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Ensuring quality through quality assurance

by: LAWRENCE M. SHUER

Many of you may have noticed a renewed emphasis on quality assurance at Stanford Hospital & Clinics. This emphasis - along with changes that are being implemented by several departments - is the result of months-long work by a committee composed of medical staff members and supported by administrative personnel.

The committee was commissioned at the end of 2001 by the Medical Center Executive Committee - Philip Pizzo, dean of the medical school; Michael Peterson, then-interim CEO of SHC; and Chris Dawes, president and CEO of Packard Children's Hospital - to review the quality assurance procedures for all clinical departments.

The panel's creation was recommended by the Ad Hoc Care Review committee formed last year, which specifically examined the quality assurance procedures in the Department of Gynecology and Obstetrics. The dean and the hospital CEOs asked the committee - dubbed MCQARC (Medical Center Quality Assurance Review Committee) - to address specific concerns regarding quality assurance practices at the hospital. The concerns were that:

• The process must assure patient confidentiality.

• The process must be independent and objective, and must use outside experts in the field when appropriate.

• The peer-review process must use consistent, fair and equitable guidelines, employing criteria that are well-defined and encompass all options.

• The process must be done in a timely manner.

• The review process should be well-documented and should yield clear recommendations.

• Evidence of physician deficiencies, as revealed through the QA process, should be part of the appointment/re-appointment criteria for faculty and medical staff.

• A clearly defined process should be in place to resolve disputes.

The committee met several times and came up with its recommendations, which have been approved by the medical board and are in the process of being implemented by each department. For the most part, MCQARC found that the peer-review process is functioning quite well in our medical center. Still, the committee found there was room for improvement - specifically, in ensuring that the process is conducted in a uniform way throughout the medical center. The committee therefore recommended the following:

• QA/QI committees must include both faculty and community physicians in services that include community-based physicians.

• Community physicians and faculty must be willing and prepared to participate in the QA process when called upon.

• The importance of confidentiality must be emphasized to protect the patients and physicians involved.

• Cases should no longer be prescreened, and all cases of concern must be reviewed.

• Each department must use a recently developed evaluation form to assess its current QA/QI process and submit the form to MCQARC, which will determine whether the department's QA process meets the outlined criteria. Each department should periodically re-evaluate its QA process to ensure continued compliance.

In addition, MCQARC has adopted peer-review guidelines that are slightly different from our previous guidelines.

The committee has made other recommendations that are being implemented. One of these is a requirement that all medical staff members submit conflict-of-interest disclosures on a regular basis, such as in conjunction with the semiannual reappointment process. Currently, this is required only of faculty members. Our bylaws are being revised to reflect this change.

In that we are an academic medical center, some of the care here is innovative or experimental. As the MCQARC committee noted, however, conducting peer review with this form of care can be challenging. The committee therefore emphasized that it is essential for us to identify care that is truly experimental, and that such care must always occur under the auspices of the Institutional Review Board. Working out the definition of what is experimental and what may be just a variation on a theme is a matter being considered by a separate committee commissioned by Dean Pizzo.

MCQARC has also noted that strong emphasis must be placed on quality improvement, which is closely linked to quality assurance. The committee emphasized a point that should be obvious: Our efforts are better devoted to developing processes that prevent errors, rather than focusing solely on single events.

Peer review is an essential component of medical care. We must all participate in the process willingly, with the goal of improving our quality of care. I believe the process of examining how care review is accomplished across the medical center has been quite instructive and should be repeated periodically.

If you have suggestions, questions or concerns about care review, please call me at (650) 723-5371 or write: lshuer@stanford.edu