Excellence in Ambulatory Care: A Practical Guide to Developing Effective Quality Assurance Programs.

Excellence in Ambulatory Care: A Practical Guide to Developing Effective Quality Assurance Programs.

Benson and Townes present a concise definition, description, and structural framework for the quality assurance function in ambulatory care settings. They begin with a brief history of the quality assurance movement and proceed to outline what they perceive to be the key challenges to successful implementation of effective QA programs, including physician and organizational acceptance, organizational commitment, national leadership, cost factors, program comprehensiveness, appropriate processes, development of common indicators and standards, and, finally, progression to full quality management.

A generic model for am ambulatory quality assurance program is presented. This encompasses two specific processes, "monitoring and evaluation" and "problem resolution," which are established via a nine-step model:

1. Determine the focus of responsibility for QA activity. 2. Determine the organization's scope of services. 3. Select significant aspects of care for routine tracking. 4. Choose specific indicators of quality to monitor. 5. Develop criteria and related standards as QA

indicators. 6. Routinely monitor and evaluate the chosen indicators. 7. Take appropriate problem resolution action. 8. Track resulting corrective actions or improvements. 9. Create a permanent record of all QA activities.

Benson and Townes illustrate this approach through descriptions of established QA programs in five distinct ambulatory settings, including a proprietary group practice, a university health group with major prepaid involvement, a major university-affiliated hospital complex, an ambulatory surgical facility, and a system of three community health centers.

The remainder of the book expands on the nine points of the model. The authors begin by giving detailed examples of how to define organizational aims in performing quality assurance and how to structure a program and gain the necessary organizational commitment. Deciding what to monitor and evaluate, selecting guideposts for comparison, and collecting and analyzing data are are reviewed.

Selecting an instrument for evaluating the quality of care is covered next. As an example of a highly structured quantitative system, the authors present their own AmbuQual system, currently in use at their community health center setting. It provides a mechanism for constantly measuring the level of performance against predetermined quality indicators and provides the focus for taking corrective action. Using this system as an example, the authors present examples of tracking identified problems through their resolution while developing a written record for documenting the entire QA effort.

The book finishes with a look ahead, outlining what the authors believe will be the future directions of quality assurance efforts. They contrast where they believe the profession will be in 10 years in terms of the challenges outlined in the first chapter.

This book will be of great value to those either setting up a quality assurance program or evaluating an existing one. The authors present current standards against which QA programs are judged.

The book dwells too heavily on the role of the Joint Commission on Accreditation of Healthcare Organizations as the standard bearer of QA, especially given its recent withdrawal from the managed care arena. The authors should be forgiven their use of AmbuQual as the QA instrument they highlight, given their familiarity with the product. They might, however, have undertaken an exploration of the marketplace and give some background on other products.