A roundtable discussion: hospital leaders discuss QI implementation issues.

To address critical questions regarding the practical application of quality improvement (QI) concepts within health care, the Joint Commission visited six hospitals that have been implementing QI for several years. After the site visits, the leaders of these hospitals participated in a roundtable discussion of QI issues. The discussion centered around nuts-and-bolts topics, such as leadership, implementing QI, barriers/resistances, medical staff involvement, cultural change, institutionalizing QI, and external environment. The roundtable discussion is excerpted in full from a new book, Striving Toward Improvement: Six Hospitals in Search of Quality, which tells the stories of the six hospitals and their transitions to QI.

From quality assurance to quality improvement.

As we are learning to master the methods of quality assurance, a new conceptual approach focused on quality improvement is being advocated. But this new approach is not a derailment for health care practitioners committed to improve patient care quality. Rather, it is a progressive step that builds upon the concepts and methods of quality assurance. Whereas quality assurance tends to focus on correcting problems in patient care quality--especially individual practitioners' problems--quality improvement focuses on finding opportunities to improve quality by changing systems as well as individual practitioner behavior. Whereas quality assurance tends to rely primarily on standards or guidelines for the structures and processes of care and the intensive review of individual cases with undesirable outcomes, quality improvement also utilizes statistical profiles of outcomes, structures, and processes as baselines against which improvement can be measured. Whereas quality assurance may engender defensiveness in an individual practitioner, quality improvement is based on the health care practitioner's professional ethic and pride in providing even better care to patients tomorrow than is possible today. To improve patient care quality, it is necessary to examine the structures, processes, and outcomes of care. The structures and processes can be controlled by the practitioner and organization; the outcomes are the benchmarks against which the effectiveness of the structures and processes can be evaluated. Outcomes in health care are the effects of more than just the structures and processes controlled by the practitioner and organization. Therefore, outcomes are not direct and complete measures of the quality of the care provided. They are instead indicators of performance. These indicators can focus attention on care that lies outside the normal statistical parameters of performance and can provide baselines against which improvements can be measured. The monitoring and evaluation process described in Joint Commission standards is a method for establishing priorities and using indicators to improve the quality of patient care. This method can be used to focus case-based review of care and to establish baselines for continuous improvement. This conceptual approach that emphasizes quality improvement and the use of the monitoring and evaluation process is guiding the Joint Commission's development of clinical indicators and revision of its standards and survey process to help health care organizations in the transition from quality assurance to quality improvement.

Young adult chronic patients: three hypothesized subgroups.

Shortly after the 1963 passage of the Community Mental Health Centers Act, New York State launched the construction of four new psychiatric centers, including the Richard H. Hutchings Psychiatric Center in Syracuse. The Hutchings acute care crisis stabilization model was intended to significantly diminish the phenomenon of chronic psychiatric disability. After a decade of operation, however, the Hutchings Center must deal with a caseload of young and chronically disabled individuals who are contributing to the build-up both in the hospital and in the community of the new long-stay patient. The idiosyncratic needs of this chronic group must be defined so that prescriptive programs can be built to meet their needs. The Hutchings Center's original goal of returning patients to and serving them in the community remains the same, but the process of treatment, rehabilitation, and long-term community support must change.

Meeting training needs of foreign psychiatric residents in state hospitals.

Foreign medical graduates entering psychiatric residency programs in the United States must cope with cultural, language, educational, and status barriers during their crucial first year of training. The authors point out the shortcomings of American residency programs for foreign trainees and describe how a program was developed to meet their special needs. It includes a more authoritarian form of instruction patterned after the educational structure the students were used to in their native countries and courses in American culture, English language, and problem-solving techniques.