Advancing The Quality of Health Care A Policy Statement (1974) / Chapter Skim
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2 The Principles of Quality Assurance
2 The Principles of Quality Assurance
Pages 7-42
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From page 7... ...
But we can postulate the principles that are fundamental to any such method and that can guide the future evolution of the program, including desirable legislative changes. In the following discussion these principles are grouped under seven general headings: scope, methods and data requirements, standards, sanctions and behavior, management and control, costs and evaluation, and research.
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From page 8... ...
On balance, the committee considers the geographic area advantages to be greater. The committee recommends that quaZity assurance programs be estabZished initiaZZy to encompass a total population in a geographic area rather than a partio~Zar health mare organization.
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From page 9... ...
the committee recommends that quality assurance programs use information both about patients receiving services and about the genera Z population, most of whom fizz not be receiving servioes during a specific period. Providers of medioaZ care Fizz be reviewed primarily in regard to persona, health ware services provided, but paraZZeZ survey information should be empZoyed to assess the heaZth needs and demands of aZZ persons in the review area, including those not receiving services during the period under consideration, using terms, definitions, and oZassifioations oomparabZe to those used for the patient record information.
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From page 10... ...
41) she committee recommends that Special project support be proffered to quality assurance programs that agree to undertake assessments of the relative health needs and health status of the general and underserved populations.
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From page 11... ...
However, the development of coding schemes for problems is helping to overcome the difficulties. The importance of covering ambulatory care in quality assurance programs warrants its inclusion as soon as possible.
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From page 12... ...
Methods for ooZZeoting data Resource and organization data, gathered by a variety of agencies, include the number of hospital beds in a community, vital statistics, and the ratio of physicians to population. Hos pi ta Z discharge abs tract includes a uniform basic set of data collected for all patients discharged from all hospitals and expressed in standardized terms, definitions, and classifications.
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From page 13... ...
Figure 1 Quality of Care Assessment: Possible relationships between the type of data by which the assessment of the quality of care will be made and method by which that data will be collected. Type of Data Method- and Sources Routinely Reported Data about Population, Resources, and Organizations Hospital Discharge Abstract Claims Form Encounter Form Source-Oriented Medical Record Problem-Oriented Medical Record Direct Observation of Physicians Simulation Techniques Patient Interview Tracer Disease Strategy Population Survey Combination of Above Structure Process Outcome Combination X X X X X X X This type of data can be collected by this method.
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From page 14... ...
Encounter f orm includes a uniform basic data set as part of the record for each patient visit; a statement of the patient's problems, diagnosis, procedures such as laboratory tests, services provided and disposition of the patient is included. It can be linked to a claims form and in some instances to a hospital discharge abstract Souroe-oriented medical record is the traditional manner in which the medical record is kept.
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From page 15... ...
Analysis of the sample data provides a basis for generalizing about the effectiveness of medical processes, provider performance, and organizational management at a collection site. Pop u Cation survey is the collection of data by means of household interviews or health examination surveys from properly selected random samples of a defined population or an entire population, both those who have and those who have not actually used health services during a specified time period, such as two weeks or a year.
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From page 16... ...
StruoturaZ, prowess, and outcome data Any method of assessing the quality of health care should either measure improvements in the health of the population served by the system as well as in the population not served, or should measure a set of variables that have a highly predictable and reproducible correlation with changes in health status. In addition, a quality assurance system should assist in efforts to understand the relative effect of personal health care services on health status as against the effect of other influences such as the environment.
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From page 17... ...
However, except for data derived from hospital case fatality rates or complication rates, which can be obtained from a hospital abstract or medical record, patient outcome data are generally available only from patient interviews and population surveys. Such outcome data are usually expensive, although methods recently tested suggest that under certain circumstances functional capacity or disability and distress levels can be assessed Reliably and collected at the time of and during hospitalization.; Only through the use of a community survey or survey of a registered population can information be obtained from a properly selected random sample of those in a population who used services as well as those who did not.
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From page 18... ...
On the other hand, data obtained from claim forms, encounter forms, or hospital discharge abstracts may not be sufficiently detailed to judge fairly all aspects of the performance of an individual provider, or the care of a particular patient. Observations of a practitioner's work -require a great amount of time and are difficult to standardize.
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From page 19... ...
There are a number of problems with this approach. First, as indicated before, this type of review is likely to result in increased costs without corresponding improvement in health status.
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From page 20... ...
The hospital discharge abstract data set is so constructed that it can be linked to similar uniform basic data sets of claims review and encounter forms. Regional or institutional comparisons of items contained in this data set such as the utilization rate for a specific operation or death rates in myocardia~ infarction would be useful to quality assurance systems as a first step.
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From page 21... ...
The PSRO program should and can be oriented around this fundamental emphas -- The use of explicitly predetermined criteria should be avoided unless they are grounded in objective studies showing beneficial patient outcome. The use of explicit criteria based on norms of current practice or even consensus of experts, without reference to patient outcome, can stifle innovation, increase costs, increase demand for scarce manpower resources, and increase the risk of harm to the patient from the care itself.
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From page 22... ...
First, the committee agrees that the data system for quality assurance should allow evaluation of care to be integrated into the delivery system. Implicit in that concept is that selected patient data should be quickly retrievable, related to patient problems, compatible with other data requirements related to patient care or health planning, susceptible to continual revision, and frequently compared to existing standards that are in turn periodically reviewed when new data are available.
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From page 23... ...
It is then possible to divide outcome data into categories for individual patients and for out-populations of various categories of patients. Within this framework, the remaining issues to be covered are the kind of data to be collected, the uniformity of basic data sets, methods for collecting and retrieving data, the compatibility of the data-with other health data collection systems, and the patient's medical record.
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From page 24... ...
The National Center for Health Statistics has been developing contractual arrangements for state and local comportents of this system. The use of comparable terms, definitions and classifications by these systems and quality assurance programs is essential.
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From page 25... ...
As a step in this direction, the members of the American Association of Health Data Systems, representing fifteen regional data systems, have already adopted the uniform basic data set for hospital discharge abstracts. The committee recommends that basin patient identifioation Satan services, and diagnostic categories be stated in uniform terms, definitions and oZassifioations and that oompatibiZity between public and private data systems be enoourageZ.
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From page 26... ...
They are usually constituted as nonprofit corporations whose trustees represent the major health interests and the public. The commi ttee recommends that qua Zity assurance data, as eZZ as other data, be recorded only once; that aZZ data be uniform with respect to terms, definitions of terms, and cZassifioations; and that, in order to faoi Zitate the uniformity and parsimony of data and to minimize demands upon the pro viders, the National Center for Health Statistios be assigned responsibi City Hi thin HEW to formulate uniform terms, definilions of terms, and classifications, and to formulate data co Z Zeotion systems in aooordanoe with this recommendation.
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From page 27... ...
This is a deceptively simple point to state, but the committee stresses its importance because of the potential for abuse. The committee recommends that data ooZZeoted on individual patients in the course of quaZity assurance be kept striotZy confidentiaZ at the topaz review ZeveZ and that only aggregated or anonymous individuaZ statistioaZ data be made generaZZy avaiZabZe.
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From page 28... ...
Deviations from standards should not, however, be made on a subjective basis, such as the practitioner's relative competence or lack of knowledge, but should reflect differences in available resources and population characteristics. Although medical care standards should be related to the desired changes in health outcome of the population being served, it must be recognized that medical care is often not the most important variable affecting health status.
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From page 29... ...
40.) The committee recommends that standards be formuZated initiaZZy at the topaz review ZeveZ, and the FederaZ activity foous on the reties, comparison and approvaZ of Zo~aZZy developed standards.
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From page 30... ...
If providers, who are required to participate in quality assurance programs, also have to bear the cost of those programs, they will pass it on to the consumers. Since consumers of health care services include government, and government's revenue comes from taxation, the taxpayer would support the government's consumer role as well as his own.
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From page 31... ...
trust fund. The committee recommends that the Federal government bear the total costs of estabZishing quality assurance programs by nonprofit organizations with assurances that topaz sources Fizz be able to bear their share of the costs of maintenance.
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From page 32... ...
To the maximum extent feasible, the quality assurance system should serve as an educational device to improve provider performance, although state licensing bodies and existing continuing education programs will continue to play a role. The purpose of quality assurance is the elevation of performance of all providers, not the detection and punishment of a few offenders or incompetents.
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From page 33... ...
For specialty boards, evidence of continued failure of any provider to meet quality assurance standards should be the basis for withdrawal or modification of specialty qualifications. A substantial amount of information about provider performance will be amassed by quality assurance systems.
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From page 34... ...
The first to be red eased would be aggregate statistical data describing the frequency of events an their outcomes by institutions and services; next would be data relating to specific health care processes and their objectively established efficacy; and finally, as a last resort, data about the performance of individual practitioners. -- Information designed for the public should be readily accessible to the public and not buried in obscure reports.
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From page 35... ...
The following discussion and recommendations address the degree of professional expertise required for participation at the several levels of the quality assurance system -- the initial review level and the supervisory level -- and the appropriate participation of consumers in the management and control of the program. Expertise : review Zeve Z .
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From page 36... ...
The committee's examination has been Jimited to publicly authorized quality assurance systems, such as PSROs, in which it is understood that nonproviders will assume some supervisory responsibilities in the inevitable bureaucracies. But, it is essential that providers seek and be accepted for supervisory positions so that their expertise will be available to the government in its administration of quality assurance programs.
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From page 37... ...
Figure 2 Relative Rot .es of Providers and Consumers in Review of Care and Supervision of Quality Assurance Systems Level of Participation Federal policy setting State review Area review Review of care by local quality assurance system or institution ~ / 1' '''' / .
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From page 38... ...
The Federal health bureaucracy is fragmented, and it is unclear who bears the responsibility for the administration of quality assurance programs. There is an office charged with responsibility for the PSRO programs but it is in jurisdictional conflict with other agencies that have a.role in quality assurance activities.
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From page 39... ...
To make effective the sanctions that the quality assurance programs choose to administer, they must have the authority to impose fiscal sanctions. The Social Security Administration, or any successor agency for financing health care, should accept, implement, and, if necessary, delegate authority for any fiscal sanctions imposed by the quality assurance agency.
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From page 40... ...
Because the development and application of quality assurance standards are decentralized, each local review unit should forward information about local standards to a central repository for comparison and analysis. Also, aggregated statistical data on provider performance within regions across the country should be centralized, at least on a sample basis, so that comparisons can be made between provider performance in various regions.
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From page 41... ...
Project grants for these purposes should be made available in addition to sums paid to quality assurance programs for start-up and maintenance costs. The committee recommends that a substantial research and development program be launched to augment and improve the teehnoZogy of qua City assurances inoZuding data ooZZeotion and analysis, and that, before quality assurance systems become operational, designs and tease Line data for their evaZuation Size be developed and ready for impZementation.
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