Reporting quality of health care to the board.

The reporting of quality of health care to the governing board has long been an enigma. Now we are in the midst of a revolution in health care, as we shift our focus from solely the clinical performance of individuals to a broader scope of assessing and improving all activities around patient services and patient care - i.e., management outcomes integrated with clinical outcomes to help identify opportunities to improve patient care. In addition, apprised of corporate liability for the quality of care provided in health care organizations, governing boards are raising questions and demanding mare information. To maintain this high degree of interest in quality of health care, information should be restricted to what the board needs to know. This article will be confined to the hospital's organization wide quality system of monitoring and evaluating. While medical staff credentialing and privileging are also board responsibilities and quality management activities should be used in the privileging and credentialing process,(2) they will not be addressed in this article.

Several articles(3-5) have recently appeared concerning the type of information to be presented to governing boards, and some on indicators,6,7 but the impetus for this article came from Baders' excellent article, "What Governing Boards Expect from Physician Executives." (8) In 19891991, I was struggling with what and how to more appropriately report quality of health care to the governing board. Baders' article caused me to focus my efforts and better utilize our hospital-specific indicators when reporting health care outcomes to the board.

The director of quality assessment oversees the entire quality assessment/quality improvement system in our hospital and is responsible for ensuring the free flow of information to/from clinical departments and committees. Summaries of quality reports, with a statement of the problems, discussions, conclusions, recommendations, and actions for improvement, are reported to the Quality Council (representatives from the board, medical staff, nursing, and administration). Figure 1, page 38, shows the format for the monthly reporting to the Quality Council.

Each month, the medical director selects from the Quality Council reports those important aspects of health care outcomes that best illustrates that quality of health care has improved as a result of the quality assessment/quality improvement system. The format for this report to the board is shown in figure 2, page 38.

Examples

Safety: Occupational Safety and Health Act (OSHA) recordable quality report. In 1985 and 1986, our OSHA recordable rates were high. In 1987 the hospital became committed to rectifying this situation.

A safety officer was hired and put a number of work programs into effect. The most significant being a worksite analysis--i.e., a preevaluation of the physical requirements for a position, coupled with a preemployment physical, inservice safety education, and weekly life safety environmental surveys. Figure 3, page 39, shows the excellent improvement we enjoyed as a result. While we are very happy with this, we have identified an abnormal trend in some areas and will be focusing our attention on these areas. We are looking on this as an opportunity to continue to improve.

Pharmacy Committee: Vancomycin 

Drug Use Evaluation. Two months prior to the initiation of this drug use evaluation, three cases where vancomycin was thought to contribute to acute transient renal insufficiency were identified. This acute nephrotoxicity was thought to arise from the increased use of an antibiotic that was, until recently, infrequently used. The increased use is explained by documented cases of coagulase negative staphylococcus and methicillinresistant staphylococcus aureus in the hospital.

The Physician's Desk Reference recommends every 6 hours dosing unless there is evidence of renal failure. To evaluate this the pharmacy and therapeutics committee developed a study to check serum vancomycin levels to determine peak serum levels, as well as trough levels (figure 4, page 39).

Conducting this study has resulted in the following:

Acute transient renal insufficiency that was seen as use of the drug began to increase in the later part of 1990 has been eliminated.

The empiric every six hour dosing interval has been replaced by a more appropriate every eight hour interval. This is of particular significance because the elderly are the patient population for whom this drug is most frequently prescribed.

Prescribers are now more aware of the pharmacokinetics of vancomycin and of the availability of serum levels to guide therapy.

Cesarean Section. There continues to be a national movement to reduce the cesarean section rate. Our obstetricians feel the safest way to reduce the c-section rate is to have a "trial of labor" for vaginal delivery on women who have had a prior c-section, unless there is some underlying medical condition that would preclude vaginal delivery. We monitor c-section rates, along with vaginal births after a prior cesarean section (VBAC). Our goal has been to keep the c-section rate percentage below 23 percent and the VBAC percentage above 20 percent.

As figure 5, page 40, reveals, over the two-year period of 1990 and 1991, we accomplished our c-section goal and far exceeded our goal for VBACs. As a result, we will raise our VBAC goal to 34 percent and reduce the c-section goal to 22 percent. In addition, we will continue to keep abreast of the perinatal and maternal morbidity and mortality rates to be certain quality isn't being jeopardized.

Indicators. Judgments about quality can only be made through monitoring and evaluating various outcomes. "The use of quality indicators offers a unique opportunity for a hospital to make meaningful comparisons over time between its indicator rates and the data reported by comparable hospitals. As data are assessed over time, a hospital will be able to establish and monitor an expected level of performance for each indicator. This level might be the mean for comparable hospitals, the hospital's historic level, or some other measure. Poorer-than-expected performance would trigger an investigation into the reasons and an action plan for improvement." (6) This traditional quality assessment model now requires a conceptual bridge to benchmarking as a part of the continuous quality improvement evolution.

"Rate-based indicators measure events for which a certain proportion of the events that occur are expected when state-of-the-art care is provided; further assessment is required when the rate at which the event occurs crosses a threshold or data trending and/or problem analysis suggest opportunities for improvement." Even if a function is in control, we may wish to improve its overall performance-i.e., another opportunity for continuous quality improvement.

The indicators identified in figure 6, page 40, were determined by our governing board in conjunction with other quality assessment data analysis to be useful in their determining if high-quality health care is being provided at our hospital.

Following and reporting on these indicators quarterly, one can easily "spot" abnormal trends or patterns. If the evaluation of the outcome variations reveals a potential system problem, this may require the formation of a CQI team(9,10) to further investigate and make recommendations for improvement. A short narrative summary of this whole process is an appropriate report to the board of governors.

This mechanism and format for reporting to the board has been further enhanced by using transparencies that focus the attention, discussion, and understanding of the board. The overall process has been well received by our board.

"In 1994, the indicator monitoring system (IMS) will become operational for the Joint Commission and accredited hospitals. Optional participation by hospitals in 1994 and 1995 will allow time for hospitals to prepare for 1996 accreditation. In 1996, the IMS will be integrated with the entire accreditation process and participation in the IMS will be a required part of accreditation."(11) We are incorporating most of these indicators into our quality assessment and evaluation system and will report findings to our board as well.

With the board having ultimate responsibility to the public for the quality of health care in the hospital, board members want to be appropriately and completely informed and to understand what the quality reports are stating. Information on quality of health care requires explanation and interpretation, and the board looks to the medical director(8) for independent clinical expertise and medical judgment.

References

1. Couch, J. Ed. Health Care Quality Management for the 21st Century. Tampa, Fla.: American College of Physician Executives, 1991.

2. Fleming, G. "Implementing a Quality Assessment Program." Physician Executive 18(1):9-16, Jan.-Feb. 1992.

3. Orlikoff, J., and Totten, M. The Board's Role in Quality Care. Chicago, Ill.: American Hospital Publishing, Inc., 1991.

4. Bader, B. Informing the Board About Quality. Rockville, Md.: Hospital Trustee Association of Pennsylvania and Bader & Associates, Inc., 1991.

5. Kelley, J. "Quality Assurance Reporting to the Governing Board." Trustee 43(5):10-2, May 1990.

6. Maryland Hospital Association. Guidebook for Quality Indicator Data: A Continuous Improvement Model. Lutherville, Md.: the Association, 1990.

7. Joint Commission on Accreditation of Healthcare Organizations. Primer on Indicator Development and Application: Measuring Quality in Health Care. Oakbrook Terrace, Ill.: the Commission, 1990.

8. Bader, B. "What Governing Boards Expect from Physician Executives." Physician Executive 17(1):8-13, Jan.-Feb. 1991.

9. Berwick, D., and others. Curing Health Care. San Francisco, Calif.: Jossey-Bass, Inc., 1990.

10. Nash, D., and Markson, L. "Managing Outcomes: The Perspective of the Players." Frontiers of Health Services Management 8(2):3-51, Winter 1991.

11. Joint Accreditation of Healthcare Organizations Update, Feb. 1993.

1. Readmission 

Readmission is an unplanned admission (excluding neonates) to the same hospital within 31 days of discharge. The denominator is the total number of discharges.

2. Unplanned Admission Following Ambulatory Surgery An unplanned admission following outpatient (ambulatory) surgery/procedure is an unplanned inpatient admission to the same hospital within 48 hours following an outpatient procedure. The denominator is the total number of outpatient surgery/procedures performed.

3. Unplanned Return to Surgery

This indicator would provide trend information on patients who had to return to surgery because of complications or unplanned outcomes. The denominator is the number of inpatient surgical procedures performed.

4. Unplanned Transfer to Critical Care Units This item provides trend information on patients who required unplanned or emergency admission to a critical care unit from a generic patient care area. This is an absolute number; no denominator applies.

5a. Perioperative Mortality

Perioperative mortality refers to any patient who has had a surgical procedure (inpatient or outpatient) and who dies in the same hospital within 48 hours. The denominator is the total number of surgical procedures.

5b. Inpatient Mortality

This indicator provides trend information on hospital-wide mortality. The denominator for this indicator is patient discharges.

6. Medication Errors

This indicator provides trend information on variances in medication administration. The denominator is doses administered.

7. Patient Fails

This indicator provides trend information on inpatient falls. The denominator for this indicator is patient days.

8. Patient Satisfaction

This indicator provides trend information from the ARMC Patient Response Survey. This instrument provides feedback on the admissions process, housekeeping function, food service, nursing care, and ancillary departments and overall satisfaction with the hospital.

9. Patient Wait Times

This indicator addresses information on patient waiting times in outpatient areas. At present, these data are available from the radiology department and the emergency department. Expansion into other areas can be developed.

10a. Cesarean Section

The denominator is the total number of deliveries.

10b. Vaginal Birth after C-Section (VBAC)

This is recommended by the American College of OB/GYN as a method of reducing the rate of C-sections. The denominator is the total number of previous C-sections.

11a. Surgical Wound/Postoperative Infection (no infection preop)

This indicator will provide trend information on infections specifically arising out of surgical or invasive procedures that were not present before surgery or from "dirty" surgical cases. The denominator is the total number of procedures (inpatient and outpatient) performed.

11b. Ventilator-Acquired Pneumonia

Ventilated patients who develop pneumonia.

11c. Cesarean-Section-Acqnired Infection

Patients who develop endometritis within three days following cesarean section.

12. Hospital Staff Turnover/Absenteeism

This indicator provides trend information on turnover rates of employment and absenteeism. This may provide rudimentary assessment of employee morale and satisfaction.