Quality assessment tools add value.

Although cost containment has been a driving force in the reorganization of health care markets, the assurance of quality remains of paramount concern to payers, insurers, provider organizations, and patients.

Competitive advantage will increasingly become available to those health care organizations that can demonstrate mastery of the cost-quality relationship and deliver true value to their stakeholders (i.e., value = (quality/cost) x volume[1]). Health care organizations can expect that they will increasingly be asked to show objective evidence of this value. Demonstrating quality will require data collection on the processes of health care delivery and clinical outcomes. The quality assessment. tools (QAS) available to organizations for collecting this data include traditional quality assurance (QA) measures and newer quality improvement (QI) techniques adopted from industrial models. Health care organizations that master these techniques will be more likely to survive, even thrive, in increasingly competitive care environment.

The similarities and differences

Evaluating the quality of care has focused on the individual provider through quality assurance activities. The data used in this process have, in large part, been derived from the retrospective or concurrent review of medical records, hospital discharge abstracts, and insurance claim forms. The essential elements of traditional QA include:

1. Identify a problem

2. Set a performance standard

3. Screen to assure compliance to the performance standard

4. Gather individual feedback and identifying deficiencies

5. Institute corrective action to achieve the performance standard

6. Emphasize health care structure, process, and outcome

In this paradigm, structural data is readily available (i.e., facilities, equipment, and staffing patterns), process measures target individual provider performance, and evaluating the outcome is often limited by subjective judgment. Quality assurance has carried a punitive and regulatory feeling, highlighted by the strategy of retrospective utilization review, medical care audits, and individual physician profiles that focus on identifying substandard performance. Limitations include possible ineffectiveness (i.e., no change in clinical practice), lack of available external benchmarks for comparison in some circumstances, the potential for collecting data with questionable utility, and a distorted emphasis toward people rather than systems as the principal cause of most quality problems. Comparative characteristics of QA and QI as QAS tools are noted in Table 1.

[TABULAR DATA OMITTED]

The QI process is concurrent and future-oriented, focusing on designing the most effective systems to convert specific patient needs into effective clinical outcomes. It emphasizes a cross-disciplinary team approach that is inclusive of organizational leadership, clinical care professionals, and support services.

The QI model considers the causes of variation in systems, and it distinguishes common causes of variation from special causes (i.e., very unusual events). It is process and outcomes oriented on a system-wide basis, and process is evaluated from the perspective of patient satisfaction. In contrast, QA assessment tools tend to target high volume, high-risk services (i.e., blood utilization and coronary artery bypass surgery) and evaluating variation is limited to special causes (i.e., very unusual events, such as those that result in an incident report).

Quality assurance may be further distinguished from QI in several ways. The punitive nature of QA motivates people by fear, whereas the QI process motivates people in a positive manner to improve the whole organization in a team effort. QI is customer-focused - both internally and externally - while QA exists in most health care organizations for the purpose of meeting regulatory requirements. QA data-gathering has traditionally been carried out in a perfunctory manner, whereas the importance of data-gathering and statistical thinking to identify causes of variation is highlighted in the QI model. Statistical thinking is emphasized in the QI processes and may be applied to any area of health care delivery from support services to professional decision-making.

Quality improvement emphasizes the inter-relatedness of departments and the absence of individual blame for process failure. While QA addresses conformity with a list of approved actions, QI investigates the reasons behind conformity (or lack thereof) with the use of agreed-upon "best practices" as a benchmark. QI requires a commitment from senior management to actively participate and integrate quality planning into the organization's strategic planning process. In this fashion, the organization's quality plan becomes well known to all employees, who are then invited to incorporate the new philosophy into their, daily routines.

Both QA and QI require ongoing monitoring and a feedback process in order to act on the results of acquired health care data. Some dimensions of quality are shared by the QA and QI process and these include efficiency, effectiveness, accessibility, and acceptability (i.e., satisfaction with process and outcome). Provider competence (i.e., technical and interpersonal), which is a principal focus of QA, may be viewed as a prerequisite for QI when defined as the ability of the provider to use the best available knowledge and judgment to produce optimal health and satisfaction of the patient consumer.

The following points should be considered when developing an optimal quality improvement team proposal:

* Define the team's mission: What is the opportunity for improvement the team will address?

* Define the beginning and end points for the process to be improved.

* Identify the indicators to be used to measure success.

* Describe the measurement process.

* Identify the information needed to understand the current process.

* Identify the departments and the staff from departments that will need to participate in the cross-functional team.

* Estimate the time required to complete the team's mission.

* Estimate the costs (i.e., staff time, hardware, and software required).

* Quantify the estimated positive effects of the project (i.e., increased revenue and/or volume, reduction in costs and/or time required to perform the service, and the potential for acquiring new business or services).

Should traditional

quality assurance be used?

The desire to achieve optimal quality in delivering health care services is the fundamental basis for both QA and QI. Historically, from the time of the Flexner report in the early 20 Century, health care leaders have set quality standards for structuring medical education and delivering health care services.[2] Various professional organizations, such as the American College of Surgeons, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the American College of Physicians, and the specialty certification boards, have placed quality assurance and improvement as their top priority. The philosophy of QI as outlined by Deming[3] and Juran[4] has been embraced by industry as a means to assure competitiveness and market share by producing excellent products.

Although applying QI to health care has been described as a paradigm shift, it is unlikely that traditional QA will be entirely discarded in the near out significant changes in external regulatory requirements and the broad adoption of QI processes by health care institutions. It is likely, therefore, that these two QAS tools will co-exist and remain intimately related.

The JCAHO, for example, continues to require hospitals to have processes in place that monitor operative and invasive procedures, blood and medication usage, medical records pertinence, infection control, and general clinical care. Most hospitals continue to employ an incident reporting system for identifying unusual events that produce, or have the potential of producing, an adverse outcome.

Collecting data expressed as a rate (i.e., Cesarean section, mammography, and pap smear rates) is receiving increasing attention both for individual physicians and groups of physicians. As QI becomes an instinctual element in the health service organization, these QA activities should serve to identify sentinel events for which a QI process should be applied. The goal should be to identify the cross-departmental team that has the greatest potential impact on the care process in question and move its performance curve to the point where a best practice standard can be achieved. To the extent that continual efforts to improve quality permeate the organization, it will be easier to identify the few circumstances where people, rather than processes, are the issue. Clearly-articulated educational and training policies should be in place to foster process improvement.

As compared with QA, the techniques of QI should be viewed as a richer set of sequential steps that involve the entire organization in the continual study of health care processes. The goal of QI should be achieving excellence as defined by patient satisfaction, clinical and functional status outcomes, cost, and external regulatory requirements.

Are they related?

Optimizing utilization management will increasingly be recognized as a responsibility of all members of the health care team; QI processes that address utilization should be developed with consideration of best practice guidelines across the continuum of care. Aligning administrative and provider interests to achieve quality improvement, while at the same time reducing cost, must be a goal in this process. Existing guidelines can be integrated with the unique process improvement requirements of a particular institution. Cross-departmental QI efforts in utilization management should target provider settings with adverse utilization variance and/or high cost/unit of service.

A thorough review of practice styles and contracted incentive structures in the current process of care will likely be required before initiating significant changes. Such changes will require the support of all members of the health care team; physician buy-in is critical. If providers conclude that the quality of patient care will improve and will not come at the expense of physician remuneration, support will be enthusiastic.

The increasing prevalence of capitated contracting arrangements with physician-hospital organizations is an example of the creation of a provider risk-sharing environment in which quality improvement and utilization management efforts can be embraced by physicians. Such an environment may also result in physicians taking a more active role in the evaluation of new medical technology - a principal component of health care cost inflation. Ultimately, this will require a change in the educational process of all health care professionals.

A team-based QI process may also be organized around outcomes evaluation. Optimal outcomes should be, defined by the health care team and might include evaluating:

1. Functional status at multiple points after a health care service is delivered.

2. Clinical status indicators (i.e., systolic function after myocardial infarction).

3. Stakeholder satisfaction with the process of care and outcomes (i.e., patient satisfaction including access, physician satisfaction and collegial collaboration, employer satisfaction, organization management satisfaction, and family member satisfaction).

4. Financial status (i.e., risk-sharing arrangements for disbursement of net revenues, medical loss ratio for a health plan, operating margins for provider groups, costs per unit of service, return on assets, return on equity, and retained earnings or fund balance).

5. Community service outcomes (i.e., community goodwill, the delivery of free care to the uninsured, and responsibility for the stewardship of technology).

Identifying the significant factors that impact a given health status outcome by the stakeholders, of a cross-disciplinary team characterizes the process of a successful QI effort.

Conclusion

The rapid evolution of the health care marketplace can be expected to continue as we move closer to the 21st Century. Externally-imposed pressures for cost reduction will increasingly be accompanied by internal pressure within health care organizations as risk-sharing reimbursement arrangements become more commonplace.

Competitive advantage will be available to those organizations that can demonstrate objective value as defined by the cost-quality equation. The tools chosen by an organization to perform health care quality assessment will be an important factor in its ability to demonstrate such value. Traditional QA will in an likelihood continue, but the extent to which QI activities are adopted by the culture of an organization may determine its ability to provide objective evidence of better health status outcomes.

Key Concepts: Quality Assessment

Tools/Demonstrating Added Value/Quality

Assessment/Quality Improvement

The rapid evolution of the health care market-place can be expected to continue as we move closer to the 21st Century. Externally-imposed pressures for cost reduction will increasingly be accompanied by pressure within health care organizations is risk-sharing reimbursement arrangements become more commonplace. Competitive advantage will be available to those organization that can demonstrate objective value as defined by the cost-quality equation. The tools an organization chooses to perform quality assessment will be an important factor in its ability to demonstrate such value. Traditional quality assurance will in all likelihood continue, but the extent to which quality improvement activities are adopted by the culture of an organization may determine its ability to provide objective evidence of better health status outcomes.

References

[1.] Nelson, E.C. and McEachern, J.E., "Improving the Quality of Care Through Value Management, Symposium on Purchasing Value in Health Care: The Employers Role," June 7-8, 1994, Washington, D.C. [2.] Flexner, A., Medical Education in the United States and Canada., New York: The Carnegie Foundation for the Advancement of Teaching, 1910. Reprinted, Washington, D.C.: Science and Health Publications, 1960. [3.] Deming, W.E., Out of the Crisis, Cambridge, MA: MIT-CAES, 1986. [4.] Juran, J.M., Juran on Leadership for Quality. New York: Free Press, 1989.