Integration forces QI staff to expand scope
Well-documented patient records are key
By Patrice Spath, ART
Consultant in Health Care Quality and
Resource Management
Forest Grove, OR
(Editor's note: In the first of a two-part series, Ms. Spath addresses the growing number of accreditation responsibilities facing quality management departments as their health care organizations expand and integrate with non-hospital facilities. This month, readers will learn several important activities with regard to quality outpatient services and where to start when developing quality programs outside the hospital. Next month, readers will learn more about how to complete appropriateness reviews and where to find disease-specific criteria to assess outpatient quality.)
Hospitals are quickly contracting with physician clinics and other outpatient providers in an effort to unite providers throughout the health care delivery system. Although each integration approach is unique, they all have a consistent mission: 1) integrate a variety of providers; 2) deliver a continuum of health care services; and 3) increase market position and leverage.
Those collaborative efforts are challenging traditional hospital-based quality management programs to extend performance measurement activities into the outpatient environment. The leaders of the integrated delivery system must be assured that they are delivering seamless, cost-effective quality health care services. However, providers who have never been accredited by the Joint Commission on Accreditation of Healthcare Organizations or another accrediting group are unlikely to have systematic performance measurement and improvement activities in place. In many instances, it is up to the hospital's quality management staff to design and implement ambulatory quality systems.
A helpful reference for the development of ambulatory quality management systems is the accreditation standards of the Accreditation Association for Ambulatory Health Care (AAAHC) in Skokie, IL. The AAAHC was an arm of the Oakbrook Terrace, IL-based Joint Commission until 1979, when it split away as a separate nonprofit organization. The AAAHC accredits ambulatory centers, surgery centers, university health services, diagnostic imaging centers, multispecialty group practices, occupational health services, urgent or immediate care centers, and other ambulatory providers that may contract with health plans. As of 1995, the AAAHC had accredited approximately 465 organizations, 11 of which are health maintenance organizations.
The AAAHC standards are very similar in concept to the Joint Commission's requirements, with an emphasis on important activities being in place. For quality management, the AAAHC suggests the following important activities be periodically evaluated:
* education of -- and effective communication with -- patients concerning their conditions' diagnoses and treatments, appropriate preventive measures, and use of the health care system;
* accessibility and availability of health services;
* appropriateness and timeliness of diagnoses based on findings of the initial assessment (history and physical examination);
* treatment is consistent with clinical impression or working diagnosis;
* appropriateness and timeliness of consultations;
* absence of clinically unnecessary diagnostic or therapeutic procedures;
* appropriateness and timeliness of referrals;
* appropriateness and timeliness of follow-up regarding findings and tests;
* patient cooperation/compliance with treatment recommendations;
* continuity of care;
* provision for services when the organization's facilities are not open;
* appropriateness, accuracy, and completeness of clinical record entries;
* adequacy of transfer of information when patients are transferred to other health care providers;
* patient satisfaction;
* health services provided are consistent with current professional knowledge;
* clinical records are legible, documented accurately in a timely manner, and readily accessible to health care providers.
While the adequacy of clinical records is mentioned last by the AAAHC, it should be the starting point for clinic quality management activities. Without adequately documented patient records, many of the other review activities cannot be performed. The AAAHC has very specific clinical record requirements:
* Reports, histories and physicals, progress notes, and other patient information (such as laboratory reports, X-ray readings, operative reports, anesthesia records, and consultations) are reviewed and incorporated into the record in a timely manner.
* If a patient's clinical record is complex and lengthy, a summary of past surgical procedures, as well as past and current diagnoses or problems, is documented in that patient's record to facilitate the ongoing provision of rational care.
* The presence or absence of allergies and untoward reactions to drugs is recorded in a prominent and uniform location in all patient charts on a current basis.
* Entries in a patient's record for each visit include, but are not limited to:
-- date, department (if departmentalized), and provider name and professional status (for example, PT, MD, RN, and so forth);
-- chief complaint or purpose of visit;
-- clinical findings;
-- diagnosis or impression;
-- studies ordered, such as laboratory or X-ray;
-- therapies administered;
-- disposition, recommendations, and instructions given to the patient;
-- authentication and verification of contents by practitioner.
* Significant medical advice given to a patient by telephone is entered in the patient's record and appropriately signed or initialed.
* Entries in a patient's clinical records are legible to the clinical personnel in the organization.
* Any notation in a patient's clinical record indicating diagnostic or therapeutic intervention as part of clinical research is clearly contrasted with entries regarding the provision of non-research related care.
* Discussions with the patient concerning the necessity, appropriateness, and risks of proposed surgery, as well as discussions of treatment alternatives, are incorporated into the patient's medical record.
Periodically select a sample of clinic records and analyze the completeness of documentation. The form shown in Figure 1 (see p. 71) can be used to note review findings for each physician.
Patient satisfaction is an important quality component in outpatient services. The performance measures for each clinic should include periodic assessments of consumer satisfaction. Typical methods for measuring satisfaction include:
* self-administered questionnaire;
* direct observation;
* telephone/mail surveys;
* focus groups;
* interviews;
* content analysis (letters of complaint or praise).
At a minimum, each clinic should regularly survey patient satisfaction using self-administered questionnaires, such as the one shown in Figure 2 (see insert). The results should be gathered and analyzed. To obtain maximum understanding of customer needs, select patients can be invited to a focused group discussion session, where answers to open-ended questions can be solicited.
In conjunction with documentation reviews and patient satisfaction measures, studies of the appropriateness of outpatient care should be done.
[Editor's note: To contact the Accreditation Association for Ambulatory Health Care, call (708) 676-9610.] *
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