Medicare A Strategy for Quality Assurance, Volume II: Sources and Methods (1990) / Chapter Skim
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4. Site Visits
4. Site Visits
Pages 91-115
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From page 91... ...
The remainder of this chapter describes the site visit process and documents the main groups, organizations, and facilities visited. It also discusses major issues raised during the visits and gives examples of the types of quality-of-care problems that health care providers identify through their quality assessment systems or that they consider basic health care systems Issues.
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From page 92... ...
Visits to Organizations During the site visits to organizations such as hospitals, hospital associations, HMOs, home health agencies (HHAs) , and Medicare PROs, the committee generally used the "Guide for Site Visitors" (Appendix B)
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Although all of the meetings concentrated on quality assurance for Medicare, each brought forward somewhat different views. Documentation After the site visits, each IOM staff member and some committee members prepared lengthy trip reports based on written and tape-recorded observations.
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Meetings Experts in data base development and employee retiree benefits (Chicago) Metropolitan Chicago Hospital Council and member hospitals (Chicago)
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Pennsylvania Health Care Cost Containment Council, Data Commission (Harris burg) Thomas Jefferson University Hospital (Philadelphia)
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Home Care Association of Washington and representatives of several home health care agencies Medical directors and hospital administrators of hospitals in eastern Washington State and western Idaho (Spokane) Medical directors of major Seattle hospitals (Seattle)
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Edward Hook, M.D., University of Virginia, Charlottesville (meeting in Richmond) NOTE: PRO is Peer Review Organization, HMO is Health Maintenance OrgaTuzation, arid HCFA is Health Care Financing Adrninis~ation.
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From page 98... ...
setting-related topics of health care delivery and quality assessment and assurance that focused on particular difficulties or circumstances of ambulatory care settings, home health care, teaching hospitals, and small and rural hospitals; internal health care organization issues such as leadership, systems of health care delivery, and accountability for quality; quality assessment methods, including data issues, guidelines, and outcomes assessment; quality assurance methods, including concerns about duplication of efforts, the value of education and feedback of quality-of-care information, disclosure, dealing with very poor practitioners, legal issues in peer review, .
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From page 99... ...
Problems Reported by PROs and Other External Regulatory Bodies Generic Screens The first set of problems were those identified by the inpatient generic screens that PROs use in their retrospective review of hospital charts.2 PROs reported that the screens frequently flagged the following problems: abnormal results of diagnostic services that are not addressed and resolved or where the record does not explain why they are unresolved; care resulting in serious or life-threatening complications that were not related to admitting signs and symptoms, generally involving the neurological, endocrine, cardiovascular, renal, and respiratory systems; medical instability at discharge; nosocomial infections (specifically, temperature elevation greater than 2 degrees more than 72 hours after admission and indications of infection following an invasive procedure) ; trauma suffered in the hospital (specifically, hospital-acquired decubitus ulcer)
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From page 100... ...
They also mentioned lack of knowledge and understanding of the Medicare program or of how to obtain care through an HMO as problems. Various PROs noted the following: lack of thorough diagnosis and appropriate follow-up;3 poor monitoring of patient status; premature discharge; poor technical knowledge of physicians; specialists who practice beyond their competence in performing some procedures; surgical specialists not calling in medicine consultants soon enough; nurses not calling in physicians appropriately (as a function of inexperience and work overload)
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From page 101... ...
; nosocomial infections and patient falls (both of which are PRO generic screens) ; and lack of informed consent.
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. One hospital's ambulatory review program found readmissions for hospital-acquired wound infection to be a problem, which was traced to inadequate discharge planning and instruction about wound care.
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Examples included accuracy of demographic data, presence and accuracy of discharge summaries, and general problems of record-keeping. One provider mentioned lack of documentation of earlier breast examinations as a an obstacle to appropriate breast cancer screening, diagnosis, and care.
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Poor compliance with preventive care guidelines (in one case, influenza immunizations; in another, breast cancer screening) was also noted as a problem in office-based practice.
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2. At the time of the site visits, very few PROs were involved in "intervening care" review of home health agencies or skilled nursing facilities.
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and of providers and practitioners who are the targets of such activities (e.g., hospitals, health maintenance organizations, ambulatory care centers, home health agencies, private practice phy
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From page 107... ...
We believe that it would be helpful to us if the site visitors could meet with a group of no more than 6-8 individuals, including, for instance, a Member of the Board of Trustees or Directors, the Medical Director, the Chairman of the QA Committee, the QA Coordinator, and perhaps the director of your Medical Records or Data Processing Department; it might also be very informative for us to meet with some clinicians on your staff (physicians, nurses, discharge planners and the like) who may have a special perspective on quality review and assurance activities within the institution.
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5. A discussion among those present concerning your thoughts as to the crucial elements of a successful quality review and assurance system that might be applicable to the Medicare program and special quality of care issues related to the elderly.
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From page 109... ...
Associate Study Director Enclosures: Study description IOM Brochure Description of site visitors APPENDIX B GUIDE FOR SITE VISITORS STRATEGIES FOR QUALITY REVIEW AND ASSURANCE IN MEDICARE PLANNING Site visitors should meet for at least a half hour every morning to plan strategy. DEBRIEFING The site visit team should try to meet for an hour at the end of each day and definitely before the departure of team members for a general debriefing.
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From page 110... ...
Medicare (not Medicaid) study Educational purpose Focus is truly on quality not cost containment Settings hospitals, free-standing clinics, MD offices, and HMOs, HHAs Other activities of study public hearings, written testimony, focus groups, commissioned papers' site Visits Confidentiality of quality information Invite them to speak not only for organization, also as individuals Desire for materials now or later - follow-up Introduction of those present How you would like visit to be organized (large/small groups)
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- among private accrediting and review organizations? and - between the public and private sectors?
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DONAlDSOlI AND KATHLEEN N LOHR HEALTH CARE FACILITIES WITH INTERNAL OUALITY ASSURANCE PROGRAMS: The following is the pool of questions suggested by the Committee.
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What is the effect of the external QA review on the institution, medical staff? How much burden does the quality assessment system place on providers?
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? As a subject of external quality assessment and assurance activities (PRO review, licensure, accreditation, etc.)
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SITE VISITS 115 How does the organization influence providers' decisions about indications for procedures, special care, or hospital admission and length of stay? How do you (your institution)
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