Medicare A Strategy for Quality Assurance, Volume II: Sources and Methods (1990) / Chapter Skim
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6. A Quality Assurance Sampler: Methods, Data, and Resources
6. A Quality Assurance Sampler: Methods, Data, and Resources
Pages 140-291
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From page 140... ...
The committee concluded that it could best address its charges by an overview of strengths and limitations of methods of quality assessment and assurance, as provided in Volume I, Chapter 9 of this report, and by a description of the rich mix of methods in use in hospitals, ambulatory care groups, and home health care, as given here. This chapter describes a wide variety of techniques of quality assessment, drawing on information from several different study sources.
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From page 141... ...
Other Sources The "sampler" derived from the site visits is supplemented by examples of methods described in research studies; of reports of model programs in journals such as Quality Review Bulletin; and of approaches described in legislation, manuals of accreditation, and guidebooks published by health care associations. Some techniques of quality assessment and assurance, such as credentials review, have become time-honored; some approaches, such as the use of tracer conditions, have been more theoretical than widely implemented; and some, such as generic outcome screening, have been developed so recently that the technology is still rapidly changing and difficult to assess.
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From page 142... ...
Data provided to this study from a survey by 13 multi-hospital systems provide an estimate of the allocation of quality review resources in 58 hospitals located in 21 states. Our site visits indicated that resources devoted to quality assessment vary greatly from a small hospital with one staff member responsible for coordination of quality assurance, utilization review, risk management, discharge planning, and infection control to major urban hospitals with numerous staff and considerable computer support devoted to these functions.
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From page 143... ...
more commonly used in one setting; for example, patient care algorithms are most developed in ambulatory care settings. For brevity we discuss these methods in detail only once.
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From page 144... ...
For health care organizations, methods include credentialing systems, policies, and patient care systems to structure or guide patient management at both administrative and clinical levels. "Detecting" problems is the quality assessment or monitoring function.
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From page 145... ...
HOSPITAL External Methods of Preventing Problems in Hospitals Medicare Conditions of Participation Hospitals are eligible to receive reimbursement from Medicare by meeting a set of Conditions of Participation. Under Section 1865 of the Social Security Act, hospitals that are accredited by the Joint Commission or the American Osteopathic Association are "deemed" to have met all the regulatory requirements specified in the Act, except for a rule concerning utilization, the psychiatric hospital special conditions, and the special requirements for hospital providers of long term care.
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From page 146... ...
The Accreditation Manual (Joint Commission, l989b) is organized around sets of`'standards" defining requirements related to 24 hospital service areas, including the governing board, medical staff and nursing services, quality assurance, hospital departments, special care units (e.g., intensive care unit, burn unit)
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From page 147... ...
GB.1.15. The governing body requires a process or processes designed to assure that all individuals who provide patient care services, but who are not subject to the medical staff privilege delineation process, are competent to provide such services.
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From page 148... ...
Included in its functions (Code of Massachusetts Regulations, 243 CMR 3.01 to 3.16) is patient care assessment (PC A)
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From page 149... ...
. Internal Methods of Preventing Problems in Hospitals Medical Staff Standards The Joint Commission's Medical Staff Standards (Joint Commission, 1989b)
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From page 150... ...
These may include the finance officer, security officer, legal counsel, personnel officer, biomechanical engineer, nursing director, chiefs of departments, medical director, quality assurance director, and' of course, the risk manager, whose responsibilities have usually been cast as pertaining principally to malpractice loss control. In recognition of the mutual goals of quality assurance and the patient care component of risk management, a new Joint Commission standard requires an operational link between quality assurance functions and those risk management functions related to patient care safety and quality assurance.
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From page 151... ...
In this sense, it is analogous to infection control. External Methods of Detecting Problems in Hospitals Medicare PROs The efforts of Medicare PROs to detect quality problems by the use of a set of "generic screens" are possibly the broadest systematic approach to "external" problem finding (see Volume I' Chapter 6, and Chapter 8 in this volume for more details)
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From page 152... ...
DONAI~SON AND KATHLEEN N LOHR EXHIBIT 6.H2 Example of Hospital Interventions Concerning Nursing Interventions for Patients at High Risk of Falls A
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From page 153... ...
A QUALITY ASSURANCE SAMPLER 153 b) Have overbed light within patient's reach c)
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From page 154... ...
. Data sets can also be used to screen the processes and outcomes of ambulatory and inpatient care.
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From page 155... ...
As a near-term strategy, they are best suited to directing quality assessment efforts toward topics, populations, or providers requiring further study. Currently, Medicare data bases do not include clinical data, measures of
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From page 156... ...
Efforts to devise a uniform needs assessment instrument, to develop a uniform clinical data set (UCDS) , and to include patient functional status could greatly augment the value of administrative data bases for internal and external quality assurance programs.
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From page 157... ...
The Maryland Hospital Association's Quality Indicator Project preceded the Joint Commission's clinical indicator initiative. Developed as a voluntary hospital effort to provide interhospital quality-of-care data (Summer, 1987)
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From page 158... ...
fires or internal disasters in the facility which disrupt the provision of patient care services or cause hand to patients or personnel; 3. equipment malfunction or equipment user error during treatment or diagnosis of a patient which did or could have adversely affected a patient or personnel; 4.
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From page 159... ...
The medical staff office typically handles credential and privilege requests and reappointment recommendations from individual departments. It receives, in addition, data provided to it by quality review committees.
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From page 160... ...
In the 1990 Accreditation Manual for Hospitals (Joint Commission, l989b) , the "Quality Assurance" standard states that for each facility, there is an ongoing quality assurance program designed to objectively and systematically monitor and evaluate the quality and appropriateness of patient care, pursue opportunities to improve patient care, and resolve identified prob lems.
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From page 161... ...
Generic screening is conducted by nurse reviewers in the quality assurance department. This function may be coordinated with that of utilization review, discharge planning, and infection control.
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From page 162... ...
Monitoring is intended to signal the need for a more focused review, not to replace case review. For monitoring, the Joint Commission distinguishes "sentinel events" and "comparative rate indicators." Sentinel events are serious complications or outcomes that should always trigger a more intensified review, such as a maternal death or the occurrence of a craniotomy more than 24 hours after emergency room admission.
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From page 163... ...
163 ._ Ct ._ o ED Cal ·_4 Cq ._ C~ Ct Ct a: o Pa Ct 4 ' Ct To Ed o GO C)
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From page 164... ...
DONALDSON AND KATXLEENN. LOHR EXHIBIT 6.H3 Ten Step Monitoring and Evaluation Model of the Joint Commission 1.
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From page 165... ...
Surgical Case Review Surgical case review addresses the indications or justification for all invasive surgical and diagnostic procedures performed in inpatient and ambulatory care settings (Longo et al., 1989~. For cases in which tissue is removed, surgical review includes a comparison of the surgeon's pre-operative diagnostic findings and the post-operative pathology findings.
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From page 166... ...
166 o Ct Cal ._ ._ ._ Cal Cal lo: Ct U
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From page 169... ...
169 ~ 3 ~= -it ° ' ~ ' ~ ~ ~ 3 ~ ~ ~ a, 3 ~ ~ ~ ~ ,, ~_ ~ ~ ~ ~ | ~ ~ ~ E ' ~ ~ ~ ~ e E 2 -0 _ E E ~: ~ ~ ~ == E l; ° ~ ° ~' 5 E it ~ ~ ° a A E .
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From page 170... ...
aSOURCE: Joint Commission, 1 989e review committee of those cases failing to meet criteria for justification, and (4) documentation in minutes of findings, conclusions, recommendations, actions, and follow-up.
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From page 171... ...
Along with approving pharmacy policies and procedures and maintaining the hospital formulary, the pharmacy and therapeutics review committee also reviews serious untoward drug reactions. Medical Record Review Medical record review is conducted by a medical record review committee.
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From page 172... ...
DONALDSON AND KATHLEEN N LOHR EXHIBIT 6.H6 Example of Integrated Patient Care Monitoring - Data Source Document for Quality Assurance, Risk Management and Utilization Review Ado.
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From page 173... ...
This approach offers an opportunity for more evidence to be brought forward and thus a chance to recognize not unreasonable decisions; peer review generally reinforces a strong collegial sense of the complexity and uncertainties in the case. After reviewing the record, the physician advisor may decide that the quality problem was not practitioner-related.
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From page 174... ...
renal isotope study, etc.) when clinical situations dictate Review cases with cardiac catheterization complications: Contrast media reaction Evidence of arteriothrombosis following procedure Hematoma or excessive bleeding at injection site Circulatory impairment of the extremity Cerebrovascular accident during or within 24 hours of the procedure Medication error, requiring intervention Dissection of artery during acute PTCA requiring intervention Equipment malfunction/failure/disconnection that results in or has the potential to result in patient injury CRITICAL CARE UNIT SCREENS Review of readmissions to the unit within 48 hours after transfer Complications occurring after central line insertion Review of reintubations within 24 hours of extubation Equipment failure Ventilator malfunction Defibrillator malfunction Intravenous (IV)
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From page 175... ...
PSYCHIATRY SCREENS If the patient is admitted to the psych unit by a physician who is not a psychiatrist, a psychiatric consultation must be obtained within 24 hours A comprehensive treatment plan by staffing must be done with the physician in attendance on each patient, describing problems, goals, arid estimated dates of achievement Initial staffing within 60 hours and weekly staffing review thereafter Progress notes must be completed at least every 48 hours Renewal of seclusion and restraint orders every 48 hours Social history will be on the chart within 48 hours after admission to the unit Review of all suicides or attempted suicides Transfer from a psychiatric unit to a medical, surgical, or intensive care unit when primary care becomes medical (oxygen, IVs, fever more than 48 hours, draining infections, cardiac monitoring) Patient on suicide precautions within 2 days of discharge will be reviewed by Psychiatry Section Patients discharged against medical advice will be reviewed Patients with assaultive behavior or assaulted patients will be reviewed EMERGENCY MEDICINE SCREENS Correlation of clinical and radiology results Compliance with chest pain protocol Review of patients whose emergency room stay is longer than 4 hours Review of all deaths in emergency room and deaths within 48 hours after .
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From page 176... ...
DONAIDSON AND KATHLEEN N LOHR EXHIBIT 6.lI8 Example of Surgical Review Screens ~ ~ Outpatient ~ 3 Inpatient ACCOUNT #DATE Improper or no informed consent for procedure performed 2.
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From page 177... ...
This information is useful for tracking problems in a department or on a hospitalwide basis; problems of this nature may be more appropriately linked to administrative and policymaking groups than to individual practitioners. If the case is practitioner-related, the physician advisor may seek additional review from others in the same or a related specialty, the appropriate departmental or other committee, the department chair, or the medical director.4 One hospital described the tasks of peer review as the following: First, a physician advisor decides whether an adverse patient occurrence has taken placed If the physician reviewer determines that the standard of care was met, the case is dropped.
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From page 178... ...
The severity scores may be used in profiling practitioner performance for reappointment and for documentation toward any further action to be taken. Results of review may be presented or distributed in summary form at departmental medical staff meetings.
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From page 179... ...
The [Iealth Care Quality Improvement Act of 1986. The Health Care Quality Improvement Act (HCQIA)
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From page 180... ...
Part A is mainly concerned with peer review; Parts B and C, which relate to reporting of disciplinary actions, are discussed in the section on ambulatory care, later in this chapter. Part A of the HCQIA provides professional review entities and physicians participating in the peer review process immunity from private civil antitrust suits (with a few exceptions)
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From page 181... ...
the U.S. Circuit Court of Appeals answered a question left open by Patrick: if the state courts retain the power to overturn a peer review decision, are peer review bodies and their members shielded from federal antitrust scrutiny under the state action doctrine?
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From page 182... ...
Other major unexpected findings were revealed in another 10 percent of cases." Autopsies can provide information on the rates of and reasons for discrepancies between clinical diagnoses and postmortem findings. Utilization Review Quality and utilization review functions are sometimes linked to minimize duplicative review of the medical record (as noted earlier with respect to activities of a quality assurance department)
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From page 183... ...
These rates are even higher for patients who are very ill, have had invasive procedures, or who are immunologically compromised. Hospital infection control programs have been established to prevent and to promote early identification and control of infections, and they are required by the Joint Commission as a hospitalwide function.
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From page 184... ...
For example, staff at one site visit hospital related the experience of tracing a series of infections to an ice bucket used during surgery. In addition, infection control programs, under the direction of an infection control officer, are responsible for employee health programs and staff education (for further information see the Accreditation Manual Infection Control Standard Joint Commission, 1989b]
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From page 185... ...
The former medical director of an Air Force hospital described one innovative approach. He routinely assigned new staff to keep diaries of problems in patient care during their first month, and he required other staff to spend some of their first month observing the delivery of care and interpersonal process in patient care areas throughout the hospital.
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From page 186... ...
Still others might be considered monitoring devices to identify poor practitioners with the use of lengthy external processes. These include PRO sanctions, disciplinary actions by state medical boards, and malpractice settlements.
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From page 187... ...
If the practice issue is considered to be amenable to education and if the physician is receptive to this approach, a corrective action plan is developed, approved, implemented, reported to HCFA, and tracked for later evaluation. Corrective actions were stressed by PROs we visited as providing a much needed alternative to expulsion from the Medicare program or exoneration.
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From page 188... ...
, the Peer Assistance Recovery Program sponsored by the American Academy of Family Physicians, and other programs sponsored by specialty societies. Sometimes physicians are referred to their hospital quality assurance committee for corrective action plans.
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From page 189... ...
Some PROs prefer to develop and monitor corrective actions themselves. Other PROs see themselves as catalysts and stress the considerable advantage in involving the physician's hospital as a way of reinforcing internal quality assurance activities and CME coordinators.
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From page 190... ...
At its most informal and noncoercive, it may take the form of reminders and exhortation by the medical director, chief of a department, or chairman of a quality assurance committee. These individuals, acting on behalf of the medical staff and in response to identified patterns of poor outcomes, may also invoke a variety of more serious actions.
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From page 191... ...
Findings from quality review may also be used for facility planning by
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From page 192... ...
Although many hospitals still track progress on identified problems with manual systems, some have developed or purchased software to track progress on quality indicators from identification through assessment of contributing factors, corrective actions, and monitoring. In some cases these indicator tracking data bases are integrated with other quality assurance subsystems such as credentialing, risk management, incident reporting, and generic screens.
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From page 193... ...
Efforts aimed at the former include licensure and certification for physicians in solo and office-based group practice as well as credentialing and privileging activities (similar to those in hospitals) in ambulatory care facilities such as clinics, independent practice association (IPA)
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From page 194... ...
The Health Care Quality Improvement Act of 1986 Part B of the HCQIA establishes a National Practitioner Data Bank (NPDB) for collection of several types of information.
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From page 195... ...
All the boards are evaluated for recognition according to the ABMS `'Essentials for Approval of Examining Boards in Medical Specialties." Each board thus requires similar levels of training and experience. The residency program must be approved by the Accreditation Council for Graduate Medical Education (ACGME)
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From page 196... ...
The Quality Assurance Standard for ambulatory care requires that "an ongoing quality assurance program [exists that is] designed to objectively and systematically monitor and evaluate the quality and appropriateness of patient care, pursue opportunities to improve patient care, and resolve identified problems (Joint Commission, l989c, p.
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From page 197... ...
External Methods of Preventing Problems Directed at Prepaid or Managed Health Care Plans Federal HMO Act The HMO Act of 1973 required that HMOs seeking federally qualified status meet certain standards of organizational structure, benefit levels, and financial stability, and that they have an organized medical structure capable of providing clinical services that, in turn, are subjected to quality review. They must have an ongoing quality assurance program with an emphasis on health outcomes.
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From page 198... ...
Internal Methods of Preventing Problems in Ambulatory Care Efforts to prevent quality problems in ambulatory care lie almost exclusively in the province of organized group practices, especially prepaid systems. Organizations providing ambulatory care have many ways to structure the delivery of care so that it is provided safely and effectively.
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From page 199... ...
Applicants are reviewed by multispecialty regional medical staff executive committees and by a regional review committee that includes medical and administrative staff and consumer members. After an initial appointment, a 2-year probationary period ensues during which physicians are reviewed quarterly by department chiefs and at 6-month intervals by regional medical staff executive committees.
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From page 200... ...
(Stocker, 1989~. Practice Guidelines and Algorithms In medicine, and particularly in organized ambulatory care practices, guidelines and algorithms serve many uses, but primarily they are intended to be educational.
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From page 201... ...
In these cases they take on a variety of formats, depending on their highly individualized use. Exhibit 6.A2 is a flow diagram developed at Harvard Community Health Plan for care of women with dysuria; Exhibit 6.A3 is an example of health care screening guidelines used at the Ochsner Clinic; and Exhibit 6.A4 is a data base form devised to help HMO practitioners track age-specific preventive care and counseling needs.
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From page 202... ...
Pa ~ 3 Fever or flank pain r >~ No 5 ~' -- in < Pregnant ~8 No /Doclmcuted [m\ Yes \ past 3 months No 0 r -~ / 3 Ibis\ 3 - -` past year/ ~ No 12 , ~ / Hx urinary tract \ / structural \ ( abnormality or \ other medical \~illness ~ ~ No 1. Single dose Rx (D)
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From page 203... ...
SOURCE: Harvard Community Health Plan, used with permission (abbreviations and other details as in original)
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From page 204... ...
Blood Pressure Complete Blood Count (Courter) Urinalysis Fasting Blood Sugar Electrocardiogram Chest X-ray Cholesterol, Triglycerides Breast Exam Hemoccult Flexible Sigmoidoscopy Testicular Self Exam Instruction Eye Examination I
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From page 205... ...
AGE 60 YEARS AND ABOVE DATE OF EXAMINATION AND CORRESPOhlDING AGE hlISTORY AND PHYSICAL f XAMlNATlON: Blood Pressure q visit Height once /MMUN/ZA T/ONS: dT q 10 years = = = = = = = _ = = = = = = = = = = _ _ Pneumo~ax once only all ~ 65 yrs _ _ _ _ _ _ _ _ _ _ _ _ _ ~ _ __ _ l I I_ _ _ _ _ _ Influenza q year all > 65 years _ _ _ _ _ _ _ _ _ _ _ _ _ _ = _ = = _ _ __ _ · Hep titis B one series only = = = = = = = = _ = = _ = = = = == _ l l l _ _ _-_ _ SOURCE: The George Washington University Health Plan, used with permission.
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From page 206... ...
Geriatric Programs Some HMOs, such as the Kaiser Foundation Health Plan of the Southern California Region, have formed multidisciplinary task forces to review and develop policies specifically for care of their elderly members. A geriatric nurse practitioner evaluates the home environment when needed and oversees long term care for its enrollees.
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From page 207... ...
. External Methods of Detecting Problems in Ambulatory Care PRO Review of HMOs and CMPs Before HCFA awards a Medicare risk contract, it requires an HMO or a CMP to have an internal quality assurance plan.
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From page 208... ...
DONALDSON AND KATHLEEN [J. LOHR EXHIBIT 6.AS Example of Office Group Practice Mission Statement Our goals are, in order of priority: I
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From page 209... ...
For instance, Kansas law requires independent, on-site quality assessment at least once every 3 years. New York law requires all HMOs to have internal quality assurance programs, and state on-site inspections occur every 6 months.
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From page 210... ...
The NCQA survey includes a review of several hundred medical records; in the case of IPAs, this activity specifies at least 10 records from each primary care practitioner to be forwarded to a central location. Under the"squeal law" in Massachusetts, hospitals, clinics, HMOs, and nursing homes are required by statute (Massachusetts General Laws c.l11, Sec.
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From page 211... ...
Internal Methods of Detecting Problems in Ambulatory Care Methods to identify quality problems that can be used by prepaid, managed, or fee-for-service organizations, clinics, and practices fall into several categories. Some are off-the-shelf, proprietary "quality assurance" programs.
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From page 212... ...
DONALDSON AND KATHLEEN N LOHR on an ambulatory basis have come increasing concerns about ambulatory care quality assurance.
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From page 213... ...
hospital practice; (7) medical records; and (8)
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From page 214... ...
to quality assessment in ambulatory care settings; ambulatory staging definitions were developed for 22 conditions including alcoholism, otitis media, pharyngitis, sinusitis, urinary tract infection, and viral pneumonia.
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From page 215... ...
However, the investigators concluded that the concept was valid and would have utility if applied to better medical records. The Joint Commission, in collaboration with the Ohio Department of Heals Services (Card and Lehmann, 1987; P.D.
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From page 216... ...
Components of Ambulatory Care Quality Assessment Programs Process measures for detecting problems in ambulatory care. Problems in ambulatory care can be identified by examining processes of care or by
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From page 217... ...
Systolic blood pressure ~ 90mm Hg + age + 5, and/or lb. Diastolic blood pressure < 90mm Hg unless notation of why not (e.g., notation that patient not tolerating more aggressive therapy)
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From page 218... ...
Just as hospitals are in the process of developing and refining quality-of-care indicators, the search for efficient ambulatory indicators has been launched. Group Health Cooperative of Puget Sound uses a framework recommended by the Joint Commission in looking at systemwide and departmental indicators.
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From page 219... ...
Findings of these reviews can be presented in a formal report or given in a more informal discussion approach (Warner, 1989~. Outcome measures for detecting problems in ambulatory care.
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From page 220... ...
The RAND Health Insurance Experiment developed a large series of health status measures (physical, social, mental) (Brook et al., 1984~; some were used to review ambulatory care for experimental enrollees in both HMO and fee-for-service settings.
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From page 221... ...
. Outcomes such as patient health status measured at some transitional point in care can help to evaluate preceding care in another setting; that is, health status at the time of admission to the hospital or admission to home health care tells something about the previous steps of patient management.
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From page 222... ...
M D _ADM. DATE DISCH DATE SURG PROCEDURES CODES 250 1 250 2 250 3 251 DEFINITION: All hosc~tal~z~t~or~s for diabetic acidosis with lab reports irld~cat~rly blood sugar .~250 nag dl ar erial phi 7 30 or venous CO.\12 and ketone or hetor~en~'a DATA TO BE COLLECTED REGARDING OUTPATIENT CARE: 1 Was there a phys~c,a,~ Visit related to this d~ay~los~s outside the hospital within 10 days prior to Odr~liSS'Orl ?
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From page 223... ...
A QUALITY ASSURANCE SAMPLER EXHIBIT 6.A7 Continued INSTRUCTIONS ''Prirr~ary M.D.'' is the physicians who had seen the patient roost frequently during the preceding year. ''Consultants)
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From page 224... ...
DONAI~SON AND KATHl~ENN. LOHR EXHIBIT 6.A8 Example of Outpatient Clinic Sentinel Events OCHSNER MEDICAL INSTITUTIONS QUALITY ASSESSMENT DEPARTMENT 17 SENTINEL EVENTS Principal Diagnosis Qualifiers Denominator on Trending Report Prematurity Pulmonary embolism/infarct Cellulitis Hypokalemia Ruptured appendix GI catastrophies GI hemorrhage Chronic stomach ulcer with hemorrhage Chronic stomach ulcer with hemorrhage and perforation Endometrial cancer Bom in house Before 37 weeks Exclude intentionally induced within 30 days of Clinic visit Must have been seen in the Clinic within 30 days Lower extremities No operative procedures Serum level <3 mEq/1 Diuretic therapy prior to hospitalization Supported by Pathology report Seen in the Clinic/ Emergency Department within 10 days of ~ .
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From page 225... ...
A QUALl7Y ASSURANCE SAMPLER 225 Denominator on Principal Diagnosis Qualifiers Trending Report Breast cancer Stage II, III/IV none Breast surgery Cervical cancer Abnormal Pap smear none III, IV, V Pap smear within a year Asthma Clinic visit within # of clinic one month patients seen for Dx asthma during the review period Diabetic acidosis Severe preclampsia and eclampsia Gangrene Ruptured ectopic pregnancies Drug toxicity and/or reaction Cancellation/delay in surgery Other: Review that indicates none admission to the hospital resulted from ambulatory care management none none Only extremity Comorbidity diagnosis of peripheral vascular disease none none All patients with insulin-dependent diabetes seen in the hospital during the review period # of OB Clinic patients seen in the clinic during the review period of clinic patients seen during period with a peripheral disease # of new OB clinic patients seen in the clinic during the review period none Ambulatory care concern none none SOURCE: Ochsner Medical Institutions, used with permission.
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From page 226... ...
DONALDSON AID KATHLEEN N LOHR EXHIBIT 6.A9 Example of Health Status Measure PHYSICAL CONDITION During the past 4 weeks .
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From page 227... ...
Quality assurance program activities in HMOs include guideline development, criteriabased record review, generic screening, patient surveys, and complaint review. They also involve analysis of access and system problems, such as waiting time in the reception areas, dropped phone calls, and rate of repeat X-rays because of poor film quality.
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From page 228... ...
"mances Protection you have against hardship due to medical expenses 1 2 3 4 5 Technical Quality Thoroughness of examinations and accuracy of diagnosis 1 2 3 4 5 Skill, experience, and training of doctors 1 2 3 4 5 Communication Explanations of medical procedures and tests 1 2 3 4 5 Attention given to what you have to say 1 2 3 4 5 Advice you get about ways to avoid illness and stay healthy 1 2 3 4 5 Interpersonal Care Personal interest in you and your medical problems 1 2 3 4 5 Respect shown to you, attention to your privacy 1 2 3 4 5 Amount of time you have with doctors and staff during a visit 1 2 3 4 5 Outcomes The outcomes of your medical care, how much you are helped Overall quality of care and services 1 1 2 2 3 4 5 3 4 5 SOURCE: Adapted with permission from Group Health Association of America, Inc.
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From page 229... ...
The quality management program of Group Health Cooperative of Puget Sound (GHC) includes the rigorous credentialing and performance assessment efforts described earlier, departmental case reviews, departmental and systemwide clinical indicators, and multidisciplinary and regional review committees.
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From page 230... ...
"Quality assurance" in IPAs is complicated by several factors: dispersed delivery sites; sites that may participate in many HMOs; variation in medical record format between sites; and lack of a history of quality review. Quality review in IPAs has generally consisted of claims review of utilization patterns (e.g., rate of specialty referrals, hospital admissions, length of stay, pharmacy)
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From page 231... ...
Although quality assurance programs tend to be the most well developed in large clinic settings, even very small practices sometimes develop programs. For instance, the Pike Street Clinic in Seattle, which serves mainly low-income elderly in the immediate area, has voluntarily developed a Medical Practices Committee.
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From page 232... ...
system, originally designed for use in hospitals, has been adapted for ambulatory use. It is being tested by Kaiser Foundation Health Plans, Oakland, California, in two sites Hawaii and North Carolina (Johnsson, 1988~.
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From page 233... ...
General Percent of patients with verified hypertension, 100% (i.e., blood pressure >140/90 taken on three occasions during a two month period) who received physician assessment and follow-up.
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From page 234... ...
AmbuQual bases its review of care in the ambulatory setting on 10 "care parameters," although it has now developed some 150 indicators to measure 40 aspects of care. Weightings of the relative importance of each of the 10 care parameters were assigned by 48 Joint Commission ambulatory facility surveyors as follows: practitioner performance appropriateness of services patient compliance support staff performance accessibility continuity of care patient risk minimization medical record system patient satisfaction cost of services 1.92 1.39 1.25 1.11 0.91 0.90 0.70 0.68 0.59 0.54 These weights imply, for instance, that the impact on patients' health of "appropriateness of services', is twice that of "risk minimization" activities, and that "practitioner performance" has approximately 3.5 times the importance of "cost of services." Patterns of Treatment.
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From page 235... ...
Violation of state-specific medical practice acts provide specific grounds as well, including drug abuse and the incorrect prescribing of medication (AMA, 1986; Grad and Marti, 1979~.~4 State medical boards may require physicians to enter an impaired clinician program, or they may require continuing education in areas of deficiency. In some states the publishing of the disciplined physician's name in the newspaper is a powerful option.
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From page 236... ...
After feedback and discussion regarding the appropriateness of surgical intervention, surgical rates dropped to the state average the following year (MMAF, 1989~. Many health analysts believe this approach has great promise as a physician practice "change agent." Internal Methods of Correcting Problems in Ambulatory Care As with external methods, intraorganizational approaches to corrective action mimic those of hospitals, and they are not discussed in detail here.
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From page 237... ...
Finally, the nature of home care means that minimal professional supervision of direct care will occur at the same time that there is heavy reliance on nonprofessional caregivers who work with vulnerable clients.
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From page 238... ...
Ago ~ S ~s~ ~ at ~- [~ EX "1BIT 6.~14 Example of Grievance Plan for Group Model Hh40 at A^ ~ h~1~ talcs Sugar Comical or ~O~-Id=~ ~ C~c~ *
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From page 239... ...
The federal government partially funds home care services through Medicare, Medicaid, the Older Americans Act (Title III) , and the Social Services Block Grant (Title XX of the Social Security Act)
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From page 240... ...
However, a survey conducted by the National Association for Home Care (NAHC) reported that 82 percent of respondents (typically Medicare-certified, nonprofit, free-standing agencies)
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From page 241... ...
Much of the new home health survey process and enforcement remedies are similar to the changes in nursing home regulation, which in turn derive from the recommendations of the IOM Committee on Nursing Home Regulation (IOM, 1986~. The new home health requirements create a patients' bill of rights, specify notification and disclosure of agency ownership, require that home health agency personnel be either licensed or trained in a program that meets standards specified by the Secretary of DHHS, include some requirements for the content of the training, and require that the agency include each patient's plan of care in the clinical record.
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From page 242... ...
In states that do license agencies, a large number of entities providing home care escape licensure altogether. Many agenciesesiimates range from 15 percent of the total to a number equal to the number of licensed agencies operate as nurse `'pools,' or employment agencies and thus are not required to be licensed (Harrington, 1988~.
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From page 243... ...
A few states mandate criminal record checks of job applicants, but such reviews are required more frequently for independent providers than for agency providers (Hawes and Kane, 1989~. Voluntary Accreditation (NLN, NHCC, Joint Commission j Three voluntary accreditation programs are now in place for home health agencies.
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From page 244... ...
The Joint Commission now accredits community-based home health agencies in addition to existing accreditation for hospital-based agencies (Joint Commission, 1988~. Standards require staff who provide home health or support services to participate in orientation, in-service training, and continuing education programs.
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From page 245... ...
Internal Methods of Preventing Problems in Home Health Care Methods used frequently by home health care agencies for ensuring the capacity of the organization to provide high quality in-home care include staff selection, continuing training requirements, and standards of work performance. Staff Selection, Supervision, and Continuing Education Staff selection begins by ensuring that those health professionals who must be licensed are, in fact, so licensed and by ensuring that those who are not required to be licensed (such as home health aides)
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From page 246... ...
External Methods of Detecting Problems in Home Health Care Assessing Care Provided in the Home Quality assessment has typically been built on the techniques or approaches developed in the acute care sector, including admission and continuing stay reviews and medical care evaluations (Kane et al., 1979; Kane, 1981~. However, these approaches must be adapted and supplemented for post-acute care because of the different goals and situations involved.
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From page 247... ...
(1981) developed a detailed manual on quality assessment using process measures for nursing home patients.
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From page 248... ...
This is the rationale in nursing home regulation in New York, for example, in which "sentinel health events" represent negative outcomes (decubitus ulcers, urinary tract infections) that should have been avoided if appropriate care had been provided (Schneider et al., 1980; 1983~.
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From page 249... ...
Practitioners fear that patients who are ill will be unfairly negative in their assessments, influenced not so much by the actual quality of services as by their pre-existing health status or other sociodemographic characteristics (Lebow, 1974; Cleary and McNeil, 1988~. Further, researchers recognize that satisfaction may not be an adequate indicator of quality if patients lack the knowledge to evaluate the technical aspects of care, if they feel intimidated in expressing their opinion, or if they have become habituated to lowered expectations (Kane and Kane, 1988~.
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From page 250... ...
Measures of caregiver burden are important aspects of the assessment of the overall quality of home care services. Many of these measures have been developed in the area of dementia (Gilhooly et al., 1986; Zarit et al., 1986~.
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From page 251... ...
This requirement has now been consolidated in some states with current requirements for home health care hotlines. For example, the Virginia Department of Aging, through the Office of the State Long-Term Care Ombudsman, is developing a model consumer protection program for home care users that will focus on trained volunteer mediators and self-advocacy training for consumers and their families.
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From page 252... ...
Internal Methods of Detecting Problems in Home Health Care The National Long Term Care Channeling Demonstration provided descriptive information about quality-of-care issues in the home care industry. These include caregivers' absenteeism and lateness, their failure to complete assigned tasks, their failure to follow medical instructions, rough care, theft, and inappropriate matching of home care personnel to clients' needs (ABA, 1986; DHHS, 1989a; P.D.
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From page 253... ...
Comments: Yes No Undecided SOURCE: West Georgia Medical Center, used with permission.
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From page 254... ...
Home health agencies may hold case conferences and conduct concurrent and retrospective record review for appropriateness of care from the viewpoint of overuse as well as unmet needs. For example, the Visiting Nurse Service in Rochester, New York, includes in "utilization review" the appropriateness and effectiveness of care, and the West Georgia Medical Center considers the possible need for additional services (Exhibits 6.HH2 and 6.HH3~.
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From page 255... ...
Home health certification surveyors make periodic visits to evaluate the agency for compliance and report back to the agency about its performance relative to these standards. The Joint Commission and NLN surveys are much the same.
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From page 256... ...
, has meant that regula tory personnel have had to rely on various forms of persuasion in attempt ing to ensure compliance with standards. In effect, then, feedback and, to some degree, consultation have been the major methods used by survey agencies to assure quality in nursing homes and Medicare-certified home health agencies in this country for some time.
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From page 257... ...
Second, the feedback should include information on how the agency can improve its selfmonitoring capacity. This is in line with substantial work in the health care field that argues for a regulatory process that intervenes by creating expectations for the process of internal quality assurance (Vladeck, 1988~.
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From page 258... ...
DONALDSON AND KATHLEEN N LOHR EXHIBIT 6.HH4 Example of Outcome-Based Quality Measures for Home Health Settings Client's Name or Number P,imary Diagnos~s GENERAL SYMPTOM DISTRESS (Suggested introduction To Client: May Be Paraphrased)
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From page 259... ...
State Departments of Health Complaints made to a state department of health or hotline about home health services are investigated by the department as described above. The department may then take various actions, such as freezing new cases or prohibiting the home health agency from taking new cases until the problem
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From page 260... ...
Although this sampler includes external quality review, such as that conducted by the Medicare PROs as well as by state departments of health, data commissions, and hospital associations, it has also delineated the great variety of internal, organization-based efforts at quality assessment and assurance. It reviews some of the considerable research experience that has accumulated for developing instruments for quality review as well as numerous examples of methods shared with the committee during its site visits.
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From page 261... ...
The terms medical director, chief of staff, physician in chief, director of medical affairs, and vice president for medical affairs are all used to describe the individual responsible for managing the hospital's medical staff and the quality of care provided by the medical staff (Fisher, 1986~.
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From page 262... ...
16. Much of this section is based on a paper, "Issues Related to Quality Review and Assurance in Home Care," prepared for the study by C
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From page 263... ...
An Overview of the Methodology Used by The Joint Commission to Evaluate Medicare-Certified HMOs. Quality Review Bulletin 13:415~17, 1987.
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From page 264... ...
Taking Stock of Mortality Data: A Joint Commission Conference. Quality Review Bulletin 15:54-57, 1989.
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From page 265... ...
Indicators of Quality in Ambulatory Care. Quality Review Bulletin 11:136-137, 1985.
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From page 266... ...
Joint Commission. 1988 Home Care Standards for Accreditation.
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From page 267... ...
Joint Commission. 1990 AHC Ambulatory Health Care Standards Manual.
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From page 268... ...
Review of State Quality Assurance Programs for Home Care. Submitted to U.S.
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From page 269... ...
Chicago, Ill.: Joint Commission on Accreditation of Healthcare Organizations, 1987. NAHC (National Association for Home Care)
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From page 270... ...
Quality Assurance Strategies for Home-Delivered Long-Term Care. Quality Review Bulletin 15:156-162, 1989.
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From page 271... ...
Integrating Quality Assessment and Physician Incentive Payment. Quality Review Bulletin 15:23~237, 1989.
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From page 272... ...
The Development of a Home Care Quality Assurance Program in Alberta. Home Health Care Services Quarterly 7:13-28, 1986.
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From page 273... ...
The Gerontologist 26:260-266, 1986. APPENDIX MERCY HEALTH SERVICES SURVEY OF QUALITY MANAGEMENT PROGRAMS, STAFF, AND RESOURCES During the spring of 1989, Mercy Health Services in Farmington, Michigan, conducted a survey of hospital systems and their member hospitals.)
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From page 274... ...
Data verification, coding, and analysis were done in three phases by the MHS principal investigators with participation by the IOM study staff. This Appendix discusses only data that were designated as pertinent to quality management functions conducted at corporate or individual hospitals.
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From page 275... ...
In other cases a quality managemerlt function may not be performed at the hospital. Results Corporate Resources and Assessment Table Alla shows the number of corporate offices, among the 11 responding, that had formal programs at the corporate level supporting the areas of quality management, risk management, and utilization management.
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From page 276... ...
DONALDSON AND KATHLEEN N LOHR TABLE A.lb Number and Percentage of Respondents with Formal Programs at the Corporate Level, by Type of Functional Area Functional Area Number Percentage Nursing Medical staff Quality management Risk management Quality arid risk management Quality and utilization management 1 Medical records Pharmacy Medical education Ethics 7 4 2 2 2 64 54 36 18 9 9 18 18 9 9 NOTE: Number of respondents was 11.
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From page 277... ...
reported that medical staff are paid for their participation in utilization management. By contrast, only 24 percent of medical staff are paid for quality management, and only 19 percent for participation in infection control programs.
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From page 278... ...
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From page 279... ...
279 0 car ~on 1 1 1 0 0 0 0 0 ~ ~ 0 ~ car cap I I I 0 0 0 0 0 0 0 car cab ~ 0 ~ 0 ~0 0 ~ ~ ~ ~ ° ~ ~ ~en ~ ~ ~ ~ ~ ~ O ~ax cry 0 oc 0 0 ~ _, ~ 0 0 ~0 ~0 0 0 ~ 0 0 oo 0 ~0 0 ~ 0 0 0 0 0 ~O cry ~ O ~In ~In ~ ~ ~ ~ O car cad ~ ~ ~ ~ ~ ~ cry 0 ~ ~ 0 c ~: O ~u, c Y - _ 2 ~ E _ _a ' - - E E E ' E O E ° E ~ ~ - a '~ a c a ._ , 5 E c >' ° E E E E E E ° 0 _ ° ' O E E , °° C E ~, E ~ ~ E >- 5 E j ~ c Y ~ Y o E E E E ° m ~ E~: oo v ~ =~ _ ._ o ._ ~_ e~ ._ ~4 o c, c, C: O cn ~D o ._ ~ O ~; ¢ =: ~: c~
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From page 280... ...
V N LOHR TABLE A.3 Number and Percentage of Responses Citing Strengths, Needs, and Challenges of Respondents' Quality Management Programs Number of Response Category Responsesa Percentage Strengths Systemwide quality indicators 5 26 Insurance and claims management 4 21 Coordination with the Joint Commission 3 16 Governance focus on quality 2 11 Staff in facilities serve as systems 2 11 Same studies in hospitals 1 5 Integration of quality, utilization, and risk management Consultation Needs Data systems and capabilities 7 35 Financial impact and implications of quality 3 15 Increased integration of quality, utilization, and risk activities 3 15 Govemance-level quality reporting 2 10 Applications 1 5 Joint studies 1 5 Relationship with PROsb 1 5 Medical staff issues 1 5 Standardization among facilities 1 5 Challenges Senior leadership commitment to quality 4 19 Develop effective, integrated quality/ utilization risk processes 4 19 Proliferation of external demands 3 14 Document improvements in quality 3 14 Increase in the system's reputation for quality 2 10 Software and hardware updates 2 10 Sources and uses of valid data 1 5 Communication with organizations in the system 1 5 Fiscal issues l 5 aNumber of respondents was 11.
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From page 282... ...
7 10 18 Combined QM/UM/RMa 4 9 4 17 Combination with medical staff office 3 3 3 9 Separate QM 1 2 4 7 Formation systems 1 2 2 5 QM/RM O O 1 1 Combination with focus on nursing Total 1 0 0 l 11 23 24 58 meet. aQM is quality management, UM is utilization management, RM is risk manage Sta~ time spent on quality management functions.
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From page 283... ...
283 Cal A: ~4 Ct Ct Ct ._ o ._ Cal a: C:: ~4 Ct a: Ct ._ _ C)
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From page 284... ...
N(HrslQ) Range Hospitalwide functions Indicator development 1 lSO 15 Committee time 1 750 223 21- 25 Concurrent record review Retrospective record review 1 54 1256 Adverse patient occurrence 1 21 292 64-120 Data collection/analysis 1 90 19 Medical staff Indicator development 15 Committee time 1 420 2372 9-735 Concurrent record review Retrospective record review 11,500 Adverse patient occurrence 278 27-130 Data collection/analysis 2170 144-195 Reappointment/privileging 130 Medical staff functions Blood usage Surgical case review Medical records Pharmacy and therapeutics 1 36 1 108 Cable A.6 shows no respondent in this category.
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From page 285... ...
285 Al ~4 Ct I: Cal o .= ._ Ct ._ .° lo: ~4 Ct :^ C-O.
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From page 286... ...
286 ~: To Ct Cq ._ ._ Cal .= Cal Cal o .= Cal A: be ._ r c4-o.
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From page 288... ...
288 be en Ct ._ Cal · Em Ct o Pa .
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From page 289... ...
289 _ A: as C)
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From page 290... ...
290 :' ._ at ;_' C)
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From page 291... ...
Although corporate offices, by and large, do not yet have separate quality management functions, it appears that they have begun to move in the last few years to greater integration of activities (e.g., systemwide quality indicators) between hospitals and to see this as a desired task.
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Key Terms
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