Moving from "small qa" to "large qa". An outcomes framework for improving quality management.

In this article we describe an "outcomes framework" for planning and analyzing quality management systems in relation to their ultimate purpose, enhancing the wide range of health care benefits. "Small qa" includes those methods that focus on structure or process and induce improvement of outcomes. These methods are essential but, predictably, often involve minimal improvement of health care. "LARGE QA" is defined as those methods that focus on unacceptable outcomes and deduce processes and structures to be changed to enhance outcomes. These methods focus on either "problems" or "opportunities" that predict substantial improvement in health care benefits. We briefly describe and analyze this outcomes framework for quality management in terms of its conceptual factors and its current and future emphasis. We then describe several major national program developments and resources that will facilitate moving the balance of quality management effort from small qa to LARGE QA.

A critique of the use of generic screening in quality assessment.

This article summarizes available information on the efficiency and effectiveness of generic occurrence screening when used in quality assessment. Generic screening is relatively inefficient because of its multitiered review system and high rates of errors and false positives. Overall sensitivity may approach 70% to 80%, but specificity is estimated to range from about 22% to 73%. Effectiveness of generic screening in identifying problems in quality is limited by variability in peer review. Other limitations of generic screens include their lack of inherent relationship to the quality of patient care and their inability to provide direct performance measures for use in the periodic reappraisal of clinical privileges of medical staff members. We propose the monitoring of specific adverse surgical and medical clinical outcomes and related risk factors to increase efficiency in quality assessment and provide a more adequate database for the continual improvement of patient care and clinical performance.

Medicine and pharmacy: our once and future status as professions.

Pharmacists are challenged to fulfill in modern health care their historic role as professionals who, working with physicians, hold patients' well-being as their foremost concern. Advances in biomedical science and technology and drastic increases in the cost of care have changed the way medical care is organized, delivered, and paid for. The future of medical care depends on whether professionalism survives or succumbs to the profit motive and whether, faced with increased competition and restricted funding, care-givers will sustain the ethic of providing care to all who need it. The conflict between the medical care that is possible because of scientific advances and the care that will be paid for will be decided politically. Pharmacists can best improve the quality of care by dedicating themselves to rational drug therapy. Drug-use evaluation in hospitals must increasingly demonstrate patient benefit, not just cost savings. Pharmacists can improve the prevention of adverse drug reactions by more timely dissemination of drug information to physicians. Pharmacists should be assertive in identifying nonrational prescribing trends. Pharmacists' responsibility for therapy will expand as the use of biologic manipulation as an adjunct to or substitute for drugs increases. The future will require pharmacists to distinguish between efficiency in providing quality services and narrow economic motivations. Wise choices will help to ensure pharmacy a full partnership in patient care.

Measuring clinical performance of individual internists in office and hospital practice.

No standardized methods exist for reliably measuring physicians' performance against clinically valid standards. In this study, statistically reliable peer review based on current national standards of internal medicine was used to evaluate the clinical performance of 66 internists in office and hospital practice. Evaluation was limited to the substantiation of diagnosis, prescribing indicated drug regimen, monitoring, and attaining expected patient response. Performance in substantiating diagnosis was better than in therapeutic management, and management in hospitalized patients was superior to office management. Superior performance by a physician was not consistent across diagnoses, but substandard office treatment in at least one diagnosis was associated with substandard office treatment in other conditions. Internists' performance was unrelated to their certification status but inversely related to the number of years since graduation from medical school. This method could be used to evaluate the effectiveness of continuing education in improving physicians' performance and to validate current examinations used in recertifying internists.

A survey of patient satisfaction, knowledge and compliance.

A survey was carried out by telephone on 201 patients receiving continuing care from internists for commonly occurring chronic conditions. Although 90% of patients knew the names and therapeutic purposes of the drugs prescribed for them, only 30% could name any side effects to watch for. Almost 90% were satisfied with their physicians' explanations but only 58% actually had a good understanding of their condition. More than 90% complied with their drug regimen but only 39% adhered to the prescribed low-sodium diet and only 55% of diabetic patients tested their urines as instructed. Overall, degree of satisfaction and knowledge of their own condition did not correlate with degree of compliance. Patients need more adequate education regarding their condition and potential side effects of drugs. More systematic attention should also be given to methods of motivating patients to comply with regimens that require a change in behavior.

Determining physicians' performance. Continuing medical education and other interacting variables.

Participation in formal continuing medical education (CME) is required by many organizations and state governments as the foremost means of assuring the quality of medical care. Analysis of the literature reveals that CME in all its forms is effective in improving competence, i.e., the ability to provide good care. However, that competence is not regularly reflected in physicians' habitual performance in the care of patients. A number of factors are known to narrow the gap between competence and performance, including clear specification of standards, individual feedback on actual performance, and a professional environment conductive to the maintenance of high standards. In the presence of such factors, CME can improve physicians' performance when directed to objectively identified deficiencies. However, public assurance of the quality of medical care can only be provided through certification that individual physicians' performance conforms to contemporary valid standards.

Measurement of physicians' performance using existing techniques.

Existing techniques permit objective and valid measurement of limited elements of physicians' performance. These limited aspects, however, are of considerable importance to patients. The basic components of performance in medicine and surgery can be defined and used as the basis of organized programs for such evaluation. Interhospital comparisons can provide an effective impetus for assessing and improving performance of individual staff members when this is indicated. Professional auspices are needed for the development and application of methods that can provide continuing assurance that the clinical activity of physicians corresponds to contemporary standards.A system of incentives should be provided to physicians to promote their participation in voluntary programs of self-assessment. The incentives should be in the form of performance assessment credits, comparable in definition to continuing medical education credits, but granted for participation in an accredited program that objectively measures physicians' performance against national standards of the respective specialty.

The private initiative in PSRO.

Private Initiative in Professional Standards Review Organizations (PIPSRO), a privately funded project sponsored by four major health care associations, has developed principles to guide the formulation of the respective responsibilities of HEW and the private sector in regulating quality assurance. The management committee of PIPSRO studied alternatives to the federal government's approach to regulation and concluded from the results that the special function of PSROs in regulating quality assurance should be to ensure that a basic standard of care is maintained for all Medicare and Medicaid patients.

Concurrent quality assurance in hospital care. Report of a study by Private Initiative in PSRO.

To test the feasibility and effects of incorporating concurrent quality assurance (CQA) into the concurrent utilization reviews required by PSRO's, adherence to essential criteria of medical care and attainment of expected immediate outcomes were monitored prospectively in 5604 cases of seven conditions in 24 experimental and 26 control hospitals in five PSRO areas. CQA was not consistently associated with improved documentation in records, but was associated with slightly better adherence to treatment criteria in all five PSRO areas (P less than 0.03). Adherence to pooled documentation or treatment criteria was unrelated to outcomes. However, failure to adhere to disease-specific scientifically validated treatment criteria was associated with unsatisfactory outcomes in bacterial pneumonia (P less than 0.01) and acute myocardial infarction (P less than 0.02). CQA was professionally acceptable, technically feasible and compatible with PSRO reviews. Given adequate physician support, CQA can produce slightly greater adherence to treatment criteria. If the criteria are valid, adherence may lead to improved immediate outcomes in some diseases.