The evolution of the health care quality professional
The evolution of the health care quality professional
A look at 20 years of changing responsibilities
Responsibilities in the health care quality field have changed drastically since the 1970s. Unforeseen duties have cropped up, while others have disappeared or been transformed. Increasingly, the roles of quality and utilization professionals are becoming intertwined.
To lend some perspective to the state of today's health care quality profession, Hospital Peer Review takes a retrospective look at job titles and their complex evolution over the past two decades.
Medical Audit Coordinator
Starting in the 1950s, the medical audit was a way for hospital medical staffs to review the care provided to all patients. In 1974, the Joint Commission on Hospital Accreditation (now the Joint Commission on Accreditation of Healthcare Organizations) required hospitals to regularly and objectively evaluate patient care using the medical-audit model.
The audit, or patient care evaluation, followed a prescribed format, such as specify audit topic and construct measures of quality; measure actual practice against criteria; review the data and analyze variations; analyze deficiencies and plan corrective action; plan follow-up; communicate the audit summary.
A specific number of audits had to be completed each year based on the number of hospital admissions.
Quality Assurance Coordinator
The medical audit, which the Joint Commission had endorsed, fell out of favor in the early 1980s because this methodology looked primarily at numbers of studies completed and not necessarily at problems in patient care. Instead of periodic studies of quality, medical staffs were required to implement an ongoing review of the quality and appropriateness of care. The Quality Assurance (QA) Standard became effective for Joint Commission accreditation in January 1981.
QA departments were charged with identifying and resolving patient care problems. Review activities became problem-focused. A variety of data sources were used to uncover problem areas.
Hospitals were required to prioritize problems, establish clinically valid criteria, select appropriate assessment methods, determine the cause of problems, design a corrective action, and follow up to see if the action resolved the problem.
Requirements too vague
Indicators of quality were developed by each service to identify problem areas to work on. Improving clinical outcomes of health care services was the goal and the process was ongoing and comprehensive.
Without the numeric requirements of the medical audit to guide them, however, QA departments found the Joint Commission requirements too vague. In 1987, more detailed specifications for monitoring and evaluation were ushered in. Hospitals were given a 10-step process, akin to the clinical research model, to monitor performance.
The role of today's quality management coordinator is that of information manager. Quality managers are responsible for collecting and reporting the performance measures still required by Joint Commission standards. They also are actively involved in benchmarking projects and improvement initiatives to meet the demands of managed care.
Utilization Review Coordinator
After seven years of ineffective Medicare regulations to control expenditures of the federal health care program, Public Law 92-603 was passed in 1972. The new statute created the Professional Standards Review Organization (PSRO).
Those statewide organizations required hospitals and skilled nursing facilities to create a system to review admissions and utilization of medical services to ensure appropriate resources were used consistently for all Medicare patients.
In response, the utilization review (UR) coordinator position took on a new scope. The UR coordinator was responsible for:
* concurrent admission and continued stay review to identify over- or underutilization of services for Medicare patients;
* retrospective analysis of utilization practices to identify over- or underutilization of services;
* use of criteria to judge the medical appropriateness of health care services.
UR coordinators had to report their admission and concurrent UR activities, UR committee minutes, and medical audits to the PSROs.
DRGs arrived on scene
During the late 1970s, the government found that UR programs did little to reduce overall Medicare expenditures. Redesigned UR requirements were passed as the Peer Review Improvement Act of 1982. This coincided with the Medicare Prospective Payment System, which changed the Medicare payment system from a cost-based to a diagnosis-related system.
The responsibility of evaluating the cost efficiency of Medicare services was taken away from the individual health care providers and given to professional review organizations (formerly known as PSROs).
The Prospective Payment System paid hospitals at a fixed rate of reimbursement and offered incentives for cost efficiencies. At this time, many hospitals increased the number of UR staff, and utilization review evolved into what is now called utilization management.
The Joint Commission also required review programs for hospital utilization, starting in the 1970s. Eventually, the review requirements were strengthened and given their own standard in the Joint Commission's accreditation manual. Unlike Medicare utilization review requirements, the Joint Commission standards applied to all patients regardless of payer source.
The utilization management (UM) coordinators of today spend much of their time interacting with insurance companies. They verify that patients are authorized for admission and continued stay. They also respond to payment denial notices. The UM coordinator continues to monitor the appropriateness of Medicare hospitalizations, although the Conditions of Participation no longer require they review 100% of all Medicare admissions.
Quality Improvement Coordinator
The 1980s saw a groundbreaking shift in the health care field. The health care quality improvement coordinator arrived, and a new focus on quality improvement (QI) - rather than quality assurance - began.
Quality assurance coordinators often took on this role or new personnel and departments were added. The 1992 Joint Commission standards emphasized interdisciplinary team building and joint assessment and improvement. The continuous quality improvement philosophy espoused by the QI coordinators was that all processes can be improved.
In addition to leading QI efforts, QI coordinators of today provide continuous quality improvement (CQI) education to staff and physicians, facilitate CQI teams, and report summaries of QI projects.
Case Manager
In the 1970s, the team nursing concept gave way to primary care nursing. A primary care nurse typically would coordinate care for all patients under his or her care.
The nursing shortage of the late 1980s made it difficult for nurses to coordinate care for more complex cases and perform all their other duties. Some hospitals designated nurse case managers to coordinate care for these more complicated cases. Case managers developed and used care guidelines or pathways to ensure appropriate care and services were provided to patients.
As managed care pushed for lower health care costs, many hospitals in the 1990s have found the case management model ideal for uncovering efficiencies, saving resources, reducing medical outcome variations, and managing patient care across the continuum.
Discharge Planner
Discharge planning activities have been required by the Medicare Conditions of Participation and Joint Commission standards since the 1970s. Discharge planners, usually with a nursing or social services background, help arrange post-hospital services for patients.
They also served as consultants to all members of the health care team and advocated for seamless care delivery. In the 1990s, the Joint Commission required discharge planning to begin at the time of hospital admission. The bedside nurse began screening for patients who required the services of the discharge planner.
Today's discharge planner also may serve as a case manager, a utilization management coordinator, or work in tandem with these other professionals. *
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