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System measures ambulatory care quality.

System Measures Ambulatory Care Quality

The ultimate mission of quality assurance is to enable us to manage quality. We need to be able to manage the quality of the care delivered by our organizations just as we now manage budgets and personnel. But we will not be able to manage quality until we first are able to measure it. However, in order to measure quality in a meaningful way, we must develop a systematic approach toward monitoring it. A rational monitoring system is the foundation for an effective quality assurance program.

Monitoring Quality

In order to successfully monitor quality, we need to focus on three important concepts.

* We must invest our energies in issues that make a difference to our patients' health.

* We must design our monitoring program on the basis of a rational ambulatory framework.

* We must be certain that this framework is both structured and comprehensive.

The point of quality, of course, is to affect the health of our patients in a positive way. If the ultimate mission of quality assurance is to enable us to manage quality, what we must do in quality assurance is to direct our energies toward issues that can yield positive health status outcomes. If they do not, they are not quality assurance issues.

Ambulatory quality assurance can be more effective if the program is based on a rational framework. The framework should reflect the spectrum of "health-related" activities that occur in the ambulatory setting. Methodist Hospital of Indiana has developed the concept of the Ambulatory Care Parameter, a perspective from which we can view our ambulatory program. It is a perspective that by definition has the potential to affect our patients' health. There are 10 Ambulatory Care Parameters. The Ambulatory Care Parameters provide a rational framework that we can use in structuring a quality assurance program. The parameters along with their definitions are shown in figure 1, page 17.

Using the Ambulatory Care Parameters, we can develop a quality assurance program that is both structured and comprehensive. Each of the 10 parameters can be divided into several important areas, referred to as aspects. For each aspect, we can look at one or more items, called an indicator, that will help us know how we are doing in the selected area.

Figure 2, page 18, shows how this could be done for the Patient Risk Minimization Parameter. Patient risk minimization could be divided into four aspects--quality control, infection control, patient safety, and medical risk control. For each aspect, there are several indicators that the quality assurance committee will review in order to make a judgment about how well the organization is doing on the particular aspect. For example, on the medical risk control aspect the quality assurance committee could look at the indicators of medical emergency plans, medical emergency drills, CPR certification, and medicine sensitivity documentation.

Using this type of system for all 10 of the Ambulatory Care Parameters, we can ensure that we have developed a structured and comprehensive approach to quality assurance. The approach is based on a rational ambulatory framework, the Ambulatory Care Parameters, and on the overriding notion that everything that we look at has the potential to affect the patient's health.

The system that has been developed at Methodist Hospital to do this in an ambulatory care setting is called AmbuQual. Instead of reinventing the wheel, an organization can review the list of suggested indicators for each of the four aspects within each of the 10 parameters and pick the ones that seem most appropriate.

Measuring Quality

The AmbuQual system provides a continuous quantitative evaluation of the "level of quality." Each of the 10 Ambulatory Care Parameters will have a score between 1 and 100. This score, of course, can change. A slippage of quality will result in a lower score. Interventions designed to improve quality should result in a higher score. The score for each of the Ambulatory Care Parameters can be tracked over time. In fact, there is a software package that supports the AmbuQual system and that can be run on an IBM/PC compatible computer. The software will graph the scores for the past three years.

Program Quality Index

As shown in figure 3, page 18, the weighted combined scores for the 10 Ambulatory Care Parameters form the Program Quality Index (PQI). Each of the parameters is weighted on the basis of its potential impact on the health of the patient (see figure 1). The Program Quality Index is also a score between 1 and 100 and reflects the level of quality of the entire program.

Figure 4, page 19, is a sample score sheet that reflects the current level of performance of an actual ambulatory organization on each of the 10 Ambulatory Care Parameters as well as the current Program Quality Index.

Generic Indicators Chart

The heart of the AmbuQual system is the generic indicators chart. An excerpt from the generic indicators chart is included in figure 5, page 19. For each suggested indicator, the generic indicators chart proposes a standard (criterion), a threshold level (referred to in AmbuQual as QIP, the Quality Improvement Plan level), possible data sources, a weight, and who on the management staff should be responsible for that indicator. In addition, because each indicator is given a score of 1-100, the generic indicators chart suggests how that score can be obtained. Some of the more qualitative (subjective) indicators are scored by the quality assurance committee. The more quantitative indicators are scored simply by documenting the percentage compliance. The composite score for all of the indicators in a parameter becomes the parameter score. Each ambulatory organization can take the generic indicators chart and modify it so that it is responsive to the unique mission and needs of the organization. It is then no longer a generic indicators chart. It is the "ABC Managed Care Center's" quality assurance program. It is a quality assurance program that not only monitors quality, but also begins to measure quality.

Managing Quality

This approach to ambulatory quality assurance really does provide the opportunity to manage quality. Management can manage the standards (criteria) in our organizations. It can revise them, upgrade them, even lower them in order to make them relevant. The thresholds (QIP levels) are also set by management, which can raise them, lower them, or leave them the same.

Trouble-Shooting Quality

The AmbuQual scoring system provides the opportunity for management to trouble-shoot quality. Figure 4 shows the score sheet for all of the parameters. Figure 6, page 20, is a sample score sheet for the Patient Risk Minimization Parameter. The score sheet breaks the parameter into each of the four aspects and the associated indicators. The score for each of the aspects and each of the indicators is listed. Aspects or indicators with low scores can be evaluated by the manager and efforts can be taken to improve the scores. Improving the score, ideally, will raise the level of quality and have a positive impact on the patient's health.

The Quality Objective

In ambulatory centers at Methodist Hospital, we have the objective this year of raising the level of quality by five percent. We will be able to track whether or not we have accomplished this goal because of our capacity to measure the level of quality. We want to raise our Program Quality Index (PQI) score five percent. By using the AmbuQual system, we will be able to track each month how we are doing on our quality objective.

Quality as the

Competitive Edge

With or without the AmbuQual system, it is critical for physician executives to make certain that the ambulatory quality assurance system that we design is structured in a carefully thought out manner. We must be certain that we are looking at issues that really affect our patients' health. We must be equally certain that our system is structured and comprehensive so that we are not overlooking issues that we should be monitoring. We also need to make certain that the system that we design has the capacity to measure quality. If we can measure quality, we can begin to manage quality.

Competition in the ambulatory health care setting is vigorous. We are rapidly approaching the point where we can no longer compete on the basis of cost. Quality will become the competitive edge. The AmbuQual system, or systems similar to AmbuQual, will give us that competitive edge. It will provide numbers that we can use in documenting not only the high-quality care we normally give, but also our commitment to continuous improvement of that quality.

Dale S. Benson, MD, FACPE, is Director, Ambulatory Care Services, Methodist Hospital of Indiana, Inc., Indianapolis. He is an Associate Member of the College's Forum on Quality Health Care and of its Society on Managed Health Care Organizations.
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Title Annotation:includes related article
Author:Benson, Dale S.
Publication:Physician Executive
Date:Mar 1, 1990
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