, skilled, and energetic clinicians who feel that the system in which they work is responsive to the needs of their patients. Individuals will be encouraged to provide the highest standard of care if they see that these efforts result in improved outcomes for their patients. Furthermore, health care professionals have demonstrated the ability and desire to adjust their practice patterns when data point out the most effective patterns. We believe that the American health care system will achieve better results for its elderly patients if it encourages, stimulates, and rewards the motivation for caring that led many of us to enter the health care professions.

Institute of Medicine. Medicare: A Strategy for Quality Assurance. Volumes I and II. Lohr, K.N., ed. Washington, D.C.: National Academy Press, 1990.