History, administrative experiences, and empirical issues.

We present a summary of the history and the significance of the American Psychological Association's (APA) contract with the Civilian Health and Medical Program for the Uniformed Services (CHAMPUS), which helped develop and operate a national system of quality assurance involving peer review. We elaborate on the contributions of this early APA/CHAMPUS quality assurance system, including the definition and selection of psychologists peer reviewers, case selection, documentation, prospective review, confidentiality, timeliness, and centralized management. Limitations of aspects of the system, particularly the limitations of resources for education and administration, are discussed. A number of general suggestions are offered for administrative improvement in a national system of quality assurance involving third-party payers. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A review of methods used for medical quality assurance in hospitals: advantages and disadvantages

This paper reviews the advantages and disadvantages of medical quality assurance methods commonly used in hospitals. A computer-based literature search up to April 1993 was done using the terms quality assurance, quality control, audit, utilization review, accreditation, occurrence screening and total quality management. In addition, a manual search was undertaken of references of papers obtained by the computer search and of the contents of the following journals: Quality Review Bulletin, Australian Clinical Review and the British Medical Journal. An assessment of the advantages and disadvantages of 15 quality assurance methods used in hospitals was made. Many quality assurance methods used in hospitals have significant disadvantages. A systematic method that provides meaningful and useful information to clinicians and improves patient care is urgently required. New methods such as occurrence screening and total quality management are slowly emerging and have much potential.     

The role for regional autopsy centers in the evaluation of covered deaths. Survey of opinions of US and Canadian chairs of pathology and major health insurers in the United States

OBJECTIVE: To evaluate the advantages and disadvantages of, as well as the attitudes of health care professionals and insurers toward, the development of regional autopsy services. DESIGN: Survey of 150 medical school departments of pathology in the United States and Canada and 12 representative major health insurers in the United States. RESULTS: Of the 25 respondents from the pathology departments, most were in favor of regionalization of autopsy services, if properly underwritten. Of the five respondents from the health insurers, most were disinterested in the autopsy as a measure of outcome and unwilling to provide support. CONCLUSIONS: Health care is being regionalized around networks of insurers rather than hospitals. The networks are defined by a mixture of hospitals, physician groups, and other health care professionals. Within networks, the goal is to subscribe groups of patients, covered lives, for all medical needs from primary to complex care. As the economic risk of caring for patients is shifted to physicians, the incentive to provide service at the lowest possible cost grows, as does the need to assure that medical mismanagement does not occur. To provide quality care at affordable costs, it is necessary that outcomes, including deaths, be professionally evaluated. The present system of death investigation involves hospital colleagues and is potentially biased. Regional autopsy centers that provide timely expert information should be part of the health care system. Medical schools are potential sites for regional autopsy programs because they have the personnel needed to conduct appropriate death-related studies. Most schools are affiliated programmatically and economically with surrounding hospitals and physicians in a manner in which outcomes, costs, and quality of clinical service are of common interest.     

Managed care, school health programs, and adolescent health services: opportunities for health promotion

The rapid expansion of managed care creates opportunities and dilemmas for those involved in school health and adolescent health promotion. Managed care organizations (MCOs), public health agencies, and school and adolescent health providers share certain common goals and priorities including an emphasis on prevention, cost-effectiveness, and quality of care--and a willingness to explore innovative approaches to health promotion and disease prevention. However, MCOs often face conflicting challenges, balancing the goals of cost containment and investment in prevention. In considering support for school health programs, MCOs will be interested in evidence about the effectiveness of services in improving health and/or reducing medical expenditures. Mechanisms for improving prevention efforts within MCOs include quality assurance systems to monitor the performance of health plans, practice guidelines from professional organizations, and the contracting process between payers and health care providers. Development of partnerships between MCOs and schools will be a challenge given competing priorities, variation in managed care arrangements, structural differences between MCOs and schools, and variability in services provided by school health programs.     

Clinical microbiology quality assurance program: a Taiwan experience

Quality assurance programs have been established during the last two decades in developed countries to promote high quality performance in clinical laboratories. In Taiwan, such a program for clinical microbiology laboratories has been in place since July 1987. It has been supported by the Department of Health, Executive Yuan, R.O.C. and was set up by the authors. The manpower status, facilities and equipment, and performance of clinical laboratories were investigated during the first year and standards of laboratory quality were recommended. Since then, under a continuing education program, we have conducted seminars, symposia, workshops, short-courses or panel discussions approximately 4 times a year. There have been about 150 participants per session and they have come from local hospitals (primary care hospitals), regional hospitals (secondary care hospitals) and medical centers (tertiary care hospitals). Proficiency test specimens or external unknown specimens were sent to all the laboratories twice a year and approximately 3 specimens were used each time for the evaluation of each laboratory's diagnostic capability and quality of service. Results indicated that there were tremendous improvements in the quality of laboratory performance. At the same time, several laboratory manuals describing the methods of quality control of clinical specimens, test procedures, media and reagents, personnel management and a compilation of reports etc. were published as guidelines of basic requirements for each level of the laboratories. For local hospital laboratories in remote areas, several regional hospitals or medical centers with high quality laboratories were selected to serve as back-ups. Our evaluation has shown that the performance and quality of service provided by most clinical microbiology laboratories in Taiwan have now reached nearly the level of those found in the so-called "developed countries".     

The Polish experience of quality improvement in primary care

THE POLISH HEALTH CARE SYSTEM: The health care system in Poland is based on a model typical of east-central European countries, with features such as state-owned health care organizations, centralized management and administration, and primacy of access to care over quality. Poorly planned and uncoordinated reforms have been undertaken to transfer some of the authority for health service management to local governments. PRIMARY HEALTH CARE IN POLAND: The reform of the health care system entails substitution of family physician-based for medical specialist-based primary care. Newly trained family physicians, as the first to start private surgery clinics financed from public sources, are the forerunners of the comprehensive reform and property structure transformation. MAKING THE TRANSITION FROM QUALITY ASSURANCE TO QUALITY IMPROVEMENT: Since the early 1990s, more and more organizations, individuals, and professional groups have begun to perceive health care regulations and other external control mechanisms as ineffective. Attempts have been made to replace periodic, restrictive activities with systematic continuous quality improvement efforts. Systems of voluntary accreditation are being developed and fostered. Groups have started meeting to develop medical practice guidelines and conduct peer review. Concern about quality of health care services is now reflected in the Polish legislation for the first time, as well as in numerous local and nationwide projects and publications. CONCLUSION: Despite some successes, the pioneers of quality improvement (QI) still have a long way to go. Continuation of educational activities and creation of a system of motivation for the development, of QI in primary care should be prioritized and encouraged.     

The medical basis of psychiatry

The authors state that the medical model represents the most useful and appropriate model available for the practice of psychiatry. They discuss the implications for psychiatry of the three essential features of the medical model: the concept of disease and diagnosis, the concept of etiology and treatment, and the nature of the doctor-patient relationship. They conclude that the adoption of the medical model for psychiatry would have profound implications for residency training, continuing education, delivery of care, standards of ethical and professional practice, dealings with third-party payers, and conflicts with other professions.     

Physician practice management companies

Physicians are increasingly courted by insurers and hospitals as partners for integrated delivery systems. A new integrative option has emerged for physicians--the physician practice management company (PPMC). PPMCs have formed in response to several supply and demand factors. They hold out great promise for physicians, but closer scrutiny suggests that this promise has not yet been realized. PPMCs warrant managerial and research attention due to their contracting potential as physician networks in dealing with employers and payers.     

The quality assurance process as a management method for psychology training programs.

Describes a psychology training program in a community-based psychological service center managed by a system of quality assurance. Professional psychology doctoral candidates practice in the center and participate in the quality assurance management process as part of their training. Trainees participate in the practice and serve on peer review panels. It is concluded that the peer review system appears well received, functional, useful, and worth continuing. (8 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A brief history of quality assurance and peer review.

Presents a historical overview of quality assurance. The following innovations are noted: (a) the establishment of professional schools directly linking training with practice, (b) credentialing, (c) the setting of minimum standards for facilities and faculty in training institutions, (d) assessment of outcome, (e) personal supervision, (f) peer review, and (g) continuing education as a requirement for maintaining licensure. Peer review at present seems most favored and looks most promising. Credentialing and continuing education recently have been subject to considerable criticism. Several national peer review programs presently in effect and functioning are cited. (5 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Professional psychology in California responds to the special issue on peer review.

The recent Special Issue of Professional Psychology (February 1982) raises serious questions about our profession's involvement in programs of peer review and quality assurance. You can be sure that it was read with great interest by clinical psychologists here in California. We call on you, as the editor of Professional Psychology, to continue and to expand your exploration of the issues involved in peer review and quality assurance programs. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The role of APA in the development of quality assurance in psychological practice.

Discusses the American Psychological Association's (APA) involvement in quality assurance for psychological services. The APA's role includes providing development of accreditation standards for practitioner training programs; standards and model guidelines for psychology licensure; and a sponsor-approval system for continuing professional education, ethical principles, and peer review screening criteria. Although many elements of a comprehensive quality assurance system for psychology exist, many problems still must be resolved, including the need to educate the public and the profession as to the value of quality assurance efforts, limited enforcement and capability, lack of integration of separate activities, and an insufficient data base on which to evaluate the effectiveness of these activities. It is concluded that a conflict exists between increasing professional self-regulation and consumer and governmental skepticism toward the profession in general. (11 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Workshops in Neuropsychological Assessment.

A past issue of Professional Psychology (February 1982) dealt with peer review and quality assurance. These issues are of particular interest to clinical neuropsychology, as evidenced by several articles in Professional Psychology. Over the past 5 years, clinical neuropsychology has rapidly emerged as an important diagnostic and treatment specialty within psychology. Unfortunately, from the standpoint of peer review and quality assurance, this growth has not been appropriately governed. The intention of writing this letter is to bring attention to this particular problem. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A peer review feedback method of promoting compliance with preventive care guidelines in a resident ambulatory care clinic

BACKGROUND: Simple distribution of clinical practice guidelines to physicians does not change practice behavior. A low-cost, continuous peer review feedback method was used to promote resident physicians' compliance with nine preventive care guidelines at the ambulatory care clinic at the Marshall University School of Medicine (Huntington, West Virginia). METHODS: Preventive care guidelines were distributed and a peer review feedback program was instituted in the resident physician primary care practice. The frequency of resident physician use of nine preventive care services was assessed and compared during three periods: preguideline (September 1, 1993, to March 1, 1994; 148 patients), guideline (September 1, 1994, to March 1, 1995; 148 patients), and one-year follow-up (September 1, 1995, to March 1, 1996; 150 patients). The patients in the three periods were similar in age, gender, and risk for influenza and pneumococcal infection. RESULTS: During the guideline period, resident physicians offered patients four preventive care services-tetanus toxoid immunization, clinical breast examination, Papanicolaou smear testing, and hemoccult testing significantly more often than during the preguideline period. All services were offered significantly more often during the one-year follow-up period compared with the preguideline period and as often as in the guideline period. CONCLUSION: A low-cost, continuous peer review feedback program significantly and durably improves resident physician compliance with clinical practice guidelines on preventive care services. However, the effectiveness of the poor review feedback method may not generalize to private practice or other settings. Research on other methods to promote compliance with clinical practice guidelines and to influence physician behavior in general should continue.     

Physicians' view of practice guidelines. A survey of Italian physicians

After more than 10 years of development, two different views of practice guidelines are emerging: either as an educational tool for the medical profession, or as a forum where health care issues can be debated by physicians and non-medical groups. Physicians use practice guidelines in the former model to set their own standards of good quality care, while the latter approach needs contributions from other components in order to decide what should be provided by our health care systems. In a survey of Italian physicians' opinions and attitudes toward practice guidelines, responders supported the "narrowest" model. More than 80% stated that improvement of quality of care and reduction of variation in clinical and practice styles should be the aim of practice guidelines, without representatives from outside the medical profession being involved (61%, 79% and 86% disagreed with a possible involvement, respectively, of patients, health care administrators and representatives of the public at large). Overall, 38% of physicians had a positive attitude toward guidelines viewed as a quality assurance tool for the medical profession. Overall, physicians seem to ignore that the need to rationalize health care calls for input from other professions and members of society. Indeed, most of the issues facing medicine today are mainly a matter of how much value our societies attach to the benefit expected from the available health services. The answers as to what should be done in health care probably cannot be left to the medical profession alone.     

Effect of peritoneal fluid and serum from patients with endometriosis on mouse embryo in vitro development

BACKGROUND AND OBJECTIVES: The purpose of this study was to determine the effect of pregnancy care within family practice on medical students' choices of family practice as a career and to determine the effect the degree of emphasis on pregnancy care has on students' choices of specific residency programs. METHODS: Eight hundred and ten randomly selected student members of the American Academy of Family Physicians (AAFP) and 805 randomly chosen members of the American Medical Student Association (AMSA) were sent an 11-item survey that asked how their career (specialty) and specific residency program choice would be affected if family practice residencies included more (or less) training in pregnancy and delivery management. RESULTS: Fifty-one percent of AAFP members and 37% of AMSA members would be less likely to enter family practice if pregnancy care was eliminated from the specialty. Six percent of AAFP members and 9% of AMSA members stated that they would be more likely to enter family practice if the specialty ceased this training. Students who plan to enter family practice favor a residency program with a stronger pregnancy care experience over a residency program with less emphasis on this training by a 10:1 ratio. CONCLUSION: This study shows significant medical student interest in a high level of pregnancy care experience in family practice training programs.     

Quality assurance in psychological services.

The Canadian Council on Hospital Accreditation (1985) has insisted that a hospital-wide quality assurance program is essential for accreditation, and hospital departments are in various stages of quality assurance program development. The present authors review the rationale and issues (e.g., professional autonomy, malpractice, health care costs, consumerism) that forced the development of quality assurance and some generally accepted definitions of key concepts. The current status of the Children's Hospital of Eastern Ontario Psychology Department's program of quality assurance is described, with special reference to structure, process, and outcome criteria. Implications that quality assurance programs have for the professional practice of psychology and functioning within the public hospital setting are discussed. (French abstract) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Capitation. Theory, practice, and evaluating rates for gastroenterology

Capitation risk contracting has the potential to combine insurance functions with medical care functions. Success depends on a careful consideration of the capitation rate and a thorough understanding of all capitation contract issues. Proper incentives to physicians in a specialty network stimulate a major reengineering effort to squeeze the inefficiency out of the system. Within the network, true peer review can effectively diminish variability in medical care. Such variability leads to increased cost without benefit to health status. The superior medical management of a capitated specialty network can create added value by coordinating more cost-effective and appropriate evaluation and therapy.     

Medical risk report: improving patient management and record keeping through a problem-oriented approach

The problem-oriented record satisfies the needs of the contemporary practitioner by addressing the transition from diagnosis to treatment. The technique organizes collected data, identifies all patient problems (medical and dental), defines solutions and/or management of those problems, and documents treatment rendered. Predictably, the problem-oriented record will avoid problems associated with malpractice litigation, conform to regulations of third-party payers, and facilitate practice analyses and quality assessment, i.e., through computer-assisted tracking of patient care based on problems and not just treatment rendered. As many practices today focus on a "patient-centered" approach to practice, the problem-oriented record clearly supports such a philosophy in its completeness of managing patient care information. The dentist, in consultation with other health care providers, can and should feel confident treating patients from the growing population of patients with medical risk. By integrating the problem-oriented approach into patient management and record keeping, dentists can more easily develop a plan for the complexities that accompany patients. Whether these complexities are of a medical, dental, or combined nature, the problem-oriented record helps the practitioner organize information, plan for treatment, and document patient care in a complete and concise manner.