MANAGING QUALITY IN-HOSPITAL PRACTICE

Background. While routine clinical decision-making has a substantial e ffect on quality, most practising physicians do not routinely examine their outcomes. Objectives. To set up a practical process for identify ing problems in hospital practices of primary care physicians, examine their causes, and develop a quality improvement process that intimate ly involves practising physicians in problem-solving. Design. ALL hosp ital admissions to the Primary Care Service were screened over a 14-mo nth period using simple pre-specified criteria. Quality problems were verified by medical record reviews carried out by two physicians. Thes e problems were discussed at monthly meetings of physicians to charact erize the problems fully, identify their causes, and document adverse effects on patient outcomes. Setting. One community hospital. Particip ants. Primary care physicians from three group practices and four solo practices who admit patients to the Primary Care Service. Interventio ns. Monthly group discussions plus discussions with individual physici ans when time did not permit all quality problems to be discussed at g roup meetings. Certain issues of high sensitivity were also discussed with the individuals rather than in an open forum. Outcome Measures. M issed or delayed diagnoses, inappropriate treatments, and complication s and their root causes. Results. Quality problems were identified in 6% of all admissions. Of these, 60% mere missed or delayed diagnoses, 22% were iatrogenic complications and 18% were inappropriate treatment s. Root cause analysis suggested that physician behaviors led to 75% o f problems; systems problems to 20% and inadequate knowledge to 5%. Pr ocess improvements included development of a call-in system to reduce delays in obtaining X-ray reports; implementation of an anticoagulatio n monitoring system in one group practice; and a protocol of regular f eedback of errors in diagnosis to emergency room physicians. Participa ting physicians reported increased awareness of common errors and grea ter attention to detail in patient evaluations. Conclusions. Knowledge of root causes of quality problems is essential for improving quality of care. A simple routine approach to examining adverse outcomes and how care might be improved in the future was set up. Active participat ion of practising physicians is essential. Other organizations could u se this process for routinely reviewing and improving quality.