Managing quality in hospital practice.
BACKGROUND
While routine clinical decision-making has a substantial effect on quality, most practising physicians do not routinely examine their outcomes.


OBJECTIVE
To set up a practical process for identifying problems in hospital practices of primary care physicians, examine their causes, and develop a quality improvement process that intimately involves practising physicians in problem-solving.


METHODS
All hospital admissions to the Primary Care Service were screened over a 14-month period using simple pre-specified criteria. Quality problems were verified by medical record reviews carried out by two physicians. These problems were discussed at monthly meetings of physicians to characterize the problems fully, identify their causes, and document adverse effects on patient outcomes.


METHODS
One community hospital.


METHODS
Primary care physicians from three group practices and four solo practices who admit patients to the Primary Care Service.


METHODS
Monthly group discussions plus discussions with individual physicians when time did not permit all quality problems to be discussed at group meetings. Certain issues of high sensitivity were also discussed with the individuals rather than in an open forum.


METHODS
Missed or delayed diagnoses, inappropriate treatments, and complications and their root causes.


RESULTS
Quality problems were identified in 6% of all admissions. Of these, 60% were missed or delayed diagnoses, 22% were iatrogenic complications and 18% were inappropriate treatments. Root cause analysis suggested that physician behaviors led to 75% of problems; systems problems to 20% and inadequate knowledge to 5%. Process improvements included development of a call-in system to reduce delays in obtaining X-ray reports; implementation of an anticoagulation monitoring system in one group practice; and a protocol of regular feedback of errors in diagnosis to emergency room physicians. Participating physicians reported increased awareness of common errors and greater 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 participation of practising physicians is essential. Other organizations could use this process for routinely reviewing and improving quality.
Weinberg
N S
NS
Patient Care Improvement Council, Partners Community Health Care, Inc., Boston, MA, USA. nswein@massmed.org
Stason
W B
WB
D000328:Adult; D000368:Aged; D005260:Female; D006764:Hospitals, Community / Q000592:standards*; D006801:Humans; D007325:Institutional Practice / Q000592:standards*; D008297:Male; D008404:Massachusetts; D008485:Medical Audit / Q000379:methods*; D008499:Medical Records; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D010821:Physicians, Family / Q000592:standards*; D010818:Practice Patterns, Physicians'; D011340:Problem Solving; D012189:Retrospective Studies; D017749:Total Quality Management / Q000379:methods*