Reinvigorating stalled CQI efforts through physician involvement

Continuous quality improvement (CQI), loosely synonymous with total quality management (TQM), was designed for the comparatively simple world of industry. Now that the gurus of CQI have attempted--originally with full support of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)--to apply the industrial CQI model to hospitals, they've noticed something: The model doesn't work, and hospital CQI programs are faltering enough to persuade the Joint Commission to scale back its CQI accreditation requirements. One major shortcoming behind the performance to date of CQI in hospitals: Physicians don't fit into the industrial model of CQI. Physicians are too important, and too many programs are stalled, to continue to implement CQI as though physicians don't exist. The techniques described here should help to reinvigorate faltering programs, giving hospital management a chance to "do it right the second time."     

Guarding quality in challenging times. Interview by Emily Friedman.

As Dennis S. O'Leary, MD, FACPE, reaches the 18-month mark in his tenure as president of the Joint Commission on Accreditation of Hospitals, Chicago, the organization's future is a foremost concern. In this concluding article of a two-part series, he discusses his vision of where the Commission is going, and how and why. Among key issues that will affect the Joint Commission's future, he says, are changing determinants of quality, evaluation of nonhospital organizations, the interplay of the increasingly diverse individuals and groups that participate in Joint Commission activities, and Joint Commission relations with key health professions and other interest groups, including consumers. The first article, which focused on the Joint Commission's "clinical indicators" project, was published in the July-August issue of Physician Executive.     

Quality management in ambulatory care: the future is now

Ambulatory care has always been a stepchild. Hospitals have been and are the focal point of quality activity. Traditionally driven by Joint Commission decree and more recently inspired by market forces, hospitals find the resources to do quality. It was quality assurance in the '80s. It is quality management in the '90s. Some of this activity has oozed out into ambulatory care, but not much. We in ambulatory care have been too busy producing as many patient visits as possible in an environment of limited resources. All that is now changing. As ambulatory care becomes more and more important in the overall health care delivery scheme, medical quality management in this environment will also take on greater significance. Leading the way will be the electronic medical record.     

The JCAH quality initiative: what can hospitals and physicians expect?. Interview by Emily Friedman.

In his new position at the JCAH, Ol'Leary has been shaking things up. His most talked-about move has been to initiate a broad-scale reconfiguration of the Joint Commission's approaches to evaluating quality. The principle element of this effort calls for structural and functional indicators to be augmented by clinical performance and outcome criteria. This is the first of two articles concerning Dr. O'Leary's views of the future of the Joint Commission. In this article, he discusses the new quality assurance initiative; in an article in the September-October issue of Physician Executive, his vision of the future of the JCAH, and the environment in which it will be operating, will be explored.     

Practice guidelines. Cookbook medicine

A large measure of the confusion and doubt currently being sowed in the ongoing debate over the advisability and effectiveness of practice guidelines is a matter of terminology. In deference to the wishes and fears of physicians, the term "requirements" is not used. But requirements they are. Their quality and the degree to which they are useful will depend on their level of detail and the degree to which they are based on positive outcomes. Regardless, attorneys and others will always view and use them as requirements.     

The private practitioner in hospital quality assurance

External forces continue to dictate the necessity of delivering high-quality health care along with methods of proving that the claimed quality is attained. Gone are the days when both the institution and its practitioners could answer quality questions simply by stating that they were delivering excellent health care to their patient population. The federal government, via the Health Care Financing Administration, and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) are mandating that institutions prove, without question, that they are delivering health care of the highest quality. The essential key to attaining these goals is cooperative private practitioners.     

Reporting quality of health care to the board

The reporting of quality of health care to the governing board has long been an enigma. Now we are in the midst of a revolution in health care, as we shift our focus from solely the clinical performance of individuals to a broader scope of assessing and improving all activities around patient services and patient care--i.e., management outcomes integrated with clinical outcomes to help identify opportunities to improve patient care. In addition, apprised of corporate liability for the quality of care provided in health care organizations, governing boards are raising questions and demanding more information. To maintain this high degree of interest in quality of health care, information should be restricted to what the board needs to know. This article will be confined to the hospital's organizationwide quality system of monitoring and evaluating. While medical staff credentialing and privileging are also board responsibilities and quality management activities should be used in the privileging and credentialing process, they will not be addressed in this article.     

Interdisciplinary, functional approach to quality review

Dramatic changes in the standards of the Joint Commission on Accreditation of Healthcare Organizations, as part of its "Agenda for Change," pose new challenges for health care managers. The goal of the "Agenda for Change" is to focus accreditation on the actual performance of important functions while continuously stimulating improvement in the organization's performance and outcomes of care. In 1994, seven important functions--improvement of performance, leadership, management of information, assessment of patients, education of patients and families, operative and other procedures, and treatment of patients--were identified by JCAHO. Performance, as defined by JCAHO, can be measured through observing specific dimensions, such as, availability, safety, timeliness, effectiveness, continuity, efficiency, and respect and caring. These are considered important elements in the determination of quality, value, cost, and patient outcome. In 1995, JCAHO identified 11 important functions--patient rights and organizational ethics, assessment of patients, care of patients, education, continuum of care, improving organizational performance, leadership, management of the environment of care, management of human resources, management of information, and prevention and control of infection. In addition each institution has the opportunity to decide by prioritization where it wants to devote resources. This article reports on one hospital's response to the new JCAHO initiatives.     

Strategic issues requiring public accountability: food for thought

Although the exact outline of U.S. health reform has become fuzzy because of political events, it seems clear that major changes in the manner in which health care is delivered and financed are under way. The initiative for the most part has been assumed by state government and by the health care field itself, as managed care becomes ever more entrenched and the health care system becomes ever more integrated. An expected outcome of these changes will be demands for greater public accountability on the part of health care providers and organizations. In this article, the author discusses some of the issues--professional compensation, documenting community service, ensuring public input into planning efforts, economic credentialing and quality of care, and managing ethics under managed competition--that will have to be addressed at the local level as these shifts take place.     

My third year as chief of staff

Passing a Joint Commission survey, dealing with a sexual harassment complaint and writing a performance pay plan are just a few of the issues that a chief of staff in the VA wrestled with during his third year on the job.     

A case of wrongful use of quality management. Summit Health, Ltd., v. Pinhas

Summit Health, Ltd., v. Pinhas liberalized the jurisdiction of the Sherman Antitrust Act to include cases of intrastate hospital credentialing. The U.S. Supreme Court decision eased the requirements for plaintiffs to sue when they perceived that health care organizations were acting as monopolies. The court removed the defense that a plaintiff had to prove that the decision of a health care organization affected interstate commerce for the case to be heard in court. Important as the case is in antitrust law, however, greater lessons can be gained by health care organizations from analyzing the events that led to the lawsuit.     

How to fight the regulator glut: the role of the HCFA-type survey

More and more hospitals in this country are being threatened by the removal of their Health Care Financing Authority (HCFA) Medicare Certification. A perception of competitiveness among HCFA, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and other organizations has heightened this concern. This unpleasant situation has provoked many hospitals to prevent any type of regulator decertification. One of the practical methods of prevention is the use of a HCFA-type survey. These surveys prepare institutions for unexpected, unarmored review by regulators and should be part of the quality improvement (QI) process even in institutions with limited resources. This article discusses the means to accomplish the HCFA-type survey. The development of the survey process involves institutional commitment, hospital policy and procedures, a department review schedule, selection of review personnel, preparation of review personnel, record keeping, and department education.     

Task analysis of healthcare delivery: A case study

Human error and medical error are highly known as contributors to patient safety [Institute of Medicine (IOM), November 1999. To err is human: building a safer health system. Available at: http://www.nap.edu/openbook/0309068371/html/11.html (accessed 05.03.07); Institute of Medicine (IOM), March 2001. Crossing the quality chasm: a new health system for the 21st century. Available at: http://www.nap.edu/openbook/0309072808/html (accessed 05.03.07); Joint Commission on Accreditation of Healthcare Organizations (JCAHO), 2007. Failure mode, effect, and criticality analysis (FMECA) worksheet. Available at: http://www.jcaho.org (accessed 24.06.07)]. A study was performed to identify the process flow affiliated with elder patients transitioning through different continuums of emergency and non-emergency care. This research is part of a larger research effort to develop and implement a web-based healthcare system that enables hospitals and nursing homes to share patient information resulting in increased knowledge of a patient's medical history, decreased errors and enhanced patient safety. Future research efforts for this study are also presented.     

Meet the mandate to measure clinical quality

The mandate for health care organizations to be accountable for quality, as well as price, is now unavoidable. The Joint Commission's ORYX project is requiring every hospital to measure clinical outcomes of a majority of its patients within the next three years. This mandate can be met best with systems of clinical outcomes measurement that provide valid, reliable risk adjustment; yield meaningful information about many different diseases and procedures; and measure more than mortality or cost--all using primarily billing data. New outcomes measurement tools with all of these capabilities are available and have already enabled quality improvement in dozens of hospitals across the U.S.     

Quality versus variance: a plea for a different focus and terminology

Much has been written about quality assurance in medical practice over the past 15 years. Medicine suddenly found itself trying to design systems that ensured that medicine was being practiced according to standards of quality when it had neither a definition of its product nor defined standards of practice. Consequently, early quality assurance programs focused primarily on documentation of patient care. As the process matured, it evolved to generic screens, with tolerances and outliers. The theory was that the quality of medical care was enhanced by physicians who practiced within often artificially established norms and was diminished by physicians who practiced outside those same norms. It was much like saying that the quality of manufacturing a new car could be improved by reducing all systems down to one of closely standardizing, observing, and documenting how each individual assembly worker put on a lock nut and then holding each worker independently accountable for the final quality of the care. Physicians felt they were being held responsible for conforming to a rigid set of poorly designed and retrospectively applied standards. Moreover, they were held accountable for applying those standards to all practice situations. Understandably, physicians felt at the mercy of nonphysician quality assurance "detectives" in hospitals and became increasingly suspicious of nurses and administrators, who were perceived as abusing the system at the expense of the physicians. Because of these inadequacies of the earlier quality assurance programs, paranoia among physicians about the quality assurance process remains rampant today. The use of blind outcome scores and practice patterns in credentialing and the reporting of these data to databanks have reinforced the paranoia.(ABSTRACT TRUNCATED AT 250 WORDS)     

基于质量损失的交叉质量结构参数设计方法

本文根据复杂产品的复杂质量特性构成,提出了具有交叉性的质量结构,将田口方法中参数设计方法引入到具有交叉质量结构的产品质量设计中来。在一般田口参数设计基础上,将信噪比转化为标准质量损失,以多元回归分析为工具,以使复杂产品系统综合质量损失最小为目标,确定各设计参数的设计水平,并以实例验证了所提方法的可行性和有效性。     

Auditing,consulting, and audit market concentration

In its recently published Green Paper, the European Commission (Audit policy: lessons from the crisis. Brussels, 2010) discusses various methods to enhance the reliability of audits and to re-establish trust in the financial market. The Commission primarily focuses on increasing auditor independence and on reducing the high level of audit market concentration. Based on a model in the tradition of the circular market matching models introduced by Salop (Bell J Econ 10(1):141–156, 1979), we show that prohibiting non-audit services as a measure intended to improve auditor independence can have counter-productive secondary effects on audit market concentration. In fact, our model demonstrates that incentives for independence and the structure of the audit market are simultaneously determined. Because market shares are endogenous in our model, it is not even clear that prohibiting non-audit services indeed increases an auditor’s incentive to remain independent.     

Managing health care quality.

Using the cited principles of professional staff credentialing and quality assurance, a department chairman, medical director, or other health care executive will be in an excellent position to assess quality of care against established standards and manage problems in the routine provision of medically appropriate care. He or she will also be able to assure the hospital's board that the hospital and its medical staff are well positioned to meet future challenges to provide effective quality, utilization, and risk management.     

Database Requirements for Epidemiological Estimates of Radiation Risks in Continuously Exposed Populations

Using the revised risk coefficients recommended by the 1990 report of the International Commission of Radiological Protection (ICRP), computations have been made on the minimum databases required for detecting radiogenic cancer excesses from epidemiological surveys of populations exposed to low level radiations. The computations have been made separately for Indian and Western populations using their representative demographic data. The western database requirements are generally found to be about half the Indian requirement.
For the exposures in high background radiation areas at the rate of say 5 mSv/y, the minimum required database is 121,500 person years, in the Indian case. Similarly, for Indian occupational workers exposed at the rate of say, 10 mSv/y, it is required to observe 30,000 persons for the first 40 years or 3600 persons over their entire lifetime for obtaining statistically significant results.     

Physician executives in the '90s: report of a national survey

In fall 1990, Witt Associates again catalogued the progress of physicians as they obtain management positions of increasing importance. The firm has conducted a continuing study of the position since 1979. The current survey of vice presidents of medical affairs/medical directors renders a candid portrait of the physician manager. The profile that emerges is a 53-year-old white male, working almost 50 hours a week in a full-time position, appointed by the hospital and reporting to the Chief Executive Officer. This individual is board certified and has major responsibilities for quality assurance, credentialing, risk management, and utilization review. His or her salary is into six figures.