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Quality improvement in the era of health reform.

In a recent editorial in JAMA entitled "The Missing Ingredient in Health Reform--Quality of Care,"(1) Chassin reminds us that the current public debate has focused on issues of access and cost with very little attention paid to how quality of care will be assured and improved. He states that assuring quality must be a principal goal of health reform, fully equal to the goals of universal access and affordable cost. In fact, he argues that the goal of assured quality holds the key to our ability to control cost safely, without jeopardizing health.

Friedman talks about implications for physicians of "changing the system."(2) She points out that data-based quality assessment will be a strong consideration in changing the system. She also points out that patient outcomes data, comparative information about physicians and hospitals, large experiential data banks, and statistical scrutiny of treatment options have become a permanent part of the health care landscape.

As reliable (or even unreliable) clinical parameters based on these data are promulgated, payment eventually will be linked with compliance with them. Threats to autonomy inherent in reform are often cited: practice parameters as "cookbook medicine," managed care and capitation as constraints on autonomy, salaried practice as asking physicians to serve two conflicting masters, and right to die issues as inappropriate challenges to physicians' judgment.

In a New England Journal of Medicine "Sounding Board" article on physician autonomy, the author challenges the medical profession to take action to maintain and increase its involvement in health care policy.(3) Involvement of the profession must, however, be based on legitimate grounds. Otherwise there will be continued loss of public credibility.

In a commentary in QRB, a number of health care practitioners with diverse backgrounds, including both managed care and fee-for-service, developed a series of health reform principles for quality recommendations for the congressional debate.(4) Included is an appendix, developed by Paul Batalden, of questions for transforming health care.

Batalden additionally contributed an editorial outlining a framework for thinking about the continual improvement of health care.(5) Four major ingredients are listed:

* "Improvement knowledge."

* Policy for leadership.

* Tools and methods.

* A systematic approach to applying the above ingredients to daily patient care.

The Institute for Healthcare Improvement's fifth annual "Forum on Quality Improvement in Health Care" challenges its invitees to focus on "real changes" in policy and communities, operations, and clinical care that result in significant improvements in cost, outcomes, and satisfaction for patients and others. The goal will be a transformed health care system that could make "real changes" in the health status of communities. This will require shifting the focus of improvement efforts from individual organizations to the community as a whole. It is the hope that reform proposals will develop policy to facilitate collaborative behaviors, rather than competing ones.

As suggested by Bader, improvement efforts need to be tested in the real work of clinical practice while facilitating greater collaboration among professionals especially doctors and nurses.(6) Batalden and Berwick challenge us to find the best clinical practices and to disseminate that information as widely as possible.(7) Bader challenged us by stating that "if quality improvement programs avoid clinical issues and stick to studying safe, administrative issues...CQI deserves banishment to the paradigm junkyard.(6)

Kralewski comments on a growing body of research that supports the hypothesis that modifying physician decision making is one of the most promising ways to change practice styles and provide cost-effective care.(8) He points out that, as yet, there is little agreement on how to achieve those ends. He suggests that the most promising approach to this issue appears to be some combination of:

* Timely provision of guideline and practice comparison data through use of some type of computerized information system.

* Involvement of physicians or other opinion leaders in the development of the program, especially the guidelines.

* Reinforcement of process through financial or other incentives.

The American Hospital Association has published a monograph on practice pattern analysis (PPA) concerning the hospital's role in providing meaningful feedback to its health care practitioners.(9) This author has previously reported on an education-based approach to analyze and reduce practice variations.(10) The American Academy of Pediatrics's Ambulatory Care Quality Improvement Program, an effort to improve office-based practices, will regularly select themes (immunizations in 1992-93; asthma management and developmental assessment in 1993-94) for which care maps and exercises will be developed. Data will be compiled and fed back to participating physicians.

James, in a number of articles, discusses the efforts of his organization to measure and address variation in clinical practice to improve patient outcomes. In shorter(11) and longer articles,(12) he relates how data can be used constructively to reduce physician fears and liberate innovation among practicing clinicians. The latter treatise is must reading for serious advocates of clinical quality improvement. He proposes QI-based practice guidelines as a decision support and measurement tool. He reemphasizes process management as a common thread that brings together a number of current national health care initiatives. When focused on clinical processes of care, process management is case management, according to James. A section outlines background principles for implementing practice guidelines and provides helpful definitions as well as case studies and lessons learned. He further describes how quality improvement uses statistical process control to separate assignable from random variation. The former arises from identifiable special causes that can be tracked and eliminated. Blumenthal described the application of run charts and various types of control charts in clinical and operational decision making.(13)

Burns agrees that guidelines facilitate the management to excellence but insists that physician involvement is needed for quality maximization in both the provider and the purchasing systems. As suggested by Berwick, a question often arises in the early stages of using total quality management in health care organizations. The question ("But how can we get physicians involved?") is asked by lay executives and clinical leaders alike, and implies both necessity and barriers."(14,15) It is acknowledged that most all patient care processes touch physicians, who appear inescapably in one or more of Juran's so-called "triple roles." In every significant clinical process, it seems that physicians are either customers, suppliers, or processors. Not infrequently, physicians leave their mark on the "administrative processes" as well as the "clinical" ones.

Involving physicians is challenging, whether they are full-time faculty at academic medical centers or salaried employees of staff model HMOs. It is acknowledged that the voluntary medical staffs of community hospitals have enormous demands on their time, with multiple imperatives seeking a ration of the hours available. Resource-based relative value scale (RBRVS) payment reform and other economic realities seem to intrude further on the time available outside of practice or personal demands.

There are many ways to overcome the barriers of time, professional norms, terminology, and even income. The type of physician participation must be carefully crafted to optimize the educational returns and the process improvement efforts. Identifying possible CQI champions from within the medical staff can be a rewarding initial step. These "champions" are often, but not always, recognized physician leaders. They create a nexus to encourage the interest and involvement of their colleagues. Moreover, the organization must take the appropriate steps to respond to physicians' interest as it occurs. Formal training as well as "just in time" training must be provided to provide the information and tools for process improvement activities. The data-driven aspects of quality assessment and improvement, with the goal of performance improvement, intrigue clinicians much more than do the standards-based attribution of traditional quality assurance. As Berwick observes, "offering physicians data without blame stimulates curiosity, and curiosity stimulates learning .... The guideline is this: show data and accuse no one!"(16) The physician executive seems particularly well prepared to assume a prominent role in clinical performance measurement as health care organizations move from traditional QA to continuous quality improvement.

On a national level, the National College of Quality Assurance (NCQA), the managed care accrediting agency, is responding to the prospect of an increased quality data requirement under reform by compiling a version of performance measures. Its "HEDIS 2.0" consists of more than 60 standardized measures for assessing a health plan's capacity in delivering selected services, providing access, and certain other plan characteristics.(17) Schoenbaum discusses this endeavor in another article in this issue.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has introduced a new format for its publication QRB and a new name, Journal of Quality Improvement. In the lead article, one may comprehend the implications of the latest buzzword "IOP"--improving organizational performance.(18) In JCAHO's 1994 Accreditation Manual for Hospitals and the president's column in its newsletter Perspectives, one can follow the vision of that organization for health care organizations to strive for performance improvement as we quantify, and reduce variation. Furthermore, it is suggested that this definition of performance incorporates a dimension of scale. This awareness can help organizations to better allocate and concentrate resources to improve performance and the quality of care. O'Leary acknowledges the Commission's fundamental role by identifying the JCAHO as the "measurement people."(19)

Beginning in 1994, health care consumers will have access to another major source of quality data. The JCAHO has changed its confidentiality and disclosure policies, allowing access to JCAHO performance information. O'Leary has written of access to provider performance information as a growing health care reform issue.(20) His recent writings and presentations have outlined a quest for value and quality.

Increasingly, health care providers will be accountable to our citizens, as well as to the government and other external accrediting agencies. We must learn to measure the right things and do so with precision if such data are to serve as a basis for improvement. It is recognized that such data are available, both good and bad, and undoubtedly will be used as patients and health care payers reach decisions on what services to seek and from whom.

O'Leary suggests it is our professional will that is most in question in this final decade of the 20th Century. Massive databases are coming on line, and most health care organizations are measuring many aspects of quality and documenting performances within. It would appear that the physician executive is uniquely prepared to guide the clinical measurement side of the total quality management movement. Furthermore, this individual may be best prepared to act as interpreter for hospital management and governing bodies of the increasingly available outcome data. In that role, the physician executive could be regarded as a credible facilitator of the medical staffs willingness to use data in process improvement as we all strive to add value to all of our patient encounters.

No less than the American Medical Association has admonished physicians to "take charge" of the outcomes data and Donabedian and hosts of others advise us on how to do so.(21) O'Leary observes that the vast quantity of data being generated requires us to be selective in both the acquisition and use of clinical measurements.(22) Some wise advice might be, "Never collect more data than you plan to use." He further suggests that we pose the question and then design performance measures to answer the query. Perhaps a carefully crafted inquiry will enable us to answer questions such as, "What are the best practices, and how do we rationally allocate our finite resources?"

Finally, in a probable era of budgetary limitations and managed competition, data-driven clinical decisionmaking may allow us to do what needs to be done. It requires us to respond to O'Leary's challenge--do we, as a profession, have the will to provide both the philosophical underpinning and the performance data to satisfy the scrutiny that lies ahead? Physician executives and other health professionals hold the key, both in knowledge and leadership skills. Shall we open the door to performance and other outcome improvements, or shall we turn that key over to eager regulators?


1. Chassin, M, "The Missing Ingredient in Health Reform--Quality of Care." JAMA 270(3):377-8, July 21, 1993.

2. Friedman, E. "Changing the System-- Implications For Physicians." JAMA 269(18):2437-42, May 12, 1993.

3. Mirvis, D. "Physician Autonomy." New England Journal of Medicine 328(18):1346-49, May 6, 1993.

4. Goldfield, N., and others. "Health Reform Principles For Quality: Recommendations For the Congressional Debate." QRB 19(6):174-81, June 1993.

5. Batalden, P. "The Continual Improvement of Health Care," American Journal of Medical Quality 8(2):29-31, Summer 1993.

6. Bader, B. "Avoiding the Paradigm Junkyard. The Quality Letter 2(4):11-5, May 1990.

7. Announcement of Fifth Annual National Forum on Quality Improvement in Health Care, Institute for Health Improvement, Dec. 6-8, 1993, Orlando, Fla.

8. Kralewski, J. "Improving Clinical Decision Making as a Means of Achieving Cost-Effective Medical Care." Physician Executive 19(3):63-4, May-June 1993.

9. Practice Pattern Analysis. Chicago, Ill.: American Hospital Association, 1991.

10. Jones, F. "Education-Based Practice Pattern Analysis: A Tool For CQI of Patient Care." American Journal of Medical Quality 7(4):120-4, Winter 1992.

11. James, B. "Quality Improvement in Hospitals: Managing Clinical Processes." Internist 34(3):11-3,17, March 1993.

12. James, B. "Implementing Practice Guidelines through Clinical Quality Improvement." Frontiers of Health Services Management 10(1):3-37, Fall 1993.

13. Blumenthal, D. "Total Quality Management and Physicians' Clinical Decisions." JAMA 269(21):2775-8, June 2, 1993.

14. Berwick, D. "The Clinical Process and the Quality Process." Quality Management in Health Care 1(1):1-8, Fall 1993.

15, Berwick, D. "TQM: Redefining Doctoring." Internist 34(3):8-10, March 1993.

16. Berwick, D. Ibid.

17. "HEDIS 2.0." Washington, D.C. :National Committee for Quality Assurance, 1993.

18. "Defining Performance of Organizations." Journal of Quality Improvement 19(7):215-21, July 1993.

19. O'Leary, D. "We're the Measurement People." Joint Commission Perspectives 13(2):2-3, March-April 1993.

20. O'Leary, D. "Access to Provider Performance Information-An Inevitable Outcome." Joint Commission Perspectives 12(5):2-3, Sept.-Oct. 1992.

21. Donabedian, A. "Quality in Health Care: Whose Responsibility Is It?" American Journal of Medical Quality 8(2):32-6, Summer 1993.

22. O'Leary. D, "Measurement Key to Agenda for Change and Health Reform." Joint Commission Perspectives 13(3):2-3, May-June 1993.

Frederic G. Jones, MD, FACPE, is Executive Vice President, Medical Affairs, Anderson area Medical Center, Anderson, S.C.
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Author:Jones, Frederic G.
Publication:Physician Executive
Date:Nov 1, 1993
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