Measuring the Quality of Care for the Cancer Patient Robert
J.
Marder, MD
In recent years, the efforts to better define quality of patient care have focused on
attempts to improve on the measurement of quality. These efforts raise three questions: (1) Why attempt to measure quality? (2) What is the best way to measure quality of care of the cancer patient? and (3) What must be done to achieve this? Three main reasons for measuring quality of patient care are to describe the current state, plan strategies for improvement, and implement and monitor improvements. To measure quality, both the definition of quality and the tools available for measurement must be addressed. The difficulty in developing a measurable definition of quality is achieving agreement on the measurable components of quality. The tools to measure quality have evolved to focus on monitoring of key indicators for comparative use. The utility of indicators lies in demonstrating that they have the capacity to identify opportunities for improving care. The Joint Commission is improving measurement tools through the development and testing of oncology indicators for reliability and the capacity to identify opportunities for improving care. The development and teaching of new quality improvement methods to health care professionals also is necessary. Cancer 67:1753-1758,1991.
T
HE MEASUREMENT of quality in health care is a topic
that has received tremendous attention over the past few years.' -4 The motives for this vary from the desires of health care practitioners and organizations to improve care to the economic concerns of third party payers. In discussing the measurement of quality of care for the cancer patients, three questions must be addressed: (I) why attempt to measure quality of care in cancer care; (2) can quality be measured for cancer care; and (3) what needs to be done to improve the measurement of quality of cancer care? This report looks at these questions from the perspective of the health care field in general and of the Joint Commission on Accreditation of Healthcare Organizations (J AHO) in particular. What is the basis for the desire to measure quality of care for the cancer patient? There are at least three main reasons: (I) to describe the current state of cancer care,
Presented at the American ancer Society National Conference on Cancer and the hanging Heaithcare System, San Francisco, alifornia, May 3- 5, 1990. From the Division of Research and Standards, Joint om mission on Accreditation of Healthcare Organizations, hicago, Illinois. Address for reprint ; Robert J. Marder, MD, Division of Research and Standards, Joint Commission on Accreditation of Healthcare Organizations, 875 North Michigan Avenue, Chicago, IL 60611. Accepted for publication September 14, 1990.
(2) to assist in planning strategies for improvement of cancer care, and (3) to implement and monitor improvements in cancer care. These reasons can be viewed as sequential in the process of improving care. It is important to note that the motivations behind each of these reasons can be varied. One party may wish to describe the current state of cancer care to stimulate discussion; another party may wish to describe it to determine who are the inadequate providers and adjust reimbursement accordingly. Similarly, once the current state is described, the strategies for improvement could vary from encouragement to discipline. Finally, the desire to implement and monitor improvements can be viewed from similarly divergent perspectives. It is important to recognize that although all dedicated health care professionals wish to know more about the quality of care they are delivering, they must operate in an environment where there is no guarantee that the data derived in the pursuit of measuring quality will always be used in an acceptable and responsible manner. The mission of the JCAHO is to " enhance the quality of health care provided to the public by establishing contemporary standards, evaluating healthcare organizations, rendering accreditation decisions, and providing educational and consultative support to healthcare professionals. In providing leader hip to the healthcare field, the
1754
CANCER TABLE 1.
March 15 Supplement 1991
Vol. 67
Oncology Care Task Force Members
John W. Yarbro, MD, PhD (Chairman) Director of Hematology and Medical Oncology University of Missouri Hospital and Clinics Paul Carbon e, MD Director Wisconsin Clinical Cancer Center Robert En ck, MD Director, Riverside Regional Cancer Institute Ri verside Methodist Hospital L. Penfield Faber, MD Dea n of Surgery Rush Presbyterian- St. Luke Medical Center Irvin Fleming, MD Chief, Surgical Services St. Jude's Children's Hospital Leslie Ford, MD Chief Community Oncology and Rehabilitation Branch National Cancer Institute Margaret Hanson Frogge, RN, MS Vice President, Clinical Services Riverside Medical Center Gerald Hanks, MD, FACR hai rman , Department of Radiation Therapy Fox Chase Cancer Center Am erican Cancer Society
Joint Commission seeks to a clearer understancling of the views and interests of various publics who have major interests in healthcare."s Over the past few years, the JCAHO has been engaged in a strategic initiative, entitled " The Agenda for Change," to improve its ability to perform those functions. A major component of this initiative is the development of indicators, which are performance measures for use by health care practitioners and organizations and by the J AHO. An indicator is defined as a quantitative measure that can be used as a guide to morutor and evaluate the quality of important patient care and support service activities. 4 The reason for undertaking the development of indicators is that, through its role in evaluating health care organizations and rendering accreditation decisions, the J AHO has become increasingly aware of the need for reliable and responsible measurement tools as an integral part of that process. We have also come to understand that it is the use of these measurements that will determine their value. In November 1988 the J AHO convened a national multidisciplinary expert Task Force (Table I) to develop a set of indicators for oncology care. 6 Through this effort we can assist in describing the current state of oncology care, planning strategies for improvement in cancer care, and monitoring those improvements. By the involvement by the J AHO of the oncology community in the development, testing, and use of these indicators, we hope to create performance measures that can be used responsibly to improve patient care. The remainder of this report assumes that this desire for improvement, both on the part of health care professionals and the JCAHO, is the underlying basis for the desire to measure quality. Despite all the demands to measure quality, the second
Kay Horsch Chairman of the Board American Cancer Society Robert V. P. Hutter, MD Chairman, Department of Pathology St. Barnabas Medical Center Lisa Lattal, MHA Ambulatory Services Manager Johns Hopkins Oncology Center Dolores Krull Michels, CTR Manager, Tumor Registry Alleghen y General Hospital L. Jerem y Miranksy, PhD Administrator, Hospital Review Systems Memorial Sloan-Kettering Cancer enter Marvin M. Romsdahl , MD, PhD Professor of Surgery, University of Texas M.D. Anderson Cancer Center Raymond Weiss, MD Chief, Medical Oncology Walter Reed Army Medical Center David Winchester, MD, FA S Director, Cancer Department American Cancer Society
question still remains: Can quality be measured? There are two aspects of quality measurement that must be addressed in answering this question: (I) the definition of quality and (2) the tools available for measurement. Clarity on the principles for constructing a definition of quality for health care has grown out the work of Donabedian,7 a leader in modern medical quality assurance and from the industrial quality control arena. The key principle is simple: to measure quality, quality must be defined in a measurable way.2,7.8 However, this requires a definition of quality that is more than a slogan, such as "Quality is Job I" or "Quality is patients first." One of the difficulties in developing a measurable definition of quality is achieving an agreement upon the measurable components that comprise quality.2,7 In the recent Institute of Medicine (lOM) report to Congress on quality assurance for Medicare,9 the 10M Committee noted that they reviewed more than 100 definitions of quality in the medical literature. The one clear conclusion was that quality is multidimensional and can be viewed from the mUltiple perspective of the organization, of the provider, of the patient, and of society. This is clearly reflected when one begins to analyze potential measures of quality for use in improving care. The Ishikawa or "fishbone" diagram is one tool that has been used to perform this analysis. lo This type of diagram illustrates the many factors that may have an impact on a given outcome (Fig. I). Understanding the relative impact of the patient, practitioner, and organizational and external factors involved in outcomes for oncology patients is critical to defining and assessing quality. Although currently there is no single "official" general definition for quality in health care, a national consensus
M EASURING QUALITY OF CARE
No.6
Social
Policy----.,;'
FIG. I. Outcome: a product of multiple causes.
is building toward one. In 1989 the JCAHO proposed that quality patient care be defined as " the degree to which patient services increase the probability of desired patient outcomes and reduce the probability of undesired outcomes given the current state of knowledge." I I The key words " degree," " probability," and "outcomes" reflect the desire to use this definition in a measurable way, and the phrase " patient services" reflects the linkage between the processes and outcomes comprising ca re and the need to evaluate both. The phrase "current state of knowledge" reflects that the pursuit of quality is not a static endeavor and also cannot be viewed through absolutes; it must take into account the constraints on and responsibilities of health care professionals. The 10M has chosen a similar definition: " Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.,,9 The major addition to the J AHO definition is the recognition that the hea lth of the population is a measurable aspect of quality beyond the health of individuals within that population . Within these two general defi nitions for the quality of care, lies the framework for constructing the more specific definitions necessary for individual health care services, disciplines, or organizations. The 10M identified 18 dimensions that could be involved in a definition of quality and explicitly incorporated eight of the e dimension s (Table 2).9 The task for the oncology professionals now is to asses these, and potentially other, dimen ions of quality specific to the cancer patient and to build consensus around a measurable definition that can be u ed for improving cancer patient care. Beyond the definition of quality, the answ r to the question of whether quality ca n be measured requires the
Marder
1755
assessment of the measurement tools themselves. The Donabedian framework of structure, process, and outcome is the basis for the evolving approaches to the measurement of quality.? Traditionally, the JCAHO and others involved in evaluating health care have focused on structure and process using the measurement tool of standards compliance determined by inspection.4 However, the JCAHO has both observed and stimulated the current evolution in the assessment approaches toward quality of care. Over the past 10 years, this as essment ha moved from implicit reviews, suc.h as morbidity and mortality conferences, to time-limited studies or retrospective audits, to statistical profiling or continuous monitoring of key indicators for use on comparative basis, either as trends in internal rates or as external comparisons with peer groups.12 The current attractiveness of statistical profiling is that it appears to provide a more objective means of collecting data for use in improving care and that comparative data will reveal areas for improvement not otherwise appreciated. However, if the goal of the measurement of quality is to improve care, the ultimate utility of statistical profiles lies in demonstrating that these measures have at least the capacity to identify opportunities for improvement in care and that ultimately these opportunities can indeed lead to improvement. Demonstrating the relationship between proposed outcome measures of quality and improvements in health care, however, is an extremely complex and difficult task. First, it is affected by an attribute of the measurement tool: that it accurately and reliably can identify areas where the opportunities for improvement lie. Unfortunately, the accuracy and reliability of the data currently viewed as possible measures of quality are still often unproven. Second, the relationship between outcome measure and improvement is affected by an attribute of the users of this information: that given these data they can indeed find these opportunities and make improvement. MeasureTABLE 2.
Dimensions in Definition of Quality
Scale of quality Nature of entity being evaluated Goal-oriented Aspects of outcomes specified Risk verslls benefit trade-om Type of recipient ide ntified Role and responsibility of recipient asserted onstrained by technology and tate of scientific kno\\ ledge ontinuity, management, coordination Standards of care Technical competency of provider Interpersonal skills of provider Acceptability Acce ibility Statements about use onstraincd by resources onstrained by consumer and patient circumstance Documentation required Data from Lohr.9
1756
CANCER
March 15 Supplement 1991
ment alone will not improve care. Rather, it is the use of these measurements in conjunction with a combination of traditional tools for stimulating improvement, standards compliance, and use of practice guidelines, which will guide health care professionals in the quality improvement process. Thus, proving the value of a given performance measure for use in quality improvement is clearly a long-range project. The importance of outcome measurement to assessing quality does not mean that measuring only outcomes will measure quality. The movement toward focusing on the measurement of outcomes, although important, must be tempered by a number of factors. First, the assessment of outcomes, although a key aspect in an operational definition of quality, is not the sole means for assessment of quality.'3.'4 Outcomes worthy of measurement must be clearly linked to processes and structures that can undergo improvement. The measurement of outcomes for which those linkages cannot be established will not only be frustrating but may lead to frank misinterpretation of quality of care being rendered. Second, measurement of processes that are clearly linked to outcomes may be advantageous if the processes occur in a more timely fashion or are more amenable to measurement than the outcomes themselves. 13. 14 Third, because of the multidimensional aspects of quality, a variety of measurement and assessment approaches may be needed to fully encompass the definition. Thus, measures of both processes and outcomes are important to measuring performarice. Can quality of the cancer care be measured today? We clearly know that our measurement tools are imperfect and are still developing. 1s- 17 We also know that the degree to which health care professionals understand the use of these measures is evolving as well. It may well be that the ability to precisely "measure" quality may be an unobtainable goal in its absolute, definitive sense. However, through the development of processes for analyzing and using data that relate to quality, the goal of improving patient care can be obtained. This leads to the final question: what needs to be done today to improve the measurement of quality of care for the cancer patient? Two activities, the improvement of the available measurement tools and the improvement of our understanding of the use of these tools, must be pursued vigorously. The first step is to improve the available measures of process and outcome relevant to cancer care. The indicator development process in oncology of the JCAHO is a major effort to assist in this area. In developing these indicators, the JCAHO has improved its process for developing and testing performance measures for health care organizations. The steps to this development process are as follows: (I) selection of a key area of patient care for indicator development; (2) patient-focused analysis of the key processes involved in care to define the scope of indicator development; (3) convening ofa multidisciplinary
Vol. 67
expert task force to develop complete indicators, including the indicator statement, definitions of terms, rationale, collection approach, and description of underlying factors; (4) initial testing of the indicators for feasibility , collectibility, and face validity in a limited number of test sites; (5) refinement of the indicators by the task force based on the initial test site findings; (6) large-scale testing of the indicators for reliability and usefulness in improving patient care; (7) task force review oftbe findings for further indicator refinement; and (8) implementation of the final indicator set in accredited hospitals for the purpose of developing a national data base to be used by the health care organizations and by the JCAHO for feedback on performance and improvement in quality of care. The oncology care indicators (Table 3) have completed the initial development phase and are currently in the first phase oftesting" s The scope of these indicators deal with breast, colon, and lung cancer and focus on the diagnosis and treatment of the primary tumor with limited aspects of follow-up. The JCAHO clearly recognizes that there are other aspects to cancer care, including screening, prevention, and continuity of care and long-term followup, which are important in the complete definition of quality of care for the cancer patient. The JCAHO views the current set of oncology indicators as a starting point toward improving the measurement of processes and outcomes related to cancer care upon which the JCAHO and others can build. Clearly, the JCAHO is only one of a number of organizations and individual research teams involved in the effort to improve measurement of cancer care. However, a description of those efforts is beyond the scope of this article. What is critical is that all of these efforts deriving from their various perspectives share what they have learned to advance the developing science of performance measurement for health care. Beyond the development of performance measures, the second, and perhaps more important, activity necessary today to make the measurement of quality of care relevant is to enhance the capacity of the health care field to understand and use these measures. Health care professionals are traditionally taught to focus on and treat one patient at a time. Some of the epidemiologic aspects of the statistical approach toward measuring quality are less familiar and sometimes uncomfortable for many practitioners. Because many of the approaches for measuring process and outcome focus on multifactorial aspects of quality, multidisciplinary groups need to be convened on the individual organizational level to assess the data and design solutions that take into account the many factors that could be involved. New standards and guidelines on the use of this information are an important component of the Agenda for Change of J AHO. Oncology has some advantages over some of the other disciplines in the area of data assessment and use. First,
No.6
MEASURING QUALITY OF CARE TABLE 3.
Marder
l757
Oncology Indicator Summary List
I (G-D I): Surgica l pathology consultation reports containing histologic type, tum or size, status of margins, appropriate lymph node exami nati on, assessmen t of invasio n or extension as indicated, a nd AJCC/pTNM classification for patients with resection for primary cancer of the lun g, co lon/rectum or female breast 2 (G-D3): Patients undergoing treatment for primary cancer of the lun g, colo n/rectum, or female breast withou t AJCC pathologic stage of tumor designated by treating physician 3 (G-D4): Absence of a written pathology report in the medical record of the treating institution, documenting the pa thologic diagnosis of patients receiving initial treatment for primary lung, colorectal , or fema le breast cancer 4 (G-T I): Patients hospitalized within 6 months of initial therapy for primary cancer of the lung, colon/rectum , or female breast, exclud ing those patients hospitalized for receipt of chemotherapy or for eva luation or treatmen t of metastatic or recurrent disease 5 (G-T2): Systemic in itial assessment of pain for all patients hospi tali zed due to metastatic lung, colorectal, or female breast ca ncer with pain 6 (G-FI): Survival of patients with primary cancer of the lung, colon/rectum , or female breast by stage and histologic type 7 (B-D I): Absence of estrogen receptor diagnostic analysis in female patients with invasive primary breast cancer undergoing initial biopsy or reseciton for a tumor larger than I cm in greatest dimension 8 (8-02): Absence of documented AJCC clinical staging in medical record prior to first course of therapy for female patients with primary breast cancer 9 (B-T I): Female patients with AJCC pathologic Stage IIl yri,ph node-positive primary invasive breast cancer not treated with systemic adj uvant therapy 10 (B-T2): Treatment of female patients with primary invasive AJCC clinical Stage I or II breast cancer by excisional biopsy, segmen tal mastectomy, or quadrantectomy withou t radiation therapy
II (B-F I): Referral to support or rehabilitation groups or provision of psychosocial support for female patients with primary breast cancer 12 (L-D I): Patients with serious complications resulting from mediastin oscopy or transthoracic needle biopsy for possible or confirmed diagnosis of primary lung cancer 13 (L-D2): Patients with non-small cell primary lung cancer undergoing thoracotomy with incomplete surgical resection of tumor 14 (L-TI): Surgical complications of pulmonary resection for patients with primary lung cancer, including empyema, bronchopleural fistula , postoperative atelectasis requiring bronchoscopy, reoperati on for postoperative bleeding, persistent requirement for mechanical ventilation greater than 5 days postoperation, readmission within 7 days of discharge. or death 15 (C/R-D I): Operative report on patients with resection of primary colorectal cancer lacking documentation of location of primary tumor wi thin the large intestine. local extent of disease. extent of resection and assessment for residual disease in abdomen, including li ver and additional colonic primaries. by vision , palpation, and/or biopsy 16 (C/R-D2): Preoperative evaluation by attending physician for patients with primary colorectal cancer lacking examination of the entire colon, liver function tests, chest radiograph. and CEA levels 17 (C/R-T I): Documentation of referral to. or consultation by, a radiation oncologist for patients with primary rectal cancer Stage II or greater 18 (C/R-T2): Patients with primary rectal cancer undergoing abdominoperineal resections with 8 cm or more of free distaJ surgical margin present on specimen as documented in surgical pathology gross description 19 (C/R-T3): Patients receiving enterostom y care and management instruments fo llowing resection for primary colorectal cancer wi th enterostomy present on discharge
the broad involvement of the oncology practitioners in randomized clinical trials and protocols of care has already provided the fi eld a statistical perspective. 19 Second, because oncology care already is often delivered from a team perspective and multidisciplina ry discussion of patie nts through tumor boards is often the norm, the structures and processes for multidisciplinary problem-solving are already in place.2o A major goal of the efforts of the JCAHO in the development of indicators is to assist hospitals in their understa nd ing of how the J AHO and ho pitals can best use this information . A number of potential uses have been identified thus far. To adequa tely use performa nce data , at least four strategies must be pursued as part of thi s process: (I) integration into existing structures, (2) developm ent of better methods for problem-solving, (3) affecting the underl yi ng culture, and (4) co mmitment of resources. The integration of m easures of quality into the ex isting structures and processes within the health care organiza tions is key to accepta nce of these measures. It is not necessary to redesign the entire hea lth care system to acco mmodate a new approach toward mea uring or assessing qua lity. To the exten t that the e new approaches can
be integrated into existing and familiar structures and processes, there wiU be an enha nced acceptance of these approaches. Multidisciplinary tumor boards are a key aspect of assessing quality of individual cancer patients. They also offer the opportunity for considering quality of care statistics that will be less individualized but would a lso yield opportunities for improvement.2° In addition , traditional quality assurance committees can be educated to incorporate the use of these new tools into their processes. These committees may a lso be encouraged to expand thei r membership to include broader representation of disciplines and be less departmentally focused. The developm ent of methods for health care professionals to problem-solve is a challenging task. The industrial quality co ntrol science has developed a number of tool s useful in problem-solving processes.8 Such tools as pareto diagram , system analysis methods, and statistical run charts ca n provide more efficient means of assessment of data and can focus on problem-solving. Many of these tools may be translatable to health care. and several orga ni zations, including J AHO, are actively involved in this process. The most critica l task ahead is the shift of the underlying health care culture from the mind et of quality assurance
1758
CANCER
March J5 Supplement 1991
to quality improvement. 2 1 Quality assurance implies a tremendous burden to the health care community. From a medicolegal standpoint, it implies we have the ability to assure something we know is multifactorial and complex. Quality improvement is less of a burden in that it takes our natural desires to become better and places it in a organized process leading to continuous improvement. Part of the underlying philosophy of continuous improvement is a diminished focus on finding the " bad apple" and an increased focus on the systemic causes for problems that can be treated with systemic solutions. 2 l ,22 The key to the effective use of all of the performance measures currently being constructed is this attitude of underlying culture. If this is not changed from a variety of standpoints, both external and internal , these data can be misused and viewed as strictly punitive. Finally, an integral part of the mindset for continuous improvement is reflected in the commitment of resources for this activity. One of the true measures for the commitment to quality is commitment of the resources to monitoring and improvement. Until this underlying culture is affected so that quality is not viewed as the sole responsibility of the quality assurance coordinator, but the responsibility of all, with appropriate resources devoted to enactment of this shared responsibility, the rest of the activities will be mere slogans. All of these issues are in need of creative minds and committed professionals to advance our ability to assess quality and improve care. The American Cancer Society has made a commitment to assist the JCAHO and oncology professionals understand how to use indicators to improve care through a 2-year cancer control grant. This combined effort will place oncology in the lead of health care professionals in the use of performance measure information. In conclusion, these are exciting and challenging times for the health care field in general, and oncology care in particular, as we begin to understand the measurement of quality. The JCAHO believes it is engaged in a decadelong process with the ultimate goal being the continuous improvement of the quality of cancer care. The JCA HO is committed to working with the oncology community to develop reliable and useful measures of quality. This process will be dependent both on time and on changes in organizational culture, and the value of this effort will
Vol. 67
be determined by the interaction between the process of measurement and the use of those measures by dedicated health care professionals. REFERENCES I. Reiman AS. Assessment and accountability: The third revolution in medical care. N Eng/ J M ed 1988; 319:21 - 23. 2. Lohr KN , Yordy KD, Thier SO. Current issues in quality of care. Ilea/til Affairs 1988; 5- 18. 3. Hackabarth GM , Krakauer H, Roper WL, Winkenwerder W. Effectiveness in health care: An initiative to evaluate and improve medical practice. N Eng/ J M ed 1988; 319: 1197-1202. 4. O' leary DS. The Joint Commission looks to the future. JAMA 1987; 258:951-952. 5. Minutes of the Board of Commissioners, Joint Commission on Accreditation of Healthcare Organizations, Chicago, August 27, 1988. 6. Marder RJ . Joint Commission plans for clinical indicator development for oncology. Cancer 1988; 64:310-313. 7. Donabedian A. The quality of care: How can it be assessed? JAMA 1988; 260: 1743- 1748. 8. Laffel G , Blumenthal D. The case for using industrial quality management seience in health care organizations. JAMA 1989; 262:28692873. 9. Ilealth, healthcare and quality of care. In: Lohr K, ed. Medicare: A Strategy for Quality Assurance, vol. I. Washington, DC: National Academ y Press, 1990. 10. The basics of quality improvement. In: Scholtes PR, ed. The Team Handbook. Madison, WI: Joiner Associates, Inc., 1989. II . Joint Commission on Accreditation of Health care Organizations. PerspeL'tives 1989; 9:7. 12. Roberts JS, Schyve PM , Prevost J, Ente B, Carr M. The agenda for change: Future directions of the Joint Commission on Accreditation of Healthcare Organizations. In: Quality Assurance in Hospitals. Rockville, MD: Aspen, 1990; 44- 62. 13. Lohr K. Outcome measurement: Concepts and questions. inqllity 1988; 25:37-50. 14. Joint om mission on Accreditation of Healthcare Organizations. haracteristics of clinical indicators. QRB 1989; 15:33- 42 . 15. Schroeder SA . Outcome assessment 70 years later: Are we ready? N EnglJ M ed 1987; 316: 160- 161. 16. Greenfield S, Aronow HU. Elashoff RM , Watanabe D. Flaws in mortality data: The hazards of ignoring comorbid disease. JAMA 1988; 260:2253-2255. 17. Jencks F, Williams DK, Kay TL. Assessing hospital-associated deaths from discharge data: The role of length of stay and comorbiditics. JAMA 1988; 260:2240-2246. 18. Joint om mission on Accreditation of Hcalthcare Organizations. Perspectives 1989; 9:6. 19. Ford LG. Therapy: State-of-the-art assessment of quality. Cancer 1989; 64:2 19-22 2. 20. Fleming 10. Multidisciplinary treatment planning. Cancer 1989; 64:279-281 . 21. Roberts JS, Schyve PM . From QA to QI: Issues of evolution, revolution and accreditation. The Quality Letter for Ilealthcare Leaders. 1990; 2:9- 12. 22. Berwick DM . Continuous improvement as an ideal in health care. N Eng/ J Med 1989; 320:5 3- 56.
J.
Marder, MD
In recent years, the efforts to better define quality of patient care have focused on
attempts to improve on the measurement of quality. These efforts raise three questions: (1) Why attempt to measure quality? (2) What is the best way to measure quality of care of the cancer patient? and (3) What must be done to achieve this? Three main reasons for measuring quality of patient care are to describe the current state, plan strategies for improvement, and implement and monitor improvements. To measure quality, both the definition of quality and the tools available for measurement must be addressed. The difficulty in developing a measurable definition of quality is achieving agreement on the measurable components of quality. The tools to measure quality have evolved to focus on monitoring of key indicators for comparative use. The utility of indicators lies in demonstrating that they have the capacity to identify opportunities for improving care. The Joint Commission is improving measurement tools through the development and testing of oncology indicators for reliability and the capacity to identify opportunities for improving care. The development and teaching of new quality improvement methods to health care professionals also is necessary. Cancer 67:1753-1758,1991.
T
HE MEASUREMENT of quality in health care is a topic
that has received tremendous attention over the past few years.' -4 The motives for this vary from the desires of health care practitioners and organizations to improve care to the economic concerns of third party payers. In discussing the measurement of quality of care for the cancer patients, three questions must be addressed: (I) why attempt to measure quality of care in cancer care; (2) can quality be measured for cancer care; and (3) what needs to be done to improve the measurement of quality of cancer care? This report looks at these questions from the perspective of the health care field in general and of the Joint Commission on Accreditation of Healthcare Organizations (J AHO) in particular. What is the basis for the desire to measure quality of care for the cancer patient? There are at least three main reasons: (I) to describe the current state of cancer care,
Presented at the American ancer Society National Conference on Cancer and the hanging Heaithcare System, San Francisco, alifornia, May 3- 5, 1990. From the Division of Research and Standards, Joint om mission on Accreditation of Healthcare Organizations, hicago, Illinois. Address for reprint ; Robert J. Marder, MD, Division of Research and Standards, Joint Commission on Accreditation of Healthcare Organizations, 875 North Michigan Avenue, Chicago, IL 60611. Accepted for publication September 14, 1990.
(2) to assist in planning strategies for improvement of cancer care, and (3) to implement and monitor improvements in cancer care. These reasons can be viewed as sequential in the process of improving care. It is important to note that the motivations behind each of these reasons can be varied. One party may wish to describe the current state of cancer care to stimulate discussion; another party may wish to describe it to determine who are the inadequate providers and adjust reimbursement accordingly. Similarly, once the current state is described, the strategies for improvement could vary from encouragement to discipline. Finally, the desire to implement and monitor improvements can be viewed from similarly divergent perspectives. It is important to recognize that although all dedicated health care professionals wish to know more about the quality of care they are delivering, they must operate in an environment where there is no guarantee that the data derived in the pursuit of measuring quality will always be used in an acceptable and responsible manner. The mission of the JCAHO is to " enhance the quality of health care provided to the public by establishing contemporary standards, evaluating healthcare organizations, rendering accreditation decisions, and providing educational and consultative support to healthcare professionals. In providing leader hip to the healthcare field, the
1754
CANCER TABLE 1.
March 15 Supplement 1991
Vol. 67
Oncology Care Task Force Members
John W. Yarbro, MD, PhD (Chairman) Director of Hematology and Medical Oncology University of Missouri Hospital and Clinics Paul Carbon e, MD Director Wisconsin Clinical Cancer Center Robert En ck, MD Director, Riverside Regional Cancer Institute Ri verside Methodist Hospital L. Penfield Faber, MD Dea n of Surgery Rush Presbyterian- St. Luke Medical Center Irvin Fleming, MD Chief, Surgical Services St. Jude's Children's Hospital Leslie Ford, MD Chief Community Oncology and Rehabilitation Branch National Cancer Institute Margaret Hanson Frogge, RN, MS Vice President, Clinical Services Riverside Medical Center Gerald Hanks, MD, FACR hai rman , Department of Radiation Therapy Fox Chase Cancer Center Am erican Cancer Society
Joint Commission seeks to a clearer understancling of the views and interests of various publics who have major interests in healthcare."s Over the past few years, the JCAHO has been engaged in a strategic initiative, entitled " The Agenda for Change," to improve its ability to perform those functions. A major component of this initiative is the development of indicators, which are performance measures for use by health care practitioners and organizations and by the J AHO. An indicator is defined as a quantitative measure that can be used as a guide to morutor and evaluate the quality of important patient care and support service activities. 4 The reason for undertaking the development of indicators is that, through its role in evaluating health care organizations and rendering accreditation decisions, the J AHO has become increasingly aware of the need for reliable and responsible measurement tools as an integral part of that process. We have also come to understand that it is the use of these measurements that will determine their value. In November 1988 the J AHO convened a national multidisciplinary expert Task Force (Table I) to develop a set of indicators for oncology care. 6 Through this effort we can assist in describing the current state of oncology care, planning strategies for improvement in cancer care, and monitoring those improvements. By the involvement by the J AHO of the oncology community in the development, testing, and use of these indicators, we hope to create performance measures that can be used responsibly to improve patient care. The remainder of this report assumes that this desire for improvement, both on the part of health care professionals and the JCAHO, is the underlying basis for the desire to measure quality. Despite all the demands to measure quality, the second
Kay Horsch Chairman of the Board American Cancer Society Robert V. P. Hutter, MD Chairman, Department of Pathology St. Barnabas Medical Center Lisa Lattal, MHA Ambulatory Services Manager Johns Hopkins Oncology Center Dolores Krull Michels, CTR Manager, Tumor Registry Alleghen y General Hospital L. Jerem y Miranksy, PhD Administrator, Hospital Review Systems Memorial Sloan-Kettering Cancer enter Marvin M. Romsdahl , MD, PhD Professor of Surgery, University of Texas M.D. Anderson Cancer Center Raymond Weiss, MD Chief, Medical Oncology Walter Reed Army Medical Center David Winchester, MD, FA S Director, Cancer Department American Cancer Society
question still remains: Can quality be measured? There are two aspects of quality measurement that must be addressed in answering this question: (I) the definition of quality and (2) the tools available for measurement. Clarity on the principles for constructing a definition of quality for health care has grown out the work of Donabedian,7 a leader in modern medical quality assurance and from the industrial quality control arena. The key principle is simple: to measure quality, quality must be defined in a measurable way.2,7.8 However, this requires a definition of quality that is more than a slogan, such as "Quality is Job I" or "Quality is patients first." One of the difficulties in developing a measurable definition of quality is achieving an agreement upon the measurable components that comprise quality.2,7 In the recent Institute of Medicine (lOM) report to Congress on quality assurance for Medicare,9 the 10M Committee noted that they reviewed more than 100 definitions of quality in the medical literature. The one clear conclusion was that quality is multidimensional and can be viewed from the mUltiple perspective of the organization, of the provider, of the patient, and of society. This is clearly reflected when one begins to analyze potential measures of quality for use in improving care. The Ishikawa or "fishbone" diagram is one tool that has been used to perform this analysis. lo This type of diagram illustrates the many factors that may have an impact on a given outcome (Fig. I). Understanding the relative impact of the patient, practitioner, and organizational and external factors involved in outcomes for oncology patients is critical to defining and assessing quality. Although currently there is no single "official" general definition for quality in health care, a national consensus
M EASURING QUALITY OF CARE
No.6
Social
Policy----.,;'
FIG. I. Outcome: a product of multiple causes.
is building toward one. In 1989 the JCAHO proposed that quality patient care be defined as " the degree to which patient services increase the probability of desired patient outcomes and reduce the probability of undesired outcomes given the current state of knowledge." I I The key words " degree," " probability," and "outcomes" reflect the desire to use this definition in a measurable way, and the phrase " patient services" reflects the linkage between the processes and outcomes comprising ca re and the need to evaluate both. The phrase "current state of knowledge" reflects that the pursuit of quality is not a static endeavor and also cannot be viewed through absolutes; it must take into account the constraints on and responsibilities of health care professionals. The 10M has chosen a similar definition: " Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.,,9 The major addition to the J AHO definition is the recognition that the hea lth of the population is a measurable aspect of quality beyond the health of individuals within that population . Within these two general defi nitions for the quality of care, lies the framework for constructing the more specific definitions necessary for individual health care services, disciplines, or organizations. The 10M identified 18 dimensions that could be involved in a definition of quality and explicitly incorporated eight of the e dimension s (Table 2).9 The task for the oncology professionals now is to asses these, and potentially other, dimen ions of quality specific to the cancer patient and to build consensus around a measurable definition that can be u ed for improving cancer patient care. Beyond the definition of quality, the answ r to the question of whether quality ca n be measured requires the
Marder
1755
assessment of the measurement tools themselves. The Donabedian framework of structure, process, and outcome is the basis for the evolving approaches to the measurement of quality.? Traditionally, the JCAHO and others involved in evaluating health care have focused on structure and process using the measurement tool of standards compliance determined by inspection.4 However, the JCAHO has both observed and stimulated the current evolution in the assessment approaches toward quality of care. Over the past 10 years, this as essment ha moved from implicit reviews, suc.h as morbidity and mortality conferences, to time-limited studies or retrospective audits, to statistical profiling or continuous monitoring of key indicators for use on comparative basis, either as trends in internal rates or as external comparisons with peer groups.12 The current attractiveness of statistical profiling is that it appears to provide a more objective means of collecting data for use in improving care and that comparative data will reveal areas for improvement not otherwise appreciated. However, if the goal of the measurement of quality is to improve care, the ultimate utility of statistical profiles lies in demonstrating that these measures have at least the capacity to identify opportunities for improvement in care and that ultimately these opportunities can indeed lead to improvement. Demonstrating the relationship between proposed outcome measures of quality and improvements in health care, however, is an extremely complex and difficult task. First, it is affected by an attribute of the measurement tool: that it accurately and reliably can identify areas where the opportunities for improvement lie. Unfortunately, the accuracy and reliability of the data currently viewed as possible measures of quality are still often unproven. Second, the relationship between outcome measure and improvement is affected by an attribute of the users of this information: that given these data they can indeed find these opportunities and make improvement. MeasureTABLE 2.
Dimensions in Definition of Quality
Scale of quality Nature of entity being evaluated Goal-oriented Aspects of outcomes specified Risk verslls benefit trade-om Type of recipient ide ntified Role and responsibility of recipient asserted onstrained by technology and tate of scientific kno\\ ledge ontinuity, management, coordination Standards of care Technical competency of provider Interpersonal skills of provider Acceptability Acce ibility Statements about use onstraincd by resources onstrained by consumer and patient circumstance Documentation required Data from Lohr.9
1756
CANCER
March 15 Supplement 1991
ment alone will not improve care. Rather, it is the use of these measurements in conjunction with a combination of traditional tools for stimulating improvement, standards compliance, and use of practice guidelines, which will guide health care professionals in the quality improvement process. Thus, proving the value of a given performance measure for use in quality improvement is clearly a long-range project. The importance of outcome measurement to assessing quality does not mean that measuring only outcomes will measure quality. The movement toward focusing on the measurement of outcomes, although important, must be tempered by a number of factors. First, the assessment of outcomes, although a key aspect in an operational definition of quality, is not the sole means for assessment of quality.'3.'4 Outcomes worthy of measurement must be clearly linked to processes and structures that can undergo improvement. The measurement of outcomes for which those linkages cannot be established will not only be frustrating but may lead to frank misinterpretation of quality of care being rendered. Second, measurement of processes that are clearly linked to outcomes may be advantageous if the processes occur in a more timely fashion or are more amenable to measurement than the outcomes themselves. 13. 14 Third, because of the multidimensional aspects of quality, a variety of measurement and assessment approaches may be needed to fully encompass the definition. Thus, measures of both processes and outcomes are important to measuring performarice. Can quality of the cancer care be measured today? We clearly know that our measurement tools are imperfect and are still developing. 1s- 17 We also know that the degree to which health care professionals understand the use of these measures is evolving as well. It may well be that the ability to precisely "measure" quality may be an unobtainable goal in its absolute, definitive sense. However, through the development of processes for analyzing and using data that relate to quality, the goal of improving patient care can be obtained. This leads to the final question: what needs to be done today to improve the measurement of quality of care for the cancer patient? Two activities, the improvement of the available measurement tools and the improvement of our understanding of the use of these tools, must be pursued vigorously. The first step is to improve the available measures of process and outcome relevant to cancer care. The indicator development process in oncology of the JCAHO is a major effort to assist in this area. In developing these indicators, the JCAHO has improved its process for developing and testing performance measures for health care organizations. The steps to this development process are as follows: (I) selection of a key area of patient care for indicator development; (2) patient-focused analysis of the key processes involved in care to define the scope of indicator development; (3) convening ofa multidisciplinary
Vol. 67
expert task force to develop complete indicators, including the indicator statement, definitions of terms, rationale, collection approach, and description of underlying factors; (4) initial testing of the indicators for feasibility , collectibility, and face validity in a limited number of test sites; (5) refinement of the indicators by the task force based on the initial test site findings; (6) large-scale testing of the indicators for reliability and usefulness in improving patient care; (7) task force review oftbe findings for further indicator refinement; and (8) implementation of the final indicator set in accredited hospitals for the purpose of developing a national data base to be used by the health care organizations and by the JCAHO for feedback on performance and improvement in quality of care. The oncology care indicators (Table 3) have completed the initial development phase and are currently in the first phase oftesting" s The scope of these indicators deal with breast, colon, and lung cancer and focus on the diagnosis and treatment of the primary tumor with limited aspects of follow-up. The JCAHO clearly recognizes that there are other aspects to cancer care, including screening, prevention, and continuity of care and long-term followup, which are important in the complete definition of quality of care for the cancer patient. The JCAHO views the current set of oncology indicators as a starting point toward improving the measurement of processes and outcomes related to cancer care upon which the JCAHO and others can build. Clearly, the JCAHO is only one of a number of organizations and individual research teams involved in the effort to improve measurement of cancer care. However, a description of those efforts is beyond the scope of this article. What is critical is that all of these efforts deriving from their various perspectives share what they have learned to advance the developing science of performance measurement for health care. Beyond the development of performance measures, the second, and perhaps more important, activity necessary today to make the measurement of quality of care relevant is to enhance the capacity of the health care field to understand and use these measures. Health care professionals are traditionally taught to focus on and treat one patient at a time. Some of the epidemiologic aspects of the statistical approach toward measuring quality are less familiar and sometimes uncomfortable for many practitioners. Because many of the approaches for measuring process and outcome focus on multifactorial aspects of quality, multidisciplinary groups need to be convened on the individual organizational level to assess the data and design solutions that take into account the many factors that could be involved. New standards and guidelines on the use of this information are an important component of the Agenda for Change of J AHO. Oncology has some advantages over some of the other disciplines in the area of data assessment and use. First,
No.6
MEASURING QUALITY OF CARE TABLE 3.
Marder
l757
Oncology Indicator Summary List
I (G-D I): Surgica l pathology consultation reports containing histologic type, tum or size, status of margins, appropriate lymph node exami nati on, assessmen t of invasio n or extension as indicated, a nd AJCC/pTNM classification for patients with resection for primary cancer of the lun g, co lon/rectum or female breast 2 (G-D3): Patients undergoing treatment for primary cancer of the lun g, colo n/rectum, or female breast withou t AJCC pathologic stage of tumor designated by treating physician 3 (G-D4): Absence of a written pathology report in the medical record of the treating institution, documenting the pa thologic diagnosis of patients receiving initial treatment for primary lung, colorectal , or fema le breast cancer 4 (G-T I): Patients hospitalized within 6 months of initial therapy for primary cancer of the lung, colon/rectum , or female breast, exclud ing those patients hospitalized for receipt of chemotherapy or for eva luation or treatmen t of metastatic or recurrent disease 5 (G-T2): Systemic in itial assessment of pain for all patients hospi tali zed due to metastatic lung, colorectal, or female breast ca ncer with pain 6 (G-FI): Survival of patients with primary cancer of the lung, colon/rectum , or female breast by stage and histologic type 7 (B-D I): Absence of estrogen receptor diagnostic analysis in female patients with invasive primary breast cancer undergoing initial biopsy or reseciton for a tumor larger than I cm in greatest dimension 8 (8-02): Absence of documented AJCC clinical staging in medical record prior to first course of therapy for female patients with primary breast cancer 9 (B-T I): Female patients with AJCC pathologic Stage IIl yri,ph node-positive primary invasive breast cancer not treated with systemic adj uvant therapy 10 (B-T2): Treatment of female patients with primary invasive AJCC clinical Stage I or II breast cancer by excisional biopsy, segmen tal mastectomy, or quadrantectomy withou t radiation therapy
II (B-F I): Referral to support or rehabilitation groups or provision of psychosocial support for female patients with primary breast cancer 12 (L-D I): Patients with serious complications resulting from mediastin oscopy or transthoracic needle biopsy for possible or confirmed diagnosis of primary lung cancer 13 (L-D2): Patients with non-small cell primary lung cancer undergoing thoracotomy with incomplete surgical resection of tumor 14 (L-TI): Surgical complications of pulmonary resection for patients with primary lung cancer, including empyema, bronchopleural fistula , postoperative atelectasis requiring bronchoscopy, reoperati on for postoperative bleeding, persistent requirement for mechanical ventilation greater than 5 days postoperation, readmission within 7 days of discharge. or death 15 (C/R-D I): Operative report on patients with resection of primary colorectal cancer lacking documentation of location of primary tumor wi thin the large intestine. local extent of disease. extent of resection and assessment for residual disease in abdomen, including li ver and additional colonic primaries. by vision , palpation, and/or biopsy 16 (C/R-D2): Preoperative evaluation by attending physician for patients with primary colorectal cancer lacking examination of the entire colon, liver function tests, chest radiograph. and CEA levels 17 (C/R-T I): Documentation of referral to. or consultation by, a radiation oncologist for patients with primary rectal cancer Stage II or greater 18 (C/R-T2): Patients with primary rectal cancer undergoing abdominoperineal resections with 8 cm or more of free distaJ surgical margin present on specimen as documented in surgical pathology gross description 19 (C/R-T3): Patients receiving enterostom y care and management instruments fo llowing resection for primary colorectal cancer wi th enterostomy present on discharge
the broad involvement of the oncology practitioners in randomized clinical trials and protocols of care has already provided the fi eld a statistical perspective. 19 Second, because oncology care already is often delivered from a team perspective and multidisciplina ry discussion of patie nts through tumor boards is often the norm, the structures and processes for multidisciplinary problem-solving are already in place.2o A major goal of the efforts of the JCAHO in the development of indicators is to assist hospitals in their understa nd ing of how the J AHO and ho pitals can best use this information . A number of potential uses have been identified thus far. To adequa tely use performa nce data , at least four strategies must be pursued as part of thi s process: (I) integration into existing structures, (2) developm ent of better methods for problem-solving, (3) affecting the underl yi ng culture, and (4) co mmitment of resources. The integration of m easures of quality into the ex isting structures and processes within the health care organiza tions is key to accepta nce of these measures. It is not necessary to redesign the entire hea lth care system to acco mmodate a new approach toward mea uring or assessing qua lity. To the exten t that the e new approaches can
be integrated into existing and familiar structures and processes, there wiU be an enha nced acceptance of these approaches. Multidisciplinary tumor boards are a key aspect of assessing quality of individual cancer patients. They also offer the opportunity for considering quality of care statistics that will be less individualized but would a lso yield opportunities for improvement.2° In addition , traditional quality assurance committees can be educated to incorporate the use of these new tools into their processes. These committees may a lso be encouraged to expand thei r membership to include broader representation of disciplines and be less departmentally focused. The developm ent of methods for health care professionals to problem-solve is a challenging task. The industrial quality co ntrol science has developed a number of tool s useful in problem-solving processes.8 Such tools as pareto diagram , system analysis methods, and statistical run charts ca n provide more efficient means of assessment of data and can focus on problem-solving. Many of these tools may be translatable to health care. and several orga ni zations, including J AHO, are actively involved in this process. The most critica l task ahead is the shift of the underlying health care culture from the mind et of quality assurance
1758
CANCER
March J5 Supplement 1991
to quality improvement. 2 1 Quality assurance implies a tremendous burden to the health care community. From a medicolegal standpoint, it implies we have the ability to assure something we know is multifactorial and complex. Quality improvement is less of a burden in that it takes our natural desires to become better and places it in a organized process leading to continuous improvement. Part of the underlying philosophy of continuous improvement is a diminished focus on finding the " bad apple" and an increased focus on the systemic causes for problems that can be treated with systemic solutions. 2 l ,22 The key to the effective use of all of the performance measures currently being constructed is this attitude of underlying culture. If this is not changed from a variety of standpoints, both external and internal , these data can be misused and viewed as strictly punitive. Finally, an integral part of the mindset for continuous improvement is reflected in the commitment of resources for this activity. One of the true measures for the commitment to quality is commitment of the resources to monitoring and improvement. Until this underlying culture is affected so that quality is not viewed as the sole responsibility of the quality assurance coordinator, but the responsibility of all, with appropriate resources devoted to enactment of this shared responsibility, the rest of the activities will be mere slogans. All of these issues are in need of creative minds and committed professionals to advance our ability to assess quality and improve care. The American Cancer Society has made a commitment to assist the JCAHO and oncology professionals understand how to use indicators to improve care through a 2-year cancer control grant. This combined effort will place oncology in the lead of health care professionals in the use of performance measure information. In conclusion, these are exciting and challenging times for the health care field in general, and oncology care in particular, as we begin to understand the measurement of quality. The JCAHO believes it is engaged in a decadelong process with the ultimate goal being the continuous improvement of the quality of cancer care. The JCA HO is committed to working with the oncology community to develop reliable and useful measures of quality. This process will be dependent both on time and on changes in organizational culture, and the value of this effort will
Vol. 67
be determined by the interaction between the process of measurement and the use of those measures by dedicated health care professionals. REFERENCES I. Reiman AS. Assessment and accountability: The third revolution in medical care. N Eng/ J M ed 1988; 319:21 - 23. 2. Lohr KN , Yordy KD, Thier SO. Current issues in quality of care. Ilea/til Affairs 1988; 5- 18. 3. Hackabarth GM , Krakauer H, Roper WL, Winkenwerder W. Effectiveness in health care: An initiative to evaluate and improve medical practice. N Eng/ J M ed 1988; 319: 1197-1202. 4. O' leary DS. The Joint Commission looks to the future. JAMA 1987; 258:951-952. 5. Minutes of the Board of Commissioners, Joint Commission on Accreditation of Healthcare Organizations, Chicago, August 27, 1988. 6. Marder RJ . Joint Commission plans for clinical indicator development for oncology. Cancer 1988; 64:310-313. 7. Donabedian A. The quality of care: How can it be assessed? JAMA 1988; 260: 1743- 1748. 8. Laffel G , Blumenthal D. The case for using industrial quality management seience in health care organizations. JAMA 1989; 262:28692873. 9. Ilealth, healthcare and quality of care. In: Lohr K, ed. Medicare: A Strategy for Quality Assurance, vol. I. Washington, DC: National Academ y Press, 1990. 10. The basics of quality improvement. In: Scholtes PR, ed. The Team Handbook. Madison, WI: Joiner Associates, Inc., 1989. II . Joint Commission on Accreditation of Health care Organizations. PerspeL'tives 1989; 9:7. 12. Roberts JS, Schyve PM , Prevost J, Ente B, Carr M. The agenda for change: Future directions of the Joint Commission on Accreditation of Healthcare Organizations. In: Quality Assurance in Hospitals. Rockville, MD: Aspen, 1990; 44- 62. 13. Lohr K. Outcome measurement: Concepts and questions. inqllity 1988; 25:37-50. 14. Joint om mission on Accreditation of Healthcare Organizations. haracteristics of clinical indicators. QRB 1989; 15:33- 42 . 15. Schroeder SA . Outcome assessment 70 years later: Are we ready? N EnglJ M ed 1987; 316: 160- 161. 16. Greenfield S, Aronow HU. Elashoff RM , Watanabe D. Flaws in mortality data: The hazards of ignoring comorbid disease. JAMA 1988; 260:2253-2255. 17. Jencks F, Williams DK, Kay TL. Assessing hospital-associated deaths from discharge data: The role of length of stay and comorbiditics. JAMA 1988; 260:2240-2246. 18. Joint om mission on Accreditation of Hcalthcare Organizations. Perspectives 1989; 9:6. 19. Ford LG. Therapy: State-of-the-art assessment of quality. Cancer 1989; 64:2 19-22 2. 20. Fleming 10. Multidisciplinary treatment planning. Cancer 1989; 64:279-281 . 21. Roberts JS, Schyve PM . From QA to QI: Issues of evolution, revolution and accreditation. The Quality Letter for Ilealthcare Leaders. 1990; 2:9- 12. 22. Berwick DM . Continuous improvement as an ideal in health care. N Eng/ J Med 1989; 320:5 3- 56.
