American Journal of Medical Quality

The purpose of this project was to determine whether changing clinicians' behaviors to reduce costs in a large academic medical center is facilitated by the prior existence of a total quality management program. Ten teams, made up primarily of clinicians, were charged with devising strategies for altering specific clinical behaviors to reduce costs without detriment to quality of care. Half the teams followed the center's total quality management approach. Team success was assessed by how well three key tasks were completed: problem definition, design of plan of action, and plan implementation. Two teams achieved outright success es, three had outright failures, and five were in between. Adherence to a total quality management approach was not found to be associated with team suc cess. A much better predictor of success was the level of involvement and support by clinicians and managers; because that factor is largely controlled by institution al incentives, those incentives may need to be realigned before the effectiveness of a total quality management approach can be properly evaluated.

Satisfaction with access to medical care and quality of care were compared using a survey instrument adapted from the Group Health Association of America Consumer Satisfaction Survey. Participants were mem bers of a large health maintenance organization employed by an employer group (Company) and other non-company members (Control). Overall, members reported high satisfaction with both access to medical care and quality of care. There were no significant dif ferences in satisfaction between Company and Control respondents. Stepwise regression identified the strongest predictor of satisfaction with access to care as ease of arranging appointments. Satisfaction with quality of care was predicted most strongly by out comes of medical care. These findings indicate that items with which members are least satisfied (access to doctor after hours, office waiting time, and time for routine appointment) do not predict either satisfaction with access to care or satisfaction with quality of care. Managed care organizations must develop and utilize evidence-based evaluation tools such as this one to assess the quality of care.

The cutbacks in Medicare and Medicaid reimburse ment, and the Republican takeover of Capitol Hill and the state legislatures as a result of recent elections, suggest that the payer-driven forces of managed care, capitated payment, and the regional networks (alliances) will serve as centerpieces to improve the organization, financing, and delivery of America's health services. These "voluntary" alliances that are now being forged as an amalgam of health providers and insurance underwriters, often foreshadow the pow erful, geographically linked regional health networks that are evolving into oligopolies throughout the United States. As the Department of Justice and the Federal Trade Commission are unable to appropriately analyze the efficacy of most prospective mergers, the American health field increasingly can expect monopo listic environments. In this process, the public eventu ally may demand the formation of state health services commissions. Within this framework, the German decentralized, multipayer, multitier approach, which historically is self-governing and allows for negotiating reimbursement rates between insurers and providers, offers a preferred option to the traditional American public utility model.

In 1993, Continental Medical Systems, Inc. (CMS), a provider of comprehensive medical rehabilitation, devel oped the Total Outcomes and Prediction Program® (TOPP®) to measure and evaluate key medical rehabilitation out comes, quality indicators, and patient satisfaction at its 37 acute rehabilitation hospitals. The broad purposes of TOPP® are to manage patient treatment, improve the cost-effec tiveness of care, and provide outcomes reporting for man aged care and other interested parties. The challenge was to develop a system which could measure, evaluate, and report medical rehabilitation patient outcomes in a way that could be easily understood by multiple audiences, including payers, accrediting organizations, physicians, patients and families, case managers, and CMS clinical staff. Using data from the Uniform Data System for Medical Rehabilitation database, CMS created descriptive outcomes reports for each hospital and for the corporation overall, including performance statistics, outcomes report cards, and quality report cards. These initial reports, as well as updates, quarterly reports, and special ad hoc requests, provide CMS corporate and hospital staff with statistically valid and reliable information to manage the outcomes of medical rehabilitation treatment. TOPP@ has assisted CMS with meeting accreditation standards for outcomes man agement and measurement and has been used in managed care contract negotiations. Future TOPP® efforts will inte grate resource use data, medical acuity and outcomes from acute, subacute, and outpatient rehabilitation levels into CMS' outcomes reporting system.

This study investigates a new method of measuring quality of care. Taking place at a tertiary psychiatric hos pital with 5,128 admissions from January 1989 through December 1995, this study uses artificial neural networks (ANNs) to predict hospital length-of-stay (LOS) and uses the standard deviation of LOS in a formula to measure quality of care, Q. ANNs are trained with data using unique patient identifiers and are compared with iden tical ANNs trained without these identifiers. These two types of ANNs make a LOS prediction, P, with a slightly different accuracies, and this fact is exploited in mea suring Q. The authors defined U as the standard devia tion of the difference between the actual and the predicted LOS of the ANNs with unique patient identi fiers, and defined G as the standard deviation of the dif ference between the actual and the predicted LOS of the ANNs without using these unique identifiers. Dividing U, the variation of individual LOS patterns intertwined with systemic LOS patterns, by G, the variation of pre dominately systemic LOS patterns, yields the ratio U/G, in which systemic effects are factored out leaving a mea sure of the average severity of patient illness. Ratios that exceed unity are seen in the patients who are more severely ill. The formula for quality of care, Q, divides the best LOS prediction accuracy, P, which is inversely pro portional to overall variation in the delivery system, by U/G, which is inversely proportional to quality of care, written as: Q = P/(U/G). Q reflects the patients' per spective because LOS is concrete and tangible to patients. The study took place during hospital downsizing (polit ical change), a consent decree (policy change), new administrative and medical personnel (staffing change), and the introduction of clozapine and risperidone for schizophrenia (therapeutic change). These events had a predominantly positive impact on Q. The value of Q cor related well with the Joint Commission on Accreditation of Health Care Organizations (JCAHO) triennial evalu ations. Some conclusions that emerged from this study: 1) System variation, reflected in the standard deviation of LOS, increased with frequent changes in top manage ment. 2) There was a clear-cut beneficial effect of cloza pine, and to a lesser extent of risperidone in schizophrenia, allowing more community placement. 3) With a dedicated professional staff quality of care can pre vail despite increasing variation in LOS (systemic prob lems). 4) The number of hospital employees per Q unit halved when the overall hospital Q ranged from low to high values as a result of policy and staffing improve ments, suggesting an increased efficiency of operation. 5) Q can be an objective outcome measure of quality care from the patients' perspective.

Effective discharge planning should serve to reduce length of stay (LOS) and lower readmission rates. A com bined prospective/retrospective study was undertaken to assess the effectiveness of anticipated discharge order forms in decreasing LOS for staff pediatric patients. Resident physicians provided advance notice of the planned discharge date to nursing staff and patient fam ily members. Patient selection was random, and the data were collected prospectively. These subjects were matched with patients for whom the order form was not used, and the data was collected retrospectively. Matching variables included: diagnosis, age, gender, race, and method of payment. There were 103 matched pairs. LOS was collapsed into low and high categories. There was a significant difference when comparing subject groups (χ² = 8.5; P = 0.005). Whereas only 14% of experimental patients were categorized as high LOS, 32% of control patients were classified as such. Physician prediction of discharge date helped decrease patient LOS.

This study examines the extent, motivation, and per formance implications of formal quality improvement (QI) programs in Pennsylvania nursing care facilities. Responses to a 20-item survey sent to facility adminis trators indicate that continuous quality improve ment/total quality management (CQI/TQM) adopters are more motivated by quality of care and human resource concerns in implementing QI, more satisfied with the results of QI efforts, and more aware of a com petitive environment than are non-adopters. There are few differences between adopters and non-adopters with respect to organizational characteristics or per formance on quality of care measures. Comparison with the results of a study of QI implementation in hospitals reveals some differences in motivation, but similarities in satisfaction with results.

Florida legislation implemented in the fall of 1992, unique in the nation, mandated that practice guidelines regarding cesarean section deliveries be disseminated to obstetric physicians. The law also required that peer review boards at hospitals be established to review ce sarean deliveries and that the exact dates of implemen tation of the guidelines be reported to a state agency. To determine the impact of the legislation, we conducted a retrospective analysis of 366,246 total live births oc curring in Florida hospitals during 1992 and 1993, be fore and after formal hospital certification of the implementation of the guidelines. Changes in primary and repeat cesarean rates were analyzed for 108 inde pendent groups of births, controlling for the mother's age, race, payment source, and the timing of the imple mentation of the guidelines at hospitals. The guideline certification program did not accelerate the consistent but gradual downward trend in cesarean births which had already been evident in the three prior years. The data do suggest that the guideline program may have af fected repeat cesareans more than primary cesareans, especially in the first quarter of 1993, immediately after the hospital certification period. Reductions in repeat cesareans involved both Medicaid and commercially in sured births, whereas reductions in primary cesareans were found almost exclusively within commercially in sured mothers, where the existing rates are highest. Although births with a prior cesarean represent only 12.5% of all births, significant decreases in repeat ce sareans were found in groups representing 72.6% of this population. By comparison, significant decreases in pri mary cesareans were found in groups representing only 36.5% of the births without a prior cesarean. The date of guideline implementation reported by hospitals was not related to any systematic change in observed ce sarean section rates. We concluded that the mere dis semination of practice guidelines by a state agency may not achieve either the magnitude or the specificity of the results desired without an explicit and thorough guideline implementation program. Blunt legislative man dates may be ineffective when multiple initiatives are already achieving desired outcomes.

A hospital performance improvement project to improve the quality of x-ray interpretations in the emergency department is described. To amplify the benefits of this project, a multimedia computer pro gram containing this information was created and dis tributed via the mail and over the internet. Users are encouraged to copy the program disks and distribute them to others (no fees or royalties). The advantages of this method over conventional journals in print are described. Successful distribution of this program, known as Radiology Cases in Pediatric Emergency Medicine (RCPEM), and positive feedback from users, stimulated the continuation of this project, which has now released its fifth volume with two more volumes planned. RCPEM (a hospital performance improvement project) now continues to expand as the knowledge gained is disseminated over the internet to improve the quality of care rendered to children all over the world. Amplifying the benefits of other performance improve ment projects can be done in a similar manner.