Monitoring the Quality of Health Care

The health care system in the United States enters the twenty-first century as a vast industry, indeed by some measures the largest in the country. The system comprises powerful financial interests, vast administrative bureaucracies both governmental and private, and large complexes that develop and manufacture the products used in health care. Latterly, these corporate and government interests have spawned yet another large industry, aimed at assessing whether the other participants in the health care financial bonanza are getting value for their investments. This most recent development began with various attempts at quality assurance and has subsequently adapted to become the field known generically as managed care.

Historically, the push for more external oversight of health care came from third-party payers, including the government, who wanted to ensure the efficiency and effectiveness of the services they paid for and to minimize waste, fraud, and abuse. To help “manage” health care in that sense, measurements of the quality of medical practice were called for, partly because, as costs rose; identifying and selecting the best resources was viewed as a means to cost effectiveness (Stryer, et al., 2000).

Although health care quality has been defined in many different ways, it is probably fair to say that none has clearly captured all the elements involved. One of the more comprehensive definitions, developed for the Department of Veterans’ Affairs, states that “quality health care is care that is needed and delivered in a manner that is competent, caring, cost effective and timely and that minimizes risk and achieves achievable benefits” (Barbour, 1996). This definition, though adequate, has all the grace usually found in the products of committees, of which it clearly is an example. Translated from committee jargon, the definition can be summed up as “quality health care is doing the right thing, at the right time, and in the right way.” To provide health care of high quality, then, we have to know what is the right action, seize the right time, and single-mindedly pursue the right way—a tall order, indeed.

The complexity and variability of the definitions given for the quality of care confuse physicians, patients and even specialists on this issue. Donabedian, a leader in the field of health care quality, has recognized that “several formulations are both possible and legitimate, depending on where we are located in the system of care and on what the nature and extent of our responsibilities are” (Donabedian, 1988). This wise view acknowledges that among professionals the types of interest in quality may vary. A conscientious physician in a busy practice may have a compelling interest in the quality of her or his daily interactions with patients, which is assessed essentially by immediate patient feedback. Similarly, nurses or other professionals want ongoing reassurance of the merits of their work. To such professionals, retrospective reviews months after the fact have secondary interest or importance. Their central focus is on the outcomes for particular patients, although the responses of groups have been of interest to professionals and have prompted many improvements in management.

In health care, quality assurance systems that assume one size fits all are nearly meaningless. They produce data that, for any particular segment of the health care spectrum, cannot help to improve performance. This point cannot be overemphasized. One reason for the limited acceptance of quality management programs has been that while they may help one segment of health care providers when implemented, other individuals or groups of health care providers have found their contributions to be irrelevant or marginal. In fact, even a cursory examination makes clear that different health care constituencies require differing forms of quality management. If quality assurance is to progress, it is mandatory to distinguish those differing interests.

“The knowledge, judgment, and skill of the physician is the single most important determinant of the quality of health care.” This is the conclusion of Enthoven and Vorhaus (1997), although they caution that completing a residency and achieving licensure do not ensure that a physician has those necessary qualities. This “single most important determinant” of health care has received surprisingly little attention in the many recent initiatives to improve its quality. The well-honed skills of the physician are indeed essential to good care, and no structure, good process or oversight can compensate for their absence. It is remarkable, then, that in many institutions, quality management is carried out quite separate from physicians’ and other providers’ practice. It is even the case that first-line providers often are not privy to the findings of the quality managers.

Legislative and market-driven reform initiatives are creating enormous pressures not only to improve the quality and efficiency of health care delivery in the United States but also to industrialize the structure and function of health care delivery. It is no coincidence that the health care sector is investigating and applying the tools with which manufacturing and service industries have improved their performance in changing environments. As health care as an industry moves toward full automation, it puts health organizations under pressure to interchange standards, to integrate data and to gather data on resource usage, outcomes and quality. Organizations are establishing partnerships to share the costs of collecting and integrating data.

Several attempts have been made to use administrative databases to assess the quality of care, to make comparisons or to set benchmarks (Lee and Wan, 2002; Wan, et al., 2002). Of the large banks of administrative data in hospitals, insurance corporations and state and federal agencies, many are essentially files of reimbursement claims, but the files have recognized advantages. They are accessible due to routine collection and electronic storage. They contain information on thousands, sometimes millions, of cases. They provide a more complex, less skewed description of services than accounts from a single location do. Moreover, they contain information covering long time periods, allowing longitudinal studies; and the spectrum of cases allows study of large subgroups of populations.

For many years, physicians and other health care professionals have reviewed written medical records to assess outcomes. Medical record review is widely used for oversight, both internally by hospitals and other facilities and by oversight agencies (e.g., peer review organizations acting for third party payers, insurance companies and governmental bodies.)

It is likely that health care providers will increasingly compete on the basis of value (the quality of care in relation to the total cost of care) and that health plan members (not patients) and purchasers of care (not third-party payers) will be viewed as the main customers of the health care system. Whether or not this comes to pass, the attitudes and satisfactions of patients will continue to be paramount.

Historically, professional accountability has been handled directly by the licensing, accreditation and credentialing of providers, by granting privileges and by continuing medical education. All health professionals: physicians, nurses, pharmacists, laboratory technologists, physician’s assistants and others must follow programs of preparation and meet defined professional standards to become eligible for licensing by state boards.

Dissatisfaction with traditional quality assurance has led administrators to apply other industrial models of quality management to the health care field (Thompson, et al., 2000). Two such models from industry are total quality management (TQM) and continuous quality improvement (CQI). The concepts ofTQM and CQI are often thought of as the same, but they are not. TQM has been as defined as “the management philosophy and system that promotes positive organizational change, as well as an effective cultural environment, for continuous improvement of all aspects of the organization.” CQI has been defined as “a systematic approach to the measurement, evaluation and improvement of the quality of all products and services, through the use of disciplined inquiry and teamwork” (Gift, 1992).

All the changes and introductions of measurement tools reviewed here have transformed medical practice, and the revolution is far from complete. Much more study, research, reflection and testing are necessary to bring quality management and accountability in health care to functional maturity. More developments have been tried and found wanting than have found satisfactory use. In some areas the level of knowledge is no more than embryonic, and in others it is still in its infancy. However, enough initiatives have reached levels of respect and implementation to demonstrate that the assessment and improvement of quality in health care will remain important, perhaps essential elements of practice and administration. The most significant achievement of recent years is the now willingness by all sectors of the health care industry as well as the health care professions to include not only cost but also quality assessments as part of what has become the business of health care.

Under pressure by powerful third party payers to cap soaring health care costs, health care provider organizations have felt the urgent necessity to deliver care more efficiently if they want to stay in business. Such a cost-efficiency approach to the delivery of health care focuses on two potential relationships: that between cost and utilization and that between cost and productivity. In view of such priorities, the recipients of health care have a strong intuition- and the right- to inquire about the quality of the health care services being rendered (Donabedian, 1980; Kazandjian, 1995).

Previous chapters have taken a hard look at both the conceptual and the methodological problems of coming to terms with the quality of health care in this era. A variety of study designs and analytic approaches can be used to examine the effects of an intervention program on patient care outcomes, individually and in the aggregate. For example, clinical case management is designed to improve patient care outcomes and to reduce the cost of care. The implementation of case management in hospitals could be based on a variety of study designs. The level of scientific rigor, contingent upon the study design, ranges from a case study to a randomized control trial. The case study only describes the configuration or structure of the case management program. However, little can be said about its cost-effectiveness. However, a clinical trial study design, assigning the intervention randomly to the experimental group with case management and a control group without the intervention, enables the investigator to draw strong causal inferences from the study findings. This chapter explains how causal analysis can be used to evaluate quality improvement programs, using multiple indicators for patient care outcomes.

After a period of intense focus on efforts to improve the cost efficiency of health care, there is a sense of rising urgency about identifying and improving the associated levels of the quality of care. A widely acknowledged indicator of quality is the occurrence of adverse, sentinel, events during care. The step toward reducing the risk of such events is to understand sometimes about their causes and the variation in their occurrence.

Health care delivery in the United States is still evolving away from the traditional, relatively simple professional paradigm characterized by a formal or implicit contract between a patient and a professional provider. It is far from clear what ultimate form will emerge for health care in this country. At present, care is increasingly provided through large corporate or governmental entities that, overwhelmingly, are fiscal intermediaries in its delivery.