Physician performance assessment: nonequivalence of primary care measures

BACKGROUND: Assessment of the performance of primary care physicians requires multiple, reliable measures. This article explores the appropriateness of selected Health Plan Employer Data and Information Set (HEDIS) measures, developed to assess health plans, to assess individual physician performance. OBJECTIVES: To determine the consistency and reliability of 4 measures of primary care physician performance measures: cancer screening, diabetic management, patient satisfaction, and ambulatory costs. METHODS: The study population consisted of all 194 family practitioners and general internists providing ambulatory services in 1998 to a defined patient panel of 320,000 adult health maintenance organization members. Administrative data on physician practice and performance were assessed with multiple regression and analysis of variance. RESULTS: Each performance measure was significantly related to 1 or 2 of the other measures: high cancer screening rates with good diabetic management and high patient satisfaction, good diabetic management with high cancer screening rates, high patient satisfaction with high cancer screening rates and high ambulatory costs, or high ambulatory costs with higher patient satisfaction. Although 76% of the physicians ranked in the highest third for at least 1 measure, 81% of these high performers ranked in the lower third for at least 1 other measure. Three percent of physicians ranked exclusively in the top or bottom third on all measures. CONCLUSIONS: Care should be taken in assessing physicians based on narrow performance measures. Assessments of individual physicians with current performance measures might identify areas in which improvement is needed and to provide feedback to improve performance quality and efficiency. However, assumptions should not be made from one measure of performance to another.     

Continuous quality improvement through team supervision supported by continuous self-monitoring of work and systematic patient feedback

BACKGROUND: Evaluation of clinical supervision (CS) and exploration of its effects on the quality of care is a timely topic for research. The current emphasis in nursing is shifting towards continuous quality improvement (CQI), and the integration of this with CS seems to be an interesting challenge. So far the studies have relied mainly on supervisees' self-report data and patients have rarely been involved in research. However, the perspective of CQI requires that patients are involved in the quality improving efforts. AIM OF THE STUDY: The aim of this study is to describe how CQI was implemented through team supervision and supported by continuous self-monitoring of work and systematic patient feedback. METHODS: The team supervision intervention was organized on five wards between 1995 and 1998. The methods of statistical process control and control charts were applied in the study as part of the intervention. FINDINGS: Improvements in both patient satisfaction and the staff's self-monitoring of work were evidenced. A slow and minor upward trend was detected in the control charts and the variation decreased in the assessments. The patients' high and the staff's critical ratings drew nearer towards the end of the study. However, significant differences were found between the wards and not all wards showed improvements. Staff found it difficult to discern the effects of continuous patient satisfaction feedback and self-monitoring. CONCLUSIONS: The findings of the study show that CQI integrated with team supervision improves patient satisfaction and the overall quality of care.     

Looking forward: the end of autonomy

Forecasting how medicine will be practiced 50 years from now presents a challenge. While advances in technology will have a major impact, new cultural outlooks on physician professionalism and autonomy will have an even greater significance in daily practice.
The current healthcare system is in crisis. As members of a profession with responsibilities to both individual patients and society, all physicians have a duty to help solve the critical issues plaguing the healthcare system today. Solutions will require some major changes in the way physicians practice medicine.
The most important – and the most difficult – change will be relinquishing our long-held belief in the premise of physician autonomy. As recognized in the Institute of Medicine's (IOM) Quality Chasm report, medicine today requires "more to know, more to do, more to manage, more to watch, and more people involved than ever before." Looking forward, these complexities will only intensify.
To create the high-quality healthcare system of the future, the profession must discard its view of the physician as an independent, self-governing craftsman and adopt practices that are consistent with the principles of evidence-based medicine, continuous quality improvement (CQI), and transparency.     

持续质量改进在经外周静脉置入中心静脉导管护理中的实施及效果

目的评价持续质量改进（CQＩ）在经外周静脉置入中心静脉导管（PICC）患者中的应用效果。方法对2011年1月一12月收治且行PICC置管的40例患者进行回顾性调查,找出PICC置管护理存在的主要问题,分析PICC置管并发症的相关因素,制定相应的护理对策予以实施,并另选择2012年1月一12月49例PICC置管患者为对照,就实施CQI前后PICC置管患者并发症的发生率和患者满意率进行比较。结果实施CQI后PICC置管并发症发生率均比实施前降低（P〈0．05）,患者对护理的满意率上升至87．8％,比实施CQI前明显提高（P〈0．05）。结论实施CQI有利于降低PICC置管并发症的发生,患者满意率大幅提高。     

Patient satisfaction profiling of individual physicians: impact of panel status

RATIONALE, AIMS AND OBJECTIVES: Evaluation of physician performance is increasingly based on patient satisfaction. However, few data are available regarding the extent to which individual physician profiles might be influenced by factors such as whether a physician's practice is open or closed. We evaluated whether panel status (whether or not a physician is accepting new patients) is associated with patient satisfaction with their primary care physician (PCP). METHODS: Cross-sectional analysis of patient satisfaction surveys. Surveys were available for 1,750 patients cared for by 69 PCPs. Patient satisfaction with their PCP was determined based on a composite of six questions derived from the Medical Outcomes Study. We used Generalized Estimating Equations to adjust for physician level variation. RESULTS: Patients of closed-panel physicians were more likely to rate their satisfaction with the provider as 'Excellent' or 'Very Good' compared to patients of open-panel physicians (78% vs. 69%, P <0.0001). After adjusting for satisfaction with the practice site, provider years in practice, managed care coverage, provider productivity, and patient race, the association between a closed panel and satisfaction remained significant (odds ratio 1.60, 95% confidence interval 1.10-2.31). CONCLUSIONS: Individual physicians' patient satisfaction data are confounded by factors not likely to be adjusted for in available profiles. After adjusting for other variables, physicians with closed panels still had better patient satisfaction compared to physicians with open panels. Further research is necessary to determine if panel status might also confound patient satisfaction.     

From quality assurance to quality improvement. The Joint Commission on Accreditation of Healthcare Organizations and Emergency Care.

The transition from quality assurance to quality improvement is at an early stage, but it clearly has begun. The progressive anticipated changes in the tone and content of JCAHO standards will place the JCAHO in a different posture in relation to accredited hospitals. Standards are of course a set of requirements that must be met as a condition of accreditation. But the JCAHO's bottom line expectation will be a meaningful and demonstrated improvement in hospital performance. How hospitals reach this objective is their business. This shifts the onus of responsibility to where it belongs and suggests a more facilitative role for the JCAHO. Although the JCAHO is introducing standards requirements that are minimally essential to the achievement of improved performance, full-fledged adoption of CQI concepts will not be mandated. Management structures and styles in health care organizations vary considerably, and CQI is but one means to the desired end of improved performance. We believe, however, that it is the best means and that most organizations will discover this for themselves. Notwithstanding the magnitude of needed internal behavioral change, excellence in performance is what most health care organizations want for themselves and their patients. CQI offers them the opportunity to reach this lofty goal.     

Organization of hospital-based acute pain management programs.

BACKGROUND: The management of acute pain is an aspect of hospital-based practice that has been neglected. Control of pain is important for ethical reasons, for compliance with new guidelines and standards, and for optimizing patient satisfaction and outcomes. METHODS: Be review the rationale for establishing priority to the control of acute pain, the importance of an institutional approach to improve pain management, and specific steps in the establishment and conduct of an acute pain program. RESULTS: Improvement in pain control depends on an institutional approach to facilitate changes in attitude and prioritization. Pain management programs should provide for patient and staff education, adequate documentation of care, institutional standards for pain control, quality assurance/continuous quality improvement (CQI) activities, and periodic review of practice and policy. CONCLUSIONS: Effective pain management can set the stage for a rehabilitational approach to postoperative care, which should lead to earlier recovery and improved outcomes.     

Data-driven quality improvement in the Emergency Department at a level one trauma and tertiary care hospital

To demonstrate how a comprehensive and internally driven Continuous Quality Improvement (CQI) program was designed and implemented in our Emergency Department (ED) in 1999. This program involved monthly data collection and analysis, data-driven process change, staff education in the core concepts of quality, and data reanalysis. Data components collected during the program included census data, physician profiling, and focused clinical audits. CQI measures collected at the beginning of the program and quarterly included: (1) CQI metric data (turnaround times [TAT] and rates of left against medical advice [AMA] or left without being seen [LWOBS]), (2) rates and nature of patient complaints, and (3) results of patient satisfaction surveys performed by an outside consulting firm contracted by hospital administration. During the 4 years since its implementation the program demonstrated improvement in all measured areas. Despite an increase in patient volume of 32% to nearly 37,000 visits/year, and only minimal staffing adjustments, the mean quarterly TAT decreased from 183 min to 165 min (9.8% decrease), the rate of complaints dropped by 56.1% (2.1 per 1000 patients to 0.92), and patients leaving AMA or LWOBS decreased 66.7% from 2.7% to 0.9%. Overall, 44.8% of ED patients rated their care as "excellent." In summary, we demonstrate how a comprehensive quality improvement program was structured and implemented at a tertiary care center and how such a program demonstrated improvement in specific CQI parameters.     

Opinion of Japanese rheumatology physicians on methods of assessing the quality of rheumatoid arthritis care

Objective To examine the opinion of rheumatology physicians in Japan regarding desirable quality assessment methods. Methods We conducted a cross‐sectional self‐administered mail survey on a random sample of physicians and surgeons registered with the Japan Rheumatism Foundation. In the survey, respondents were asked to rank seven proposed assessment methods for the quality of rheumatoid arthritis care, namely patient satisfaction, risk‐adjusted outcomes such as complication incidence and admission rate, guideline compliance, waiting time at clinics, voting by local general practitioners, degree of newspaper and magazine reportage, and volume of patients receiving treatment for rheumatoid arthritis. Results Among 531 respondents (response rate 48%), the respondents ranked patient satisfaction most favourably (mean rank 1.6), followed by complication/admission rate and number of patients. Guideline adherence was ranked almost the same as voting by local physicians. Waiting time and media reportage were not considered good methods for quality evaluation. Ranking distribution did not differ by working facility or place, volume of patients or years in practice. Multivariate analysis revealed that respondents who care for a large number of rheumatoid arthritis patients (>40 regular patients) were less likely to rank guideline adherence highly (first to third) than those who care for few patients (≤10 regular patients), with an odds ratio of 0.38 (P < 0.01) after adjustment for other variables. Conclusions A majority of Japanese rheumatology physicians consider patient satisfaction the most trustworthy method of assessing the quality of rheumatoid arthritis care. Future research should explore convincing methods of assessing the technical quality of rheumatoid arthritis care.     

Personal, organizational, and market level influences on physicians' practice patterns: results of a national survey of primary care physicians

BACKGROUND: One of the principal tenets of managed care is that physicians' clinical decisions can be influenced both to improve the quality and consistency of care and to decrease health care expenditures. Medical decision making, however, remains a complex phenomenon and the most important determinants of physicians' approaches to clinical decision making remain poorly understood. OBJECTIVES: To determine how clinical decisions are associated with individual characteristics, practice setting and organizational characteristics, attributes of the patient population under care, and the market environment. RESEARCH DESIGN: Cross-sectional, nationally representative survey of patient-care physicians. SUBJECTS: Primary care physicians who provide direct patient care at least 20 hours per week. MEASURES: Proportion of physicians who would order a referral, diagnostic test, or treatment for 5 clinical scenarios thought to be representative of discretionary medical decisions. RESULTS: Responses were received from 4,825 primary care physicians who cared for adult patients (Response Rate 65%). The distribution of results for each of the five clinical scenarios demonstrates significant variability both within and between physicians. No evidence was seen of a consistent practice style across the vignettes (eg, "aggressive" or "conservative"). The organizational setting of practice was the most consistent predictor of behavior across all the clinical scenarios, with the exception of back pain, which was minimally related to any of the environmental factors. When compared to physicians in solo practice, physicians in all other practice settings were less likely to order a test or referral or pursue treatment. Practice involvement with managed care and measures of financial influences and administrative strategies associated with managed care were minimally and inconsistently associated with reported physician behaviors. CONCLUSIONS: The ability of managed care to improve the quality and consistency of care while also controlling the costs of care depends on its ability to influence medical decisions. Our findings generally demonstrate that managed care has a weak influence on discretionary medical decisions and that the influence of managed care pales in comparison to personal and practice setting influences.     

Trends in the perceived complexity of primary health care: a secondary analysis

Rationale If the complexity of the patient's medical problems increases or the complexity of the interactions between the doctor and the patient, the staff or the health care system increase, then complexity of patient care will increase. This study examined trends in patient complexity, and identified doctor, practice and improvement strategy characteristics associated with perceived complexity. Methods This secondary analysis used data from three Community Tracking Surveys with 22 134 primary care doctors completing surveys about themselves, their practice setting, practice improvement strategies and complexity of care in three consecutive 2‐year time periods (1996–1997, 1998–1999, 2000–2001). Data were analysed using hierarchical logistic regression. Results The proportion of primary care doctors who perceived that complexity of care had increased over the past 2 years rose from 31.5% to 35.9%. Perceived complexity of patient care was consistently related to being in solo practice and the belief that they could not frequently obtain high‐quality services and referrals for patients. As availability of services increased, complexity decreased whereas as use of practice improvement strategies increased, complexity also increased. Conclusions Understanding that we cannot determine whether respondents understood care as ‘complicated’ or ‘complex’, potential consequences of this increase in complexity include an increase in medical errors and referral rates along with decreased quality of patient care and career satisfaction.     

Patient satisfaction in gastroenterology clinics.

Satisfaction surveys of patients who had a gastrointestinal procedure at an ambulatory surgery center in 2002 were drawn from a national database and analyzed. The resulting data were used to report the status of patient satisfaction with their care and to illustrate several ways in which patient satisfaction data can be used to guide quality improvement efforts. It was found that patient satisfaction is generally quite high, with ratings of nurses and physicians topping the list. On the other hand, convenience factors such as parking and waiting times were rated lower. Uses of data to guide quality improvement efforts were illustrated in terms of response category percentages (i.e., percentage of time an item was rated "good," "poor," etc.) and a measure of item priority.     

Legal issues in emergency radiology. Practical strategies to reduce risk.

Various joint commission and individual state standards affect emergency radiology practice and have legal implications. The ACEP has entered the burgeoning field of practice guidelines; fortunately, their practice guideline preparation system is arguably the most thorough in medicine at this time. This is of great importance to emergency physicians, because practice guidelines are not without their own potential legal, educational, and compliance problems. Trends toward cost-reduction through reduced radiograph utilization are a real phenomenon in all of medicine. It remains to be seen if costs can be reduced without increasing legal exposure. Excellent clinical guidelines are helpful to emergency physicians. The Massachusetts ACEP model, which appears to effectively blend closed claim data into practice guidelines, has built-in educational support and compliance incentives. This model may become a national standard in the future. Pediatric radiology risk management issues, such as the statute of limitations, have been discussed. Emergency physicians should be knowledgeable about the most commonly missed pediatric emergency radiologic diagnoses. Some aspects of common emergency radiology practice patterns are of relevance to a discussion of risk management in emergency radiology. Issues such as emergency physician radiograph interpretation responsibilities and follow-up systems emerge repeatedly in malpractice claims. The use of CQI strategies may prove helpful in improving practice patterns. Communication between emergency physician and radiologists is critical. Good communication requires the development of good rapport and should pay dividends in improved patient care.     

Prevention of nosocomial infections in the medical office

Nosocomial infections are usually considered to be a problem of hospitals. However, outpatient care is also not without risks to the patient or to the healthcare workers. Cases of iatrogenic infections following invasive acts such as intramuscular injections in medical offices have occurred repeatedly and have resulted in malpractice charges against the physicians involved. This illustrates a need for physicians in private practice to establish a concept for the prevention of nosocomial infections in their office. This concept should include patients as well as healthcare workers and must be adapted to the particular setting of the practice. After implementation of such a concept, it will be possible to provide care to all patients--the routine patient, the routine patient undergoing an invasive procedure, the patient who is colonized with a resistant microorganism, as well as the patient who presents himself with an infectious disease--under conditions that minimize the risk of nosocomial infection to the patient as well as to the healthcare workers. The essential elements of such a concept include written guidelines for disinfection, sterilization and personnel protection. Depending on the type of practice, additional guidelines, i.e. guidelines for reprocessing of endoscopes in a gastroenterology practice, will be needed.     

Incorporating quality improvement concepts and practice into a community health nursing course

Community health nursing students learned to incorporate continuous quality improvement (CQI) methods in their community health clinical settings. With the help of faculty guides, the students, clinical faculty, and key personnel from the community site collaborated on improvement projects that contributed to the agency's ongoing mission. Successful implementation of the CQI principles improved clinical operations, as well as patient care. In addition, the projects contributed to improved student and faculty satisfaction with the overall community experience. Students completed the projects and their clinical rotation with a sense of making a genuine contribution to the agency, and faculty reflected that the students were more engaged and invested in the project outcomes.     

A National Center for EMS Provider andPatient Safety: Helping EMS Providers Help Us

With the strong encouragement of leading health care agencies, business principles are being implemented throughout health care, including emergency medical services (EMS). The reason is simple—quality of care can be enhanced by incorporating the management concepts of continuous quality improvement (CQI). The CQI process couples carefully identified, measurable performance indicators with information systems to monitor, analyze, and trend data. Benchmarking outcomes with other EMS systems allows the identification of “best practices” and the evolution of standards. Emergency medical services professionals must actively participate with the broader health care community in creating performance measurements to ensure that high-quality care is delivered consistently.     

Human immunodeficiency virus: the initial physician-patient encounter

Human immunodeficiency virus (HIV) infection is increasingly becoming a disease managed by HIV specialists. However, all primary care physicians have an important role that can affect the epidemic in the United States. These physicians must be able to appropriately identify patients at risk, screen for and diagnose HIV, provide counsel, and refer those who are infected to specialists. The primary care physician will often continue to provide medical care in collaboration with an HIV specialist. The patient will receive optimal care when the primary care physician is knowledgeable regarding HIV and the evaluation of the newly diagnosed patient. Through appropriate screening, evaluation, diagnosis, and counseling, the primary care physician will not only improve the care of the individual patient but also potentially decrease the spread of HIV. This article answers some of the questions that primary care physicians are likely to have when evaluating an adult with newly diagnosed HIV infection.     

Is patient satisfaction a legitimate outcome of pain management?

Though many studies have measured patient satisfaction with pain management using the American Pain Society (APS) Satisfaction Survey or its variants, little is known about the relationship among the survey items, or whether items relate to satisfaction at all. In an effort to refine the measurement of patient satisfaction, a modified version of the APS survey, which was given to 787 patients as part of a study of postoperative pain management in six community hospitals, was subjected to principal components analysis to determine the survey's empirical structure. Correlations among the five components found were low; a weak relationship (r = -0.24) was discovered between pain intensity and satisfaction. A heuristic model estimated by structural equations analysis yielded additional insights. Though many items thought to influence patient satisfaction were not closely related to patient-reported satisfaction, they indicate important clinical factors relevant to quality of care, and thus, to continuing quality improvement (CQI) efforts. Results suggest that satisfaction was influenced by effectiveness of medication, independent of pain intensity, and by communication. Pain severity ratings near the time satisfaction was measured were more influential than earlier ratings.     

Industrial models of continuous quality improvement. Implications for emergency medicine.

CQI or TQM programs were developed from industrial models dating back to the 1930s. The original philosophic underpinnings guiding CQI included SPC, in which rigorous statistical methods were used to study industrial flow processes. As originally adopted by the Japanese, CQI is credited, to a significant degree, with the emergence of the Japanese economy as a major world leader. Nonetheless, the original CQI concepts were developed and implemented by American researchers, including Deming and Juran. The application of industrial models of quality improvement to service businesses in general and the health care industry in particular have met with substantial success in a number of different settings. Far from representing a management fad, CQI represents a solid management philosophy with a strong statistical background that stands in sharp contrast to traditional management in this country. CQI recognizes that the majority of defects result from a failure of the processes through which the product or service is generated, as opposed to the workers themselves. To a significant degree, CQI empowers service providers (through the strong commitment of top management) to participate in improving the processes through which products and services are delivered. As efforts unfold to contain health care costs and maintain quality in the face of declining resources, CQI programs are likely to be essential to success. Nonetheless, adopting CQI requires a significant commitment on the part of top management to the training and retraining of health care providers and the recognition that traditional management philosophies and techniques have largely failed to produce the quantum leaps in quality that will be required in the coming years.     

持续质量改进管理方法在抗肿瘤药物临床试验血标本采集中的应用

目的 探讨持续质量改进（CQI）理论在抗肿瘤药物临床试验血标本采集的应用及效果.方法 对2011年3-12月送往中心实验室的1896份临床试验血标本中94份不合格血样原因进行分析,针对血标本采集存在的问题,于2012年2月开始运用持续质量改进的方法,对采血者、患者依从性及采血流程从管理上进行改进,评价持续质量改进后的效果.结果 实施CQI后,血标本不合格率由4.92％下降至1.42％,患者对护士采血技术满意度由85.6％上升至97.2％,服务态度满意度由90.5％上升至99.5％,实施前后比较差异均有统计学意义（x2值分别为42.93,15.57,14.97;P ＜0.01）.结论 实施持续质量改进提高了临床试验血标本合格率及患者满意度.