Comnnentary
Standards for Peer Evaluation: The Hospital Quality Assurance Committee Sanford E. Feldman, MD, and Douglas W. Roblin, PhD Critics of current provision of hospital and medical care have suggested required periodic recertification of physicians as a component in improvement of quality.1 A better target for reform exists: the hospital quality assurance committee. Systemic and organizational effort at improvement in quality of care will have far more leverage directed at the medical staffs of, for example, the approximately 560 hospitals in California than at the 55 000 individual physicians in the state. While the goal of improved quality of care presumes its application to all physician services, practical considerations indicate the inpatient acute hospital as a more suitable immediate focused setting than "all medical care." Ambulatory care need not be ignored, though there is limited measurable information regarding the errors and mistakes that occur in physician's offices and outpatient clinics. Major failures, such as delay in diagnosis, will eventually be revealed in hospital records, after admission. Outpatient care will be as readily approachable as inpatient care when appropriate ongoing research has developed indicators for treatment, methods of outcome measurement, and studies of physician decision making in offices and
clinics. We need not delay in pursuit of quality improvement in the acute hospital setting. Information regarding appropriateness and outcome of patient care is widely available. Unfortunately, little in that information suggests that hospital or physician error occurs less frequently than it did in 1974, as reported in the California Medical and Hospital Associations' Medical Insurance Feasibility Study.2 Review of hospital records of 20 000 patients revealed 4.65% as injured to a greater or lesser degree by unexpected iatrogenic mishap. Of
970 reported incidents, "potentially compensible events," a considerable number 94 (9.7%), resulted in death. In a recent similar analysis of hospital medical records from New York State in 1984, the incidence of "adverse events" was found to be 3.7%. Over one quarter, 27.6%, were considered to be due to negligence. Fourteen percent of the adversely affected patients died "at least in part as a result of the adverse event."3 The key to effective evaluation and improvement of quality of care in the hospital is the quality assurance system, whether it be a single quality assurance committee or a complex departmental network. State legislatures and courts have long respected professional self-critical evaluation-peer review-as the means to judge the capacity of physicians to perform and to evaluate the effectiveness of colleagues' work. Medicare participation rules, mediated through the joint commission, require all hospitals to have such medical staff mechanisms for assessment and "assurance" of quality. Not all hospital staff quality committees, however, adequately recognize problems, identify physicians who need assistance and consultation, systematically analyze the Sanford E. Feldman is with the Department of Surgery, Mount Zion Hospital and Medical Center of the University of California, San Francisco. Douglas W. Roblin is with the Kaiser Foundation Health Plan, Inc., Oakland,
California. Requests for reprints should be sent to Sanford E. Feldman, MD, Clinical Assistant Professor, Department of Surgery, Mount Zion Hospital and Medical Center of the University of California, San Francisco, 1600 Divisadero Street, San Francisco, CA 94118. This paper was submitted to the Journal February 2, 1991, and accepted with revisions July 17, 1991.
American Journal of Public Health 525
Cun.taiy course and outcome of patient care, or, when necessaly, educate or discipline colleagues. To the contraly, medical staff committees often become aware of problems only after letters of inquiny are received from plaintiffs' attorneys, licensing boards, or Medicare peer review organizations, or when publicly disclosed outcome data require explanation of startling differences in morbidity and mortality. Moore's Heart Faiure4 describes examples of delayed recognition and identification of medical failure. Although safeguards are presumably in place in accredited hospitals, deficiencies in quality of care and elevated morbidity and mortality have continued to occur.5 Accreditation has affirmed adequacy of organizational structure, not necessarily excellence of care. Too often quality assurance systems have been dutifuily collectingreports from various departments and services, casually reviewing a few random charts, and referring to an executive committee conflicts regarding credentials. Quality assurance committees have not critically questioned the performance of colleagues or been critical of their own function. Suggestions have been made for improvements of quality assurance program effectiveness. Caper6 has outlined a plan for ongoing review, using modem datacollection and analysis techniques. Similarly, the principles of "continuous quality improvement" descnibed by BerWick,7 based on formal assurance of the interest and participation of medical staff leadership, agreed desire of all concerned to perform at highest capacity, awareness that organizational and systemic reform is essential for betterment of care, and critical understanding of their facility's "room for improvement," may dictate a different dimension of quality. Improvement will be ensured by ongoing assessment of the work of the staff, systematic collection of clinically relevant data, and appropriate appraisal and analysis of care and outcome. Quality committees must be willing to evaluate the process of physician decision and to identify need for consultation and education. A medical staff with day-to-day information on the principal medical conditions and surgical procedures in its repertoire can anticipate problems, rationally designate privileges, and be prepared to counsel, advise, and prescibe educational intervention when needed. Some hospital stafs have already initiated such ventures. The effectiveness of 526 American Journal of Public Health
medical staff activity is not easy to examine. Confidentiality protection of committee deliberations, necessary to encourage physician candor in peer review, often obscures the visibility ofthe review function. Just as standards and indicators for clinical practice have become necessary and acceptable, so too are standards needed for the development and function of quality assurance. These medically oriented standards should encompass the goals and objectives of the medical staff relating to patient care, complemented by nursing and administrative components, and outline the technique of review and evaluation, including the uses and application of data analysis, the obligation to seek external review, and the recommendation of educative and disciplinary measures when necessary. Within the bounds of such standards, a medical staff may establish programs for instruction in medical record review for which informal record perusal is inadequate, for data collection and analysis, and for profile analysis, focusing on components of particular interest. Staff anxiety induced by exposure to these sensitive subjects will be allayed by knowledge that, in any case, others are collecting the same data. The staffs knowledge and intelligent analysis can blunt unjustified criticism. The committee should be instructed in ethical and legal considerations to facilitate tactful confrontation with physicians whose work needs criticism, or perhaps active intervention. Interaction with medical societies and schools and other hospitals can be arranged for systematic, nonthreatening external review programs. Providers of medical care in the hospital will be held increasingly accountable for its quality. According to the Institute of Medicine's (IOM) Medicare: A Strategy for Qual#y Assurance, 8 Currently available methods of quality assurance ... suggest that a small number of outliers account for a large number of serious quality problems,... are inadequate in coping successfully with outlier providers, . . . tend to focus on single events and single settings, ... may not identify underuse and overuse of services, . . . are constrined . . . by regulatory and legal systems, and . . . are of questionable value in improving average provider behavior.
In its recommendations for expanding the "mission" of Medicare to include an explicit responsibility for ensuring the quality ofcare for Medicare enrollees, the IOM has asked Congress to adopt goals, indluding strengthening "the ability of health care orgaizations and practitioners to assess
and improve their performance" and iden-
tifying "system and policy barriers to achieving quality of care, and generating options to overcome such barriers." Recommendation Seven of the IOM report urges Congress to require that Medicare conditions of participation be made consistent with the overall federal quality assurance effort. The report emphasizes "use of process of care information and especially patient outcomes data in evaluating quality of care" and notes the importance of the "capacity of an organization to render high quality care." That capacity "to enhance the ability of professionals ... to assess and improve quality of care" will be reflected in the structure and function of the hospital's quality assurance mechanism, generally the quality assurance committee. Changes in the hospital and medical staff's organization brought about by Medicare's Program to Assure Quality (MPAQ) will be applicable to other than Medicare patients as well. With general recognition of the critical role of hospital committees in assurance of quality, new regulatory efforts will be directed toward hospital staffs. Jost has stated that "regulation can police the professional self regulation process to assure that it in fact serves the purpose of quality regulation." He points to the mutual interest of government and professionals in ensuring continued existence and fairness of peer review activities and the need for "some shelter in the process"-"institutions pursuing quality control in good faith should be protected from the cost of litigation." If regulatory attention to hospital continuous quality improvement accords with goals and inclinations of professionals in providing excellent care, physicians and their professional organizations should seek some accommodation to increased regulation. That accommodation to regulatory efforts will be least painful and most productive if medical staffs recognize and understand their role in appraisal of "variations, effectiveness, and appropriateness of medical care intervention." Participatory medical staff evaluation and professional association encouragement of health services research will lead to rational interaction with government interest in the improvement of quality of care. 0
References 1. GelihomnA. Periodic physician recredentialing. JAMA 1991;265:752-755. 2. Mills DH, ed. Report on the Medical Insur-
April 1992, Vol. 82, No. 4
C-mmesX ance Feasibilty Stdy. San Francisco, Calif: Sutter Publications Inc; 1977. 3. Harvard Medical Practice Study. Patients, Doctors, and Lawyers: Medical Injury, Malpractice Litigation, and Patient Compensation in New York Cambridge, Mass. Harvard Medical Practice Study, 1990 4. Moore TJ. HeartFailwe-A Citcal Inquiy into American Medicine and the Revoluion
in Heart Care. New York, NY: Random House, 1989. 5. Dubois RW, Rogers WH, Moxley JH 3d, Draper D, Brook RH. Hospital inpatient mortality: is it a predictor of quality? NEWg JMed 1987;317:1674-1680. 6. Caper P. The epidemiologic surveilance of medical care. Am J Pub&ic Healhk 1987;77: 669-670. 7. Berwick D. Continuous improvement as an
ideal in health care. N Engi J MedL 1989; 320:53-56. 8. Institute of Medicine, Lohr KN, ed. Medicare: A Strategy for Quality Assurance. Washington, DC: National Academy Press; 1990;1:2. 9. Jost TS. The necessary and proper role of regulation to assure the quality of health care. Houston Law Rev. 1988;25:525598.
Enwbam 1n Williams 1W, Going SB, Ld.mas. T&, et aL Body fatness aoddk .relevated bloodpresrnm., totsld.o1esta., and serum I.popwt*in ratios in children and adolescents Am 1F.abic Health. I92.823S8-363
Therderenoeto an s.endixcmp359 is inoonvct (therein . );bodyden*yisdiscwsedinTable tThcr*rem. to Tzd* I under Remdtsm p360 m invwrect the between bodyfatandCVDriskhsarediscusedint.ble2
Standards for Peer Evaluation: The Hospital Quality Assurance Committee Sanford E. Feldman, MD, and Douglas W. Roblin, PhD Critics of current provision of hospital and medical care have suggested required periodic recertification of physicians as a component in improvement of quality.1 A better target for reform exists: the hospital quality assurance committee. Systemic and organizational effort at improvement in quality of care will have far more leverage directed at the medical staffs of, for example, the approximately 560 hospitals in California than at the 55 000 individual physicians in the state. While the goal of improved quality of care presumes its application to all physician services, practical considerations indicate the inpatient acute hospital as a more suitable immediate focused setting than "all medical care." Ambulatory care need not be ignored, though there is limited measurable information regarding the errors and mistakes that occur in physician's offices and outpatient clinics. Major failures, such as delay in diagnosis, will eventually be revealed in hospital records, after admission. Outpatient care will be as readily approachable as inpatient care when appropriate ongoing research has developed indicators for treatment, methods of outcome measurement, and studies of physician decision making in offices and
clinics. We need not delay in pursuit of quality improvement in the acute hospital setting. Information regarding appropriateness and outcome of patient care is widely available. Unfortunately, little in that information suggests that hospital or physician error occurs less frequently than it did in 1974, as reported in the California Medical and Hospital Associations' Medical Insurance Feasibility Study.2 Review of hospital records of 20 000 patients revealed 4.65% as injured to a greater or lesser degree by unexpected iatrogenic mishap. Of
970 reported incidents, "potentially compensible events," a considerable number 94 (9.7%), resulted in death. In a recent similar analysis of hospital medical records from New York State in 1984, the incidence of "adverse events" was found to be 3.7%. Over one quarter, 27.6%, were considered to be due to negligence. Fourteen percent of the adversely affected patients died "at least in part as a result of the adverse event."3 The key to effective evaluation and improvement of quality of care in the hospital is the quality assurance system, whether it be a single quality assurance committee or a complex departmental network. State legislatures and courts have long respected professional self-critical evaluation-peer review-as the means to judge the capacity of physicians to perform and to evaluate the effectiveness of colleagues' work. Medicare participation rules, mediated through the joint commission, require all hospitals to have such medical staff mechanisms for assessment and "assurance" of quality. Not all hospital staff quality committees, however, adequately recognize problems, identify physicians who need assistance and consultation, systematically analyze the Sanford E. Feldman is with the Department of Surgery, Mount Zion Hospital and Medical Center of the University of California, San Francisco. Douglas W. Roblin is with the Kaiser Foundation Health Plan, Inc., Oakland,
California. Requests for reprints should be sent to Sanford E. Feldman, MD, Clinical Assistant Professor, Department of Surgery, Mount Zion Hospital and Medical Center of the University of California, San Francisco, 1600 Divisadero Street, San Francisco, CA 94118. This paper was submitted to the Journal February 2, 1991, and accepted with revisions July 17, 1991.
American Journal of Public Health 525
Cun.taiy course and outcome of patient care, or, when necessaly, educate or discipline colleagues. To the contraly, medical staff committees often become aware of problems only after letters of inquiny are received from plaintiffs' attorneys, licensing boards, or Medicare peer review organizations, or when publicly disclosed outcome data require explanation of startling differences in morbidity and mortality. Moore's Heart Faiure4 describes examples of delayed recognition and identification of medical failure. Although safeguards are presumably in place in accredited hospitals, deficiencies in quality of care and elevated morbidity and mortality have continued to occur.5 Accreditation has affirmed adequacy of organizational structure, not necessarily excellence of care. Too often quality assurance systems have been dutifuily collectingreports from various departments and services, casually reviewing a few random charts, and referring to an executive committee conflicts regarding credentials. Quality assurance committees have not critically questioned the performance of colleagues or been critical of their own function. Suggestions have been made for improvements of quality assurance program effectiveness. Caper6 has outlined a plan for ongoing review, using modem datacollection and analysis techniques. Similarly, the principles of "continuous quality improvement" descnibed by BerWick,7 based on formal assurance of the interest and participation of medical staff leadership, agreed desire of all concerned to perform at highest capacity, awareness that organizational and systemic reform is essential for betterment of care, and critical understanding of their facility's "room for improvement," may dictate a different dimension of quality. Improvement will be ensured by ongoing assessment of the work of the staff, systematic collection of clinically relevant data, and appropriate appraisal and analysis of care and outcome. Quality committees must be willing to evaluate the process of physician decision and to identify need for consultation and education. A medical staff with day-to-day information on the principal medical conditions and surgical procedures in its repertoire can anticipate problems, rationally designate privileges, and be prepared to counsel, advise, and prescibe educational intervention when needed. Some hospital stafs have already initiated such ventures. The effectiveness of 526 American Journal of Public Health
medical staff activity is not easy to examine. Confidentiality protection of committee deliberations, necessary to encourage physician candor in peer review, often obscures the visibility ofthe review function. Just as standards and indicators for clinical practice have become necessary and acceptable, so too are standards needed for the development and function of quality assurance. These medically oriented standards should encompass the goals and objectives of the medical staff relating to patient care, complemented by nursing and administrative components, and outline the technique of review and evaluation, including the uses and application of data analysis, the obligation to seek external review, and the recommendation of educative and disciplinary measures when necessary. Within the bounds of such standards, a medical staff may establish programs for instruction in medical record review for which informal record perusal is inadequate, for data collection and analysis, and for profile analysis, focusing on components of particular interest. Staff anxiety induced by exposure to these sensitive subjects will be allayed by knowledge that, in any case, others are collecting the same data. The staffs knowledge and intelligent analysis can blunt unjustified criticism. The committee should be instructed in ethical and legal considerations to facilitate tactful confrontation with physicians whose work needs criticism, or perhaps active intervention. Interaction with medical societies and schools and other hospitals can be arranged for systematic, nonthreatening external review programs. Providers of medical care in the hospital will be held increasingly accountable for its quality. According to the Institute of Medicine's (IOM) Medicare: A Strategy for Qual#y Assurance, 8 Currently available methods of quality assurance ... suggest that a small number of outliers account for a large number of serious quality problems,... are inadequate in coping successfully with outlier providers, . . . tend to focus on single events and single settings, ... may not identify underuse and overuse of services, . . . are constrined . . . by regulatory and legal systems, and . . . are of questionable value in improving average provider behavior.
In its recommendations for expanding the "mission" of Medicare to include an explicit responsibility for ensuring the quality ofcare for Medicare enrollees, the IOM has asked Congress to adopt goals, indluding strengthening "the ability of health care orgaizations and practitioners to assess
and improve their performance" and iden-
tifying "system and policy barriers to achieving quality of care, and generating options to overcome such barriers." Recommendation Seven of the IOM report urges Congress to require that Medicare conditions of participation be made consistent with the overall federal quality assurance effort. The report emphasizes "use of process of care information and especially patient outcomes data in evaluating quality of care" and notes the importance of the "capacity of an organization to render high quality care." That capacity "to enhance the ability of professionals ... to assess and improve quality of care" will be reflected in the structure and function of the hospital's quality assurance mechanism, generally the quality assurance committee. Changes in the hospital and medical staff's organization brought about by Medicare's Program to Assure Quality (MPAQ) will be applicable to other than Medicare patients as well. With general recognition of the critical role of hospital committees in assurance of quality, new regulatory efforts will be directed toward hospital staffs. Jost has stated that "regulation can police the professional self regulation process to assure that it in fact serves the purpose of quality regulation." He points to the mutual interest of government and professionals in ensuring continued existence and fairness of peer review activities and the need for "some shelter in the process"-"institutions pursuing quality control in good faith should be protected from the cost of litigation." If regulatory attention to hospital continuous quality improvement accords with goals and inclinations of professionals in providing excellent care, physicians and their professional organizations should seek some accommodation to increased regulation. That accommodation to regulatory efforts will be least painful and most productive if medical staffs recognize and understand their role in appraisal of "variations, effectiveness, and appropriateness of medical care intervention." Participatory medical staff evaluation and professional association encouragement of health services research will lead to rational interaction with government interest in the improvement of quality of care. 0
References 1. GelihomnA. Periodic physician recredentialing. JAMA 1991;265:752-755. 2. Mills DH, ed. Report on the Medical Insur-
April 1992, Vol. 82, No. 4
C-mmesX ance Feasibilty Stdy. San Francisco, Calif: Sutter Publications Inc; 1977. 3. Harvard Medical Practice Study. Patients, Doctors, and Lawyers: Medical Injury, Malpractice Litigation, and Patient Compensation in New York Cambridge, Mass. Harvard Medical Practice Study, 1990 4. Moore TJ. HeartFailwe-A Citcal Inquiy into American Medicine and the Revoluion
in Heart Care. New York, NY: Random House, 1989. 5. Dubois RW, Rogers WH, Moxley JH 3d, Draper D, Brook RH. Hospital inpatient mortality: is it a predictor of quality? NEWg JMed 1987;317:1674-1680. 6. Caper P. The epidemiologic surveilance of medical care. Am J Pub&ic Healhk 1987;77: 669-670. 7. Berwick D. Continuous improvement as an
ideal in health care. N Engi J MedL 1989; 320:53-56. 8. Institute of Medicine, Lohr KN, ed. Medicare: A Strategy for Quality Assurance. Washington, DC: National Academy Press; 1990;1:2. 9. Jost TS. The necessary and proper role of regulation to assure the quality of health care. Houston Law Rev. 1988;25:525598.
Enwbam 1n Williams 1W, Going SB, Ld.mas. T&, et aL Body fatness aoddk .relevated bloodpresrnm., totsld.o1esta., and serum I.popwt*in ratios in children and adolescents Am 1F.abic Health. I92.823S8-363
Therderenoeto an s.endixcmp359 is inoonvct (therein . );bodyden*yisdiscwsedinTable tThcr*rem. to Tzd* I under Remdtsm p360 m invwrect the between bodyfatandCVDriskhsarediscusedint.ble2
