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OCR for page 53
COMMENT AND DISSENT
. .
Mildred Morehead
While ~ am in general agreement with the statements of
the committee to assure the quality of health care, and well
appreciate the thought and deliberation that went into the fi-
na~ report, there are two points that emerge in the final docu-
ment which ~ feel ~ cannot endorse.
There is overemphasis on outcome measurements and undue
restriction on process evaluation as stated in the recommendation
to limit process.measurements to ''only those for which research
has demonstrated a definite correlation with patient outcome"
(page 22) and excluding entirely those which "constitute usual
and customary practices" (page 21~. While the document points
out what are indeed potential pitfalls in the use of process
and criteria measurements, the conclusion of the above state-
ments will, in my opinion, have a deleterious effect on efforts
to improve present medical practice on a nationwide basis.
Clearly all can endorse the theory that medical care should
effect a positive outcome. However, at the present time, there
is too limited a number of conditions where definitive outcomes
can be measured. There are too many other variables associated
with outcome to have this a sole determinant, and the time and
expense to secure such judgments are of unproven value. (In-
cidenta1ly, ~ do not feel that references to the Rosser and
Watts study relating to prognosticating function at the time of
hospital discharge as an example of an outcome approach strengthens
the position for use of outcome determinations.)
On a far less sophisticated level there is much known about
the provision of medical services which can be judged from the
process of care employed; usual.and customary practice may not
always be amenable to definitive proof of efficacy, but modern
medicine has taken into account the decision factors redating
to diagnosis and therapy and the avoidance of risk (unnecessary
surgery, use of overly potent drugs, etc.~. There is a great
deal that can be done in this country today to upgrade current
practice without the need to defer until science has definite
proof for all of the modalities in.use.
~ am also uneasy about the implication that quality assur
ance programs should be oriented around clinical research tech
niques (page 21~. Clinical research is indeed essential to
increase the extent of knowledge, but in my opionion, belongs
under the auspices of others (NTH, medical schools, etc.)
rather than those who are endeavoring to meet a more basic
need, namely, assuring that what is known is not being misused
or applied to the detriment of the general population.
53
OCR for page 54
My second disagreement with the document lies in the place-
ment of the recommendation to employ the uniform hospital dis-
charge abstract. This is a worthwhile recommendation which
more properly belongs among the recommendations for data re-
quirements and not as number one of i- -and-'- 4- ¢~ -'
assessment of quality. Data collection is a prerequisite to
any method of quality assurance. This area, including recom-
mendations about the hospital discharge abstract, might more
logically be placed prior to the discussion on methods.
recommendations _
of the methods to be used in
is a prerequisite to
54
Representative terms from entire chapter:
discharge abstract
