Quality Assurance—An Overview

Volume 6, Number 3, MaylJune 1977

JOGN Nursing Journal of The Nurses Association of The American College of Obstetricians and Gynecologists

Quality Assurance-An

Overview

MARY C. BRUCKER, C N M , BS, M S and N A N C Y J O R E E D Y , C N M , BS Consumer demands, cost consciousness, and provider accountability have made the evaluation of health care, as received, a crucial and highly visible issue. T h e authors review the history of quality assurance in health care and summarize current quality assurance programs, i.e., federal programs, PSHV’s, independent programs, and nursing programs. A glossary of terms is appended.

Quality assurance is a topic alluded to frequently in health care delivery settings. Terms such as audit, utilization review, and peer review continually bombard nurses not only in the literature but also within their clinical areas. Because of consumer demand, cost consciousness, accountability, and increasing federal government involvement, the concept of quality assurance is crucial to health care personnel, and it deserves more than casual interest. Efforts to measure quality and assure its constancy are not new in health care. Quality assurance has developed through years of various programs and organized efforts of professionals. Federal legislation exists that mandates examination of quality of care. All quality assurance programs have ramifications for health care providers and recipients. Nurses, as the largest group of health care providers, must develop their role in evaluating the quality of nursing care or forfeit that role to others. By May/June 1977JOGN Nursing

understanding the history and current implementation of quality assurance, the individual nurse is able to both appreciate its importance and identify a personal role.

THE ADVENT OF QUALITY ASSURANCE IN HEALTH CARE Public concern and consumerism are powerful forces in the United States. However, in the 19th and early 20th centuries the public had a more fatalistic view of health care. A poor outcome was not linked to practitioner capabilities or access to care, but rather was generally accepted as something beyond human control.’ As time evolved, increased and advanced health care became more readily accessible. This exposure provided people with an education which made them more sophisticated consumers. Health care 9

I NDI V I DUAL

CONSUMER

GOVERNMENT 1

THIRD PARTY HOSPITALS INDIVIDUAL PR ACT IT ION ERS

I NDl V l DUAL CONSUMERS

CONSUMER

ASSURANCE FINANCIERS’

.1 ACCOUNTABI LlTY

ANA

t

FEDERAL GOVERNMENT

Figure 1. Forces behind quality assurance programs.

came to be viewed not as a privilege, but rather as a right. As more and better care became available, consumers’ standards of health consistently rose. This phenomenon has been termed the “revolution of rising expectations. ’ ” As consumers began to demand and expect quality care, identifying the care provided as adequate or inadequate became a concrete problem. Health care providers were focusing on definitions of quality care in order to engage in self-evaluation, and financiers of health care desired to investigate care, as provided, to see what they were receiving for their expenditures. With the public demand, financing’s cost consciousness, and provider accountability, ongoing ev,aluation of care was inevitable. (See Figure 1.) In fact, individual investigations through several years attempted to tackle aspects of the subject with a variety of approaches and methods. A few of the more important will be discussed. Initially, there were attempts to analyze the medical profession itself through internal investigation. The first well-publicized evaluation was the 1910 Flexner report which investigated the quality of medical e d ~ c a t i o n .It ~ exposed several medical schools as diploma mills, and many physicians were unmasked as poorly educated people who often had not completed high school. This survey had farreaching effects in medical education. Several medical schools were closed; others renovated their pro10

grams. Interestingly, direct patient care was not included in the survey. In 1912, Codman advocated publishing an abstract of every surgical case with a preliminary outcome and then reporting a final outcome 1 year later. Unfortunately, he terminated his own innovative analysis when World War I intervened. However, he did publish some of his work and thus introduced the concept of audit of health care to many people for the first times4 In 1916, J. G. Bowman, the first director of the American College of Surgeons, spearheaded a survey of hospital care. H e used an analysis of diagnosis, treatment, and outcome of appendicitis as one of his evaluation tools. Through this survey it was found that only 89 of the 692 hospitals of over 100 beds could be said to be giving reasonable care.3 Bowman’s findings prompted the American College of Surgeons to form a subcommittee to recommend minimum standards for hospitals. This committee periodically published a list of hospitals which fulfilled these minimum standards. This “hospital standardization” involved a variety of hospital functions, including medical staff organization as well as the hospital record-keeping system. The assumption was made that quality care would be the natural outgrowth of meeting these hospital

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The Joint Commission on Accreditation of Hospitals (JCAH) succeeded the American College of Surgeons in 1952 in the field of hospital accreditation. JCAH is an independent agency doing evaluations on invitation from the hospital. Accreditation by JCAH can have widespread ramifications for the hospital. Not only does it confer status, but it may also influence obtaining affiliations with teaching institutions. An analogy frequently employed is that of bank auditors periodically checking other organizations’ accounting record^.^ Such analysis can be done with objectivity because of the lack of direct involvement. In the middle 1950’s, third party payers (e.g., insurance companies, U. S. Government) began to become more cost conscious. Although JCAH had encouraged hospitals to perform audits of direct patient care for both medicine and nursing, these audits did not usually evaluate specific ways to save costs. Therefore, many hospitals were requested by third party payers to form utilization committees5 to evaluate both length of stay and care given in order to curb spending waste on unduly prolonged stays and unnecessary testing. Further refinement of the process of auditing was accomplished by Paul Lembcke. Lembcke reviewed existing methods of medical care evaluation and concentrated on, the use of objective data.3 This “scientific” methodology included the recognition that it must first be determined whether the patient actually had the disease for which he was being treated. His methodology also recognized that audits for patterns of care were necessary for an overall estimation of quality of care, not simply audits of individual cases. These concepts are integrated into today’s quality assurance programs. Other contemporary contributors to quality assurance include Beverly Payne and Avedis Donabedian. Payne elaborated Lembcke’s system and developed internal as well as external audits6 Donabedian introduced the concepts of structure, process, and outcome (see Glossary) as components of quality care e ~ a l u a t i o n . ~

troublesome questions about accessibility, priority, and reimbursement for care. Quality assurance on a large scale became a double-edged sword: Not only could quality assurance programs evaluate care given, but in doing so, they would indirectly evaluate the success or failure of a program under federal auspices. In this way the government could continue to sponsor the programs providing the best delivery of care for the funding allotted.

Medicare/ Medicaid The United States has never had a national program of health insurance. The first major venture into the field of health was the enactment of MedicarelMedicaid under Titles 18 and 19 of the Social Security Act of 1965. Medicare was designed to enable the elderly to secure health care. Medicaid was targeted at poverty-level individuals. In addition, Title 5 of the same Social Security Act has progressively allocated increasing funding for delivery of Maternal-Child Health care. Particularly due to cost vs. benefit problems, these three programs prompted the federal government to intensify investigation of health care delivery systems in this country. Medicare cost more than twice the initial budget. Medicaid also transcended original estimates. The need for Maternal-Child Health funds continues to rise each year. Prompted by both the spiraling costs of care and discrepancies in accessibility and quality of care, Congress passed Public Law 92-603, entitled Professional Standards Review Organizations (PSRO), a 1972 amendment to the Social Security Act.

PSRO PL 92-603 provides for the establishment of individual Professional Standards Review Organizations called PSRO’s. Each is composed of a minimum of 300 doctors practicing in adjoining communities. PSRO’s have the responsibility to determine the quality and appropriateness of the care given by institutions to people receiving Medicare, Medicaid, and Maternal-Child assistance.’ It has been suggested that the PSRO’s will eventually provide CURRENT QUALITY ASSURANCE the nucleus for a community-wide system for all PROGRAMS services provided under any National Health Insurance Act that might be passed.’ Federal Involvement The Secretary of H E W has designated 203 PSRO A major impetus to quality assurance programs areas. Each area is to be represented by a nonprofit began with the involvement of the federal govern- PSRO which will make decisions regarding health ment. As multiple federal programs evolved care within the PSRO area. The Secretary of HEW quickly, the government found itself faced with awards the contracts for these local PSRO’s.

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By law, nonphysician health care practitioners such as nurses, social workers, and medical technologists cannot belong to a local PSRO. But they may be part of the formal PSRO system as members of the Advisory Group which assists in developing standards and recommends policies to the PSRO.' The goal of the PSRO law is organized evaluation of the care being delivered. The individual PSRO is intended to investigate care via three major types of review: a ) concurrent reviews; b) hospital, provider, and patient profiles; and c)evaluation of health care.' Concurrent reviews include both admission certification and continued stay review. Admission certification evaluates necessity, appropriateness, and accessibility of hospital care, and it focuses on the length of stay as estimated at admission. For example, should the patient be admitted or treated on an outpatient basis? If she is admitted, is it to an appropriate hospital? How long should she be expected to stay for her condition? Continued stay review investigates hospitalization and quality of care for those patients remaining in the hospital past the initial estimated days. For example, if 50% of patients having a dilatation and curettage stay 2 days, why does this particular patient stay for 6? This review is done frequently within hospitals by utilization committees. Medical profiles are used to identify patterns of care. These profiles can be coordinated with the findings from the concurrent review to correlate care and population. They may form the basis for a national data bank for health research. Health care evaluation studies are designed to evaluate care provided, focusing on particular problem areas. This is usually accomplished by setting criteria for care for a medical problem and then comparing the care actually given to the criteria. For example, after a normal spontaneous vaginal delivery, the patient would be expected to be discharged without signs or symptoms of uterine infection. One cardinal sign of such an infection is a temperature elevation. The audit of this case would thus include checking the discharge temperature to see if that criterion for discharge had been met.

can include physicians, nurses, social workers, nutritionists, and others who deliver varying aspects of health care. Peer review has been demonstrated to be a reality within group practices or health maintenance organizations. There have been instances when groups of practitioners have identified criteria and used nonpractitioners to review the charts." Harvard University and Beth Israel Hospital are not only identifying criteria, but are setting protocol for diagnosis and treatment regimens. The protocol is being taught to nonprofessionals who then deliver direct patient care with the regimens as guides.12 Nursing Involvement While general progress was occurring in quality assurance and federal intervention became a reality, the profession of nursing was not static. One of the philosophical tenets of nursing is the concern for continued improvement of nursing care. The first major step was ANA's development of Standards of Practice, completed in the early 1970's.'' These standards are working documents to be used as a baseline for determining care. This was followed by development of standards within specialties, such as NAACOG's Obstetric, Gynecologic, and Neonatal

Nursing Functions and Standards.I4

Furthermore, a mechanism for certification of clinical expertise was developed in order to recognize quality nursing care. This is presently being implemented in a variety of specialties, including obstetrics, gynecology, and neonatology by joint sponsorship of NAACOG and ANA." (NAACOG is also currently developing a model and a postgraduate course on the implementation of standards.) Although PSRO's will be composed of physicians, they have significance for nursing. Irma Lou Hirsch has written, "Although doctors of medicine and osteopathy are named as the professionals whose practice will receive the most attention, it does not take a crystal ball to realize that the quality of care within an institution involves nursing.'"O In the medical (health) care evaluation studies, nurses can be the ones to develop criteria to screen quality of nursing care. l5 Currently, congressional bills have Nonfederal Involvement been introduced to allow nurses to be members of Although the federally legislated PSRO's are far- local PSRO's.16 A model for quality assurance in nursing has been reaching, they are not the only programs of quality devised by Norma Lang. '' This model includes review. JCAH continues to evaluate audits of patient care throughout the hospitals which they visit. Multi- identifying values; identifying structure, process, disciplinary audits have evolved from original and outcome; obtaining data; interpreting the data; JCAH medical and nursing audits." Such audits and taking appropriate action. One of the strengths 12

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ment to evaluate care being given. of the model is that it permits the use of many existing methodologies. For example, Phaneuf‘s Criteria: (The American Nurse, July 1975) Predetermined statements or elements against which method focuses on process criteria, JCAH audits aspects of the quality of care to be given or being focus on outcome, but the Lang model enables the given may be compared. There are three types of use of several methods. criteria. Because the Lang model is circular in design, it Process criteria: Descriptions of activities in the allows evaluation and re-evaluation to proceed withdelivery of care. out introducing any false concept that quality assurStructure criteria: Descriptions of the inance is a terminally directed endeavor. stitutions or programs, including the physical environment. SUMMARY Outcome criteria: Descriptions of the results of the care. Nurses today are becoming actively involved in Peer review: Evaluation of clinical management professional accountability. They already individand judgment by fellow practitioners as applied ually analyze the care they give in order to evaluate to care provided for an individual. their practice. For years, individual nurses have Standards: (NAACOG Committee on Practice Pabeen using informal peer review by simply reviewper, 1976) An agreed on level of excellence. ing colleagues’ charts. But because of demands by consumers and the cost consciousness of the federal government, nurses are urged to evaluate care more precisely. This is being done both through general References quality assurance programs using a variety of methI . Cowles, J. M . : “Malpractice Liability and PSRO.” odologies and participation on PSRO Advisory Hosp A d m i n Currents l9(6):1, 1975 Boards. Direct involvement in quality assurance en2 . Somers, A. R . : Health Care in Transition. Chicago, ables the nurse to direct her or his care as well as Hospital Research and Educational Trust, 1971 influence advances in general health care. Lack of 3. Lembcke, P. A , : “Evolution of the Medical Audit.” involvement will invite nonnursing personnel, such J A M A l 9 9 : l l l , 1967 as hospital administrators, bureaucrats, and physi4. Ball, J. R . : “Quality of Care Through PSRO.” J Leg Med 4(8):17, 1976 cians, to direct care without nursing input. An over5. Slee, V. N . : The Medical S t a f i n the Modern Hospiall understanding of the concept and importance of tal. New York, McGraw-Hill, 1965 quality assurance can assist the individual nurse in 6. Payne, B.: “Continued Evolution of a System of seeing her or his place in its implementation. Medical Care Appraisal.” J A M A 201: 126, 1967 APPENDIX: Glossary of Terms Quality assurance: A guarantee of improvement of care through continual evaluation. Chart audit: A review of charts for content and evaluation of care as applied to a previously existing set criteria of care. A chart audit may be internal or external; retrospective or concurrent. Internal chart audit: An audit performed by those inside the program. External chart audit: An audit performed by those outside the program, which thus has additional assurance of objectivity. Retrospective chart audit: An audit performed after treatment or management is concluded, in order to evaluate the care given. This is usually done in hospitals after discharge. Concurrent chart audit: An audit performed at set times during ongoing treatment or manageMay/June 1977 JOGN Nursing

7. Donabedian, A. : “Promoting Quality Through Evaluating the Process of Patient Care.” Med Care 6(3):181, 1968 8. Public Law 92-603 9. Goran, M. J., J. Roberts, M. Kellogg, J. Fielding, and W. Jessee: “The PSRO Hospital Review System.” Med Care (Suppl 1) 13(4), 1975 10. Eddy, L., and L. Westbrook: “Multidisciplinary Retrospective Patient Care Audit.” A m J Nurs 75(6):961, 1975 11. Kroeger, H., I . Altman, D. Clark, A. Johnson, and C. Sheps: “The Office Practice of Internists.” J A M A 193(5):121, 1965 12. Komaroff, A. L., B. Reiffen, and H. Sherman: “An Evaluation of Protocols for Monitoring Physician Extenders.” Med Times 102(6):99, 1974 13. American Nurses Association: A Plan for Implementation of the Standards of Nursing Practice. Kansas City, Missouri, ANA, 1975 14. Nurses Association of the American College of Obstetricians and Gynecologists: Obstetric, Gyneco-

logic, and Neonatal Nursing Functions and Standards. Chicago, NAACOG, 1974 13

15. American Nurses Association: Guidelinesfor Review of Nursing Care at the Local Level. Kansas City, Missouri, ANA, 1976 16. HR 14173 (1976), S 3606 (1976)

Address requests for reprints to Ms. Nancy Jo Reedy, C N M , 850 South Miller, Chicago, IL 60607.

Mary Brucker received her B S and M S degrees in nursing at Saint Louis University. She obtained her nurse-midwifery education from the University of Mississippi and is currently in practice with a private obst etrician-gynecologis t in Chi cago. Ms. Brucker is acting Chairperson of the Illinois Nurses Association Quality Assurance Committee and a m e m b e r of the YSHOIQuality Assurance subcommittee of the ACNM Clinical Practice Committee. She holds

memberships in NAACOG, ACNM, ANA, and ASPO. She has had clinical and teaching experience in a variety of settings, is an experienced public speaker and writer. Nancy J o Reedy received her B S N from the University of Texas. She graduated from the nurse-midwifery program at the University of Mississippi and is currently the Peranatal Center Coordinator of Prentice Woman’s Hospital, Northwestern Medical Center, Chicago. Ms. Reedy is also studying for a Master’s degree at the University of lllinois School of Public Health. She i s on the PSROIQuality Assurance subcommittee of the ACNM Clinical Practice Committee and a member of NAACOG, ACNM, AFS, and APHA. She has had extensive clinical and teaching experience and is coauthor, with M s . Brucker, of “Well Woman Gynecology” in The Journal of Nurse-Midwifery.

Nurse Educator Conference

The first annual Nurse Educator Conference will be held November 7-9, 1977, at the Hyatt Regency Hotel, downtown Chicago. The transition from student nurse to effective professional is the overall theme of the Conference. Providing a much-needed forum, the Conference will address issues and subjects of interest to all working nurse educators, including curriculum and program development, teaching methods, educational philosophy, and more. Program Advisor is Barbara J. Stevens, RN, PhD, Associate Professor of Nursing Service Administration, University of Illinois, College of Nursing, Chicago. “The program,” says Dr. Stevens, “is aimed at four general areas of nursing education interest: educational administration, pre-service (schools) faculty, in-service faculty, and teaching technologies including such topics as ‘risk taking’ and ‘coping with stress.’ The three-day series of general lecturetype sessions and intensive workshops also feature a unique evening program of ‘Dinner Dialogues.’ At informal dinner sessions, attendees will dine with Conference speakers and discussion leaders, so that an interchange of ideas on a face-to-face basis will be promoted.’’ Exhibits by leading publishers, equipment manufacturers, and other organizations in nursing education are an integral part of the 3-day conference. For further information contact S. Swartz, 12 Lakeside Park, 607 North Avenue, Wakefield, MA 01880, (617)246-0782.

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