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An emergency department perspective: process review.

An Emergency Department Perspective: Part II

Central to an effective quality management program in the emergency department (ED) is the process. It provides for direct measures of the quality of care because it encompasses the total patient experience with the health care system. The key steps necessary to improve the process review are: 1) understand the process, 2) standardize the process, 3) check, and 4) improve the process and then repeat the cycle. [2] These steps enable the traditional process review to expand from a simple inspection method into the quality management concept envisioned by Demings and the Japanese era of total quality control (TQC).

In its new Agenda for Change, the Joint Commission on Accreditation of Health Care Organizations will begin to expect accredited organizations to "demonstrate their improvement through clinical outcome assessment systems." [3] Although process review is part of the Commission's clinical indicator model, its current approach is philosophically contrary to quality management concepts and is fixed on the traditional process review approach of inspection to eliminate the "bad apples." [4] Before the Joint Commission clinical outcome assessment system can become effective, the philosophical attachment to the traditional inspection process review must be terminated.

The Outpatient Setting

The emergency department shares many quality variables with other outpatient settings. What frequently makes process review more difficult is the high degree of implicit criteria utilization required in performing even minor tasks. [5] This creates variations that are additive and that in turn lead to unanticipated outcomes. [6]

Process and Outcome Relationship

The Joint Commission supports Donabedian's measurement methods for quality health care based on structure, process, or outcome. [1]

* The structure or physical environment

in which a patient may enter

for care. * The process necessary to deliver

care. * The outcome is the result of care

provided to improve the patients'

medical condition.

Each of these elements can be reviewed or monitored by the use of process review.

In order to best understand the linkage of process to outcome, we will evaluate the patient flow of activities in the emergency department. Basic patient flow occurs in several steps.

1. Triage, or the sorting of patients,

occurs on a 24-hour basis. A nurse

evaluates patients, making decisions

on the basis of acuity and

room availability (figure 1, page


2. Registration procedures gain information

about demographics and

other pertinent family and health

insurance information.

3. Evaluation and treatment by the

nursing staff and emergency department

physician is based on a

working diagnosis. At this point,

a disposition may be made or further

diagnostic studies can be ordered.

4. Ancillary services are ordered and

priority is established on the basis

of turnaround time, common sense,

and the patient's medical


5. A disposition is made to either admit

or discharge the patient; this represents

the patient's outcome resulting

from the emergency department

physician's decision. Other elements

play a factor in this decision,

including the degree of uncertainty

of the working diagnosis and social

aspects (most importantly the patient's

family) surrounding the

patient. These additional factors

can obscure the linkage between

process and outcome.

The above scenario represents a horizontal (traditional) approach to process review and misses many small steps, especially when decisions are not based on clinical conditions alone. The horizontal approach does not account for aspects of process review that may significantly contribute to total quality variability. The outcome thus suffers from variances that occur in the process of care, which is ineffective because of the traditional process review method to identify and correct variances.

Deficiencies in the traditional process review can be overcome by utilizing the clinical indicator form (recommended by the Joint Commission) if the key quality management steps are incorporated. [7] These key steps will allow the clinical indicator format to identify variances in the process of care.

Traditional Process Review

In order to illustrate the point, a situation involving an x-ray discrepancy is utilized. A discrepancy occurs when a variance in interpretation is noted by the radiologist and reported to the emergency department. Monitoring occurs through medical record review, which notes the discrepancy. The physician is profiled, and corrective action is taken, usually in the form of recommending that the physician profiled review films with the radiologist.

This type of review:

- Relies heavily on inspection alone. - Does not account for levels of discrepancies.

It only considers yes

or no responses. - Fails to account for other causes of

discrepancies. - Does not identify the interrelationship

among different steps. - Relies on "big bang" solutions. [8]

By utilizing the quality management key steps, we are better able to establish a horizontal, vertical and lateral interrelationship. This enables us to pinpoint specific areas for improvements (figure 2, above).

Benefits of Process Review

Among the benefits to be derived from an improved process review, which outcome assessment alone cannot provide are. [9]

* An understanding of the entire emergency department and its relationship with other departments. Each health care provider is better able to understand how its interaction with patient effects the overall quality of care received. For example, radiology may not be aware that laboratory studies are also needed, requiring radiology to wait until the patient's blood is drawn. If the patient is unavailable because of radiology, lab results turnaround time may increase. * Identification of all possible customers. It is easy to assume that the only customer is the patient. Other customers of the emergency department include the private physician, payers, and the emergency medical services system. * Identification of opportunities for improvement. The Joint Commission requires the emergency department to look for opportunities for improvement. Flowchart subprocess or "loops," a form of redoing what was done previously, present an opportunity for improvement because they may present chronic deficiencies that need to be resolved.

It is important to review the process of each action, find any variations, and correct them if possible, producing an improved process. It is important to note that each process variance must be corrected by the person who initiates the process or by the person next in line. Although this still constitutes real-time inspection, by establishing standard operating procedures for each process on the basis of corrective actions, inspection can be avoided as a long-term solution. An important feature of QM is control of quality at the source, making each health care provider responsible for the quality of care provided. [10] * Physical environment. The patient's safety and convenience in being transported from a car to the emergency department or in finding a parking place is evaluated. * Admitting and registration. Procedures should exist to facilitate the patient's care upon arrival. This can be done by establishing standard operating procedures (SOP) for each action and then monitoring for compliance and opportunities for improvement. * Triage. Again, SOPs are established to gather a pertinent medical history and highlight possible risk factors. * Primary nurse evaluation involves reassessment, checking for further injuries if any. Also, at this stage triage adherance to SOP and to protocols regarding ordering of x-rays is checked. * Physician evaluation involves a detailed history. Physical differences from nursing are noted if applicable. A rule out list is satisfied through detailed exam or through ordering further diagnostic studies. * When x-ray procedures are ordered, film types and number are taken according to established protocols. For example, the radiologist protocol may require five views of the lumbar spine instead of the usual three. * Disposition is made after radiographs are viewed, treatment is initiated, and discharge instructions are given. * Through a follow-up mechanism discrepancies are discovered.

Incorporation of key quality management steps into traditional process review results in: - Assignment of discrepancies to levels

categorized from I-V in descending

order of seriousness (see table

on page 27). - Identification of where variations

occur - triage, nursing, physician

evaluation, or disposition. - Identification of the type of discrepancy

- clinically related, processing

errors through mislabeling, poor x-ray

techniques, incomplete films,


A process review is not merely inspecting whether a variance existed. It entails a summation of all variations, and it addresses the basic quality definition of freedom from deficiencies through elimination of waste, recall of patients, and customer satisfaction by evaluating the interpersonal aspect of care from parking to satisfaction with the care through follow-up. It also accounts for the linkage between structure, process, and outcome in the formual, variations in outcome equal structure variations plus process variations.


The Joint Commission is looking at quality care measures through clinical outcome assessment systems. The traditional process review will not achieve this goal without the incorporation of key quality management steps to examine each stage in the care process. The value of process review is in its ability to define the multiple and summation effects of process variations. The important steps to remember are:

- Understanding the process through

flow chart techniques. - Standardizing those processes that

achieve the desired outcome

through standard operating procedures. - Checking the results to see if they

improved the outcome. - Continuously improving the process.

In the March-April 1991 issue of Physician Executive, the author will describe outcome assessment for quality management in a hospital emergency department.


[ 1.] Donabedian, A. "The Quality of Care,

How Can It Be Assessed?" JAMA

260(12):1743-8, Sept. 23/30, 1988.

[ 2.] Kendig, P. "Leadership through Quality.

A Total Quality Process for Xerox."

Presentation in Jacksonville, Fla., Nov. 2,


[ 3.] Couch, J., Medical Quality Management

for Physician Executives in the 1990s:

Preparing for the Joint Commission's New

Initiatives. Tampa, Fla.: American College

of Physician Executives, 1988.

[ 4.] Berwick, D. "Continuous Improvement as

an Ideal in Health Care." New England

Journal of Medicine 320(1):53-6, Jan. 5,


[ 5.] Mayer, T. "Emergency Medicine Clinics of

North America." Practice Management

and Administration 5(1):103-17, Feb. 1987.

[ 6.] Tackett, S. "Quality Assurance Versus

QP4: The Missing Link." Journal of

Quality Assurance, 11(3):8-11,36, June-July


[ 7.] "Characteristics of Clinical Indicators."

QRB 15(11):330-9, Nov. 1989.

[ 8.] Grayson, J., and O'Dell, C. American

Business: A Two-Minute Warning. New

York, N.Y.: The Free Press, 1988.

[ 9.] Juran, M. Juran on Leadership for

Quality: An Executive Handbook. New

York, N.Y.: The Free Press, 1989.

[10.] Fiegenbau, A Total Quality Control,

Third Edition. New York, N.Y.: McGraw-Hill

Book Co., 1983.


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.

PHOTO : Figure 2 - Triage/ Registration Aspect of Patient Flow in the ED [9]

PHOTO : Figure 2 - Process/Outcome Flow
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Title Annotation:providing quality care in a hospital emergency room; part
Author:Dagher, Michel
Publication:Physician Executive
Date:Jan 1, 1991
Previous Article:Improve your presentation style.
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