Editorial
Quality Assurance and the Royal Australasian College of Physicians
T
he acceptance of a commitment to Quality Assurance (QA) by the College Council demands that all Fellows of the College consider their attitude to QA more closely. T h e Council commitment is directed at several areas of College activity: advanced trainees are expected to undertake a QA project during training; the Clinical Indicators project is under way; and the Board of Continuing Education has accepted that QA should be part of the Recertification process. This major step of the College may suggest that all aspects of QA activities have been clearly defined and processes well-established to allow all of this to proceed. However, there remains a considerable degree of confusion over issues such as: The definition of QA as it applies to the practice of medicine; and the implications of the College commitment for physicians in a busy clinical practice. Important questions arise for many: Can quality in medical practice be defined? Can it be measured? Will QA activities, whatever they may be, actually produce a measurable change in the process of health care delivery? A number of authors have sought to provide definitions of quality as it relates to the practice of medicine. Reerink, from Holland, has drawn attention to a number of aspects of Quality Medical Practice and these include the issues of Technical Performance, Interpersonal Performance and Organisational Performance. All of these contribute to the quality of the service delivered by a medical practitioner to an individual patient. Each of these identified components can be observed, measured, allowing one practitioner or health delivery service to be rated against others providing the same services. By breaking the process of health care delivery into measurable or definable categories, it becomes possible to identify areas for QA activities more clearly and to examine the effects of changes in the various aspects on overall health care standards. Reerink identifies other important components of the delivery of quality services as the issues of Effectiveness and Efficiency. Effectiveness relates to whether the service does what was intended and whether the service or activity is done as well as it is in other services. It seems appropriate to compare the QLIALITY ASSURANCE Ah’D THE K A U ’
standard of service delivery between similar units claiming to provide the same services. Efficiency relates to whether there is a maximum benefit for the cost. It can be seen that the process of providing health care as physicians, surgeons or general practitioners can be examined in some detail and this examination can now focus on quite specific aspects of each medicalpatient-doctor interaction, identifying how well the process is being carried out. Our performances as individuals or as teams can be studied and compared with that of our peers. This process can provide an indication of the quality (as defined above) of the management provided by different service providers. One may still ask - is all of this activity relevant, important or helpful? Donabedian, one o f the great contributors to the QA field, states that ‘Quality of care is the extent to which actual care is in conformity with the present criteria of good care’. This suggests that the comparison of our personal delivery of health care can, and should be, compared with that ‘gold standard’ set by our peers. Why then is the issue of QA and/or the provision of Quality of Care a stumbling block for many in the practice of medicine? Perhaps it relates to a concern that the processes of QA will be used to identify ‘bad apples’ in the profession rather than being used to ensure that, overall, the provision of health care is optimal. It is sad to record that many practising physicians see QA processes as punitive rather than constructive. This may reflect the way in which QA activities were first introduced in Australia with some emphasis on seeking ‘bad apples’. Ideas and feelings about the process developed at that time have continued to influence individual reactions to QA so that it is again time to examine some of the issues relevant to QA. It is appropriate to continue seeking to define what Quality of Care and QA really mean. Some ask, do the two interrelate in any way? Confusion abounds in this area of discussion. Perhaps it can be simply put that the processes of QA are directed to ensuring that good quality of care is delivered to all patients in the health system be it private or public, hospital inpatient or outpatient. Aust NZ J Med 1992; 22 323
T h e World Health Organisation has defined a number of aspects of Quality Health Care. These aspects include: Accessibility: Personal accessibility; Comprehensive in nature; Quantitatively adequate. Quality: Professional competence; Personal accessibility; Qualitatively adequate. Contextual: Person-centred; Co-ordinated care. Efficiency: Equitable; Adequate codbenefit; Efficient administration. These definitions and statements about QA all focus on the positive process of delivering good care to patients presenting for help. We can extrapolate from this to a statement that QA in medicine is concerned with reviewing the standard of care received by a patient in its organisational, staffing and procedural aspects with the aim of producing a continuous improvement in patient satisfaction and outcomes entailing the most efficient use of resources. Most physicians, at some stage of their careers, have been involved in QA activities. Many have recognised this, others are more like Moliere’s character who did not recognise he had been speaking prose for 40 years without knowing it. There is now a need for the majority of practising physicians to develop an increased sophistication and extension of their QA activities. T h e College commitment encourages us all in this direction. Emphasis needs to be placed on a number of aspects of this regard: Concentration on perceived problem areas - ‘if it works, don’t touch it’; Quantification of data - QA is data driven; Emphasis on patient satisfaction and outcomes; Continuous review of data, seeking improvement; Active participation of all participants, not an imposed process. When it comes to examining how to implement QA activity for the benefit of patients, it must be said that cardiologists have shown the way. Cardiologists, worldwide, have demonstrated the value of co-operation in the collection of hard data on processes and outcomes. T h e multicentre trials examining the role of anticoagulants and fibrinolytic agents in coronary artery disease and in other areas of cardiology have documented the value of data-gathering on appropriate size populations and the effect of this process on ultimate patient care. Other disciplines need to follow the example of our cardiological colleagues.
The W a y A h e a d .
..
Much has been said about QA in the last decade. Many would suggest it is now time to move from discussion to action. T h e College encourages us all to take some steps along the road of improving our QA activities. 324 Aust NZ J Med 1992;
T h e following points can be made with respect to the way forward for Fellows of the College in this area: There is a considerable amount of data available in many areas of medical endeavour which need to be identified clearly and worked with in establishing new QA goals in the various disciplines covered by the College of Physicians. All specialties need to look at the way in which cardiology has set about defining patient satisfaction with various procedures and the value of medications in the management of various cardiological problems. Other disciplines could do this at a unit level or even at a society level as particular problems are identified that may be examined by a multicentre study. Good practice can be defined by a better understanding of the condition and its treatment. Without additional support at the level of hospitals and universities, the College’s commitment cannot proceed very far. Hospitals, in particular, need to support QA activities by: - . Gearing hospital information systems to QA. This will mean the commitment of computer resources to much more effective data-gathering in hospital systems. Private practices will also need to attend to this matter. Surveys of appropriately gathered information should be presented to staff on a regular basis. These data presentations should be geared to examining the quality of care provided and defining ways in which quality can be improved as a result of the availability of solid information. Hospitals should accept that all registrars in advanced training at least and basic training wherever possible should be involved in undertaking QA surveys. Many hospitals do encourage this activity. Having encouraged that activity there needs to be a process whereby problems identified by the surveys can be addressed within the hospital system. Hospitals undertaking good surveys also need a forum whereby that information may be fed to other hospitals, thus saving the need for multiple repetitious studies around the country. One of the negative experiences of many hospitals undertaking QA has been the awareness that the identification of problems often fails to produce any change in practice. Hospitals need to support QA processes by establishing mechanisms to deal with identified problems. These mechanisms may be located within departments or may be hospital based. In coming to grips with QA activities in the 1990s, we firstly need to avoid jargon and truly define the processes that have been discussed. In undertaking QA activities specific aspects of the various processes that
111
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141
151
161
22
DUGGAN AND BATEY
are being examined need to be identified and defined clearly. Those who are promoting QA as a way forward in the development of health services need to encourage those in the practice of medicine with the fact that they have actually undertaken many QA activities along the way. Practising doctors need to be reassured that the present enthusiasm will merely require many of them to increase their awareness of the processes; for some there will be a need to increase their involvement in them. Practitioners need to be made aware that QA activities can lead to changes. QA enthusiasts need to demonstrate that their activities have led to change. College Council is to be commended for its decision to commit the Fellowship to QA processes. The next decade is a crucial one in seeing the processes established and supported in this regard.
QL'ALITV ASSI'RANCE AN11 THE RACP
J. M. DUGGAN Director of Gastromterology, and R. G. BATEY GastroenterologistiHepatologist, Gastroenterology Unit, John Hunter Hospital, Newcastle, NSW. Further Reading Walton M. The Deming management method. London: Mricury Books, 1959. (An eminently readable account of the Japanese Quality scene.) Berwick DM. Continuous improvement as an ideal in health care. N Engl J Med 1989; 320: 53-6. Donabedian A. The quality of care: how can it be assessed? JAMA 1988; 260: 1743-8. Reerink E. Defining quality of care: mission impossible? Qua1 Assur Health Care 1990; 2: 197-202.
Aust NZ J Med 1992; 22
325
Quality Assurance and the Royal Australasian College of Physicians
T
he acceptance of a commitment to Quality Assurance (QA) by the College Council demands that all Fellows of the College consider their attitude to QA more closely. T h e Council commitment is directed at several areas of College activity: advanced trainees are expected to undertake a QA project during training; the Clinical Indicators project is under way; and the Board of Continuing Education has accepted that QA should be part of the Recertification process. This major step of the College may suggest that all aspects of QA activities have been clearly defined and processes well-established to allow all of this to proceed. However, there remains a considerable degree of confusion over issues such as: The definition of QA as it applies to the practice of medicine; and the implications of the College commitment for physicians in a busy clinical practice. Important questions arise for many: Can quality in medical practice be defined? Can it be measured? Will QA activities, whatever they may be, actually produce a measurable change in the process of health care delivery? A number of authors have sought to provide definitions of quality as it relates to the practice of medicine. Reerink, from Holland, has drawn attention to a number of aspects of Quality Medical Practice and these include the issues of Technical Performance, Interpersonal Performance and Organisational Performance. All of these contribute to the quality of the service delivered by a medical practitioner to an individual patient. Each of these identified components can be observed, measured, allowing one practitioner or health delivery service to be rated against others providing the same services. By breaking the process of health care delivery into measurable or definable categories, it becomes possible to identify areas for QA activities more clearly and to examine the effects of changes in the various aspects on overall health care standards. Reerink identifies other important components of the delivery of quality services as the issues of Effectiveness and Efficiency. Effectiveness relates to whether the service does what was intended and whether the service or activity is done as well as it is in other services. It seems appropriate to compare the QLIALITY ASSURANCE Ah’D THE K A U ’
standard of service delivery between similar units claiming to provide the same services. Efficiency relates to whether there is a maximum benefit for the cost. It can be seen that the process of providing health care as physicians, surgeons or general practitioners can be examined in some detail and this examination can now focus on quite specific aspects of each medicalpatient-doctor interaction, identifying how well the process is being carried out. Our performances as individuals or as teams can be studied and compared with that of our peers. This process can provide an indication of the quality (as defined above) of the management provided by different service providers. One may still ask - is all of this activity relevant, important or helpful? Donabedian, one o f the great contributors to the QA field, states that ‘Quality of care is the extent to which actual care is in conformity with the present criteria of good care’. This suggests that the comparison of our personal delivery of health care can, and should be, compared with that ‘gold standard’ set by our peers. Why then is the issue of QA and/or the provision of Quality of Care a stumbling block for many in the practice of medicine? Perhaps it relates to a concern that the processes of QA will be used to identify ‘bad apples’ in the profession rather than being used to ensure that, overall, the provision of health care is optimal. It is sad to record that many practising physicians see QA processes as punitive rather than constructive. This may reflect the way in which QA activities were first introduced in Australia with some emphasis on seeking ‘bad apples’. Ideas and feelings about the process developed at that time have continued to influence individual reactions to QA so that it is again time to examine some of the issues relevant to QA. It is appropriate to continue seeking to define what Quality of Care and QA really mean. Some ask, do the two interrelate in any way? Confusion abounds in this area of discussion. Perhaps it can be simply put that the processes of QA are directed to ensuring that good quality of care is delivered to all patients in the health system be it private or public, hospital inpatient or outpatient. Aust NZ J Med 1992; 22 323
T h e World Health Organisation has defined a number of aspects of Quality Health Care. These aspects include: Accessibility: Personal accessibility; Comprehensive in nature; Quantitatively adequate. Quality: Professional competence; Personal accessibility; Qualitatively adequate. Contextual: Person-centred; Co-ordinated care. Efficiency: Equitable; Adequate codbenefit; Efficient administration. These definitions and statements about QA all focus on the positive process of delivering good care to patients presenting for help. We can extrapolate from this to a statement that QA in medicine is concerned with reviewing the standard of care received by a patient in its organisational, staffing and procedural aspects with the aim of producing a continuous improvement in patient satisfaction and outcomes entailing the most efficient use of resources. Most physicians, at some stage of their careers, have been involved in QA activities. Many have recognised this, others are more like Moliere’s character who did not recognise he had been speaking prose for 40 years without knowing it. There is now a need for the majority of practising physicians to develop an increased sophistication and extension of their QA activities. T h e College commitment encourages us all in this direction. Emphasis needs to be placed on a number of aspects of this regard: Concentration on perceived problem areas - ‘if it works, don’t touch it’; Quantification of data - QA is data driven; Emphasis on patient satisfaction and outcomes; Continuous review of data, seeking improvement; Active participation of all participants, not an imposed process. When it comes to examining how to implement QA activity for the benefit of patients, it must be said that cardiologists have shown the way. Cardiologists, worldwide, have demonstrated the value of co-operation in the collection of hard data on processes and outcomes. T h e multicentre trials examining the role of anticoagulants and fibrinolytic agents in coronary artery disease and in other areas of cardiology have documented the value of data-gathering on appropriate size populations and the effect of this process on ultimate patient care. Other disciplines need to follow the example of our cardiological colleagues.
The W a y A h e a d .
..
Much has been said about QA in the last decade. Many would suggest it is now time to move from discussion to action. T h e College encourages us all to take some steps along the road of improving our QA activities. 324 Aust NZ J Med 1992;
T h e following points can be made with respect to the way forward for Fellows of the College in this area: There is a considerable amount of data available in many areas of medical endeavour which need to be identified clearly and worked with in establishing new QA goals in the various disciplines covered by the College of Physicians. All specialties need to look at the way in which cardiology has set about defining patient satisfaction with various procedures and the value of medications in the management of various cardiological problems. Other disciplines could do this at a unit level or even at a society level as particular problems are identified that may be examined by a multicentre study. Good practice can be defined by a better understanding of the condition and its treatment. Without additional support at the level of hospitals and universities, the College’s commitment cannot proceed very far. Hospitals, in particular, need to support QA activities by: - . Gearing hospital information systems to QA. This will mean the commitment of computer resources to much more effective data-gathering in hospital systems. Private practices will also need to attend to this matter. Surveys of appropriately gathered information should be presented to staff on a regular basis. These data presentations should be geared to examining the quality of care provided and defining ways in which quality can be improved as a result of the availability of solid information. Hospitals should accept that all registrars in advanced training at least and basic training wherever possible should be involved in undertaking QA surveys. Many hospitals do encourage this activity. Having encouraged that activity there needs to be a process whereby problems identified by the surveys can be addressed within the hospital system. Hospitals undertaking good surveys also need a forum whereby that information may be fed to other hospitals, thus saving the need for multiple repetitious studies around the country. One of the negative experiences of many hospitals undertaking QA has been the awareness that the identification of problems often fails to produce any change in practice. Hospitals need to support QA processes by establishing mechanisms to deal with identified problems. These mechanisms may be located within departments or may be hospital based. In coming to grips with QA activities in the 1990s, we firstly need to avoid jargon and truly define the processes that have been discussed. In undertaking QA activities specific aspects of the various processes that
111
121
131
141
151
161
22
DUGGAN AND BATEY
are being examined need to be identified and defined clearly. Those who are promoting QA as a way forward in the development of health services need to encourage those in the practice of medicine with the fact that they have actually undertaken many QA activities along the way. Practising doctors need to be reassured that the present enthusiasm will merely require many of them to increase their awareness of the processes; for some there will be a need to increase their involvement in them. Practitioners need to be made aware that QA activities can lead to changes. QA enthusiasts need to demonstrate that their activities have led to change. College Council is to be commended for its decision to commit the Fellowship to QA processes. The next decade is a crucial one in seeing the processes established and supported in this regard.
QL'ALITV ASSI'RANCE AN11 THE RACP
J. M. DUGGAN Director of Gastromterology, and R. G. BATEY GastroenterologistiHepatologist, Gastroenterology Unit, John Hunter Hospital, Newcastle, NSW. Further Reading Walton M. The Deming management method. London: Mricury Books, 1959. (An eminently readable account of the Japanese Quality scene.) Berwick DM. Continuous improvement as an ideal in health care. N Engl J Med 1989; 320: 53-6. Donabedian A. The quality of care: how can it be assessed? JAMA 1988; 260: 1743-8. Reerink E. Defining quality of care: mission impossible? Qua1 Assur Health Care 1990; 2: 197-202.
Aust NZ J Med 1992; 22
325
