404
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
SEPTEMBER 1976
A Quality Assurance System for Prepaid Group Practice* JAMES D. SHEPPERD, M.D., Assistant Professor of Community Health Practice, LARRY A. JONES, B.A., and CHARLES FLAGLE, Dr. ENG., Howard University, Washington, D.C.
EDICAL group practice and prepayment represent an effort by the health community to bring order and organization to the delivery of health services. Prepaid group practice has as its goal the delivery of comprehensive high quality health services to its enrolled population. In order to achieve this goal, it is necessary to use many control mechanisms. This paper describes the effort made at one group practice to assess and assure the quality of health care. The methods used are an attempt to apply a quality control system designed to produce uniformity of process through monitoring "health care plans." A "health plan" is described as a set of standard diagnostic and treatment processes established for a variety of diseases and conditions. BACKGROUND
This system of Quality Assurance has been used in a primary health care program characterized by prepayment and heavy use of physician substitutes. The stated program objectives include the provision of efficient and economical high quality comprehensive health (ambulatory and inpatient) care. The groundwork for the study was laid at the East Baltimore Medical Plan (EBMP) sponsored by the Johns Hopkins Medical Institutions and the East Baltimore Community Corporation. The EBMP plan is designed to deliver all levels of care, providing on site what is feasible and contracting for the remainder. The plan is supported by a prepaid contract with the state, a blue cross contract, and a 314 e Federal grant. *Presented to the Engineering Foundation at a Conference on Evaluation in Health Services Delivery, August, 1973.
Early ideas for a quality assurance system were influenced by the work of others as well as legislative developments. It was felt that the technique of management science offers such a prepaid system the means with which to order this complex operation. The ideas began with an examination of the objectives of the prepaid health care system. In order to assure the achievement of these operational objectives a system was devised to routinely monitor the work of physicians and physician substitutes. This control system has as its features, a sensing mechanism, rapid feedback to the group, and a method of quantifying the findings. The idea of quantifying these data has grown out of the need for adequate comparisons within the clinic setting and without. The idea of closing the feedback loop is believed to be unique to this effort. METHOD OF OPERATION
The operation of any quality assurance systems requires the involvement and cooperation of the persons who are most affected-the providers. The establishment of health care plans is the first task of the quality assurance system operator. The use of group dynamic techniques-working on the professional's need for a sense of pride and accomplishments-is a starting point. The group was first led to make a decision about the level of health care to be provided. Next, agreement was reached on the need for a quality assurance system which would assist these providers in delivering that care, as well as indicate to them whether or not the care was of the level of quality they wished to provide. The group then agreed to monitor
Vol. 68, No. 5
Quiality Assiurance System for Prepaid Grouip Practice
the most prevalent diseases and/or conditions expected to be found amongst plan patients. They were hypertension, obesity, anemia, respiratory infections, pregnancy, and diabetis mellitus. Establishing health care plans for these health problems was a difficult assignment. A modification of Delphi and Delbeque techniques were used to establish standard diagnostic limits and to include or exclude the care processes to be monitored. Flow charts similar to those used in the Weed,' Problem Oriented record system were used. Ten essential process elements for each problem were selected. Providers are required to complete these flow sheets at the time of a patient visit. The medical records of the East Baltimore Medical Plan are problem oriented. It is, therefore, possible for medical records' clerk to identify the patients being treated for a monitored problem. When the chart is returned to the medical records library, the clerk reviews the flow sheet and progress note for process elements. When there is incomplete flow sheet and note, or failure to respond to an abnormal or changed finding-a notice is sent to the provider responsible. A report of completeness is filed with the Q. A. comptroller. He may then elect to release the patient recall or not, according to his judgement. The provider has a clerical assistant to ease the task. The notice to the provider has a five day time limit for a response. The second copy of the "notice" is retained by the Quality Assurance Comptroller for use in the quantification process. These data are compiled in such manner as to indicate the adherence to the health plan for problems. Comparisons can be made between care for problems, between individual providers and groups of providers. These data are compiled semi-annually or more frequently as time allows. Peer Review is performed by external auditors semi-annually. Records are examined for: 1. Adequacy of the history & physical 2. Timeliness of response to findings 3. Accuracy of diagnosis
4. 5. 6. 7.
405
Follow-up activity Appropriate use of ancillary services Appropriate use of hospital services Integration of clinical problems
The hospitalized group practice patient must also be assured quality care. The appropriate use of hospital care is critical to the financial success of prepaid plans. High quality service will attract patients, and control of utilization gives assurance of financial viability. Care plans were established for inpatients with hypertension, infectious diseases, pregnancy and extrapative surgery (hernia, circumcision, tonsilectomy). The plans were developed by the provider staff by the same group processes described for the ambulatory system. The plan began to deliver services November 15, 1971 with as one objective, "to demonstrate the feasibility controlling the cost of care through the Group Practice Prepayment delivery system." The Medical Plan is responsible for paying both the hospitalization bill as well as the physician bill for state medicaid contract enrollers. It became necessary to have a mechanism to control admissions and discharges of plan physicians in order to prevent several abuses: 1) out-of-plan admissions by non-plan physicians; 2) excessively long and needless hospitalization; and 3) unauthorized
hospitalizations. The system devised worked as follows: 1. Pre-admission authorization form signed by the Medical Director sent to Hospital indicating payment source. 2. Form accompanies patient-to Admitting Office, one copy retained by the Plan. 3. The admission notification is placed in a dated file, to be re-examined for Admission and Discharge Status at the end of 10 days. (If the patient is not discharged-Plan Physician must explain the need for longer stay to Medical Director. 4. Following discharge, the hospital bill is matched with the authorization form for data and claims
processing.
Emergency: 1. Emergency admissions authorization forms are prepared in the Hospital Admissions Office following phone call authorization by the Medical Director (within 72 hours). 2. A plan physician is assigned to the patient. 3. The follow-up processing is as described for elec-
tive admissions. (Items 2, 3, 4)
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
406
RESULTS
The ambulatory quality assurance system demonstrated that completeness of process and adherence to a health plan could be significantly improved. For hypertension we have the results of an earlier (by 2 mos.) study on adherence to the care plan prior to routine monitoring and feedback. The first study shows a range of adherence varying from 10% to 93%. (Table 1.) The subsequent study reveals significant improvement after the feedback system began with adherence rising to over 100% for elements already being completed and from 15% to 60% for plan elements being poorly adhered to the individual patient's overall adherence ranged from 64-98%. Eighty percent of charts were 90% complete or better. The diabetes care plan was being adhered to 85% of the time. The poorest adherence was for the element diet instructions (40%). This vital portion of the health plan resulted in heavy feedback, and therefore should be greatly improved in a subsequent reporting
period. The obesity plan included emphasis on diet instruction and efforts to find associated
the results of the adherence to process information. The inpatient admission and length of stay system had mixed results. Prior to the installation of the system, patients were less likely to be cared for by plan physicians 47% as by non-plan physicians 53%-usually house officers. The length of stay averaged 6.28 days. This is an acceptable figure of an H. M. O. In the five months period following' the institution of controls, there was 107 admissions staying 710 days for an average of 6.64 days. Importantly, the likelihood of a patient being cared for by a plan physician increased from 47% to 64%. In medicine, it rose to 77%, to about 70% in surgery, to 80% in gynecology, to 60% in obstetrics. The failure to significantly improve the performance of an obstetrics and pediatrics is attributed to lack of cooperating physician staff in those areas. In summary, the control system seems to have made a significant impact on two aspects: 1) having in-patients cared for by plan physicians; and 2) controlling the length of stay. DISCUSSION
Table 1. COMPARISON OF COMPLETED COMPONENTS OF THE HYPERTENSIVE CARE PLAN BEFORE AND AFTER THE QAS (EBMP).
History of Urinary Tract Infection Heart Sounds Recorded Femoral Pulses BUN Urine Analysis EKG Chest Xray Drug Treatment Diet Instruction
BEFORE FEEDBACK
AFTER FEEDBACK
Number % (41 patients)* 34 (44%)
Number % (15 patients) 14 (93%)
33 (8 1%) 4 (10%) 36 (88%) 38 (93%) 7 (17%) 28 (68%) 30 (73%) 6 (15%)
13 (87%) 1 (7%) 15 (100%) 15 (100%) 9 (60%) 12 (80%) 12 (80%) 4 (27%)
*Of 83 patients with elevated blood pressure only 41 were diagnosed as hypertensive.
conditions. There was 72% adherence overall. The individual patient scores ranged from 55% to 98% complete. 90% of the records were 80% complete or better. The peer audit was carried on by three fully trained specialists in internal medicine. The results of the peer review correlated with
SEPTEMBER 1976
Until a large portion of the U.S. population was being covered by private health insurance, little interest had been evidenced in attempting to monitor and control the quality of health care through a surveillance mechanism. In order to deal with quality health care, emphasis had been placed on the quality training following the Flexner report in the 20's. More recently assurance programs began to quantitate the amount of service provided in dollar terms. Quality was expressed in terms of professional reputation, but it was not measured for adequacy or appropriateness. More recently the Medicaid and Medicare legislation of the 60's mandated utilization review. It was through the findings of this process that the need for assurance of the quality of care came to national attention. More recent legislation, HR1, mandated a review of care for its quality and cost through professional service review organization
(PSRO).
Vol. 68, No. 5
Quality Assurance System for Prepaid Group Practice
Donabedian,2'3 Moorehead,4 Williamson,5 and others had begun to lay the groundwork for greater interest in this area. Densen,6 at Harvard, held a conference in the spring of 1970 to lay out some ground rules and terminology for the evaluation of health care delivery. The group at San Joaquin Valley7 popularized the idea of patient care profiles as part of their routine assessment of quality. Although periodic medical audits by hospital clinic staffs have been routine, most efforts have concentrated on hospital based services virtually ignoring the need for evaluation methods for ambulatory care and especially the private practitioner. Drachman at John Hopkins and Nesson at Harvard collect medical information on the computer and attempt to make this information available to the physician at the patient's next visit. These systems provide needed information but do not assure that the physician will use it. The studies by Frohlich and others8'9 on hypertension and our own work indicate that physician frequently overlook positive findings. The study presented indicates that more needs to to be done to assist the provider and assure that he uses the information in the care of the patient. With the backup of a monitoring and feedback system, the provider may significantly increase the completeness of his work. The technology of sensing an event and feeding back to the operator, information about errors, has not been applied in the health care field. This automated technology presumably is available and is used in such industries as the aircraft operations control and other areas where there are frequent routines requiring completeness of process. While completeness does not lessen the need for judgment, it does free the provider of the need to recall information, permitting him to spend the time on decision-making. The use of health plans is also not a new idea. Jaeghers promoted such ideas at Georgetown in the 1950's. Weed lays out such plans in his problem oriented systems. Brook10 and others have attempted to add the idea of quantitative adherence to such plans. It is the quantitation which will permit some objectivity to be brought into the assessment
407
of quality as well as permitting valid comparisons to be made amongst individuals and groups of providers. Health care plans provide suggestions to physicians about the care they are delivering. Such schemes must be easily adhered to and not a burden to the physician. The routinization of monitoring and feedback achieves this objective well for the ambulatory patient but less so for the hospitalized patient. The time lag between monitoring inpatients and feedback to the provider proves a more serious problem for a manual quality assurance system. With the short hospital stays more common, the feedback delay results in returning information only after the patient has been discharged. It is, however, possible to make an adequate appraisal of the providers work. IMPLICATIONS
The implications of a system of quality assurance on the current health care systems are a mixed bag. For the patient it represents a method whereby he can have his confidence in the provider boasted. The acceptance of the idea of health care plans may be looked upon as an intrusion upon the perogatives of some providers but welcomed by others. It is reasonable to assume that individual providers and groups may have established different plans for patient problems according to their training background and experience. Each of these plans might be of acceptably high quality but differing in minor respects. If a relatively simple automated feedback system is made available to monitor the physician's work and return to him information on what he has missed, a great deal of progress will be made toward assuring that quality care is tendered routinely. It would then be much more simple and less frightening to the provider to expect periodic peer reviews because quality care for routine problems would be routine rather than occurring with the probability of heads or tails on the toss of a coin. Care plans could be developed for whatever problem a provider sees routinely. The delegation of responsibility and supervision
408
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
of the performance for care provided by physicians assistant could be done with greater confidence. The problems facing the widespread use of health care plans, monitoring, and feedback systems are large but not insurmountable. The setting of acceptable standards by group consensus techniques are laborious but fruitful. The problem of the expense of monitoring in feedback operations is a real one. I suspect that widespread use and examination of the cost benefit will bring this expenditure into reason. The benefits of quality assurance should certainly prove an allowable cost from the various payment sources. Should the process review correlate as closely to peer review in the future study, the latter might be abandoned as a method of quality assessment and assurance. We might then be able to turn our attention to the efficacy of these plans and processes in producing favorable outcomes. SUMMARY
A method of quality assessment and assurance in the delivery of health care is described and discussed. The quality assurance system uses: 1) the establishment of health care plans11 and utility of their elements for patient problems; 2) routine monitoring of provider and patient adherence to these plans; 3) a system of feedback to the provider. It is the monitoring and rapid feedback which enabled the provider to consistently render all the appropriate care to his patients. The system also permits the observer to assess and compare the level of services rendered by individuals and groups of providers.
SEPTEMBER 1976
That this quality assurance system correlates highly the findings of peer review committees has significant implications as a nation gears up for a massive effort to monitor the quality of care through PSRO. LITERATURE CITED
1. WEED, L. L. Medical Records, Medical Education, and Patient Care: The Problem Oriented Record as a Basic Tool. Cleveland Case Reserve University Press, 1969. 2. DONABEDIAN, A. An Evaluation of Prepaid Group Practice. Inquiry, 6: 3, 1969. 3. DONABEDIAN, A. Promoting Quality Through Evaluating the Process of Patient Care. Medical Care, 6:181-182, 1968. 4. MOOREHEAD, P. Medical Audit as an Operational tool. American: J. Public Health, 57:1643-1656, 1967. 5. WILLIAMSON, R. Priorities in Patient Care Research and Continuing Medical Education. J.A.M.A., 204:303-308, 1968. 6. DENSEN, P. M. et al. University Medical Care Programs: Evaluation. (DHEW Publication No. (HS M) 72-3010). Washington, D.C., Proceedings of an Invitational Conference Support. 7. SASULY, R. and C. E. HOPKINS, A Medical Society Sponsored Comprehensive Medical Care Plan. Med. Care, 5:234, 1967. 8. FROHLICH, E. and H. EMMOTTEE, Evaluation of Individual Care of Hypertensive Patients. J.A.M.A., 218: 1036-1038, 1971. 9. LONGFIELD, S. B. Hypertension: Deficient Care of the Medically Served. Ann. Int. Med., 78:19-23, 1973. 10. BROOK, R. H. A Study of Methodologic Problems Associated with Assessment of Quality of Care. Doctorial Thesis, School of Hygiene and Public Health, Johns Hopkins University, Baltimore, Maryland, 1972. 11. HONIGAN, E. C. (Ed.) Peer Review Manual. Chicago, American Medical Association, Vol. 2, Appendix D, 1971, pp. 3-12.
The NAACP needs your $1000 gift or loan to the Emergency Fund Now! Do not forget its support of National Health Insurance and Medicare!
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
SEPTEMBER 1976
A Quality Assurance System for Prepaid Group Practice* JAMES D. SHEPPERD, M.D., Assistant Professor of Community Health Practice, LARRY A. JONES, B.A., and CHARLES FLAGLE, Dr. ENG., Howard University, Washington, D.C.
EDICAL group practice and prepayment represent an effort by the health community to bring order and organization to the delivery of health services. Prepaid group practice has as its goal the delivery of comprehensive high quality health services to its enrolled population. In order to achieve this goal, it is necessary to use many control mechanisms. This paper describes the effort made at one group practice to assess and assure the quality of health care. The methods used are an attempt to apply a quality control system designed to produce uniformity of process through monitoring "health care plans." A "health plan" is described as a set of standard diagnostic and treatment processes established for a variety of diseases and conditions. BACKGROUND
This system of Quality Assurance has been used in a primary health care program characterized by prepayment and heavy use of physician substitutes. The stated program objectives include the provision of efficient and economical high quality comprehensive health (ambulatory and inpatient) care. The groundwork for the study was laid at the East Baltimore Medical Plan (EBMP) sponsored by the Johns Hopkins Medical Institutions and the East Baltimore Community Corporation. The EBMP plan is designed to deliver all levels of care, providing on site what is feasible and contracting for the remainder. The plan is supported by a prepaid contract with the state, a blue cross contract, and a 314 e Federal grant. *Presented to the Engineering Foundation at a Conference on Evaluation in Health Services Delivery, August, 1973.
Early ideas for a quality assurance system were influenced by the work of others as well as legislative developments. It was felt that the technique of management science offers such a prepaid system the means with which to order this complex operation. The ideas began with an examination of the objectives of the prepaid health care system. In order to assure the achievement of these operational objectives a system was devised to routinely monitor the work of physicians and physician substitutes. This control system has as its features, a sensing mechanism, rapid feedback to the group, and a method of quantifying the findings. The idea of quantifying these data has grown out of the need for adequate comparisons within the clinic setting and without. The idea of closing the feedback loop is believed to be unique to this effort. METHOD OF OPERATION
The operation of any quality assurance systems requires the involvement and cooperation of the persons who are most affected-the providers. The establishment of health care plans is the first task of the quality assurance system operator. The use of group dynamic techniques-working on the professional's need for a sense of pride and accomplishments-is a starting point. The group was first led to make a decision about the level of health care to be provided. Next, agreement was reached on the need for a quality assurance system which would assist these providers in delivering that care, as well as indicate to them whether or not the care was of the level of quality they wished to provide. The group then agreed to monitor
Vol. 68, No. 5
Quiality Assiurance System for Prepaid Grouip Practice
the most prevalent diseases and/or conditions expected to be found amongst plan patients. They were hypertension, obesity, anemia, respiratory infections, pregnancy, and diabetis mellitus. Establishing health care plans for these health problems was a difficult assignment. A modification of Delphi and Delbeque techniques were used to establish standard diagnostic limits and to include or exclude the care processes to be monitored. Flow charts similar to those used in the Weed,' Problem Oriented record system were used. Ten essential process elements for each problem were selected. Providers are required to complete these flow sheets at the time of a patient visit. The medical records of the East Baltimore Medical Plan are problem oriented. It is, therefore, possible for medical records' clerk to identify the patients being treated for a monitored problem. When the chart is returned to the medical records library, the clerk reviews the flow sheet and progress note for process elements. When there is incomplete flow sheet and note, or failure to respond to an abnormal or changed finding-a notice is sent to the provider responsible. A report of completeness is filed with the Q. A. comptroller. He may then elect to release the patient recall or not, according to his judgement. The provider has a clerical assistant to ease the task. The notice to the provider has a five day time limit for a response. The second copy of the "notice" is retained by the Quality Assurance Comptroller for use in the quantification process. These data are compiled in such manner as to indicate the adherence to the health plan for problems. Comparisons can be made between care for problems, between individual providers and groups of providers. These data are compiled semi-annually or more frequently as time allows. Peer Review is performed by external auditors semi-annually. Records are examined for: 1. Adequacy of the history & physical 2. Timeliness of response to findings 3. Accuracy of diagnosis
4. 5. 6. 7.
405
Follow-up activity Appropriate use of ancillary services Appropriate use of hospital services Integration of clinical problems
The hospitalized group practice patient must also be assured quality care. The appropriate use of hospital care is critical to the financial success of prepaid plans. High quality service will attract patients, and control of utilization gives assurance of financial viability. Care plans were established for inpatients with hypertension, infectious diseases, pregnancy and extrapative surgery (hernia, circumcision, tonsilectomy). The plans were developed by the provider staff by the same group processes described for the ambulatory system. The plan began to deliver services November 15, 1971 with as one objective, "to demonstrate the feasibility controlling the cost of care through the Group Practice Prepayment delivery system." The Medical Plan is responsible for paying both the hospitalization bill as well as the physician bill for state medicaid contract enrollers. It became necessary to have a mechanism to control admissions and discharges of plan physicians in order to prevent several abuses: 1) out-of-plan admissions by non-plan physicians; 2) excessively long and needless hospitalization; and 3) unauthorized
hospitalizations. The system devised worked as follows: 1. Pre-admission authorization form signed by the Medical Director sent to Hospital indicating payment source. 2. Form accompanies patient-to Admitting Office, one copy retained by the Plan. 3. The admission notification is placed in a dated file, to be re-examined for Admission and Discharge Status at the end of 10 days. (If the patient is not discharged-Plan Physician must explain the need for longer stay to Medical Director. 4. Following discharge, the hospital bill is matched with the authorization form for data and claims
processing.
Emergency: 1. Emergency admissions authorization forms are prepared in the Hospital Admissions Office following phone call authorization by the Medical Director (within 72 hours). 2. A plan physician is assigned to the patient. 3. The follow-up processing is as described for elec-
tive admissions. (Items 2, 3, 4)
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
406
RESULTS
The ambulatory quality assurance system demonstrated that completeness of process and adherence to a health plan could be significantly improved. For hypertension we have the results of an earlier (by 2 mos.) study on adherence to the care plan prior to routine monitoring and feedback. The first study shows a range of adherence varying from 10% to 93%. (Table 1.) The subsequent study reveals significant improvement after the feedback system began with adherence rising to over 100% for elements already being completed and from 15% to 60% for plan elements being poorly adhered to the individual patient's overall adherence ranged from 64-98%. Eighty percent of charts were 90% complete or better. The diabetes care plan was being adhered to 85% of the time. The poorest adherence was for the element diet instructions (40%). This vital portion of the health plan resulted in heavy feedback, and therefore should be greatly improved in a subsequent reporting
period. The obesity plan included emphasis on diet instruction and efforts to find associated
the results of the adherence to process information. The inpatient admission and length of stay system had mixed results. Prior to the installation of the system, patients were less likely to be cared for by plan physicians 47% as by non-plan physicians 53%-usually house officers. The length of stay averaged 6.28 days. This is an acceptable figure of an H. M. O. In the five months period following' the institution of controls, there was 107 admissions staying 710 days for an average of 6.64 days. Importantly, the likelihood of a patient being cared for by a plan physician increased from 47% to 64%. In medicine, it rose to 77%, to about 70% in surgery, to 80% in gynecology, to 60% in obstetrics. The failure to significantly improve the performance of an obstetrics and pediatrics is attributed to lack of cooperating physician staff in those areas. In summary, the control system seems to have made a significant impact on two aspects: 1) having in-patients cared for by plan physicians; and 2) controlling the length of stay. DISCUSSION
Table 1. COMPARISON OF COMPLETED COMPONENTS OF THE HYPERTENSIVE CARE PLAN BEFORE AND AFTER THE QAS (EBMP).
History of Urinary Tract Infection Heart Sounds Recorded Femoral Pulses BUN Urine Analysis EKG Chest Xray Drug Treatment Diet Instruction
BEFORE FEEDBACK
AFTER FEEDBACK
Number % (41 patients)* 34 (44%)
Number % (15 patients) 14 (93%)
33 (8 1%) 4 (10%) 36 (88%) 38 (93%) 7 (17%) 28 (68%) 30 (73%) 6 (15%)
13 (87%) 1 (7%) 15 (100%) 15 (100%) 9 (60%) 12 (80%) 12 (80%) 4 (27%)
*Of 83 patients with elevated blood pressure only 41 were diagnosed as hypertensive.
conditions. There was 72% adherence overall. The individual patient scores ranged from 55% to 98% complete. 90% of the records were 80% complete or better. The peer audit was carried on by three fully trained specialists in internal medicine. The results of the peer review correlated with
SEPTEMBER 1976
Until a large portion of the U.S. population was being covered by private health insurance, little interest had been evidenced in attempting to monitor and control the quality of health care through a surveillance mechanism. In order to deal with quality health care, emphasis had been placed on the quality training following the Flexner report in the 20's. More recently assurance programs began to quantitate the amount of service provided in dollar terms. Quality was expressed in terms of professional reputation, but it was not measured for adequacy or appropriateness. More recently the Medicaid and Medicare legislation of the 60's mandated utilization review. It was through the findings of this process that the need for assurance of the quality of care came to national attention. More recent legislation, HR1, mandated a review of care for its quality and cost through professional service review organization
(PSRO).
Vol. 68, No. 5
Quality Assurance System for Prepaid Group Practice
Donabedian,2'3 Moorehead,4 Williamson,5 and others had begun to lay the groundwork for greater interest in this area. Densen,6 at Harvard, held a conference in the spring of 1970 to lay out some ground rules and terminology for the evaluation of health care delivery. The group at San Joaquin Valley7 popularized the idea of patient care profiles as part of their routine assessment of quality. Although periodic medical audits by hospital clinic staffs have been routine, most efforts have concentrated on hospital based services virtually ignoring the need for evaluation methods for ambulatory care and especially the private practitioner. Drachman at John Hopkins and Nesson at Harvard collect medical information on the computer and attempt to make this information available to the physician at the patient's next visit. These systems provide needed information but do not assure that the physician will use it. The studies by Frohlich and others8'9 on hypertension and our own work indicate that physician frequently overlook positive findings. The study presented indicates that more needs to to be done to assist the provider and assure that he uses the information in the care of the patient. With the backup of a monitoring and feedback system, the provider may significantly increase the completeness of his work. The technology of sensing an event and feeding back to the operator, information about errors, has not been applied in the health care field. This automated technology presumably is available and is used in such industries as the aircraft operations control and other areas where there are frequent routines requiring completeness of process. While completeness does not lessen the need for judgment, it does free the provider of the need to recall information, permitting him to spend the time on decision-making. The use of health plans is also not a new idea. Jaeghers promoted such ideas at Georgetown in the 1950's. Weed lays out such plans in his problem oriented systems. Brook10 and others have attempted to add the idea of quantitative adherence to such plans. It is the quantitation which will permit some objectivity to be brought into the assessment
407
of quality as well as permitting valid comparisons to be made amongst individuals and groups of providers. Health care plans provide suggestions to physicians about the care they are delivering. Such schemes must be easily adhered to and not a burden to the physician. The routinization of monitoring and feedback achieves this objective well for the ambulatory patient but less so for the hospitalized patient. The time lag between monitoring inpatients and feedback to the provider proves a more serious problem for a manual quality assurance system. With the short hospital stays more common, the feedback delay results in returning information only after the patient has been discharged. It is, however, possible to make an adequate appraisal of the providers work. IMPLICATIONS
The implications of a system of quality assurance on the current health care systems are a mixed bag. For the patient it represents a method whereby he can have his confidence in the provider boasted. The acceptance of the idea of health care plans may be looked upon as an intrusion upon the perogatives of some providers but welcomed by others. It is reasonable to assume that individual providers and groups may have established different plans for patient problems according to their training background and experience. Each of these plans might be of acceptably high quality but differing in minor respects. If a relatively simple automated feedback system is made available to monitor the physician's work and return to him information on what he has missed, a great deal of progress will be made toward assuring that quality care is tendered routinely. It would then be much more simple and less frightening to the provider to expect periodic peer reviews because quality care for routine problems would be routine rather than occurring with the probability of heads or tails on the toss of a coin. Care plans could be developed for whatever problem a provider sees routinely. The delegation of responsibility and supervision
408
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
of the performance for care provided by physicians assistant could be done with greater confidence. The problems facing the widespread use of health care plans, monitoring, and feedback systems are large but not insurmountable. The setting of acceptable standards by group consensus techniques are laborious but fruitful. The problem of the expense of monitoring in feedback operations is a real one. I suspect that widespread use and examination of the cost benefit will bring this expenditure into reason. The benefits of quality assurance should certainly prove an allowable cost from the various payment sources. Should the process review correlate as closely to peer review in the future study, the latter might be abandoned as a method of quality assessment and assurance. We might then be able to turn our attention to the efficacy of these plans and processes in producing favorable outcomes. SUMMARY
A method of quality assessment and assurance in the delivery of health care is described and discussed. The quality assurance system uses: 1) the establishment of health care plans11 and utility of their elements for patient problems; 2) routine monitoring of provider and patient adherence to these plans; 3) a system of feedback to the provider. It is the monitoring and rapid feedback which enabled the provider to consistently render all the appropriate care to his patients. The system also permits the observer to assess and compare the level of services rendered by individuals and groups of providers.
SEPTEMBER 1976
That this quality assurance system correlates highly the findings of peer review committees has significant implications as a nation gears up for a massive effort to monitor the quality of care through PSRO. LITERATURE CITED
1. WEED, L. L. Medical Records, Medical Education, and Patient Care: The Problem Oriented Record as a Basic Tool. Cleveland Case Reserve University Press, 1969. 2. DONABEDIAN, A. An Evaluation of Prepaid Group Practice. Inquiry, 6: 3, 1969. 3. DONABEDIAN, A. Promoting Quality Through Evaluating the Process of Patient Care. Medical Care, 6:181-182, 1968. 4. MOOREHEAD, P. Medical Audit as an Operational tool. American: J. Public Health, 57:1643-1656, 1967. 5. WILLIAMSON, R. Priorities in Patient Care Research and Continuing Medical Education. J.A.M.A., 204:303-308, 1968. 6. DENSEN, P. M. et al. University Medical Care Programs: Evaluation. (DHEW Publication No. (HS M) 72-3010). Washington, D.C., Proceedings of an Invitational Conference Support. 7. SASULY, R. and C. E. HOPKINS, A Medical Society Sponsored Comprehensive Medical Care Plan. Med. Care, 5:234, 1967. 8. FROHLICH, E. and H. EMMOTTEE, Evaluation of Individual Care of Hypertensive Patients. J.A.M.A., 218: 1036-1038, 1971. 9. LONGFIELD, S. B. Hypertension: Deficient Care of the Medically Served. Ann. Int. Med., 78:19-23, 1973. 10. BROOK, R. H. A Study of Methodologic Problems Associated with Assessment of Quality of Care. Doctorial Thesis, School of Hygiene and Public Health, Johns Hopkins University, Baltimore, Maryland, 1972. 11. HONIGAN, E. C. (Ed.) Peer Review Manual. Chicago, American Medical Association, Vol. 2, Appendix D, 1971, pp. 3-12.
The NAACP needs your $1000 gift or loan to the Emergency Fund Now! Do not forget its support of National Health Insurance and Medicare!
