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Implementing a quality assessment program.

Why do we do quality assessment?

* The public expects quality as a "right."

* State regulations require it.

* The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires that: "There is an ongoing quality assessment program designed to objectively and systematically monitor and evaluate the quality and appropriateness of patient care, pursue opportunities to improve patient care, and resolve identified problems." [1]

* The Health Care Financing Administration (HCFA) requires it.

* Court decisions have mandated it.

Ultimately, the Board is responsible for ensuring that the hospital does indeed deliver high-quality care. The Board and Administration must both be willing to commit the resources to accomplish the task. they must understand that quality assessment is performed to continually improve health care, not just to pass a point-in-time inspection.

Developing a Quality Assessment


During the upgrading phase of an existing quality assessment program, flexibility is required. To revise and enhance the present quality assessment program, one must be willing to adjust to the program and to the abilities of the personel on hand and then allow it to evolve with guidance. In the process, subordinates have to be allowed to make mistakes.

The approach must be systematic. To ensure that consensus is eventually developed, it is necessary to first establish a formal plan unique to the institution. No model plan exists that will be universally applicable, because no two hospitals have identical situations, administrators, and staff interaction.

To improve on an existing quality assessment program, the staff must feel empowered to perform in their areas of expertise. Contracts need to be formulated between subordinates and bosses that encourage responsibility, self-expression, and commitment. A vision of what a quality assessment system looks like needs to be created. Time has to be allowed for everyone in the hospital to understand quality assessment and to "buy into it" as the system evolves.

The quality assessment program must entail systematic assessment and improvement of the quality and appropriateness of all aspects of patient care and clinical performance and must ensure that correction of identified problems is carried out.

A Quality Assessment Program


Total and concurrent preadmission, admission, and continued stay review of all patient charts is an example of a quality assessment approach that heavily involves the medical staff. The elements of this example have been taken from the experience at Champlain Valley Physicians Hospital Medical Center. A very important attribute of concurrent review is the ability to install corrective action while the patient is still in the hospital. This helps improve patient care and reduces the likelihood of malpractice. Because quality assessment prevents a malpractice occurrence, its significance is often lost on the medical staff. Still, the saving of money and improvement in public relations helps quality assessment pay for itself.

In concurrent review, utilization review/quality assessment coordinators, using a modification of Craddick's occurrence screen [2] (see figure 1, page 10), identify an occurrence and report it to the quality assessment department. The occurrences are written up by the quality assessment department in short case summary reports that are sent to the medical director. This process of assisted review alleviates the need for time-consuming review of all charts by members of the medical staff. The medical director then evaluates the seriousness of the occurrences using Thomson's 1,2,3,4 Evaluation [3] (see figure 2, below).

All 3s and 4s are referred to the specific department for a case study review. If there is a pattern or trend with 1s and 2s, it is brought to the attention of the department chairman. An example of how a case review is conducted and the format for reporting findings is shown in figure 3, page 12. All this information is collated by physician and becomes part of the physician specific pattern sheet (figure 4, page 13).

If a pattern develops or if the occurrence is a serous deviation from the norm, the medical director and/or department chief will refer the case to the medical staff executive committee, which will deliberate and decide if the physician should be monitored and/or corrective action should be taken. All of the above information becomes a part of the physician quality assessment profile (figure 5, page 14), which also includes attendance at department and medical staff meetings, current DEA, state license status, litigation status, liability insurance coverage, etc., all of which information is used by the credentials committee at reappointment time. In addition, there are retrospective reviews of mortality, transfusion, pharmacy, infectious disease, tissue review, department-specific studies using department-specific indicators, etc.

Credentialing of New Applicants

Credentials review and privileges delineation during the initial appointment process is critical to the process of ensuring high-quality care. "Credentials review and privilege delineation represent front end efforts by the medical staff and the hospital to ensure that patients receive care from qualified, competent health care practitioners, and should be designed to meet both Joint Commission and Department of Health requirements. Management of the credentials function requires a comprehensive, consistent, and objective process with a high degree of attention to detail." [4] The requirements that need to be discussed before the credentials file goes to credentials committee for review are shown in figure 6, page 15.

New appointees to any department of the medical staff are granted probationary privileges consistent with documented training, experience, and record of competence. There needs to be a policy and procedure for granting additional privileges as well. An appointee's period of probation is at least one year and no more than to the end of the calendar year following the date of initial appointment. During this period, physicians are evaluated by the department chief or a designee using randomly selected charts to determine if each patient was treated adequately, on a timely basis, and appropriately. Written reports go to the Credentials Committee at three months and nine months.

Department Manager Participation

Each department or nursing unit manager is responsible for the department's overall quality assessment system. Department managers are encouraged to involve staff members in the development of indicators, in data collection, and in the problem-solving process. Ongoing generic quality assessment indicators are addressed by each department monthly (figure 7, page 15).

As a requirement of the Joint Commission on Accreditation of Healthcare Organizations, all departments must document that these indicators are performed by reporting monthly to the department managers and quarterly to the quality assessment committee. Department-specific indicators are developed by identification of important aspects of care relevant to the department or service. The data collected from each indicator are evaluated to reveal opportunities to improve patient care outcomes. This process is applied to all hospitalwide quality assessment functions and clinical and support service quality assessment activities.

The Future

A wide variety of initiatives are being undertaken in medical quality management. Practice parameters (guidelines, algorithms, etc.) are now being actively developed in many areas, and the concept is supported by the American Medical Association. These guidelines should help us to concurrently know that appropriate studies are being requested by physicians. Continuous quality improvement, a management tool to help organize, monitor, and continually improve all aspects of health care delivery, can shift the focus from finding "bad apples" to improving systems. [5] Both JCAHO and the American Hospital Association are supportive. Most outcome problems can be traced to systems breakdown, not failures of individuals. A focus on improving systems can result in greater participation by physicians in the peer review process. "Physicians are more willing to do peer review when they are asked to prevent problems by analyzing systems rather than judging colleagues." [6]

Attention needs to shift so hospital employees personally take responsibility for the success of the health care delivery of their hospital. We must develop specific methods for handling meetings, restructuring our units, managing communications, and developing our process so they align with our organizational philosophy and purpose. If a culture can be developed in which everyone in the hospital is working toward continuous quality improvement, an environment conducive to customer satisfaction will be created.


[1] Manual for Hospitals, Vol. I. Oakbrook Terrace, Ill.: Joint Commission on Accreditation of Healthcare Organizations, 1991.

[2] Eisele, C., Fifer, W., and Wilson, T. "The Medical Staff and The Modern Hospital, Estes Park Institute," Englewood, Colo., 1985.

[3] The Medical Staff Leaders Complete Practical Guidebook. Dunedin, Fla.: Thompson, Mohr & Associates, Inc., 1988.

[4] Integrated Quality Assessment: A Model for Concurrent Review. Albany, N.Y.: Hospital Association of New York State, 1988.

[5] MacInnes, R. "Managing Quality Removes Peer Review Barriers." Medical Staff Leader 19(7):1, July 1990.

[6] Brent J. Quality Management for Health Care Delivery. Chicago, Ill.: Hospital Research and Education Trust, 1988.

Gary A. Fleming, MD, was Medical Director, Champlain Valley Physicians Hospital medical Center, Plattsburgh, N.Y., at the time this article was written. He is now Director of Medical Affairs, Athens Regional Medical Center, Athens, Ga.
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Title Annotation:includes sample quality assessment survey
Author:Fleming, Gary A.
Publication:Physician Executive
Date:Jan 1, 1992
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