Quality Assurance for Alcoholism Treatment Willard 0.Foster, Jr. Mechanisms that seek assurance of quality care at reasonable cost include utilization review, accreditation, certification, licensure. and patient care audit. Within the social rehabilitative field, it is probably safe to say that only alcoholism has developed and implemented what might be considered the majority of the significant elements of a quality assurance program.
A
S SECOND- and third-party payments for health care become the rule rather than the exception, the concept of quality assurance in the rendering of such care assumes an added dimension through becoming an evaluative mechanism to facilitate fiscal accountability. This is particularly true when the source of payment is the public dollar. To a considerable extent, it is this added dimension that stipulated t h e requirement through law of regional Professional Standards Review Organizations (PSRO), a peer review committee mechanism, for those hospitals providing treatment under the Medicare, Maternal and Child Health, and Medicaid provisions of the Social Security Act (Section 249F of PL 92-603). The goal is to assure the federal government that the care purchased was necessary and of sufficiently high quality to be worth the cost as well as justifying the utilization of the hospital services employed. Under this procedure, documented clinical evidence is used to support diagnosis and corresponding treatment of those patients whose records indicate a length of stay or treatment regimen that deviates from a norm set for this purpose. Utilization review is thus developed to evaluate the appropriateness of the admission, the diagnostic evaluation, the treatment plan, the type of treatment rendered, the use of ancillary services, the length of stay, and the treatment plan outcome. Although it may be true that PSRO activity has been subjected to increasing criticism over the past 2 yr, it is obvious that most of this criticism can be related to factors that concern implementation of the PSRO process (perhaps even some lack of integrity therein) and not necessarily to the mechanism itself. Configurations o r mechanisms that seek assurance of quality care at reasonable cost include utilization review, accreditation, certification, licensure, and patient care audit. In
essence, each of these configurations is a form of peer review, using selected providers or former providers at an appropriate level of training as standard setters and evaluators. , Within the social rehabilitative field, it is probably safe to state that only alcoholism has developed and implemented what might be considered the majority of the significant elements of a quality assurance program. In 1974, as the result of intensive exploration of program performance utilizing a large number of consultants from the alcoholism field, the Joint Commission on Accreditation of Hospitals (JCAH) published an Accreditation Manual on Alcoholism Programs. Additionally, fiscal year 1979 should see the implementation of a nationally recognized accreditation procedure for the primary caregiver in alcoholism-the counselor-again as a result of consensus derived from the deliberations of significant organizations and qualified individuals representing this field. As with the establishment of program standards that serve as a baseline by which performance may be measured, a counselor accreditation process is a critical step in quality assurance, as it creates the body of peers both qualified and necessary to measure adherence to the standards without which the concept of peer review cannot be maintained. It is now appropriate, if not essential, that the alcoholism field visualize, develop, and implement outcome criteria as the final elements that complete the total concept of quality assurance applying to the unique aspects of the basic medical-social-rehabilitative process that categorizes the treatment of alcoholism. As with the development of alcoholism program standards and counselor certification, there are core components held in common with other fields of health care, most particularly drug abuse and mental health. This is reflected in the draft of the National Core Standards for Mental Health From the National Institute on Alcohol Abuse and AIcoholism. Rockville, Md. Reprint requests should be addressed to Willard 0. Foster. Jr.. Special Assistant to the Director, National Institute on Alcohol Abuse and Alcoholism, 56600 Fishers Lane, Rockville, Md. 20857. @ 1978 by Grune & Stratton. Inc. O l 4 5 ~ ~ / 7 8 / 0 2 0 3 - ~ 3 6.oO/O $01
Alcoholism: Clinicaland Experimental Research, Vol. 2.No. 3 (July). 1970
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being developed under the aegis of the National Institute of Mental Health. For a variety of reasons, not the least of which is the now greater probability of at least incremental implementation of a national health insurance plan, prompt action on the definition of output criteria by the alcoholism field would be appropriate. The feasibility of such an activity is somewhat enhanced by the nearly 4-yr accreditation experience gained by the field under JCAH auspices. The determination of such criteria can be through whatever process, experience, or innovation demonstrates as most appropriate to the needs of the alcoholism field utilizing maximum field input. There are several cogent reasons why further delay would be significantly detrimental to the field and to the progress achieved so far in the rendering of quality care. Neither drug abuse nor mental health have fully developed and formally implemented any specific components of quality assurance to date, although elements of at least core standards are being studied and/or are undergoing field testing. There is little to gain in waiting for either of these related fields to gather a body of experience in standard setting. Alcoholism can be considered sufficiently unique from either drug abuse or mental health to warrant the unilateral development of outcome criteria. Further, events could well overtake us to our detriment, as any move to establish a national health insurance plan would undoubtedly require the rapid establishment of a mechanism not unlike the presently installed PSRO, within which alcoholism interests could well be submerged both in the haste and in a questionably strong medical orientation that could prevail. Lastly, the justifiable demand for accountability of public treatment funds, together with those expended in benefits by the commercial health insurance carriers, is especially strong in the still not generally well understood process of alcoholism treatment. The establishment of peer determined and evaluated outcome criteria to round out a full and ethical program of quality assurance would be the most direct and logical answer to this demand. It has been mentioned above that the actual determination of outcome criteria can be through whatever process, experience, or innovation demonstrates as most appropriate to the field utilizing maximum field input. It might be appropriate that the federal alcoholism agency, the National Institute on Alcohol
Abuse and Alcoholism (NIAAA), assume an enabling and coordinating role as would befit its resources both in available funds and staff. It played such a role in the establishment of program standards and is currently playing a similar, although more tortuous, role in counselor accreditation. Initially, in both accreditation and certification, a contract with an appropriate organization (JCAH and Littlejohn Associates, respectively) was used by the NIAAA to draw together a body of opinion from a wide crosssection of the alcoholism field from which program standards and counselor qualifications were derived. In this respect, t h e peer mechanism was properly employed. As there is nothing yet parallel to the JCAH in the area of staff certification, implementation of the contract products (standards and qualifications) have taken different directions. However, the mechanism could be equally appropriate for the determination of field-derived outcome criteria. The contract product could then be offered to the field for voluntary implementation (perhaps through s t a t e alcoholism authorities) and utilized by the Institute to meet demands placed on it by a national health insurance program or ongoing treatment efforts supported by Federal funds. NIAAA experience in drawing together both the program standards and a staff accreditation procedure would indicate that arriving at successful consensual determination of outcome criteria will not be an easy task. The alcoholism field suffers to a major degree from problems of terminology combined with frequently disabling friction between organizations as to their appropriate roles in the resolution of issues that bear upon the integrity and interests of the field as a whole. These factors could be particularly frustrating in arriving at a set of treatment outcome criteria where even occasional prior attempts to define “recovery” have been met with a response that has been marked more by the heat of emotionality than the light of reason, at least in the eyes of an occasionally astounded but more frequently bemused social and health care community. If the alcoholism field is to maintain its momentum toward the goal of eventual recognition and acceptance (by this same social and health care community) as an ethical and effective response to the needs of alcoholic people, it is essential that the issue of outcome criteria be addressed-and soon.
A
S SECOND- and third-party payments for health care become the rule rather than the exception, the concept of quality assurance in the rendering of such care assumes an added dimension through becoming an evaluative mechanism to facilitate fiscal accountability. This is particularly true when the source of payment is the public dollar. To a considerable extent, it is this added dimension that stipulated t h e requirement through law of regional Professional Standards Review Organizations (PSRO), a peer review committee mechanism, for those hospitals providing treatment under the Medicare, Maternal and Child Health, and Medicaid provisions of the Social Security Act (Section 249F of PL 92-603). The goal is to assure the federal government that the care purchased was necessary and of sufficiently high quality to be worth the cost as well as justifying the utilization of the hospital services employed. Under this procedure, documented clinical evidence is used to support diagnosis and corresponding treatment of those patients whose records indicate a length of stay or treatment regimen that deviates from a norm set for this purpose. Utilization review is thus developed to evaluate the appropriateness of the admission, the diagnostic evaluation, the treatment plan, the type of treatment rendered, the use of ancillary services, the length of stay, and the treatment plan outcome. Although it may be true that PSRO activity has been subjected to increasing criticism over the past 2 yr, it is obvious that most of this criticism can be related to factors that concern implementation of the PSRO process (perhaps even some lack of integrity therein) and not necessarily to the mechanism itself. Configurations o r mechanisms that seek assurance of quality care at reasonable cost include utilization review, accreditation, certification, licensure, and patient care audit. In
essence, each of these configurations is a form of peer review, using selected providers or former providers at an appropriate level of training as standard setters and evaluators. , Within the social rehabilitative field, it is probably safe to state that only alcoholism has developed and implemented what might be considered the majority of the significant elements of a quality assurance program. In 1974, as the result of intensive exploration of program performance utilizing a large number of consultants from the alcoholism field, the Joint Commission on Accreditation of Hospitals (JCAH) published an Accreditation Manual on Alcoholism Programs. Additionally, fiscal year 1979 should see the implementation of a nationally recognized accreditation procedure for the primary caregiver in alcoholism-the counselor-again as a result of consensus derived from the deliberations of significant organizations and qualified individuals representing this field. As with the establishment of program standards that serve as a baseline by which performance may be measured, a counselor accreditation process is a critical step in quality assurance, as it creates the body of peers both qualified and necessary to measure adherence to the standards without which the concept of peer review cannot be maintained. It is now appropriate, if not essential, that the alcoholism field visualize, develop, and implement outcome criteria as the final elements that complete the total concept of quality assurance applying to the unique aspects of the basic medical-social-rehabilitative process that categorizes the treatment of alcoholism. As with the development of alcoholism program standards and counselor certification, there are core components held in common with other fields of health care, most particularly drug abuse and mental health. This is reflected in the draft of the National Core Standards for Mental Health From the National Institute on Alcohol Abuse and AIcoholism. Rockville, Md. Reprint requests should be addressed to Willard 0. Foster. Jr.. Special Assistant to the Director, National Institute on Alcohol Abuse and Alcoholism, 56600 Fishers Lane, Rockville, Md. 20857. @ 1978 by Grune & Stratton. Inc. O l 4 5 ~ ~ / 7 8 / 0 2 0 3 - ~ 3 6.oO/O $01
Alcoholism: Clinicaland Experimental Research, Vol. 2.No. 3 (July). 1970
277
WILLARD 0.FOSTER. JR.
being developed under the aegis of the National Institute of Mental Health. For a variety of reasons, not the least of which is the now greater probability of at least incremental implementation of a national health insurance plan, prompt action on the definition of output criteria by the alcoholism field would be appropriate. The feasibility of such an activity is somewhat enhanced by the nearly 4-yr accreditation experience gained by the field under JCAH auspices. The determination of such criteria can be through whatever process, experience, or innovation demonstrates as most appropriate to the needs of the alcoholism field utilizing maximum field input. There are several cogent reasons why further delay would be significantly detrimental to the field and to the progress achieved so far in the rendering of quality care. Neither drug abuse nor mental health have fully developed and formally implemented any specific components of quality assurance to date, although elements of at least core standards are being studied and/or are undergoing field testing. There is little to gain in waiting for either of these related fields to gather a body of experience in standard setting. Alcoholism can be considered sufficiently unique from either drug abuse or mental health to warrant the unilateral development of outcome criteria. Further, events could well overtake us to our detriment, as any move to establish a national health insurance plan would undoubtedly require the rapid establishment of a mechanism not unlike the presently installed PSRO, within which alcoholism interests could well be submerged both in the haste and in a questionably strong medical orientation that could prevail. Lastly, the justifiable demand for accountability of public treatment funds, together with those expended in benefits by the commercial health insurance carriers, is especially strong in the still not generally well understood process of alcoholism treatment. The establishment of peer determined and evaluated outcome criteria to round out a full and ethical program of quality assurance would be the most direct and logical answer to this demand. It has been mentioned above that the actual determination of outcome criteria can be through whatever process, experience, or innovation demonstrates as most appropriate to the field utilizing maximum field input. It might be appropriate that the federal alcoholism agency, the National Institute on Alcohol
Abuse and Alcoholism (NIAAA), assume an enabling and coordinating role as would befit its resources both in available funds and staff. It played such a role in the establishment of program standards and is currently playing a similar, although more tortuous, role in counselor accreditation. Initially, in both accreditation and certification, a contract with an appropriate organization (JCAH and Littlejohn Associates, respectively) was used by the NIAAA to draw together a body of opinion from a wide crosssection of the alcoholism field from which program standards and counselor qualifications were derived. In this respect, t h e peer mechanism was properly employed. As there is nothing yet parallel to the JCAH in the area of staff certification, implementation of the contract products (standards and qualifications) have taken different directions. However, the mechanism could be equally appropriate for the determination of field-derived outcome criteria. The contract product could then be offered to the field for voluntary implementation (perhaps through s t a t e alcoholism authorities) and utilized by the Institute to meet demands placed on it by a national health insurance program or ongoing treatment efforts supported by Federal funds. NIAAA experience in drawing together both the program standards and a staff accreditation procedure would indicate that arriving at successful consensual determination of outcome criteria will not be an easy task. The alcoholism field suffers to a major degree from problems of terminology combined with frequently disabling friction between organizations as to their appropriate roles in the resolution of issues that bear upon the integrity and interests of the field as a whole. These factors could be particularly frustrating in arriving at a set of treatment outcome criteria where even occasional prior attempts to define “recovery” have been met with a response that has been marked more by the heat of emotionality than the light of reason, at least in the eyes of an occasionally astounded but more frequently bemused social and health care community. If the alcoholism field is to maintain its momentum toward the goal of eventual recognition and acceptance (by this same social and health care community) as an ethical and effective response to the needs of alcoholic people, it is essential that the issue of outcome criteria be addressed-and soon.
