Quality assurance in the ambulatory care setting.

Quality Assurance in the Ambulatory Care Setting

One of the most utilitarian developments in the field of quality assurance in health care has been the introduction of industrial concepts of quality management.(1-5) These concepts, coupled with buyer demand for accountability, are bringing new perspectives to health care quality assurance. These perspectives provide a new view of quality assurance as a major responsibility and strategic opportunity for management; a competitive and marketable commodity; and a method of improving safety, effectiveness, and satisfaction with medical care.

Although medical care takes place in many settings, the organizational frame of reference for this paper will be the organized ambulatory care clinic. In this setting, resources are organized and deployed by a management team for the purpose of achieving the objectives indicated by Donabedian. "The process of health care is meant to achieve certain objectives. These are generally related to the promotion, preservation, and restoration of health. Moreover, health care ought to be conducted in a way that is acceptable, pleasing, even rewarding to clients; and it should be provided in settings that take account of the patient's comfort, sensitivities, and other needs. In summary, a judgment of quality can be made relative to technical care, to the management of interpersonal relationships between the patient and the practitioner, and to the amenities of care." [6]

Definition of Quality

Some practical and utilitarian concepts of what quality means in health care must be accepted if the purposes of this paper are to be served. The industrial literature suggests that the customer's viewpoint must be considered. Schonberger sees the customer's needs as "fitness for use, meeting the customer's requirements, right the first time, [and] reduction of variability."[3] This concept is supported by Peters and Waterman[7] and Juran.[2]

What, then, are the attributes of quality in health care? Donabedian says that "quality comprises those attributes of the process of care that contribute to its desired outcomes. The assessment of quality varies, therefore, depending on the outcomes sought, the valuations placed on the outcomes, and the appropriateness of the means used to attain them."[6] The "outcomes sought" should include, at a minimum, "safety," "effectiveness," and "satisfaction." Safety (or risk control) means that the patient has not been endangered unnecessarily by engaging with the facility. Effectiveness means that appropriate and useful therapies have been employed. Patient satisfaction refers to such concepts as care having met expectations, services being within the patient's cultural value system, and adequate attention being paid to the patient's "explanatory model."[38] The patient's support group must be included in the concern for satisfaction. In the industrial concept, reliability, fulfilling expectations, and meeting technical specifications are the customer's perceptions of quality. Safety, effectiveness, and satisfaction represent what patients anticipate as quality in medical care.

Management Information System

Quality assurance is a system for managing information. It deals with qualities (death, complications, recovery, viable delivery) and quantities (any at all, percentages, relative scales, etc.). These are the data that management uses for decision making. The purpose of such an information system in a knowledge-based industry is to enhance the likelihood of a favorable outcome.[4] Drucker says that "the effectiveness of an information system depends on the willingness and ability to think through carefully what information is needed by whom and for what purposes, and then on the systematic creation of communication among the various parties to the system as to the meaning of each specific input and output."[9] There are three fundamental questions that will help direct management in the development of this information system. First, management must determine what data it needs to determine if its operations are safe, effective, and satisfactory. Second, it must determine the sources and characteristics of the data. Third, it must decide what it is going to do in regard to evaluation, conclusions, and actions. The first two questions are interactive. Management must determine what questions it wants answered and why before embarking on data collection. Unfortunately, data gathering and number crunching systems tend to cast their shadows over both program planning and action deliberations, often confusing planning activities or prejudicing conclusions. Drucker comments, "The fewer data needed, the better the information."[9]

External Data Sources. A good start can be made in the development of an information system by making a list of contingencies from the most recent Joint Commission on Accreditation of Healthcare Organizations, (SERP), and (SIR) surveys and of problems noted in patient complaints or legal claims. Internal Data Sources. These sources should include "sentinal events," "continuous monitors," and "targeted studies." Sentinal events refer to catastrophic events that should never have happened and that should be examined fully as soon as possible. They may provide clues to systemic problems. Continuous monitors look at processes or outcomes that represent the major and usual activities of the clinic. Monitors result from systems that are designed to have no significant deviation from defined standards and are put in place to detect potential variances. This data category will be the largest and must include monitors required by the Joint Commission. Targeted studies are in-depth studies of cases selected because of some common factor, such as a diagnosis or treatment; because of trends detected from other data; or on the basis of professional interest.[10] A quality assurance information system based on this categorization can be applied at any level in the organization. Indicators should be chosen for their appropriateness to the overall operation of the clinic. Department indicators should consist of required indicators plus those that are unique to the department. The information system begins with the deliberations of management concerning the kinds of information necessary to monitor operations. Then, through consultations with quality assurance staff, medical records staff, data processing staff, and others, the qualities and the quantities of information necessary, as well as appropriate methods of reporting data, are determined. The results of these processes are reported to management for evaluation, conclusions, and action.

Organization

Juran has stated that, "A company going into `Company-Wide Quality Management' is well advised to create a company-wide quality committee of high-level managers to establish the approach. The chairman is typically the company president or executive vice president."[2] Furthermore, the "quality committee" should be made up of service chiefs. This is consistent with the JCAHO requirement that each department carry out systematic peer review activities on a periodic basis. Data gathering and processing and arraying of results can be done by quality assurance staff in accordance with the plan determined by the quality assurance committee.

The Ambulatory Setting

A quality assurance information system in the ambulatory care setting presents problems that are difficult but not unique. They are, in fact, simply exaggerations of common problems in the practice of medicine. First, the objectives of ambulatory care are more subtle than other forms. The more acute and severe the illness, the more coincident will be the objectives of the patient and the practitioner; the more chronic the illness, the more divergent may be their separate objectives. Because the objectives are less easily proclaimed in chronic care, there is greater need for behavioral skills in addition to those of diagnosis and therapeutics. Despite this lack of clarity, objectives can be determined in cooperation with the patient, and achievement can be a measure of the quality of care. In the absence of clearly stated and agreed upon objectives, care of the chronically ill in the ambulatory setting becomes chaotic, random, spiritless, and perhaps even hazardous. Second, there is relative lack of control over care in the ambulatory care setting. Commitment, compliance, and understanding of self-care by the patient; quality of the patient's home environment; the patient's keeping appointments; etc. all affect ambulatory care. In addition, the reasons for patient visits are often ambiguous to both the patient and the practitioner. Diagnoses are frequently unclear. Poorly defined treatment plans may be complicated by lack of physician continuity.[11] Craddick has summarized these problems in the following list[12] : * Charts are often illegible and

incomplete. * Outcomes of treatment may be

difficult to determine. * Large patient volume makes 100

percent screening difficult. * Outpatient clinics often lack a clearly

defined organizational structure to deal

with problems and take actions. * A large part of outpatient care is

subjective, e.g., choice of medications and

other treatment modalities, counseling,

and patient education. * Patient factors, such as compliance

and home environment, are more

difficult to evaluate and control in the

outpatient setting. Because of these and other problems, there has been wide interest in outpatient criteria for quality. Research has been done by the JCAHO;[13] Medical Management Analysis International, Inc.;[12] and a group made up of Group Health, Inc., HMO Minnesota, and Share Health Plan.[14] (The results of the latter two studies are shown in figures 1 and 2, pages 18 and 19. Excellent and comprehensive reviews of the applications of quality assurance studies have been detailed by Anderson and Shield[15] and Christoffel and Loewenthal.[16]

Application to Medical Education

The basic concepts of the scientific process, i.e., hypothesis, testing, and evaluation, are entirely parallel with the process of quality assurance, namely, determining what you want to know about operational activities, testing their achievement, and evaluating the results. The process is applicable to practitioners at any level of training and, if done appropriately, can be a major aid in the educational process. The need to be accountable for one's practice and to have the skill and desire to evaluate one's practice critically are probably the highest professional ethical responsibilities. The fact that these activities have been incorporated into JCAHO standards, Medicare rules, and hospital by-laws substantiates their critical importance to the health care delivery process in the United States. Unfortunately, there is little evidence that today's new physicians, as they apply for hospital privileges and establish their practices, have any more knowledge of the theory, methodology, applications, or requirements of quality assurance than similar graduates had 20 years ago. This lack of progress indicates, on the part of the medical education establishment, a singular rejection, or ignorance, of community practice requirements. The "teaching" ambulatory care center qualifies as a model for the principles discussed above. The goal is to teach "the best." In so doing, one must come to some conclusions regarding the nature of "the best." These determinations require constant review of the nature and art of clinical practice. The process is the most obvious method of setting standards and revising them on the basis of critical evaluation. This process is not only inherent in the teaching of medicine, but also provides the student with a model that, if carried throughout a career, can result in excellence in the practice of medicine. [Figure 1 & 2 Omitted]

References [1]Perry, L. "Hospitals Begin to Emphasize Quality in Devising Strategic Plans." Modern Healthcare 18(14):30-34, April 1, 1988. [2]Juran, J. Juran on Planning for Quality. New York, N.Y.: The Free Press, 1988. [3]Schonberger, R. World Class Manufacturing. New York, N.Y.: The Free Press, 1987. [4]Tufo, H. Presentation, Quality Assurance Workshop, Society of General Internal Medicine, Washington, D.C., April 27, 1988. [5]Graham, J. "Quality Gets a Closer Look." Modern Healthcare 17(5):20-27,30-31, Feb. 27, 1987. [6]Donabedian, A. Explorations in Quality Assessment and Monitoring. Volume III. Ann Arbor, Mich.: Health Administration Press, 1985. [7]Peters, T., and Waterman, R. In Search of Excellence. New York, N.Y.: Harper and Row, 1982. [8]Press, I. "The Predisposition to File Claims: The Patient's Perspective." Law, Medicine, and Health Care 12(2):53-62, April 1984. [9]Drucker, P. Management: Tasks, Responsibilities, Practices. New York, N.Y.: Harper & Row, 1973. [10]Tyler, R. Quality Assurance Program, Manilla V.A. Outpatient Clinic 1987; Santa Barbara V.A. Outpatient Clinic, 1984 (unpublished). [11]Benson, D. "The Ambulatory Care Parameter: A Structured Approach to Quality Assurance in the Ambulatory Care Setting." QRB 13(2):51-5, Feb. 1987. [12]Craddick, J. Medical Management Analysis: Adaptation to the Ambulatory Care Setting. Auburn, Calif.: Medical Management Analysis International, Inc., 1987. [13]"Report of Work Group #1: "The Development of Clinical Indicators for Quality Assurance Screening." Chicago, Ill.: Joint Commission on Accreditation of Healthcare Organizations, 1987. [14]Solberg, L., and others. The Minnesota Project: A Focused Approach to Ambulatory Care Quality Assurance. Minneapolis, Minn.: Group Health Plan, Inc.; HMO Minnesota; Share Health Plan, 1987. [15]Anderson, O., and Shields, M. "Quality Measurement and Control in Physician Decision Making: State of the Art." Health Systems Research 17(2):125-55, Summer 1982. [16]Christoffel, T., and Loewenthal, M. "Evaluating the Quality of Ambulatory Health Care: A Review of Emerging Methods." Medical Care 15(11):877-97, Nov. 1977.

Russell D. Tyler, MD, is Director, Santa Barbara (Calif.) VA Outpatient Clinic, and Clinical Professor of Medicine, University of Southern California School of Medicine, Los Angeles.