Another Quality Assurance Program REBECCA R. SADIN, M.A.
A brief history of quality assurance efforts preceding the Professional Standards Review Organization law is presented. The goals of the legislation and its requirements and procedures are discussed. Particular emphasis is placed on the PSRO requirements for short-stay hospital review which is the area where PSRO efforts will initially concentrate. The possibilities of non-physician involvement in the review process are briefly discussed.
Another federal effort in quality as surance was realized in October 1972 with the passage of Section 249F of Public Law 92-603 establishing Professional Standards Review Or ganizations (PSROs). A PSRO is a nonprofit organization of local practicing doctors of medicine and osteopathy whose purpose is to review the care provided in institutions that are reimbursed by Medicare, Medicaid, Maternal and Child Health, and Crippled Childrens programs. The PSRO must determine if the care is necessary, of acceptable quality, and de livered in the most economical setting. HISTORY OF QUALITY ASSURANCE EFFORTS
The PSRO law is relatively new, but the concept of quality assurance is not. The Hippocratic oath and Florence Nightingale's pledge for nurses were both guidelines for quality assurance. The Flexner Report was an attempt to improve medical practice by raising the standards of medical education. 1 Health practitioner organizations have tried to assure
Mrs. Sadin is Allied Health Advisor, Division of Peer Review, Bureau of Quality Assurance, Health Services Administration, U.S. Department of Health, Educa tion, and Welfare, Rockville, MD 20852.
Volume 55 / Number 12, December 1975
quality by developing educational standards, adopting codes of ethics, and developing stan dards of practice. Federal legislation, such as Medicare, has focused on improving health care delivery by defining conditions of participation for facilities, qualification requirements for practitioners, and utilization review regulations. The Joint Commission on Accreditation of Hospitals, Regional Medical Programs, and others have looked at the effects upon the patient of the care being provided and have concentrated on the identification and correc tion of patient care deficits. Medical Care Foundations, originally established by state or county medical societies as management sys tems for delivery of health care services, have initiated peer review of »the care provided to certain groups of patients. RATIONALE FOR PSROs
The experience of the community-based Medical Care Foundations in peer review, as well as the inadequacies of past federal efforts to control costs and assure quality, provided the rationale for Congressional enactment of the PSRO legislation. The PSROs are based upon the concept that "health professionals are the most appropriate individuals to evaluate the quality of medical services and that effective peer review at the local level is the soundest 1315
Downloaded from https://academic.oup.com/ptj/article-abstract/55/12/1315/4567569 by University of Texas at Dallas - McDermott Library user on 16 February 2019
Professional Standards Review Organizations
POLICIES, PROCEDURES, AND GUIDELINES
The Department of Health, Education, and Welfare has issued a PSRO Program Manual which contains the initial informational and procedural materials needed for implementa tion of the provisions of the law. The manual was designed to accommodate new or supple mental material as further interpretations of the law and changes in procedures are made. New chapters are being added as they are reviewed by the National Professional Standards Review Council which is composed of eleven physicians of recognized standing and distinction in the appraisal of medical practice as mandated in the PSRO legislation. PSRO REVIEW REQUIREMENTS
Professional Standards Review Organizations are required to assume responsibility for the review of institutional care provided to benefi ciaries of Medicare, Medicaid, Maternal and Child Health, and Crippled Childrens programs. Initially PSROs will establish a system for review of care provided to inpatients in short-stay general hospitals and will develop a phased plan for the performance of review in long-term care facilities. If the PSRO demon strates capability in these areas, it may develop review systems for care provided in other institutions. Ambulatory care review, while not mandated in the legislation, is allowed if the PSRO obtains the approval of the Department of Health, Education, and Welfare. The PSRO requirements of the hospital review system are divided into three major components which interrelate and feed back into each other: 1. Concurrent review which includes admission certification (AC) and continued stay review (CSR) 2. Retrospective medical care evaluation studies (MCEs) 3. Analysis of hospital, practitioner, and pa tient profiles 1316
Concurrent Review
Admission Certification. Concurrent admis sion certification is designed to assure the medical necessity of admissions to a hospital level of care for purposes of Medicare and Medicaid payment. Concurrent review elimi nates retroactive denial of claims. Written criteria relating to the need for admission which have been developed by the PSRO are applied to each admission under Medicare, Medicaid, Maternal and Child Health, and Crippled Chil drens programs by a review coordinator (a non-physician). As a result of that screening process, admissions are either certified as being medically necessary or are referred for peer review. If the admission is certified as meeting the need for admission, the patient is assigned a length of stay generally based on the fiftieth percentile length of stay norms for patients with similar diagnoses in similar age groups. If the admission is questioned, the case is referred to a physician adviser designated by the hospital or the PSRO who, after discussion with the attending physician, either certifies or denies the need for admission (for Medicare or Medicaid payment purposes only). If he deter mines the admission is not justified, he will notify the attending physician of the certifica tion denials. The attending physician may contest the denial through a reconsideration and appeals process which has been established by the PSRO. Continued stay review. Continued stay re view assures that continued stay at a hospital level of care is necessary. The process is similar to admission certification. Twenty-four to forty-eight hours before the initial length-ofstay checkpoint, patients are screened by the review coordinator using PSRO-developed cri teria for continued stay. If the criteria are not met or if the review coordinator has a question that continued stay is not warranted, referral is made to the physician adviser, and the process continues through the same review and recon sideration cycle as in admission certification. Continued stay review may also include, on a sample basis, a review of the quality of care rendered to patients with certain problems while they are still in the hospital. This kind of concurrent quality assessment involves the use of criteria identified as critical elements of care that should (or should not) be provided to patients with particular diagnoses or problems. PHYSICAL THERAPY
Downloaded from https://academic.oup.com/ptj/article-abstract/55/12/1315/4567569 by University of Texas at Dallas - McDermott Library user on 16 February 2019
method for assuring the appropriate use of health care resources and facilities." 2 The PSRO Amendment to the 1972 Social Security Act was designed to extend this concept of quality assurance across the country, and 203 PSRO areas have been designated.
Hospital Activities are all acceptable methods for doing MCEs. Hospital, Practitioner, and Patient Profiles
Retrospective Medical Care Evaluation Studies
Retrospective medical care evaluation studies (MCE) are a mechanism designed to 1) assure that services are appropriate to the patient's needs and are of acceptable quality and 2) that health care organization and administration support the timely provision of quality care. In general, MCEs are individually designed, detailed, short-duration studies which focus on groups of patients with similar problems rather than on individual patients. Studies may be prompted by cases in which concurrent review, analysis of profiles, or subjective perception have indicated possible instances of substandard care or administrative inefficiency. Study topics may focus on outcomes of hospitalization for certain diagnoses or problems, the use of a given procedure, reasons for recurrent hospitali zation, or the operating characteristics of an institution. The data needed for MCEs will relate directly to the topic under study and can be collected retrospectively from the patient's chart or concurrently by the review coordina tor. Proposed MCE requirements include the recommendation that the PSRO shall be re sponsible for the performance of four to twelve MCEs per year per hospital depending on the number of discharges per hospital. The approaches to MCE studies may vary but should include the following steps: 1) deter mination of study topic and study objectives, 2) developments of study design, including selection, adoption, or adaptation of draft criteria and standards, 3) review of criteria and standards by a group representative of those professionals whose care is subject to review, 4) collection of data from appropriate sources and preparation of a display of the data, 5) analysis of the data and identification of problems, 6) development of corrective actions and referral of data and recommended corrected action to appropriate parties, 7) implementation of cor rective actions, and 8) evaluation of corrective actions, such as restudy at a specified time. The patient care audit approaches taught by the Joint Commission on Accreditation of Hospitals, the American Hospital Association, the California Medical and Hospital Associa tions, and the Commission on Professional Volume 55 / Number 12, December 1975
The generation and analysis of hospital, practitioner, and patient profiles is the third component of the hospital review system. Profiles are an aggregation of data which reflect episodes of care delivered in a specific institu tion, or by a particular practitioner, or to a given patient over time. The purpose of profile analysis is to monitor the effectiveness of the various components of the review system to indicate where further efforts are needed. Profiles will also assist in the overall evaluation of the PSRO program. NORMS, CRITERIA, AND STANDARDS
In each of its review activities, the PSRO uses norms, criteria, and standards to identify possible instances of misutilization of health care services or delivery of a substandard quality of care. The PSRO is responsible for the development and ongoing modification of the criteria and standards and the selection of norms to be used in this area. Since these terms have different meanings to different people, the terms will be defined as they will be used by the PSROs. Norms are numerical statistical measures of usual observed performance. For example, in certain regions of the country, 80 percent of all acute appendectomies in one year were subse quently found to be justified on the basis of tissue pathology. That, then, is the norm for that area. Standards are professionally developed ex pressions of the range of acceptable variation from a norm or criterion. For example, on the basis of the foregoing norm, a PSRO decided that no hospital should tolerate less than a 70 percent rate of justification for appendectomies (i.e., only 10 percent deviation from the norm in any given hospital was declared tolerable). Criteria are predetermined elements against which aspects of the quality of care may be compared. They are developed by professionals relying on professional expertise and on the professional literature. The criteria used will depend on the type of review to be performed; thus, criteria for admission certification and continued stay review should include those key 1317
Downloaded from https://academic.oup.com/ptj/article-abstract/55/12/1315/4567569 by University of Texas at Dallas - McDermott Library user on 16 February 2019
If the care rendered is not in compliance with the criteria, the case is referred to the appro priate persons for correction.
TYPES OF PSRO CONTRACTS
Three types of contracts are available to organizations which wish to participate in the PSRO program. 1. Planning contracts are designed for those organizations requiring assistance to develop the necessary organizational and member ship requirements and a formal plan for the gradual assumption of PSRO duties and responsibilities. As of September 10, 1975, fifty-eight planning contracts have been awarded. 2. Conditional contracts are designed for those organizations that have as members at least 25 percent of the physicians eligible for membership and who have already de veloped a plan for assumption of health care review responsibilities. As of September 10, 1975, sixty-three conditional contracts have been awarded. 3. Statewide Support Center contracts are awarded to capable statewide organizations to assist PSROs with physician recruitment and organizational requirements and to provide other types of technical assistance as needed. Thirteen support centers have been funded. PSROs AND NON-PHYSICIAN HEALTH CARE PRACTITIONERS
Non-physician health care practitioners are defined in the PSRO Program Manual as 1318
follows: Non-physician health practitioners are those health professionals who 1) do not hold a Doctor of Medicine or Doctor of Osteopathy degree, 2) are qualified by education, experi ence, or licensure to practice their profession, and 3) are involved in the delivery of direct patient care or services which are directly or indirectly reimbursed by the Medicare, Medi caid, Maternal and Child Health, and Crippled Childrens programs. The law requires that membership in the PSRO be limited to doctors of medicine and osteopathy licensed and engaged in the practice of medicine or surgery in the established PSRO area. The Department of Health, Education, and Welfare, which is responsible for implemen tation of the legislation, however, recognized that, although non-physician practitioners can not be members of the PSRO, they exert considerable influence on health care outcome and, therefore, should be involved in a quality assurance system. Guidelines for Non-Physician Involvement
The PSRO Program Manual provides the following guidelines for the involvement of non-physician health care practitioners: Non-physicians including consumers may be included (it is not mandatory) on the governing body of the PSRO, although they are not eligible to vote on issues relating to the physician practice of medicine and osteopathy. Advisory groups, which are to be established to assist statewide Professional Standards Review Councils in states with three or more PSROs or to assist PSROs in states without councils, will be made up of non-physician practitioners and representatives of health care facilities within the PSRO area. The planning PSRO must include a plan for involvement of non-physician health care prac titioners in the planning and conduct of peer review. The conditional PSRO must provide evidence that non-physician health care practi tioners are involved in the PSRO review of care provided by their peers. Physicians are to be involved in the review of decisions on the medical appropriateness of care ordered by a physician but delivered by other health care practitioners. Non-physician practitioners, how ever, are to be involved in the review of the quality of services delivered by practitioners of PHYSICAL T H E R A P Y
Downloaded from https://academic.oup.com/ptj/article-abstract/55/12/1315/4567569 by University of Texas at Dallas - McDermott Library user on 16 February 2019
elements that will permit a review coordinator to screen cases in which admission or continued stay may be inappropriate. For example, a hospital review committee decided that any patient admitted for an acute appendectomy should have in his history some mention of localized pain and nausea; otherwise, hospital admission is questioned. Medical care evalua tion studies will require a more detailed list of criteria to permit a systematic assessment of the quality of care rendered. As in concurrent review, only those elements that are crucial to "good care" and that permit a medical record librarian to discriminate and screen out prob lems for further peer review should be included. These differ from practice or optimal criteria which include all the elements considered necessary for optimal care.
How to Get Involved
Establishing liaison with PSROs in their areas would certainly be an appropriate activity for professional organizations. Of course, having some idea of how to assist the PSRO to fulfill its review responsibilities is essential. Some organizations have already designated indi viduals or committees to serve as liaison with
Volume 55 / Number 12, December 1975
PSROs at state or local levels and are preparing members for participation in the PSRO review process. A small number of non-physician health care practitioners have participated in retrospective audit (MCE) workshops. Professional Standards Review Organizations, or hospitals which have been delegated review responsibility, will look to physical therapists for assistance in designing and implementing mechanisms for the review of non-physician care. Some physical therapists may be asked to serve on advisory groups to local PSROs and Statewide Professional Standards Review Coun cils. Certainly therapist participation on com mittees to conduct peer review of practitioners in physical therapy practice seems a likely possibility. As stated by Donabedian, "When emphasis is on provider education and preven tion of error, one needs participation by as many providers as possible in formulating the standards of care and in the process itself." 3 That statement obviously includes more than physicians. Further, modern hospital-oriented practice is a system delivering care through a battery of health professionals. Quality as surance is, therefore, a systems exercise per formed jointly by involved professionals. For centuries, an appeal to conscience was the only means of elevating the tone of the medical profession. Now, we have moved from the moral codes of individuals, to the standards of practice of voluntary organizations, to the legislative arena. If we had all abided by the guidelines outlined by Florence Nightingale and Hippocrates, we would have had no need for legislation mandating quality assurance. Perhaps we can yet accomplish what appeals to con science were unable to do by themselves—to improve the health care of the people of this country. It behooves us all to get busy. REFERENCES 1. Flexner A: Medical Education in the United States and Canada. A Report to the Carnegie Foundation for the Advancement of Teaching, 1910 2. Senate Finance Committee Report in HR 1, The Social Security Amendments of 1972, September 26, 1973 3. Donabedian A: Promoting quality through evaluat ing the process of patient care. Med Care 6:181-202, 1968
1319
Downloaded from https://academic.oup.com/ptj/article-abstract/55/12/1315/4567569 by University of Texas at Dallas - McDermott Library user on 16 February 2019
their own discipline. For example, a physician will decide whether physical therapy services were indicated but a physical therapist will review the services provided by another physi cal therapist. The PSRO will be expected to provide evidence that non-physician health care prac titioners have become involved in the following activities: 1. Development and ongoing modifications of norms, criteria, and standards for their areas of practice 2. Development of review mechanisms to be used for peer assessment of the performance of non-physician health care practitioners 3. Conduct of health care review of non-physi cian health care practitioners by their peers 4. Working with sponsors of continuing educa tion programs, for example, professional schools and practitioner organizations, to assure that deficiencies in care identified in the review process become topics for con sideration in appropriate educational pro grams 5. Where appropriate, participation of both physicians and non-physician health care practitioners in review committee activities, at either the PSRO or hospital level One can see, from the above, that non-physi cian health care practitioners will be expected to participate in the PSRO review of care wherever it is appropriate. As indicated, initial review will be limited to those services for which payment is made in short-term general hospitals. Continued stay review, discharge planning, and certainly medical care evaluation studies will include, at some time, the review of care provided by non-physician health care practitioners.
A brief history of quality assurance efforts preceding the Professional Standards Review Organization law is presented. The goals of the legislation and its requirements and procedures are discussed. Particular emphasis is placed on the PSRO requirements for short-stay hospital review which is the area where PSRO efforts will initially concentrate. The possibilities of non-physician involvement in the review process are briefly discussed.
Another federal effort in quality as surance was realized in October 1972 with the passage of Section 249F of Public Law 92-603 establishing Professional Standards Review Or ganizations (PSROs). A PSRO is a nonprofit organization of local practicing doctors of medicine and osteopathy whose purpose is to review the care provided in institutions that are reimbursed by Medicare, Medicaid, Maternal and Child Health, and Crippled Childrens programs. The PSRO must determine if the care is necessary, of acceptable quality, and de livered in the most economical setting. HISTORY OF QUALITY ASSURANCE EFFORTS
The PSRO law is relatively new, but the concept of quality assurance is not. The Hippocratic oath and Florence Nightingale's pledge for nurses were both guidelines for quality assurance. The Flexner Report was an attempt to improve medical practice by raising the standards of medical education. 1 Health practitioner organizations have tried to assure
Mrs. Sadin is Allied Health Advisor, Division of Peer Review, Bureau of Quality Assurance, Health Services Administration, U.S. Department of Health, Educa tion, and Welfare, Rockville, MD 20852.
Volume 55 / Number 12, December 1975
quality by developing educational standards, adopting codes of ethics, and developing stan dards of practice. Federal legislation, such as Medicare, has focused on improving health care delivery by defining conditions of participation for facilities, qualification requirements for practitioners, and utilization review regulations. The Joint Commission on Accreditation of Hospitals, Regional Medical Programs, and others have looked at the effects upon the patient of the care being provided and have concentrated on the identification and correc tion of patient care deficits. Medical Care Foundations, originally established by state or county medical societies as management sys tems for delivery of health care services, have initiated peer review of »the care provided to certain groups of patients. RATIONALE FOR PSROs
The experience of the community-based Medical Care Foundations in peer review, as well as the inadequacies of past federal efforts to control costs and assure quality, provided the rationale for Congressional enactment of the PSRO legislation. The PSROs are based upon the concept that "health professionals are the most appropriate individuals to evaluate the quality of medical services and that effective peer review at the local level is the soundest 1315
Downloaded from https://academic.oup.com/ptj/article-abstract/55/12/1315/4567569 by University of Texas at Dallas - McDermott Library user on 16 February 2019
Professional Standards Review Organizations
POLICIES, PROCEDURES, AND GUIDELINES
The Department of Health, Education, and Welfare has issued a PSRO Program Manual which contains the initial informational and procedural materials needed for implementa tion of the provisions of the law. The manual was designed to accommodate new or supple mental material as further interpretations of the law and changes in procedures are made. New chapters are being added as they are reviewed by the National Professional Standards Review Council which is composed of eleven physicians of recognized standing and distinction in the appraisal of medical practice as mandated in the PSRO legislation. PSRO REVIEW REQUIREMENTS
Professional Standards Review Organizations are required to assume responsibility for the review of institutional care provided to benefi ciaries of Medicare, Medicaid, Maternal and Child Health, and Crippled Childrens programs. Initially PSROs will establish a system for review of care provided to inpatients in short-stay general hospitals and will develop a phased plan for the performance of review in long-term care facilities. If the PSRO demon strates capability in these areas, it may develop review systems for care provided in other institutions. Ambulatory care review, while not mandated in the legislation, is allowed if the PSRO obtains the approval of the Department of Health, Education, and Welfare. The PSRO requirements of the hospital review system are divided into three major components which interrelate and feed back into each other: 1. Concurrent review which includes admission certification (AC) and continued stay review (CSR) 2. Retrospective medical care evaluation studies (MCEs) 3. Analysis of hospital, practitioner, and pa tient profiles 1316
Concurrent Review
Admission Certification. Concurrent admis sion certification is designed to assure the medical necessity of admissions to a hospital level of care for purposes of Medicare and Medicaid payment. Concurrent review elimi nates retroactive denial of claims. Written criteria relating to the need for admission which have been developed by the PSRO are applied to each admission under Medicare, Medicaid, Maternal and Child Health, and Crippled Chil drens programs by a review coordinator (a non-physician). As a result of that screening process, admissions are either certified as being medically necessary or are referred for peer review. If the admission is certified as meeting the need for admission, the patient is assigned a length of stay generally based on the fiftieth percentile length of stay norms for patients with similar diagnoses in similar age groups. If the admission is questioned, the case is referred to a physician adviser designated by the hospital or the PSRO who, after discussion with the attending physician, either certifies or denies the need for admission (for Medicare or Medicaid payment purposes only). If he deter mines the admission is not justified, he will notify the attending physician of the certifica tion denials. The attending physician may contest the denial through a reconsideration and appeals process which has been established by the PSRO. Continued stay review. Continued stay re view assures that continued stay at a hospital level of care is necessary. The process is similar to admission certification. Twenty-four to forty-eight hours before the initial length-ofstay checkpoint, patients are screened by the review coordinator using PSRO-developed cri teria for continued stay. If the criteria are not met or if the review coordinator has a question that continued stay is not warranted, referral is made to the physician adviser, and the process continues through the same review and recon sideration cycle as in admission certification. Continued stay review may also include, on a sample basis, a review of the quality of care rendered to patients with certain problems while they are still in the hospital. This kind of concurrent quality assessment involves the use of criteria identified as critical elements of care that should (or should not) be provided to patients with particular diagnoses or problems. PHYSICAL THERAPY
Downloaded from https://academic.oup.com/ptj/article-abstract/55/12/1315/4567569 by University of Texas at Dallas - McDermott Library user on 16 February 2019
method for assuring the appropriate use of health care resources and facilities." 2 The PSRO Amendment to the 1972 Social Security Act was designed to extend this concept of quality assurance across the country, and 203 PSRO areas have been designated.
Hospital Activities are all acceptable methods for doing MCEs. Hospital, Practitioner, and Patient Profiles
Retrospective Medical Care Evaluation Studies
Retrospective medical care evaluation studies (MCE) are a mechanism designed to 1) assure that services are appropriate to the patient's needs and are of acceptable quality and 2) that health care organization and administration support the timely provision of quality care. In general, MCEs are individually designed, detailed, short-duration studies which focus on groups of patients with similar problems rather than on individual patients. Studies may be prompted by cases in which concurrent review, analysis of profiles, or subjective perception have indicated possible instances of substandard care or administrative inefficiency. Study topics may focus on outcomes of hospitalization for certain diagnoses or problems, the use of a given procedure, reasons for recurrent hospitali zation, or the operating characteristics of an institution. The data needed for MCEs will relate directly to the topic under study and can be collected retrospectively from the patient's chart or concurrently by the review coordina tor. Proposed MCE requirements include the recommendation that the PSRO shall be re sponsible for the performance of four to twelve MCEs per year per hospital depending on the number of discharges per hospital. The approaches to MCE studies may vary but should include the following steps: 1) deter mination of study topic and study objectives, 2) developments of study design, including selection, adoption, or adaptation of draft criteria and standards, 3) review of criteria and standards by a group representative of those professionals whose care is subject to review, 4) collection of data from appropriate sources and preparation of a display of the data, 5) analysis of the data and identification of problems, 6) development of corrective actions and referral of data and recommended corrected action to appropriate parties, 7) implementation of cor rective actions, and 8) evaluation of corrective actions, such as restudy at a specified time. The patient care audit approaches taught by the Joint Commission on Accreditation of Hospitals, the American Hospital Association, the California Medical and Hospital Associa tions, and the Commission on Professional Volume 55 / Number 12, December 1975
The generation and analysis of hospital, practitioner, and patient profiles is the third component of the hospital review system. Profiles are an aggregation of data which reflect episodes of care delivered in a specific institu tion, or by a particular practitioner, or to a given patient over time. The purpose of profile analysis is to monitor the effectiveness of the various components of the review system to indicate where further efforts are needed. Profiles will also assist in the overall evaluation of the PSRO program. NORMS, CRITERIA, AND STANDARDS
In each of its review activities, the PSRO uses norms, criteria, and standards to identify possible instances of misutilization of health care services or delivery of a substandard quality of care. The PSRO is responsible for the development and ongoing modification of the criteria and standards and the selection of norms to be used in this area. Since these terms have different meanings to different people, the terms will be defined as they will be used by the PSROs. Norms are numerical statistical measures of usual observed performance. For example, in certain regions of the country, 80 percent of all acute appendectomies in one year were subse quently found to be justified on the basis of tissue pathology. That, then, is the norm for that area. Standards are professionally developed ex pressions of the range of acceptable variation from a norm or criterion. For example, on the basis of the foregoing norm, a PSRO decided that no hospital should tolerate less than a 70 percent rate of justification for appendectomies (i.e., only 10 percent deviation from the norm in any given hospital was declared tolerable). Criteria are predetermined elements against which aspects of the quality of care may be compared. They are developed by professionals relying on professional expertise and on the professional literature. The criteria used will depend on the type of review to be performed; thus, criteria for admission certification and continued stay review should include those key 1317
Downloaded from https://academic.oup.com/ptj/article-abstract/55/12/1315/4567569 by University of Texas at Dallas - McDermott Library user on 16 February 2019
If the care rendered is not in compliance with the criteria, the case is referred to the appro priate persons for correction.
TYPES OF PSRO CONTRACTS
Three types of contracts are available to organizations which wish to participate in the PSRO program. 1. Planning contracts are designed for those organizations requiring assistance to develop the necessary organizational and member ship requirements and a formal plan for the gradual assumption of PSRO duties and responsibilities. As of September 10, 1975, fifty-eight planning contracts have been awarded. 2. Conditional contracts are designed for those organizations that have as members at least 25 percent of the physicians eligible for membership and who have already de veloped a plan for assumption of health care review responsibilities. As of September 10, 1975, sixty-three conditional contracts have been awarded. 3. Statewide Support Center contracts are awarded to capable statewide organizations to assist PSROs with physician recruitment and organizational requirements and to provide other types of technical assistance as needed. Thirteen support centers have been funded. PSROs AND NON-PHYSICIAN HEALTH CARE PRACTITIONERS
Non-physician health care practitioners are defined in the PSRO Program Manual as 1318
follows: Non-physician health practitioners are those health professionals who 1) do not hold a Doctor of Medicine or Doctor of Osteopathy degree, 2) are qualified by education, experi ence, or licensure to practice their profession, and 3) are involved in the delivery of direct patient care or services which are directly or indirectly reimbursed by the Medicare, Medi caid, Maternal and Child Health, and Crippled Childrens programs. The law requires that membership in the PSRO be limited to doctors of medicine and osteopathy licensed and engaged in the practice of medicine or surgery in the established PSRO area. The Department of Health, Education, and Welfare, which is responsible for implemen tation of the legislation, however, recognized that, although non-physician practitioners can not be members of the PSRO, they exert considerable influence on health care outcome and, therefore, should be involved in a quality assurance system. Guidelines for Non-Physician Involvement
The PSRO Program Manual provides the following guidelines for the involvement of non-physician health care practitioners: Non-physicians including consumers may be included (it is not mandatory) on the governing body of the PSRO, although they are not eligible to vote on issues relating to the physician practice of medicine and osteopathy. Advisory groups, which are to be established to assist statewide Professional Standards Review Councils in states with three or more PSROs or to assist PSROs in states without councils, will be made up of non-physician practitioners and representatives of health care facilities within the PSRO area. The planning PSRO must include a plan for involvement of non-physician health care prac titioners in the planning and conduct of peer review. The conditional PSRO must provide evidence that non-physician health care practi tioners are involved in the PSRO review of care provided by their peers. Physicians are to be involved in the review of decisions on the medical appropriateness of care ordered by a physician but delivered by other health care practitioners. Non-physician practitioners, how ever, are to be involved in the review of the quality of services delivered by practitioners of PHYSICAL T H E R A P Y
Downloaded from https://academic.oup.com/ptj/article-abstract/55/12/1315/4567569 by University of Texas at Dallas - McDermott Library user on 16 February 2019
elements that will permit a review coordinator to screen cases in which admission or continued stay may be inappropriate. For example, a hospital review committee decided that any patient admitted for an acute appendectomy should have in his history some mention of localized pain and nausea; otherwise, hospital admission is questioned. Medical care evalua tion studies will require a more detailed list of criteria to permit a systematic assessment of the quality of care rendered. As in concurrent review, only those elements that are crucial to "good care" and that permit a medical record librarian to discriminate and screen out prob lems for further peer review should be included. These differ from practice or optimal criteria which include all the elements considered necessary for optimal care.
How to Get Involved
Establishing liaison with PSROs in their areas would certainly be an appropriate activity for professional organizations. Of course, having some idea of how to assist the PSRO to fulfill its review responsibilities is essential. Some organizations have already designated indi viduals or committees to serve as liaison with
Volume 55 / Number 12, December 1975
PSROs at state or local levels and are preparing members for participation in the PSRO review process. A small number of non-physician health care practitioners have participated in retrospective audit (MCE) workshops. Professional Standards Review Organizations, or hospitals which have been delegated review responsibility, will look to physical therapists for assistance in designing and implementing mechanisms for the review of non-physician care. Some physical therapists may be asked to serve on advisory groups to local PSROs and Statewide Professional Standards Review Coun cils. Certainly therapist participation on com mittees to conduct peer review of practitioners in physical therapy practice seems a likely possibility. As stated by Donabedian, "When emphasis is on provider education and preven tion of error, one needs participation by as many providers as possible in formulating the standards of care and in the process itself." 3 That statement obviously includes more than physicians. Further, modern hospital-oriented practice is a system delivering care through a battery of health professionals. Quality as surance is, therefore, a systems exercise per formed jointly by involved professionals. For centuries, an appeal to conscience was the only means of elevating the tone of the medical profession. Now, we have moved from the moral codes of individuals, to the standards of practice of voluntary organizations, to the legislative arena. If we had all abided by the guidelines outlined by Florence Nightingale and Hippocrates, we would have had no need for legislation mandating quality assurance. Perhaps we can yet accomplish what appeals to con science were unable to do by themselves—to improve the health care of the people of this country. It behooves us all to get busy. REFERENCES 1. Flexner A: Medical Education in the United States and Canada. A Report to the Carnegie Foundation for the Advancement of Teaching, 1910 2. Senate Finance Committee Report in HR 1, The Social Security Amendments of 1972, September 26, 1973 3. Donabedian A: Promoting quality through evaluat ing the process of patient care. Med Care 6:181-202, 1968
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their own discipline. For example, a physician will decide whether physical therapy services were indicated but a physical therapist will review the services provided by another physi cal therapist. The PSRO will be expected to provide evidence that non-physician health care prac titioners have become involved in the following activities: 1. Development and ongoing modifications of norms, criteria, and standards for their areas of practice 2. Development of review mechanisms to be used for peer assessment of the performance of non-physician health care practitioners 3. Conduct of health care review of non-physi cian health care practitioners by their peers 4. Working with sponsors of continuing educa tion programs, for example, professional schools and practitioner organizations, to assure that deficiencies in care identified in the review process become topics for con sideration in appropriate educational pro grams 5. Where appropriate, participation of both physicians and non-physician health care practitioners in review committee activities, at either the PSRO or hospital level One can see, from the above, that non-physi cian health care practitioners will be expected to participate in the PSRO review of care wherever it is appropriate. As indicated, initial review will be limited to those services for which payment is made in short-term general hospitals. Continued stay review, discharge planning, and certainly medical care evaluation studies will include, at some time, the review of care provided by non-physician health care practitioners.
