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An emergency department perspective: outcomes.

An Emergency Department Perspective--Part III, Outcomes

It is overly simplistic to assume that one event or one individual is responsible for a negative or unexpected outcome. Corrective action that censures or removes the accused employee is the result of this simplistic management philosophy. [2] Effective outcome management needs to be based on established guidelines that review the detailed processes that lead to a specific outcome. The quality management approach arranges quality attributes in a format that leads the reviewer to a comprehensive conclusion on ways to improve upon negative outcomes. Although the specific management methods for improvement are not new, [3] the applications of these methods to maximize quality in the outpatient environment care are unique.

In order to clarify the key factors for an effective quality management program, we have defined outcome as the result of each process or series of steps. Outcome is the result of the patient's entire encounter with events, interpersonal relationships, and technical procedures in the emergency department. The total outcome is equal to the summation of the independent outcomes of each process experienced by the patient. Each process outcome is the result of several subprocesses. To significantly improve the total outcome, we must look to the details of the subprocess system.

The Outpatient Setting

The Joint Commission on Accreditation of Healthcare Organizations will expect organizations to demonstrate improvement in medical care through clinical outcome assessments. The current emphasis is on improving quality in the inpatient setting. At the same time, other forces in the industry are pulling health care toward ambulatory care settings, physician offices, and alternative delivery methods. [4]

The ED shares with the outpatient setting many unique quality variables, especially those associated with time intervals. Outcome assessment has many different intervals. [5] It can be immediate, such as a response to an acute asthmatic attack when giving epinephrine; intermediate, when pain is relieved with I.M. medications; or longer, as in the case of oral antibiotic treatment. An indefinite time interval unique to a physician's office occurs when considering the treatment of chronic conditions, such as chronic obstructive pulmonary disease or hypertension. In this situation, the outcome is not measured in terms of obliterating the disease or symptoms. It is in controlling the disease process and improving the functional status of the patient.

Problems encountered in outcome assessment in the outpatient setting can be summarized as [6]:

* Methods for measuring technical and interpersonal care are limited.

* Linkage between process and outcome is difficult to ascertain, especially when the interval between providing the care and the resultant outcome is longer.

* Outcome assessment methods only measure a "unidimensional view of quality."

* Data collection is complicated by the volume of patients. The primary questions that occur are, Do we review every patient and process, and Should we rely solely on clinical indicators to identify what we should review?

* Follow-up on results of care is labor intensive, and the endpoint of follow-up is not well defined.

X-ray Discrepancy in the ED

To illustrate how the quality management approach can improve the outcome assessment, we will use the example of x-ray discrepancy in the ED. In general, an x-ray discrepancy is noted when there is a variance or difference between the ED physician's initial reading and the reading of the radiologist who subsequently reviews the x-ray. All reviews are done retrospectively, because results are available from the radiologist only after the patient has left the department.

Traditional outcome assessment concentrates on the presence of a discrepancy and on the mechanism of reporting findings and recalling the patient. Quality management examines the total patient encounter. This is best exemplified by looking at the patient flow during their encounter (see figure on page 48).

The patient perceives the need for emergency care when he or she sustains an injury or in response to an untoward event. In the case of a minor injury, the patient arrives at the ED through personal or family assistance. The patient's expectations are a parking facility in proximity to the entrance, safety, assistance at the door, and clear signs for direction.

Once the patient is in the ED, the medical condition takes priority over registration. Triage is set up to sort and facilitate movement through the system. Here the patient's expectations change to efficiency and initiation of treatment. The patient's expectations vary over the visit, depending on where in the process monitoring is obtained.

If we were to call triage a process that is further broken down by several steps (standard operating procedures or SOP), the results of those steps is an outcome of that specific process. SOPs should be based on the most efficient methods and designed to meet the patient's expectations of that process. The most efficient outcome assessment would be done by the person next in the process, because this person is in the best position to understand and identify the patient's expectations for the appropriate process. In addition, corrective action can be instituted sooner, preventing any cumulative effect on the total outcome. [7]

Similar events take place as the patient moves through the encounter. In the patient's interactions with the primary nurse, expectations shift to "less questioning" and relief of pain. SOPs should be established not only to address those expectations but also to address the technical aspects of care, i.e., in-depth history assessment and ordering of x-rays. In theory, this is the most appropriate level for a concurrent outcome assessment of these previous processes, i.e., structure, triage, and primary nursing.

The patient's expectations of the physician are making sure no serious injuries are present, finding out if there is a fracture or a problem, pain relief, and efficiency, i.e., a rapid turn-around time for x-rays that are ordered. The technical aspect of outcome assessment measures the interpretation skills of the emergency physician and the appropriate treatment and follow-up instructions.

Ordering the proper x-ray, proper labeling and notification of the radiology department, suitable turn-around time for procedures, and adequate and acceptable quality of films are all important steps in this part of the encounter. Even though the patient is unaware of these process details, a negative outcome will occur if an inefficiency exists.

Once a prior descrepancy is noted, a follow-up process is implemented. However, prior to follow-up, an outcome assessment of the discrepancy is done. The following areas are important for consideration:

* Does this discrepancy affect the patient's care? What level of discrepancy is it? In our department, we assign each discrepancy an outcome discrepancy level (ODL) to reflecty the degree to which the discrepancy affects the outcome of care. ODL I would indicate that the discrepancy contributed to the patient's death, and ODL IV and V are when the patient was required to return for repeat or additional x-rays. The levels are shown in the figure on page 49.

* Was treatment appropriate? Regardless of the diagnosis, the appropriate procedures should be performed. The SOP should cover areas such as when and whom to call for x-ray report. Proper and specific discharge instructions must be given.

* Was the patient recalled because of a computer processing error or of incomplete or unacceptable films? Did the ED physician accept less than optimal x-rays views? Did the x-ray technologist present three views, when the protocol calls for five views? If a variance exists, why?

Assessment of Follow-Up

The follow-up process provides a method of outcome assessment, addresses patient issues of concern raised during the encounter, and addresses issues about the referral system. The follow-up process must:

* Be carried out to the end. A stopping point for the ED is when another physician assumes care for the patient (transfer of responsibility).

* Be done in a timely manner, i.e., within 24 hours of the patient encounter.

* Utilize information gained from patients for continuous improvement of the process. For example, when a patient is referred to a specialist at our hospital, he or she is always given a copy of the x-ray instead of the original. We discovered from our follow-up calls that patients complained about returning to the hospital and had difficulty in finding the x-ray file room. Now, all patients who are referred by the ED physician receive a copy of their x-rays during their initial visit. This takes a few extra minutes but it eliminates the need for a return by the patient to the hospital.

* Assess the communication process. This involves assessing interdepartmental communications (between the radiology department and the ED) and the communication process between the ED physician, staff, referral physicians, and patients. Outcome assessment of the communication process is complicated by the sheer number of participants and the many different types of information given. Documenting improvement in outcomes requires highly developed policies and procedures (SOPs). These SOPs must be developed to address specifics, while acknowledging that each encounter in the patient visit may not be completely accounted for.


Outcome assessment has been defined here as the end result of each process or series of steps in the patient encounter. The quality management approach underscores the fact that total outcome is a result of several processes that the patient experiences during a visit. Improvement of the assessment mechanism requires a detailed review of each process and its resulting outcome, the total of which constitutes the final patient outcome.

Outlined in this article is the process we use to assess the outcome involving a x-ray discrepancy. This example provides some of the answers to questions of how to improve the outcome assessment mechanism. We realize that not all questions are answered and that other issues, such as validity of data, criteria, and SOPs, need to be addressed. However, only through continually questioning how and why we do things can we arrive at these answers.


[1] Goldfield, N., and Nash, D. Providing Quality Care, the Challenge to Clinicians. Philadelphia, Pa.: American College of Physicians, 1989.

[2] Hodgson, A. "Deming's Never Ending Road to Quality." Personnel Management 19(7):40, July 1987.

[3] Donabedian, A. Explorations in Quality Assessment and Monitoring, Vol. 1. The Definition of Quality and Approaches to Its Assessment. Ann Arbor, Mich.: Health Administration Press, 1980.

[4] Goldsmith, J. "A Radical Prescription for Hospitals." Harvard Business Review 67(3):104-11, May-June 1989.

[5] Lohr, K. "Outcome Measurement: Concepts and Questions." Inquiry 25(1):37-50, Spring 1988.

[6] Berwick, D. "Toward an Applied Technology for Quality Measurement in Health Care." Medical Decision Making 8(4):253/8, Oct.-Dec 1988.

[7] Loewe, D. "Quality Management at Weyerhaeuser." Management Accounting. 71(2):36-41, Aug. 1989.

Michel Dagher, DO, MBA, FACEP, is Director, Emergency Services, Emergency Consultants, Inc., Memorial Medical Center, Jacksonville, Fla. He is an associate member of the American College of Physician Executives' Forums on Quality Health Care and Entrepreneurship.
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Title Annotation:part 3
Author:Dagher, Michel
Publication:Physician Executive
Date:Mar 1, 1991
Previous Article:Training excellence: an organizational approach.
Next Article:Fraud and abuse: the payer's perspective.

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