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The components of a quality assurance program for smaller hospitals Finnie, Carol Jean 1985

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THE COMPONENTS OF A QUALITY ASSURANCE PROGRAM FOR SMALLER HOSPITALS by Carol J. Finnie B.S.N., The University of B r i t i s h Columbia, 1979 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE (Health Services Planning) in THE FACULTY OF GRADUATE STUDIES (Department of Health Care and Epidemiology) We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA OCTOBER 1985 © Carol Jean Finnie, 1985 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. The University of British Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 DE-6(3/81) i i ABSTRACT The components of a q u a l i t y assurance program f o r s m a l l e r h o s p i t a l s i n B r i t i s h C o l u m b i a have been d e f i n e d . These components have been d e f i n e d by a comparison of the normative s t a n d a r d s as d e t e r m i n e d i n the l i t e r a t u r e and by a s u r v e y of a d m i n i s t r a t o r s . S i x t e e n a d m i n i s t r a t o r s of p r e d o m i n a n t l y a c u t e - c a r e , a c c r e d i t e d , 20-50-bed h o s p i t a l s i n B.C. were surveyed. Twelve of these a d m i n i s t r a t o r s were surveyed twice. A new requirement f o r a c c r e d i t a t i o n was in t r o d u c e d by the Can a d i a n C o u n c i l on H o s p i t a l A c c r e d i t a t i o n (C.C.H.A.) c a l l e d the Q u a l i t y Assurance Standard (1985). This Standard r e q u i r e d that q u a l i t y assurance (QA) programs be e s t a b l i s h e d i n every department or s e r v i c e i n the h o s p i t a l . The Standard does not g i v e a c l e a r d e s c r i p t i o n of t h e QA f u n c t i o n s f o r e a c h i n d i v i d u a l department i n a s m a l l e r h o s p i t a l . An important and r e l e v a n t l i s t of s p e c i f i c f u n c t i o n s f o r a QA program were i d e n t i f i e d at v a r i o u s C.C.H.A. seminars held a c r o s s Canada i n l a t e 1983 and e a r l y 1984. The l i t e r a t u r e review i n d i c a t e d that there were a number of c o n t r o v e r s i a l i s s u e s a f f e c t i n g the implementation of the QA Standard. In s p i t e of many methodological problems a s s o c i a t e d with q u a l i t y measurement and assurance, most h o s p i t a l s w i l l adopt a q u a l i t y assurance model. i i i The f i r s t s u r v e y asked the a d m i n i s t r a t o r s to d e f i n e the purpose, goals and o b j e c t i v e s of a QA program. They were a l s o asked to determine the QA f u n c t i o n s f o r four areas: h o s p i t a l board, d i e t a r y , n u r s i n g and pharmacy. A d m i n i s t r a t o r s were asked to i d e n t i f y who i n the h o s p i t a l i s p r i m a r i l y r e s p o n s i b l e f o r the o v e r a l l QA program and f o r the QA program i n f o u r areas; the problems and b e n e f i t s encountered when t r y i n g to implement a QA program; and t h e i r o p i n i o n of the new QA requirements f o r a c c r e d i t a t i o n . The second s u r v e y asked the a d m i n i s t r a t o r s to a s s i g n a p r i o r i t y to t h o s e f u n c t i o n s i d e n t i f i e d i n Round I. The e m p i r i c a l f i n d i n g s were then compared w i t h the n o r m a t i v e standards. With some exceptions, the e m p i r i c a l data were c o n s i s t e n t w i t h the n o r m a t i v e s t a n d a r d s . The e m p i r i c a l f i n d i n g s shows that there are problems r e l a t e d to implementing a QA program but at the same time t h e r e are a number of b e n e f i t s r e l a t e d to the program. The p r i o r i t y r a t i n g s of the f u n c t i o n s i n d i c a t e d areas of h i g h or low i m p o r t a n c e to the a d m i n i s t r a t o r . I t i s l i k e l y t h a t t h e s e p r i o r i t y r a t i n g s a re u s e f u l f o r p l a n n i n g when a l t e r n a t i v e s must be c o n s i d e r e d d u r i n g t h i s t i m e of f i s c a l r e s t r a i n t . i v Government p o l i c i e s a l o n g w i t h the s t r o n g v o l u n t a r y s u p p o r t of a c c r e d i t a t i o n programs make i t v i t a l l y i m p o r t a n t t h a t s u i t a b l e models f o r i m p l e m e n t i n g QA are d e v e l o p e d . The D o l l model i s s u g g e s t e d as a b a s i s f o r i m p l e m e n t i n g QA. Further areas f o r r e s e a r c h are presented. V TABLE OF CONTENTS Page CHAPTER I 1 I n t r o d u c t i o n 1 Th e S t u d y 2 D e f i n i t i o n s 3 O b j e c t i v e s of the Study A Methodology 5 Th e s i s Format 6 CHAPTER II 7 L i t e r a t u r e Review 7 The E v o l u t i o n of Standards f o r Q u a l i t y of Care i n H o s p i t a l s 7 1900 to 1917 7 The Minimum Standard 9 1917 9 The H o s p i t a l S t a n d a r d i z a t i o n Program 9 1918 to 1951 9 The J o i n t Commission of A c c r e d i t a t i o n of H o s p i t a l s (JCAH) 11 1951 11 The Canadian C o u n c i l on H o s p i t a l A c c r e d i t a t i o n 12 1953 to 1983 12 The Q u a l i t y Assurance Standard 13 An I n t e r p r e t a t i o n of the Standards f o r Small H o s p i t a l s 14 S p e c i f i c Q u a l i t y Assurance Functions and A c t i v i t i e s 15 Summary - The Normative Standards f o r Q u a l i t y Assurance 15 J u s t i f i c a t i o n f o r the New Q a u l i t y Standard 16 A B r i e f Debate About the Advantages and Disadvantages of the Q u a l i t y Assurance Standard .. 17 Assumptions A f f e c t i n g the Implementation of the Q u a l i t y Assurance Standard 19 Q u a l i t y Measurement and Assurance 20 R a t i o n a l e f o r Using Q u a l i t y Assurance Models 20 Two Popular Q u a l i t y Assurance Models 21 Methods Used f o r the I d e n t i f i c a t i o n of High P r i o r i t y T o p i c s f o r Q u a l i t y Review 23 Summary and Conclusions About the Q u a l i t y Assurance Standard and Methods f o r E v a l u a t i n g Q u a l i t y of Care 23 v i TABLE OF CONTENTS Page Smaller H o s p i t a l s 25 The Beginning of Standard S e t t i n g 26 18-19th Century 26 L e g i s l a t e d Standards 27 18th-20th Century 27 P r o f e s s i o n a l Standards 29 18th-20th Century 29 The Impact of Government P o l i c i e s on Q u a l i t y of Care 33 20th Century 33 Demographic C h a r a c t e r i s t i c s 37 CHAPTER I I I 39 Methodology 39 The Sample 39 Ra t i o n a l e f o r S e l e c t i o n of t h i s Sample 39 Assumptions 41 P r o j e c t Methodology 42 Round I 42 Round I I 45 L i m i t a t i o n s 46 CHAPTER IV 48 R e s u l t s 48 Purpose, Goals, and O b j e c t i v e s of the Smaller H o s p i t a l s ' Q u a l i t y Assurance Program 48 Summary 51 Q u a l i t y Assurance Functions f o r the Board, D i e t a r y , Nursing and Pharmacy Areas i n Smaller H o s p i t a l s 54 Summary 57 Summary 59 A d d i t i o n a l E m p i r i c a l F i n d i n g s 60 Summary 68 The A p p l i c a t i o n of the D o l l and Donabedian Models ... 68 F i n a l Summary and Conclusions 72 CHAPTER V 74 Conclusi o n s and Recommendations 74 R e l i a b i l i t y and V a l i d i t y of the Study 75 R e c o m m e n d a t i o n s 76 Conc l u s i o n 80 Areas f o r Furt h e r Research and Development 81 v i i TABLE OF CONTENTS Page REFERENCES 84 QUESTIONNAIRE 93 APPENDICES 101 v i i i LIST OF TABLES Page TABLE I TABLE I I TABLE I I I Q u a l i t y Assurance Models 24 The Three Highest Scores f o r the Q u a l i t y Assurance Functions i n Four Areas: H o s p i t a l Board, D i e t a r y , Nursing and Pharmacy. Chosen by 13 A d m i n i s t r t o r s of Predominantly Acute-Care, A c c r e d i t e d 20-50 Bed H o s p i t a l s i n B r i t i s h Columbia J u n e - J u l y 1985 , The Three Lowest Scores f o r the Q u a l i t y Assurance Functions i n Four Areas: H o s p i t a l Board, D i e t a r y , Nursing and Pharmacy. Chosen by 13 A d m i n i s t r a t o r s of Predominantly Acute-Care, A c c r e d i t e d , 20-50 Bed H o s p i t a l s i n B r i t i s h Columbia J u n e - J u l y 1985 55 56 TABLE I V Q u a l i t y A s s u r a n c e F u n c t i o n s Unique to A d m i n i s t r a t o r s of Predominantly Acute-Care, A c c r e d i t e d 20-50 Bed H o s p i t a l s i n B.C., June - J u l y 1985 or to the Proceedings of the Seminars on Q u a l i t y Assurance, CCHA, 1984 58 TABLE V A Method f o r A s s e s s i n g and M o n i t o r i n g Q u a l i t y Assurance Components i n the D i e t r y Department 71 i x ACKNOWLEDGEMENTS I would l i k e t o thank my t h e s i s s u p e r v i s o r , Dr. C o r t MacKenzie f o r p r o v i d i n g p r a c t i c a l a d v i c e i n d e v e l o p i n g t h i s s t u d y . In a d d i t i o n , I w o u l d l i k e t o t h a n k Mr. F r a n c i s B r u n e l l e who p r o v i d e d the m o t i v a t i o n to pursue w i t h t h i s p a r t i c u l a r t o p i c . I would l i k e to thank a l l t h o s e a d m i n i s t r a t o r s or t h e i r delegates who p a r t i c i p a t e d i n t h i s study such as Mr. B. Swan, Mrs. D. B e l l , Ms. B. B u t l e r , Mr. W. Ransom, Mr. W. A y o t t e , Mr. J. D i l l a b o u g h and Dr. P. Mui r . In p a r t i c u l a r , I would l i k e to thank those people who gave me t h e i r a d d i t i o n a l t i m e and/or w r i t t e n m a t e r i a l such as Dr. R. F o u l k e s , Mr. J . B j o r k , Mrs. Morrow, Mr. W. C u t h i l l , Mr. D. D i n e s , Mr. J. L e s l i e , Mr. L.P. Root, Mr. M. L e i s i n g e r and Mr. C. W i l s o n . F i n a l l y , I would l i k e to thank Dr. D. C r o c k e t t , f o r h i s moral support and the use of h i s computer during the study. 1 CHAPTER I I n t r o d u c t i o n Q u a l i t y a s s u r a n c e i s a p o p u l a r i s s u e a t p r e s e n t . T h e a s s e s s m e n t o f t h e q u a l i t y o f h e a l t h c a r e h a s e v o l v e d f r o m t h e d e v e l o p m e n t o f r e g u l a t o r y r e q u i r e m e n t s t o v o l u n t a r y a c c r e d i t a t i o n p r o g r a m s . A c c r e d i t a t i o n S t a n d a r d s h a v e moved f r o m m i n i m a l r e q u i r e m e n t s t o o p t i m a l r e q u i r e m e n t s o f q u a l i t y o f c a r e . T h e m o s t r e c e n t S t a n d a r d i s t h a t h o s p i t a l s h a v e a q u a l i t y a s s u r a n c e p r o g r a m . Q u a l i t y A s s u r a n c e w a s i n t r o d u c e d a s a n " E s s e n t i a l E l e m e n t " i n t h e S t a n d a r d s f o r A c c r e d i t a t i o n o f C a n a d i a n H e a l t h C a r e F a c i l i t i e s , 1 9 8 3 . T h e r e i s now a r e q u i r e m e n t f o r a c c r e d i t a t i o n t h a t a q u a l i t y a s s u r a n c e p r o g r a m be i n p l a c e by 1 9 8 6 . T h i s p r o g r a m r e q u i r e s a w r i t t e n p l a n d e s c r i b i n g t h e o r g a n i z a t i o n and i m p l e m e n t a t i o n o f an i n s t i t u t i o n - w i d e q u a l i t y a s s u r a n c e p r o g r a m . Q u a l i t y a s s u r a n c e p r o g r a m s a r e now r e q u i r e d i n e v e r y d e p a r t m e n t d i r e c t l y i n v o l v e d i n p r o v i d i n g p a t i e n t c a r e o r i n d i r e c t l y t h r o u g h t h e p r o v i s i o n o f s u p p o r t s e r v i c e s . H o w e v e r , a d e t a i l e d m o d e l o r d e s c r i p t i o n o f q u a l i t y a s s u r a n c e p r o g r a m s f o r e a c h i n d i v i d u a l d e p a r t m e n t i s n o t p r e s e n t e d i n t h e S t a n d a r d s . T h i s f a c t h a s c a u s e d much c o n c e r n f o r t h e a d m i n i s t r a t o r o f a s m a l l e r f a c i l i t y . T h i s 2 a d m i n i s t r a t o r o f t e n has l i m i t e d human and f i n a n c i a l resources to l a u n c h a new program such as a q u a l i t y a s s u r a n c e program. The a d m i n i s t r a t o r needs to know not o n l y what the S t a n d a r d s f o r a c c r e d i t a t i o n are but how to i n t e g r a t e a q u a l i t y assurance program i n t o already e x i s t i n g h o s p i t a l a c t i v i t i e s The Study Given the s i g n i f i c a n c e of the Q u a l i t y Assurance Standard and the impact of t h i s requirement f o r s m a l l e r h o s p i t a l s , the f o l l o w i n g study questions were formulated: P r i m a r y Q u e s t i o n - What are the components of a q u a l i t y assurance program f o r the smaller h o s p i t a l ? Subquestions -1. What does the l i t e r a t u r e d e t e r m i n e as the q u a l i t y assurance components f o r s m a l l e r h o s p i t a l s ? ( i . e . normative s t a n d a r d s ) . 2. What are the purpose, g o a l s and o b j e c t i v e s of the s m a l l e r h o s p i t a l s ' q u a l i t y a s s u r a n c e p r o g r a m ? ( i . e . e m p i r i c a l f i n d i n g s ) . 3. What are the q u a l i t y a s s u r a n c e components f o r the s m a l l e r h o s p i t a l as d e t e r m i n e d by the a d m i n i s t r a t o r and/or delegate? ( i . e . , e m p i r i c a l f i n d i n g s ) . 3 4 . W h a t i s t h e c o m p a t i b i l i t y b e t w e e n t h e o r y a n d p r a c t i c e ? ( i . e . How do t h e n o r m a t i v e s t a n d a r d s a n d e m p i r i c a l f i n d i n g s c o m p a r e ? ) D e f i n i t i o n s A d m i n i s t r a t o r - a p e r s o n who i s r e s p o n s i b l e f o r t h e management o f a s m a l l e r h o s p i t a l . C o m p o n e n t - a c o n s t i t u e n t p a r t : i n g r e d i e n t , s e r v i n g o r h e l p i n g t o c o n s t i t u t e ( W e b s t e r , 1 9 7 1 , p . 5 8 0 ) . E m p i r i c a l f i n d i n g s - a r e t h o s e b a s e d o n f a c t u a l i n f o r m a t i o n a n d c a p a b l e o f b e i n g c o n f i r m e d , v e r i f i e d o r d i s p r o v e d by o b s e r v a t i o n o r e x p e r i m e n t ( W e b s t e r , 1 9 7 1 , p. 7 4 3 ) . P r o g r a m - a p r o g r a m t y p i c a l l y c o n s i s t s o f a n o r g a n i z e d g r o u p o f p e o p l e , t i m e , e q u i p m e n t , b u i l d i n g s a n d m o n e y t o p e r f o r m a c t i v i t i e s f o r t h e b e n e f i t o f c l i e n t s o r p a t i e n t s . P r o g r a m e v a l u a t i o n i s c o n c e r n e d w i t h d e t e r m i n i n g t h e v a l u e o r w o r t h o f a p a r t i c u l a r p r o g r a m ( B a k e r , 1 9 8 3 , p . 1 5 3 ) . Q u a l i t y - t h e d e g r e e o f c o n f o r m i t y w i t h g e n e r a l l y a c c e p t e d p r i n c i p l e s a n d p r a c t i c e s and t h e d e g r e e o f a t t a i n m e n t o f a c h i e v a b l e o u t c o m e s c o n s o n a n t w i t h a p p r o p r i a t e a l l o c a t i o n o f r e s o u r c e s ( S l e e , 1 9 8 2 , p . 1 ) . Q u a l i t y A s s u r a n c e - i n c l u d e s q u a l i t y - o f - c a r e m e a s u r e m e n t s a n d w h e n i t s e e m s n e c e s s a r y , e f f o r t s t o i m p r o v e h e a l t h c a r e 4 q u a l i t y ( B a k e r , 1 9 8 3 , p . 1 5 3 ) . S m a l l e r H o s p i t a l s - t h o s e p r e d o m i n a n t l y a c u t e - c a r e h o s p i t a l s o f f e r i n g a l l o r some o t h e r l e v e l s o f c a r e , c u r r e n t l y a c c r e d i t e d , w i t h 2 0 - 5 0 b e d s , i n B r i t i s h C o l u m b i a . S t a n d a r d - a n a u t h o r i t a t i v e o r r e c o g n i z e d e x a m p l e o f c o r r e c t n e s s , p e r f e c t i o n o r s o m e d e f i n i t e d e g r e e o r a n y q u a l i t y o f s o m e t h i n g s e t up a s a r u l e f o r m e a s u r i n g , o r a m o d e l t o be f o l l o w e d ( W e b s t e r , 1 9 7 1 , p . 2 2 2 3 ) . O b j e c t i v e s o f t h e S t u d y T h e m a j o r g o a l o f t h e s t u d y i s : t o d e t e r m i n e t h e c o m p o n e n t s o f a q u a l i t y a s s u r a n c e p r o g r a m f o r s m a l l e r h o s p i t a l s . The o b j e c t i v e s o f t h e s t u d y a r e : 1 . To d e t e r m i n e f r o m a r e v i e w and a n a l y s i s o f t h e l i t e r a t u r e t h e n o r m a t i v e s t a n d a r d s f o r q u a l i t y a s s u r a n c e . 2 . To d e t e r m i n e t h e p u r p o s e , g o a l s a n d o b j e c t i v e s o f t h e s m a l l e r h o s p i t a l s ' q u a l i t y a s s u r a n c e p r o g r a m a s b a s e d on e m p i r i c a l f i n d i n g s . 3 . To d e t e r m i n e t h e c o m p o n e n t s o f a q u a l i t y a s s u r a n c e p r o g r a m f o r t h e s m a l l e r h o s p i t a l b a s e d on e m p i r i c a l f i n d i n g s . F o u r a r e a s w i l l be i n v e s t i g a t e d : h o s p i t a l b o a r d , d i e t a r y s e r v i c e s , n u r s i n g s e r v i c e s and p h a r m a c y s e r v i c e s . 4 . To c o m p a r e t h e n o r m a t i v e s t a n d a r d s w i t h t h e e m p i r i c a l f i n d i n g s . 5 5. To m a k e r e c o m m e n d a t i o n s a n d c o n c l u s i o n s a s b a s e d o n a n a l y s i s o f t h e d a t a . M e t h o d o l o g y A r e v i e w o f t h e l i t e r a t u r e i s p r e s e n t e d . T h i s r e v i e w p r e s e n t s t h e h i s t o r y a n d b a c k g r o u n d i n f o r m a t i o n a b o u t t h e a c c r e d i t a t i o n S t a n d a r d s . An a n a l y s i s o f t h e c u r r e n t Q u a l i t y A s s u r a n c e S t a n d a r d i s p r e s e n t e d . C o n c e p t s r e l a t e d t o q u a l i t y m e a s u r e m e n t and a s s u r a n c e a r e a n a l y z e d . F i n a l l y , b a c k g r o u n d a n d d e m o g r a p h i c i n f o r m a t i o n a b o u t t h e d e v e l o p m e n t o f s t a n d a r d s o f c a r e f o r s m a l l e r h o s p i t a l s i n B . C . a r e p r e s e n t e d . T h e r e s u l t s o f a s u r v e y o f t h e a d m i n i s t r a t o r s ( o r t h e i r r e p r e s e n t a t i v e s ) i s p r e s e n t e d . To o b t a i n t h i s e m p i r i c a l d a t a , a n i n i t i a l s u r v e y was c o n d u c t e d w i t h a p r e - t e s t , t h e f o r m a t o f t h e q u e s t i o n n a i r e w a s e d i t e d a n d m o r e q u e s t i o n s a d d e d t o i t f o r a s e c o n d s u r v e y w i t h a p r e c e d i n g p r e - t e s t . Many o f t h e s m a l l e r h o s p i t a l s a r e i n t h e f o r m a t i v e s t a g e s o f d e v e l o p i n g a q u a l i t y a s s u r a n c e p r o g r a m . The a d m i n i s t r a t o r s a r e u n s u r e a s t o w h a t e x t e n t t h e y n e e d t o d e v e l o p t h e i r q u a l i t y a s s u r a n c e p r o g r a m i n o r d e r t o m e e t a c c r e d i t a t i o n r e q u i r e m e n t s . I n a d d i t i o n , t h e a d m i n i s t r a t o r s a r e a t v a r i o u s s t a g e s i n d e v e l o p i n g t h e c o m p o n e n t s o f a q u a l i t y a s s u r a n c e p r o g r a m . A m a j o r a s s u m p t i o n m a d e i s t h a t , t h e s e h o s p i t a l s a r e 6 a l r e a d y e n g a g e d i n q u a l i t y a s s u r a n c e a c t i v i t i e s . H o w e v e r , t h e s e a c t i v i t i e s may n o t be i n t e g r a t e d i n an i n s t i t u t i o n - w i d e q u a l i t y a s s u r a n c e p r o g r a m . T h e e m p i r i c a l d a t a i s c o m p a r e d w i t h t h e n o r m a t i v e s t a n d a r d s . C o n c l u s i o n s and r e c o m m e n d a t i o n s a r e p r e s e n t e d a s b a s e d on t h i s c o m p a r i s o n . T h e s i s F o r m a t The t h e s i s i s o r g a n i z e d t o a d d r e s s t h e o b j e c t i v e s s e t o u t a b o v e . C h a p t e r I I p r e s e n t s t h e l i t e r a t u r e r e v i e w * . C h a p t e r I I I p r e s e n t s t h e m e t h o d o l o g y . C h a p t e r IV p r e s e n t s t h e e m p i r i c a l d a t a a n d c o m p a r e s t h e d a t a w i t h t h e n o r m a t i v e s t a n d a r d s . C h a p t e r V p r e s e n t s t h e c o n c l u s i o n s a n d r e c o m m e n d a t i o n s . 7 CHAPTER I I L i t e r a t u r e R e v i e w T h i s c h a p t e r w i l l a d d r e s s t h e f i r s t o b j e c t i v e o f t h e s t u d y : To d e t e r m i n e f r o m a r e v i e w a n d a n a l y s i s o f t h e l i t e r a t u r e t h e n o r m a t i v e s t a n d a r d s f o r q u a l i t y a s s u r a n c e . The e v o l u t i o n o f t h e f o r m a l i z e d s t a n d a r d s f o r q u a l i t y o f c a r e a r e t r a c e d . T h e c u r r e n t C a n a d i a n C o u n c i l o n H o s p i t a l A c c r e d i t a t i o n " Q u a l i t y A s s u r a n c e S t a n d a r d " i s a n a l y z e d i n d e p t h . A l s o , c o n c e p t s r e l a t e d t o q u a l i t y m e a s u r e m e n t a n d a s s u r a n c e a r e a n a l y z e d . F o l l o w i n g t h i s , a d e s c r i p t i o n o f t h e d e v e l o p m e n t o f q u a l i t y o f c a r e s t a n d a r d s i n s m a l l e r h o s p i t a l s i s p r e s e n t e d . The E v o l u t i o n o f S t a n d a r d s f o r Q u a l i t y o f C a r e i n H o s p i t a l s  1 9 0 0 t o 1 9 1 7 The i d e a s u n d e r l y i n g t h e d e v e l o p m e n t o f t h e f i r s t f o r m a l S t a n d a r d f o r q u a l i t y o f c a r e r e f l e c t a g e n e r a l m o v e m e n t t h a t c a n be i d e n t i f i e d a s c o m m e n c i n g i n t h e 2 0 t h c e n t u r y . T h r e e s t u d i e s d u r i n g t h e e a r l y 2 0 t h c e n t u r y r e c e i v e d w i d e a t t e n t i o n a n d e x e r t e d v a r i o u s i n f l u e n c e s o n t h e s t a n d a r d s o f m e d i c a l c a r e a n d m e d i c a l e d u c a t i o n ( M c L a c h l a n , 1 9 7 6 , p . 2 2 3 ) . T h e f i r s t s t u d y w a s c o n d u c t e d by G r o v e s i n 1 9 0 8 . He 8 surveyed 50 h o s p i t a l s i n Great B r i t a i n . From t h i s survey, he c o n c l u d e d t h a t , t h e r e was a need f o r an a c c e p t a b l e s t a n d a r d c l a s s i f i c a t i o n of d i s e a s e s and o p e r a t i o n s and a f o l l o w - u p system f o r p a r t i c u l a r c a t e g o r i e s of diseases. In 1910, Codmern, a surgeon i n the U.S., a t t e m p t e d to i n s t i t u t e a f o l l o w - u p system of s u r g i c a l p a t i e n t s to determine whether the o p e r a t i o n s were w a r r a n t e d and i f the o p e r a t i o n s had improved the p a t i e n t s ' symptoms. The t h i r d s t u d y was c a l l e d the F l e x n e r R e p o r t (1910). T h i s R e p o r t r a i s e d the whole q u e s t i o n of m e d i c a l p r a c t i c e standards and t h e i r r e l a t i o n to e m p i r i c a l r e s e a r c h ( B e r l i n e r , 1975). T h i s Report e v e n t u a l l y became a s e r i e s of r e p o r t s that s e t the b a s i s f o r s c i e n t i f i c m e d i c i n e . The F l e x n e r R e p o r t s prompted major improvements i n the s t r u c t u r e and c o n t e n t of medical education i n the U.S. and Canada. H o s p i t a l s a l s o r e q u i r e d i m p r o v e m e n t s . C l i n i c a l l a b o r a t o r i e s f o r c o n d u c t i n g adequate s t u d i e s of s u r g i c a l p a t i e n t s were a s c a r c i t y ; medical records were u n s a t i s f a c t o r y : and the medical s t a f f were poorly supervised and unorganized. In r e s p o n s e to t h e s e c o n d i t i o n s , a r e s o l u t i o n was passed at the T h i r d C l i n i c a l C o n g r e s s of Surgeons of N o r t h A m e r i c a , 1912. T h i s r e s o l u t i o n s t a t e d t h a t "some s y s t e m of s t a n d a r d i z a t i o n of h o s p i t a l equipment and h o s p i t a l work should be developed..." (Shanahan, 1983, p. 21). 9 The Minimum Standard 1917 In r e s p o n s e to the d e f i c i e n c i e s found i n the h o s p i t a l s and amongst the p r a c t i t i o n e r s , the Am e r i c a n C o l l e g e of Surgeons (ACS) developed the Minimum Standard i n 1917. The Minimum Standard contained the f i r s t f o r mal requirements f o r the review and e v a l u a t i o n of the q u a l i t y of h e a l t h care. The S t a n d a r d a d d r e s s e d the q u a l i t y of the m e d i c a l r e c o r d , the r e q u i r e m e n t s of the m e d i c a l s t a f f and the q u a l i t y of the p h y s i c i a n s ' c l i n i c a l performance. The Standard r e q u i r e d the medical s t a f f to assess and analyze, at va r i o u s i n t e r v a l s , i t s experience i n c l i n i c a l departments and to base the assessment on the p a t i e n t s ' c l i n i c a l records (Shanahan, 1983, p. 22). The H o s p i t a l S t a n d a r d i z a t i o n Program 1918 to 1951 A y e a r f o l l o w i n g t h e i n t r o d u c t i o n of t h e Minimum Standard, the H o s p i t a l S t a n d a r d i z a t i o n Program was inaugurated by t h e ACS. The ACS r e c r u i t e d Dr. M a c E a c h e r n , t h e a d m i n i s t r a t o r of the Vancouver G e n e r a l H o s p i t a l to p r o v i d e l e a d e r s h i p i n developing the H o s p i t a l S t a n d a r d i z a t i o n Program and i n o b t a i n i n g the a c c e p t a n c e of the Program by h o s p i t a l s 10 and i n d i v i d u a l p r a c t i t i o n e r s (Agnew, 1974). Many p r o b l e m s were e n c o u n t e r e d i n t r y i n g t o g a i n a c c e p t a n c e of the Program. I t was not d i f f i c u l t to i n t e r e s t the h o s p i t a l t r u s t e e s to become i n v o l v e d but i t was d i f f i c u l t to i n t e r e s t the i n d i v i d u a l doctors. Doctors were busy and had co m p e t i n g i n t e r e s t s f o r t h e i r t i m e . The r e q u i r e m e n t of w r i t i n g up r e p o r t s was seen as a r i d i c u l o u s waste of t h e i r time. Nor d i d the p h y s i c i a n s welcome any kind of s u p e r v i s o r y c ommittee. However, t h e s e problems d i m i n i s h e d when the Program was adopted by the C a t h o l i c H o s p i t a l s A s s o c i a t i o n and when the d o c t o r s saw the a c c r e d i t a t i o n r e p o r t s as a way to i n c r e a s e t h e i r s u p p o r t i n a s k i n g f o r more equipment or more f a c i l i t i e s (Agnew, 1974). The S t a n d a r d s were c o n s t a n t l y b e i n g updated to r e f l e c t the i n c r e a s i n g complexity and s o p h i s t i c a t i o n of h o s p i t a l and m e d i c a l p r a c t i c e . The War y e a r s (WW I I ) i n p a r t i c u l a r brought great advances i n medical p r a c t i c e . F o l l o w i n g World War I I , s t u d i e s on h e a l t h c a r e p r o v i s i o n emphasized more s t r u c t u r a l or process elements r a t h e r than that of outcomes of c a r e as a d v o c a t e d e a r l i e r by Codman and Groves. S t u d i e s e v a l u a t e d s t r u c t u r a l v a r i a b l e s s u c h as t h e i n n a t e c h a r a c t e r i s t i c s of p h y s i c i a n s (e.g., t h e i r age or l e n g t h of t r a i n i n g ) and of f a c i l i t i e s (e.g., s t a f f i n g p a t t e r n s or s t r u c t u r a l soundness of b u i l d i n g s ) and process v a r i a b l e s such as the adequacy of d i a g n o s t i c and t h e r a p e u t i c i n t e r v e n t i o n . 11 The J o i n t Commission of A c c r e d i t a t i o n of H o s p i t a l s (JCAH)  1951 Due t o t h e g r o w i n g c o s t of o p e r a t i n g t h e H o s p i t a l S t a n d a r d i z a t i o n Program, the ACS sought out the s u p p o r t of o t h e r n a t i o n a l o r g a n i z a t i o n s . Thus the J o i n t Commission of A c c r e d i t a t i o n of H o s p i t a l s (JCAH) was c r e a t e d i n 1951 w i t h r e p r e s e n t a t i o n by the A m e r i c a n C o l l e g e of Surgeons, the A m e r i c a n M e d i c a l A s s o c i a t i o n , t h e C a n a d i a n M e d i c a l A s s o c i a t i o n , the A m e r i c a n H o s p i t a l A s s o c i a t i o n , and the American C o l l e g e of P h y s i c i a n s (Shanahan, 1983, p. 22). The Standards and membership of the JCAH have undergone dramatic changes s i n c e 1951. The newly r e v i s e d e d i t i o n of the Standards f o r A c c r e d i t a t i o n i n 1953 i n c l u d e d b r i e f standards on bylaws, governing bodies, b u i l d i n g s , nursing s e r v i c e s , food s e r v i c e s and d r u g c o n t r o l . In a d d i t i o n , t h e r e were r e q u i r e m e n t s of the m e d i c a l s t a f f to use the e x e c u t i v e c o mmittee ( i . e . , the M e d i c a l A d v i s o r y Committee) to co-o r d i n a t e the c l i n i c a l a r e a s , to conduct t i s s u e r e v i e w s , to r e v i e w m e d i c a l s t a f f c r e d e n t i a l s and to r e v i e w m e d i c a l r e c o r d s . 12 The Canadian C o u n c i l on H o s p i t a l A c c r e d i t a t i o n  1953-to-1983 The Canadian M e d i c a l A s s o c i a t i o n withdrew from the JCAH i n 1958 and formed a d i s t i n c t C a n a dian program under the a u s p i c e s of the Canadian C o u n c i l on H o s p i t a l A c c r e d i t a t i o n (CCHA). The CCHA was formed i n 1952 as a vo l u n t a r y commission under the Companies Act. The CCHA i s the only body o f f i c i a l l y a u t h o r i z e d to conduct an a c c r e d i t a t i o n program f o r Canadian h o s p i t a l s . The Board membership c o n s i s t e d of 12 members i n 1953. These members were from v a r i o u s a s s o c i a t i o n s : The Canadian H o s p i t a l A s s o c i a t i o n -- 5, the Canadian M e d i c a l A s s o c i a t i o n --4, the R o y a l C o l l e g e of P h y s i c i a n s and Surgeons -- 2, and L' A s s o c i a t i o n des Medecins de Langue F r a n c a i s e du Canada — 1. The members c a r r y out t h e i r r e s p o n s i b i l i t i e s as i n d i v i d u a l s r a t h e r than as r e p r e s e n t a t i v e s of t h e i r parent o r g a n i z a t i o n s . In 1971, the CCHA r e v i e w e d and r e w r o t e the S t a n d a r d s so t h a t the S t a n d a r d s were based on an " o p t i m a l " r a t h e r than " m i n i m a l " c o n c e p t . The r e q u i r e m e n t s were r a i s e d from the l e v e l of minimum e s s e n t i a l to the l e v e l of optimum ach i e v a b l e . In 1972, the Guide to H o s p i t a l A c c r e d i t a t i o n p r e s e n t e d standards that r e q u i r e d the r e s p o n s i b i l i t y of the h o s p i t a l s ' g o v e r n i n g body to be s t a t e d , the r o l e of the c h i e f e x e c u t i v e 13 o f f i c e r to be recognized, the r o l e of the medical s t a f f to be s t a t e d and t h a t c o n f l i c t i n g l i n e s of a u t h o r i t y and co m m u n i c a t i o n be a v o i d e d . In a d d i t i o n , t h e s e S t a n d a r d s in t r o d u c e d the requirement of medical s t a f f to undertake "an a p p r o p r i a t e p e e r g r o u p method by w h i c h r e q u i r e d b a s i c f u n c t i o n s of c l i n i c a l a u d i t are thoroughly performed at l e a s t monthly." By 1977, the CCHA acquired one more member to i t s board; one r e p r e s e n t a t i v e of the Canadian Nursing A s s o c i a t i o n . The r e v i s e d 1977 S t a n d a r d s r e f l e c t e d p o p u l a r p o l i c i e s then supported by the f e d e r a l government. The Standards i n c r e a s e d emphasis on h e a l t h maintenance, p r e v e n t i o n of i l l h e a l t h and o u t - p a t i e n t care. The Q u a l i t y Assurance Standard In t i m e , the CCHA h e a l t h p r o f e s s i o n a l s r e c o g n i z e d t h a t the medical a u d i t requirements were s e l f - l i m i t i n g i n terms of e v a l u a t i n g the q u a l i t y of c a r e p r o v i d e d i n h o s p i t a l s . The next major development occurred i n 1983 when Q u a l i t y Assurance was i n t r o d u c e d as an e s s e n t i a l element i n the S t a n d a r d s f o r A c c r e d i t a t i o n of Canadian Health Care F a c i l i t i e s . The q u a l i t y assurance a c t i v i t y would not be used i n the d e t e r m i n a t i o n of awards u n t i l 1986. In 1986, a q u a l i t y assurance program w i l l be an e s s e n t i a l r e q u i r e m e n t t o o b t a i n a t h r e e y e a r 14 a c c r e d i t a t i o n award. The Q u a l i t y Assurance (QA) Standard was updated i n 1985. B r i e f l y , the Standard r e q u i r e s that there must be i n s t i t u t i o n -w i d e g o a l s e s t a b l i s h e d , means t o a t t a i n t h e s e g o a l s , e v a l u a t i o n procedures to determine i f the goals are a t t a i n e d and i f not, a l t e r n a t i v e p l a n s made. The S t a n d a r d r e q u i r e s that there must be a w r i t t e n plan d e s c r i b i n g the o r g a n i z a t i o n and implementation of an i n s t i t u t i o n - w i d e q u a l i t y assurance program. T h i s S t a n d a r d r e q u i r e s t h a t q u a l i t y a s s u r a n c e programs a r e i n p l a c e i n e v e r y d e p a r t m e n t d i r e c t l y i n v o l v e d i n p r o v i d i n g p a t i e n t care or i n d i r e c t l y through the p r o v i s i o n of support s e r v i c e s . The program may use m u l t i p l e approaches to c a r r y out the plan (see Appendix I f o r complete d e s c r i p t i o n ) . An I n t e r p r e t a t i o n of the Standards f o r Small H o s p i t a l s In r e s p o n s e to the c o n s i s t e n t c o m p l a i n t s about the a c c r e d i t a t i o n program by s m a l l h o s p i t a l s , the CCHA intr o d u c e d an " I n t e r p r e t a t i o n " of the S t a n d a r d s . The i n t e n t of t h i s I n t e r p r e t a t i o n , p u b l i s h e d i n October 1984, was to a s s i s t the s m a l l h e a l t h c a r e f a c i l i t i e s 'to i d e n t i f y t h o s e e l e m e n t s of the a c c r e d i t a t i o n program which were not a p p l i c a b l e to them and to u n d e r s t a n d how the S t a n d a r d s c o u l d be "adapted" to 15 apply to a " s m a l l f a c i l i t y . " T h i s I n t e r p r e t a t i o n was w r i t t e n p r i m a r i l y f o r the n o n - d e p a r t m e n t a l i z e d a c u t e h e a l t h c a r e f a c i l i t y of l e s s than 50 beds (see Appendix I I f o r c o m p l e t e d e t a i l s ) . S p e c i f i c Q u a l i t y Assurance Functions and A c t i v i t i e s A l t h o u g h the JCAH and CCHA have i d e n t i f i e d the need f o r q u a l i t y assurance programs and have d e s c r i b e d "components" f o r these programs, they have not s p e c i f i e d other components which are more s p e c i f i c to the f u n c t i o n i n g of the program. A r t i c l e s i n the l i t e r a t u r e do s p e c i f y some of the f u n c t i o n s and a c t i v i t i e s f o r var i o u s h o s p i t a l departments. An important and r e l e v a n t l i s t of s p e c i f i c a c t i v i t i e s f o r a QA program were i d e n t i f i e d at v a r i o u s CCHA q u a l i t y a s s u r a n c e s e m i n a r s h e l d across Canada i n l a t e 1983 and e a r l y 1984. These a c t i v i t i e s are l i s t e d i n a booklet e n t i t l e d : Proceedings of the Seminars on Q u a l i t y Assurance, October 1983 to May 1984, CCHA. Summary - the Normative Standards f o r Q u a l i t y Assurance The l i t e r a t u r e review r e v e a l e d that the Standards w r i t t e n by the CCHA have r e c e i v e d n a t i o n a l r e c o g n i t i o n . However, there are no e x p l i c i t "Gold Standards" (i.e., commonly agreed upon s t a n d a r d s ) f o r s p e c i f i c f u n c t i o n s of t h e q u a l i t y a s s u r a n c e program. G i v e n t h e s e f a c t s , i t i s propos e d here 16 t h a t t h r e e d o c u m e n t s be u s e d t o r e p r e s e n t t h e n o r m a t i v e s t a n d a r d s f o r a q u a l i t y a s s u r a n c e p r o g r a m . T h e s e d o c u m e n t s a r e : 1 . S t a n d a r d s f o r A c c r e d i t a t i o n o f C a n a d i a n H e a l t h C a r e F a c i l i t i e s , 1 9 8 5 CCHA. 2 . An I n t e r p r e t a t i o n w i t h S p e c i a l R e f e r e n c e t o t h e N e e d s o f S m a l l A c u t e H e a l t h C a r e F a c i l i t i e s ( s m a l l G e n e r a l H o s p i t a l s ) , 1 9 8 4 , CCHA. 3 P r o c e e d i n g s o f t h e S e m i n a r s on Q u a l i t y A s s u r a n c e , O c t o b e r 1 9 8 3 t o May 1 9 8 4 , CCHA. As n o t e d , t h e i n t e n t o f t h i s s t u d y i s t o c o m p a r e t h e n o r m a t i v e s t a n d a r d s w i t h t h e e m p i r i c a l f i n d i n g s a n d m a k e a n a n a l y s i s b a s e d on t h i s c o m p a r i s o n . B e f o r e t h e e m p i r i c a l d a t a a r e p r e s e n t e d , t h e f o l l o w i n g d i s c u s s i o n r e v e a l s s o m e o f t h e c o n t r o v e r s i a l i s s u e s o f q u a l i t y a s s u r a n c e . J u s t i f i c a t i o n f o r t h e New Q u a l i t y S t a n d a r d A r e v i e w o f t h e l i t e r a t u r e i n d i c a t e s t h a t t h e i n t r o d u c t i o n o f t h e Q u a l i t y A s s u r a n c e S t a n d a r d was b a s e d on a n u m b e r o f b e l i e f s — f i r s t , t h a t p u b l i c a c c o u n t a b i l i t y d e m a n d s a s s u r a n c e f o r q u a l i t y o f c a r e ; s e c o n d , t h a t t h e m e c h a n i s m t o a c h i e v e q u a l i t y o f c a r e i s t o m e e t a r e c o g n i z e d s t a n d a r d ; t h i r d , t h a t t h e e s t a b l i s h m e n t o f an i n s t i t u t i o n - w i d e q u a l i t y a s s u r a n c e p r o g r a m w o u l d e n a b l e h o s p i t a l s t o a c h i e v e t h e 17 highest l e v e l of care with the a p p r o p r i a t e and e f f e c t i v e use of r e s o u r c e s . In comparison to other e f f o r t s to improve the q u a l i t y of c a r e , the Q u a l i t y A s s u r a n c e S t a n d a r d i s more c o m p r e h e n s i v e . For example, former q u a l i t y c o n t r o l a c t i v i t i e s only i n v o l v e d a u d i t i n g . A l t e r n a t i v e l y , a q u a l i t y a s s u r a n c e program co-o r d i n a t e s i n d i v i d u a l q u a l i t y c o n t r o l p r o c e d u r e s and o t h e r q u a l i t y assurance a c t i v i t i e s of an o v e r a l l planned approach. A B r i e f Debate About the Advantages and Disadvantages of the  Q u a l i t y Assurance Standard L i t t l e has been done to study the r e l a t i o n s h i p between q u a l i t y and c o s t or the problems of s t r u c t u r i n g q u a l i t y c o n t r o l i n the h o s p i t a l . The s u c c e s s f u l implementation of a q u a l i t y a s s u r a n c e program r e q u i r e s a r e c o n c i l i a t i o n of i n d i v i d u a l p r o f e s s i o n a l demands f o r autonomy with the need f o r i n s t i t u t i o n a l a c c o u n t a b i l i t y . I d e a l l y , t h e r e must be an expansion of p r o f e s s i o n a l a c c o u n t a b i l i t y to i n c l u d e a concern f o r q u a l i t y , cost and the development of e x p l i c i t mechanisms of c o n t r o l , both on a l o c a l and f e d e r a l b a s i s . The new S t a n d a r d c a l l s f o r an i n c r e a s e i n b u r e a u c r a t i c s t r u c t u r e i n order to d e l i v e r s e r v i c e and t h i s comes only with i n c r e a s e d a d m i n i s t r a t i v e cost. The new Standard r e q u i r e s the c r e a t i o n of new r o l e s , new r u l e s and new r e g u l a t i o n s t h a t 18 serve to threaten the e x i s t i n g power s t r u c t u r e . However, the CCHA argues that, i n time, a q u a l i t y assurance program should e v e n t u a l l y become a normal part of the management f u n c t i o n of a h o s p i t a l and t h a t , the t i m e spent on the program w i l l be time w e l l spent because of the improved l e v e l of p a t i e n t care (Proceedings, 1984, p. 27). The c r e a t i o n of new r o l e s could c r e a t e c o n f l i c t s between the b u r e a u c r a t i c s t r u c t u r e and p r o f e s s i o n a l s c l a i m i n g c l i n i c a l freedom. P r e v i o u s l y , the M e d i c a l A u d i t S t a n d a r d r e l i e d h e a v i l y on the m e d i c a l s t a f f to e v a l u a t e and improve the q u a l i t y of c a r e . Now the new Q u a l i t y A s s u r a n c e S t a n d a r d s h i f t s power i n the d i r e c t i o n of those i n h o s p i t a l and p a t i e n t s e r v i c e p o s i t i o n s and away from the primacy of medical s e r v i c e o r i e n t e d managers. J u s t i f i c a t i o n f o r the QA standard i s based on the b e l i e f t h a t f o r m a l i z a t i o n of the q u a l i t y a s s u r a n c e a c t i v i t i e s w i l l f a v o r a b l y a f f e c t q u a l i t y of care according to the extent that the o r g a n i z a t i o n i s s t r u c t u r e d to f o s t e r p r o f e s s i o n a l autonomy t h r o u g h m e a n i n g f u l i n v o l v e m e n t i n the program. However, a r e v i e w of the l i t e r a t u r e shows v a r y i n g about the i m p a c t of f o r m a l i z a t i o n on the q u a l i t y of care (Heatherington, 1982, p. 194). 0 19 Assumptions A f f e c t i n g the Implementation of the Q u a l i t y  Assurance Standard T h e r e a r e a number of a s s u m p t i o n s u n d e r l y i n g t h e acceptance of the Standard. One i s that people f u n c t i o n w e l l i n groups and teamwork i s f a c i l i t a t e d by the group p r o c e s s even though there are obvious s t a t u s d i f f e r e n t i a l s between the members. Another assumption i s that p r o f e s s i o n a l s want to be i n v o l v e d i n q u a l i t y assurance a c t i v i t i e s . For example, i t i s a s s umed t h a t i n i n s t a n c e s where t h e r e i s p r o f e s s i o n a l misconduct, the p r o f e s s i o n a l groups w i l l o b j e c t i v e l y assess the a c t i o n s of members of t h e i r own p r o f e s s i o n a l group and t a ke n e c e s s a r y a c t i o n . A t h i r d a s s u m p t i o n , and t h i s one i s very c r i t i c a l , i s that the government w i l l support the goals of i m p r o v i n g t h e q u a l i t y of c a r e and t h e CCHA q u a l i t y assurance standard, even though the economic cost may be very high i n i t i a l l y . In g e n e r a l , i n d i v i d u a l s tend to d e v e l o p r e g u l a r i t i e s i n t h e i r behavior and w i l l o f t e n oppose change e i t h e r o v e r t l y or c o v e r t l y . Labour c o n t r a c t s m a i n t a i n r o l e s t h a t are not amenable to change. S t a t u t e s , r e g u l a t i o n s and i n t e r n a l p o l i c i e s o f f e r o t h e r s o u r c e s of c o n s t r a i n t . In a d d i t i o n , there are resource l i m i t a t i o n s imposed by government agencies and a number of sunk c o s t s that do not allow f o r the c r e a t i o n and r e f o c u s s i n g of b u d g e t a r y r e s o u r c e s t o d e v e l o p new programs. 20 Q u a l i t y Measurement and Assurance R a t i o n a l e f o r Using Q u a l i t y Assurance Models A review of the s t a t e - o f - t h e - a r t q u a l i t y of care s t u d i e s r e v e a l e d a number of major i s s u e s a f f e c t i n g the v a l i d i t y of q u a l i t y measurement and a s s u r a n c e . F i r s t , t h e r e i s l i t t l e agreement as to the d e f i n i t i o n of q u a l i t y . The l i t e r a t u r e i s abundant w i t h c o n t r a s t i n g d e f i n i t i o n s of q u a l i t y , q u a l i t y a s s e s s m e n t , q u a l i t y a s s u r a n c e , p r o g r a m e v a l u a t i o n , e f f e c t i v e n e s s and e f f i c i e n c y . Second, v a r i a t i o n s i n d e f i n i t i o n l e a d to p r oblems i n t o p i c s e l e c t i o n , measurement and implementation. For example, s h o u l d s t u d i e s be on e p i s o d e s of c a r e or on a s i n g l e event? Measurement i s s u e s i n c l u d e : the a p p r o p r i a t e choice of data, c r i t e r i a and t a r g e t b e h a v i o u r to e v a l u a t e q u a l i t y of c a r e programs. A major i s s u e when implementing q u a l i t y assurance programs i s d e f i n i n g the purpose. Is the program meant to improve the g e n e r a l l e v e l of q u a l i t y or to i d e n t i f y and e l i m i n a t e episodes of poor care or both? In s p i t e of a l l these methodological problems a s s o c i a t e d with q u a l i t y measurement and assurance, most h o s p i t a l s w i l l adopt a q u a l i t y a s s u r a n c e model. Q u a l i t y a s s u r a n c e models provide frameworks f o r g u i d i n g the o v e r a l l plan f o r measuring and a s s u r i n g q u a l i t y of care. 21 A r e v i e w of the l i t e r a t u r e i n d i c a t e d t h a t t h e r e are a number of q u a l i t y a s s u r a n c e models. I t i s not the i n t e n t of t h i s r e v i e w to l i s t and d e s c r i b e a l l t h e s e models; they are w e l l documented elsewhere (Donabedian, 1982, Vol.1) T h i s l i t e r a t u r e review concluded that the most r e l e v a n t model f o r the s m a l l e r h o s p i t a l s i s the D o l l model. The f o l l o w i n g paragraphs present a summary a n a l y s i s made about the a p p l i c a t i o n of the D o l l model and the popular Donabedian model to smaller h o s p i t a l s . Two Popular Q u a l i t y Assurance Models The most p o p u l a r model used i n s t u d i e s found i n the l i t e r a t u r e i s t h e D o n a b e d i a n m o d e l . In o v e r v i e w , t h e Donabedian model emphasizes the s t r u c t u r e , p r o c e s s and o u t c o m e s o f c a r e . The t e r m s t r u c t u r e r e f e r s t o c h a r a c t e r i s t i c s of p r a c t i t i o n e r s and f a c i l i t i e s , and the manner i n which they are organized. Process v a r i a b l e s r e f e r to what h e a l t h p r o f e s s i o n a l s do f o r the p a t i e n t . Outcome r e f e r s to the end r e s u l t s of h e a l t h c a r e i n terms of h e a l t h and s a t i s f a c t i o n . T h i s model does not p r o v i d e r u l e s of thumb f o r what to do and what n o t t o do. The f r a m e w o r k i s a g u i d e f o r t h e a d m i n i s t r a t o r to evaluate the methods now at hand and to adopt them to h i s p u r p o s e s and to p a r t i c i p a t e i n the f u r t h e r 22 e v a l u a t i o n and development of new methods. The Donabedian model has been commonly used to evaluate medical care and has adapted r e a d i l y to the 1977 CCHA r e q u i r e m e n t of a m e d i c a l au d i t . The model was co n s t r u c t e d i n the context of a f e e - f o r -s e r v i c e system. A l t e r n a t i v e l y , the D o l l model was c o n s t r u c t e d i n a c a p i t a t i o n and s a l a r i e d system ( D o l l , 1974). I t can be argued that the D o l l model appears more a p p r o p r i a t e f o r the cur r e n t CCHA r e q u i r e m e n t s and t h a t the D o l l model i s more s u i t e d towards s m a l l e r h o s p i t a l s than the Donabedian model. Table 1 compares the D o l l , Donabedian and CCHA models. As shown, the D o l l model i s a l o g i c a l e x t e n s i o n of the CCHA models. There are t h r e e e l e m e n t s of the D o l l model: m e d i c a l e f f i c a c y , s o c i a l a c c e p t a n c e and economic e f f i c i e n c y . D o l l sees each element of h i s model as being monitored i n terms of the outcome a c h i e v e d or the p r o c e s s by which the outcome i s reached. This monitoring method i s analogous to the problem s o l v i n g approach. As compared with Donabedian, D o l l does not deal with the concept of s t r u c t u r e because he sees s t r u c t u r e as p a r t of the p r o c e s s by which the outcome i s reac h e d . Instead, D o l l s t r e s s e s the Importance of medical care i n d i c e s ( m e d i c a l e f f i c a c y ) as the o b j e c t o f , m o n i t o r i n g and has r e f e r r e d t o p r o c e s s p r i n c i p a l l y i n r e l a t i o n t o s o c i a l a c c e p t a b i l i t y and economic e f f i c i e n c y . 23 Methods Used f o r the I d e n t i f i c a t i o n of High P r i o r i t y T opics  f o r Q u a l i t y Review There are t h r e e major a c t i v i t i e s of a q u a l i t y a s s u r a n c e program: monitoring care, a s s e s s i n g problems and improving c a r e . Methods used to i d e n t i f y h i g h p r i o r i t y t o p i c s f o r q u a l i t y r e v i e w i n c l u d e : s u r v e y t e c h n i q u e s , c r i t e r i o n - b a s e d s c r e e n i n g , v a r i a t i o n s from norms, m u l t i f a c t o r i a l q u a l i t y i n d i c e s and s m a l l group methods. The most commonly used m e thods i n s m a l l e r h o s p i t a l s a r e t h e c r i t e r i o n - b a s e d screening, the s m a l l group methods, and v a r i a t i o n s from norms. For the p u r p o s e s of t h i s s t u d y , the s u r v e y method i s used. The r a t i o n a l e f o r t h i s choice of methodology i s presented i n Chapter I I I . Summary and Conclusions About the Q u a l i t y Assurance Standard  and Methods f o r E v a l u a t i n g Q u a l i t y of Care A c c r e d i t a t i o n p r o v i d e s o v e r a l l d i r e c t i o n towards a s p e c i f i c standard of care i n h o s p i t a l s by r e q u i r i n g adherence to p r o v i n c i a l h e a l t h a c t s , h o s p i t a l bylaws and r e g u l a t i o n , m e d i c a l and d e p a r t m e n t a l a u d i t s , c o n t i n u i n g e d u c a t i o n a l programs, and the l i k e . The most r e c e n t e f f o r t has been the i n t r o d u c t i o n of the Q u a l i t y Assurance Standard. The p r e c e d i n g d i s c u s s i o n r e v e a l e d the c o n t r o v e r s i a l i s s u e s a f f e c t i n g the implementation of the Q u a l i t y Assurance Standard. T h i s d i s c u s s i o n r a i s e d numerous questions about the TABLE 1 - QUALITY ASSURANCE MODELS DONABEDIAN CCHA (1977) CCHA (1985) DOLL STRUCTURE use of patient charts the c h a r a c t e r i s t i c s and organization of p r a c t i t i o n e r s and f a c i l i t i e s . PROCESS what professionals do for the patient MEDICAL AUDIT STANDARD c r i t e r i a based medical care audit. i n s t i t u t i o n - w i d e program in-house morbidity and and m o r t a l i t y surveys. QUALITY ASSURANCE STANDARD problem-solving approach, s e t t i n g of or g a n i z a t i o n a l and departmental goals, assessing whether these goals are met and i f not making plans to meet d e f i c i e n c i e s i n care, in-house consumer and patient surveys. st r u c t u r e part of process MEDICAL EFFICACY (outcome) the mounting of regional morbidity and m o r t a l i t y surveys to determine need. m o r t a l i t y data d i s t i n q u i s h e d by age group, l o c a l i t y , provider category, h o s p i t a l and disease s p e c i f i c . h o s p i t a l data l i n k e d to i n d i v i d u a l cases. c o n t r o l l e d t r i a l s i n l i m i t e d s e t t i n g s . impact of l i f e s t y l e f a c t o r s . monitoring care i n terms of the outcome achieved or the process SOCIAL ACCEPTABILITY (process) p u b l i c opinion p o l l s . OUTCOME end r e s u l t s of care i n terms of health and s a t i s f a c t i o n . the r e s u l t s of chart audit about the medical care provided. ECONOMIC EFFICIENCY (process) regional comparisons of u t i l i z a t i o n , c o st-benefit a n a l y s i s , u t i l i t y of health states and t h e i r monetary equivalents. 25 significance of the Standard for the smaller hospitals. For example, what are the a d m i n i s t r a t o r s ' opinions about the Standard and what do the a d m i n i s t r a t o r s ' perceive as the advantages and disadvantages of the Standard? Both of the above q u e s t i o n s are asked d u r i n g the c o l l e c t i o n of the empirical data. These questions were asked concurrent with the primary research question i n order that the significance of the Standard could be better understood. The review presented a r a t i o n a l e f o r using q u a l i t y assurance models. More importantly, this review represents a summary of an analysis of the various quality assurance models and recommends the use of.the Doll model over other models for the smaller hospital. The D o l l and Donabedian model w i l l be used i n the a n a l y s i s of the c o m p a t i b i l i t y between theory and p r a c t i c e . This analysis w i l l apply conjointly the models as a means for assessing and monitoring some of the empirical functions for smaller hospitals. Smaller Hospitals P o l i t i c a l , economic, p r o f e s s i o n a l and s o c i a l f a c t o r s p r o v i d e the c o n t e x t i n which q u a l i t y of c a r e s t a n d a r d s developed i n smaller h o s p i t a l s . The development of the p r o f e s s i o n a l a s s o c i a t i o n s and health p o l i c i e s by government 26 has set the background f o r the Q u a l i t y Assurance Standard. The Beginning of Standard S e t t i n g  18-19th Century H e a l t h c a r e i n the e a r l y 18th C e n t u r y i n Nor t h A m e r i c a r e v e a l s not one type of p r a c t i c e but many competing forms that were o f t e n u n o r g a n i z e d . Throughout the c o l o n i a l days and u n t i l the end of the 19th C e n t u r y , h o s p i t a l s i n Canada were mainly devoted to the care of people whose needs were l a r g e l y s o c i a l r a t h e r than m e d i c a l . These i n s t i t u t i o n s were m a i n l y refugee centers f o r the aged poor, orphans, and the s i c k poor and the i n f i r m without r e s o u r c e s . The development of t h e s e h o s p i t a l s mark the b e g i n n i n g steps towards p r o v i d i n g u n i v e r s a l h e a l t h care by b r i n g i n g i n from the c o l d , d e s t i t u t e p e o p l e . The a v a i l a b i l i t y and u n i v e r s a l i t y of h e a l t h c a r e are s t i l l today, two of the n a t i o n a l s t a n d a r d s f o r p r o v i d i n g q u a l i t y h e a l t h c a r e i n Canada. Most of t h e e a r l i e s t h o s p i t a l s were o r g a n i z e d by r e l i g i o u s o r d e r s or by c i t i z e n s ' groups, sometimes working with m u n i c i p a l a u t h o r i t i e s . Many of the d u t i e s of running the h o s p i t a l were done by v o l u n t e e r s who had a genuine concern f o r the w e l l - b e i n g of the r e s i d e n t s . T h e s e v o l u n t a r y h o s p i t a l s were l a r g e l y f r e e f r o m 27 government c o n t r o l and determined t h e i r own standards of care. Most of the s t a n d a r d s were based on the a v a i l a b i l i t y of e x p e r t i s e and resources. Doctors acted as c o n s u l t a n t s to the e a r l y c h a r i t a b l e i n s t i t u t i o n s . P h y s i c i a n s o f t e n managed h e a l t h matters such as q u a l i t y of care p o l i c i e s w i t h i n t h e i r l o c a l c o m m u n i t i e s . However, i t was o n l y f o l l o w i n g the development of s c i e n t i f i c medicine and the N i g h t i n g a l e system of nursing that the h o s p i t a l came to be g e n e r a l l y accepted as a s u p e r i o r i n s t i t u t i o n f o r medical care (Agnew, 1974). Towards the end of the 19th Century, h o s p i t a l s were seen to be workshops f o r doctors t r e a t i n g s i c k people. People were a d m i t t e d to h o s p i t a l on the grounds of i l l n e s s not on the grounds of poverty. T h i s change of o b j e c t i v e s was important because the g o a l s changed to t h o se of p r o v i d i n g q u a l i t y of care r a t h e r than p r o v i d i n g refuges. I t was only at t h i s p o i n t t h a t s t a n d a r d s e t t i n g f o r q u a l i t y c a r e i n h o s p i t a l s c o u l d begin. L e g i s l a t e d Standards 18th-20th Century In the p r e - c o n f e d e r a t i o n p e r i o d , the government was concerned p r i m a r i l y with p u b l i c hygiene and e s t a b l i s h e d l o c a l b oards of h e a l t h . These boards were i n t e n d e d to c o n t r o l 28 epidemics and were o f t e n disbanded when the immediate t h r e a t of d i s e a s e s u b s i d e d . S t a n d a r d s were s e t f o r r e p o r t i n g i n f e c t i o u s d i s e a s e s , f o r e s t a b l i s h i n g q u a r a n t i n e s and o t h e r p u b l i c h e a l t h measures. Programs and l e g i s l a t i o n were l i m i t e d , s p e c i f i c and q u i t e l o c a l i z e d . I t was not u n t i l the second h a l f of the 19th Century that l e g i s l a t e d standards were g e n e r a l i z e d and s p e l l e d out. By the e a r l y years of the 20th Century, government began to a u t h o r i z e by s t a t u t e , m u n i c i p a l i t i e s to group together i n t o u n i o n s to s e t up h o s p i t a l s f o r a d i s t r i c t . These h o s p i t a l s were governed by Boards which were composed of members t h a t were e l e c t e d a t the a n n u a l g e n e r a l m e e t i n g of the v o l u n t a r y h o s p i t a l a s s o c i a t i o n . These h o s p i t a l s were governed by Boards which were composed of members that were e l e c t e d at the annual g e n e r a l m e eting of the v o l u n t a r y h o s p i t a l a s s o c i a t i o n . The Board was r e s p o n s i b l e f o r monitoring the standards of care i n the h o s p i t a l . The B.C. H o s p i t a l A c t (1961) d e l e g a t e d u l t i m a t e r e s p o n s i b i l i t y f o r o p e r a t i n g the i n s t i t u t i o n s and p r o v i d i n g q u a l i t y p a t i e n t c a r e to the h o s p i t a l g o v e r n i n g boards. The Boards i n -turn, d e l e g a t e d the management o p e r a t i o n s to the a d m i n i s t r a t o r and the s u r v e i l l a n c e of q u a l i t y of care to the medical s t a f f . 29 P r o f e s s i o n a l Standards  18th-20th Century T h i s s t u d y i s c o n c e r n e d w i t h the q u a l i t y a s s u r a n c e f u n c t i o n s of f o u r a r e a s : b o a r d , d i e t a r y , n u r s i n g and pharmacy. The h i s t o r y of pharmacy p r e s e n t s a vague and confused s t o r y up u n t i l the 19th Century. Nursing and d i e t a r y s e r v i c e s are only c l e a r and s p e c i f i c i n the 20th Century. The beginning q u a l i t y assurance f u n c t i o n s f o r the H o s p i t a l Board was d i s c u s s e d i n the previous paragraphs. T h i s r e v i e w c o n c e n t r a t e s on t h e d e v e l o p m e n t of p r o f e s s i o n a l a s s o c i a t i o n s and l e g i s l a t i o n r e l a t e d to the p r o f e s s i o n s . These mechanisms are g e n e r a l l y n e c e s s a r y to e s t a b l i s h an i d e n t i t y f o r the p r o f e s s i o n . W i t h o u t a c l e a r i d e n t i f i c a t i o n of the p r o f e s s i o n i n terms of r e g i s t r a t i o n , e d u c a t i o n a l and s k i l l requirements, the p r o f e s s i o n i s unable to c l e a r l y d e f i n e i t ' s r o l e i n p r o v i d i n g q u a l i t y of c a r e . Medicine as the dominant p r o f e s s i o n attempted at f i r s t , to c o n t r o l o t h e r p r o f e s s i o n a l groups. E a r l y l e g i s l a t i o n governing the p r a c t i c e of these p r o f e s s i o n s were contained i n m e d i c a l l e g i s l a t i o n . The s t r u g g l e s of o b t a i n i n g t h e l e g i t i m a c y of these p r o f e s s i o n s have proceeded along s i m i l a r c o u r s e s . The s t e p s t a k e n i n l e g i t i m i z i n g t h e m e d i c a l p r o f e s s i o n a r e d i s c u s s e d b e l o w as an e x a m p l e of t h e s e 30 s t r u g g l e s . The R o y a l C o l l e g e of P h y s i c i a n s d e v e l o p e d w i t h the i d e a that i t should be a s e l f - r e g u l a t i n g body with sharp p u n i t i v e powers, accountable to no p u b l i c a u t h o r i t y . There was l i t t l e d e f i n i t e c o n t r o l of the m e d i c a l p r o f e s s i o n u n t i l A c t s were passed governing c o n d i t i o n s of p r a c t i c e of medical boards. 'Generally there was l i t t l e c o n t r o l over a l a r g e number of un l i c e n s e d p r a c t i t i o n e r s u n t i l the middle of the 19th Century. Some of the p r a c t i t i o n e r s had d i p l o m a s from r e c o g n i z e d E u r o p e a n u n i v e r s i t i e s ; some had no c r e d e n t i a l s a t a l l . M e d i c a l E n t r e p r e n e u r s moved f r e e l y a c r o s s the A m e r i c a n and Canadian borders. T h i s l a c k of e d u c a t i o n a l and p r o f e s s i o n a l standards l e d to some " f l y - b y - n i g h t " p r a c t i c e s . In 1843, the C o l l e g e of P h y s i c i a n s and Surgeons was f o r m e d f o r t h e p u r p o s e s of i m p r o v i n g t h e s t a n d a r d s of p r a c t i c e . The f i r s t M e d i c a l Act was passed i n 1865 and formed the R o y a l C o l l e g e of P h y s i c i a n s and Surgeons. M e d i c a l A c t s p r o v i d e d a r a t i o n a l e b a s i s to r e g i s t r a t i o n and the movement towards a system of self-government of the medical p r o f e s s i o n . P h a r m a c i s t s had o r g a n i z e d and f o r m e d t h e C a n a d i a n P h a r m a c i s t A s s o c i a t i o n by C o n f e d e r a t i o n . However, the s t a n d a r d s f o r p r a c t i c e i n pharmacy and m e d i c i n e remained dubious f o r a long time. The r e s p e c t i v e a s s o c i a t i o n s d i d not, at f i r s t , have the e f f e c t of e n s u r i n g adequate e d u c a t i o n standards among p r a c t i t i o n e r s . 31 The f i r s t twenty years of t h i s century were c h a r a c t e r i z e d by advances i n p r e v e n t i v e m e d i c i n e and i n h e a l t h e d u c a t i o n . New techniques such as blood t r a n s f u s i o n s and debridement of wound became p o s s i b l e from f i r s t World War a c t i v i t i e s . S m a l l e r h o s p i t a l s a l o n g w i t h l a r g e r t e a c h i n g h o s p i t a l s d e v e l o p e d t h e i r own l a b o r a t o r i e s and i n s t a l l e d X - r a y e q u i p m e n t . T e c h n o l o g i c a l d i s c o v e r i e s n e c e s s i t a t e d s p e c i a l i z a t i o n i n the s e r v i c e s provided. The p e o p l e who p r o v i d e d t h e s e new s e r v i c e s were o f t e n t r a i n e d on the job. More p r o g r e s s i v e h o s p i t a l s recognized the wastefulness of t h i s method and h i r e d i n s t r u c t o r s and students were given a probationary period. However, there were no set standards f o r admission to t r a i n i n g schools or standards f o r the education that was taught i n these schools. There was no standard r e g a r d i n g the le n g t h of the p r a c t i c a l experience or the course to produce a p r o f e s s i o n a l . In t i m e , v a r i o u s r e g i s t r a t i o n a c t s were passed and v a r i o u s p r o f e s s i o n a l s were d i s t i n g u i s h e d from others. There was a c o n s i d e r a b l e s t r u g g l e f o r n u r s e s t o o b t a i n t h e R e g i s t r a t i o n Act. Nurses had been hampered by groups of men, doctors and l e g i s l a t o r s who objected to women having c o n t r o l o v e r t h e i r own g r o u p . N u r s e s i n B.C. o b t a i n e d a weak r e g i s t r a t i o n Act i n 1918. In the f o l l o w i n g decade, e d u c a t i o n a l standards remained 32 the foremost pre-occupation of the nurses. The Weir Report i n 1930 c o n f i r m e d t h a t n u r s i n g was a p r o f e s s i o n . Dr. Weir advised i n t h i s r e p o r t that the nurses Act be r e v i s e d i n order t o r a i s e t h e s t a n d a r d s i n B.C. and t h e e d u c a t i o n a l requirements. The f i r s t r e c o r d of employment of d i e t i t i a n s i n B.C. wasn't u n t i l 1911. The B.C. D i e t i t i c A s s o c i a t i o n was founded i n 1928. The Canadian D i e t e t i c A s s o c i a t i o n was i n c o r p o r a t e d u n d e r t h e S o c i e t i e s A c t i n 1957. The B.C. D i e t e t i c A s s o c i a t i o n has p e t i t i o n e d the p r o v i n c i a l government to become in c o r p o r a t e d with no success. The maintenance of p r o f e s s i o n a l standards i s delegated to p r o f e s s i o n a l a s s o c i a t i o n s . T h e r e e x i s t s an i m p l i c i t assumption that t h i s method w i l l provide capable workers who give q u a l i t y of care. L i c e n s i n g and e d u c a t i o n a l s t a n d a r d s a r e s e t by p r o f e s s i o n a l groups. I n t e r n a l p r o f e s s i o n a l standards c o n t r o l the e d u c a t i o n a l and s o c i a l i z a t i o n p r o c e s s of the members. Labour unions are v o l u n t a r y mechanisms that d e f i n e standards of work c o n d i t i o n s , c l e a r r o l e d e f i n i t i o n s and add c o n s t r a i n t s to the system. R e s t r i c t i o n s are s e t t h a t do not a l l o w t a s k s t o be s h i f t e d or p e r s o n n e l r e d e p l o y e d t o e n h a n c e t h e e f f e c t i v e n e s s and e f f i c i e n c y of care d e l i v e r y . 33 The Impact of Government P o l i c i e s on Q u a l i t y of Care  20th Century Canadian governments i n the 20th Century are drawn more and more i n t o r e d i s t r i b u t i o n and r e g u l a t i o n p o l i c i e s . Governments have r e a c t e d to the i n c r e a s i n g c o s t s of h e a l t h c a r e by i n t r o d u c i n g p o l i c i e s c o n c e r n e d w i t h i m p r o v i n g the q u a n t i t y and q u a l i t y of care. In the e a r l y p a r t of t h i s C e n t u r y , some p r o v i n c e s began per diem grants and enacted laws r e q u i r i n g m u n i c i p a l i t i e s to b e a r h o s p i t a l i z a t i o n c o s t s of t h e i n d i g e n t r e s i d e n t . Governments were i n t e r e s t e d i n s a f e g u a r d i n g g o v e r n m e n t e x p e n d i t u r e s and began to i n t r o d u c e a number of R e g u l a t i o n s such as B u i l d i n g Codes, Plumbing Codes, Occupational Health & Safety etc. The p r o v i n c i a l governments have worked c l o s e l y w i t h vo l u n t a r y h e a l t h agencies i n p r o v i d i n g s e r v i c e s and promoting e d u c a t i o n f o r t h e p r o f e s s i o n a l s and l a y p e r s o n s . The p r o v i n c i a l s u b s i d i e s i n remote and p o v e r t y - s t r i c k e n areas has h e l p e d a l l e v i a t e r e g i o n a l d i s p a r i t i e s i n the q u a l i t y and a v a i l a b i l i t y of h e a l t h s e r v i c e s . By 1940, provin c e s showed marked d i f f e r e n c e s i n q u a l i t y and e x t e n t of s e r v i c e s ; and w i t h i n p r o v i n c e s t h e r e were s u b s t a n t i a l d i f f e r e n c e s between one community and a n o t h e r . 34 The d e l i v e r y s y stems were o b v i o u s l y i n c o m p l e t e and needed a great deal of planning to comply with modern standards. R e c o g n i t i o n of t h i s need i s r e f l e c t e d i n a c t i o n s by the f e d e r a l government. The f e d e r a l government a t t e m p t e d to e v o l v e a pla n n e d a p p r o a c h to program development and l o n g -range p o l i c y based on c a r e f u l d e f i n i t i o n of n a t i o n a l needs. N a t i o n a l H e a l t h g r a n t s were made a v a i l a b l e t o t h e pro v i n c e s i n 1948. Mandatory h e a l t h insurance programs were i n t r o d u c e d i n r e s p o n s e to p o l i t i c a l p r e s s u r e s to a c h i e v e g r e a t e r e q u i t y i n h e a l t h s e r v i c e s . The n a t i o n a l h e a l t h s t a n d a r d s f o r h e a l t h i n s u r a n c e programs a r e : u n i v e r s a l i t y , r e a s o n a b l e a c c e s s , c o m p r e h e n s i v e n e s s , p o r t a b i l i t y and non-p r o f i t a d m i n i s t r a t i o n . However, when t h e h e a l t h i n s u r a n c e p r o g r a m s were i n t r o d u c e d , the p a t t e r n s of h e a l t h c a r e d e l i v e r y were l e f t untouched. The subsequent r i s e i n h e a l t h c a r e e x p e n d i t u r e s g e n e r a t e d a whole new s e r i e s of r e g u l a t o r y c o n t r o l s , among which are d e l i b e r a t e s t r a t e g i e s to r e s t r u c t u r e the f i n a n c i n g of h e a l t h c a r e r e s o u r c e s and the p a t t e r n s of h e a l t h c a r e d e l i v e r y . At the b e g i n n i n g of the 1970's, i t was thought t h a t h e a l t h s e r v i c e s i n Canada were of h i g h q u a l i t y and t h a t c o n t r o l l i n g c o s t s would not j e o p a r d i z e the general h e a l t h of the nation. A u t h o r i t i e s were faced with the i s s u e of s t r i k i n g 35 a b a l a n c e among c o s t c o n t r o l , q u a l i t y of c a r e and t h e i n t e r n a l l y generated demand of the system (Van Loon, 1978, p. 454) . There has been a changing focus i n the debate about what i s necessary and s u f f i c i e n t to assure q u a l i t y s e r v i c e s . These d e b a t e s have l e d to the development of more c o s t - e f f i c i e n t s e r v i c e s . For example, i t i s now p o p u l a r to p r o v i d e l e s s i n t e n s i v e s e r v i c e s i n Long Term Care because the c l i e n t e l e are viewed to be " r e s i d e n t s " not " p a t i e n t s . " I t i s n o t c l e a r i f t h e i n c r e a s e i n t h e number of u t i l i z a t i o n of p h y s i c i a n s and high technology provides q u a l i t y of c a r e . In f a c t , a p o p u l a r argument i s t h a t h e a l t h c a r e could be improved, i f i t was l e s s s o p h i s t i c a t e d and i f i t was d i r e c t e d towards h o l i s t i c and p r e v e n t i v e p r i n c i p l e s . For these reasons and because of the r i s e i n h e a l t h expenditures, the B.C. government has taken steps to c u r t a i l the i s s u i n g of doctor's b i l l i n g numbers and p r o v i d i n g funds f o r new h o s p i t a l equipment and i t ' s maintenance. In B.C., the R o l e Study was one a t t e m p t made by the planners of the M i n i s t r y of Health to provide a r a t i o n a l e f o r d i s t r i b u t i n g money to h o s p i t a l s a c c o r d i n g to t h e i r d e f i n e d r o l e s . The Role Study was to be n e g o t i a t e d between government and the B r i t i s h C o l u m b i a H e a l t h A s s o c i a t i o n (B.C.H.A.). I t was thought t h a t t h i s p r o c e s s would l e a d to a b e t t e r q u a l i t y s e r v i c e . 36 However, by 1980, e f f o r t s to c o n t r o l o v e r a l l health, c o s t s were o f f s e t because of the e f f e c t i v e n e s s of p r o f e s s i o n a l b a r g a i n i n g u n i t s i n n e g o t i a t i n g e x p e n s i v e wage s e t t l e m e n t s . As a consequence, c o s t became an o v e r r i d i n g c o n c e r n of the M i n i s t r y of Health and the Role Study was abandoned f o r more r a d i c a l p l a n s . W i t h the d e e p e n i n g r e c e s s i o n of the 1980s, t h e r e was a move by the p r o v i n c i a l government towards the cor p o r a t e model of management and i n c r e a s e d power of the Treasury Board. The government gave more a u t h o r i t y to the M i n i s t r y of Finance than to the s e r v i c e o r i e n t e d m i n i s t r i e s such as H e a l t h . These a c t i o n s mark the change of o b j e c t i v e s from program development to that of cost c o n t r o l . The B.C. government brought down a budget i n J u l y 1983 which e l i m i n a t e d or c u r t a i l e d a wide range of s o c i a l s e r v i c e s . Some s e r v i c e s a f f e c t e d were f a m i l y s u p p o r t w o r k e r s , c h i l d abuse teams, t r a n s i t i o n houses f o r battered women and s p e c i a l s e r v i c e s f o r s e v e r e l y d i s a b l e d c h i l d r e n . Strong o p p o s i t i o n to t h i s budget came from many community and p r o f e s s i o n a l groups c l a i m i n g that the q u a l i t y of care would d i m i n i s h . The impact of t h e s e changes meant t h a t some of the c u r t a i l e d s e r v i c e s would have to be met by e x i s t i n g s e r v i c e s , i . e . the f a m i l y doctor, l o c a l community h e a l t h centers and h o s p i t a l s . The change of o b j e c t i v e s of the B.C. government to t h a t 37 of c o s t c o n t r o l r a i s e s q u e s t i o n s about the i m p a c t on the q u a l i t y of c a r e p r o v i d e d i n community. Has the q u a l i t y diminished or are s e r v i c e s more e f f i c i e n t ? I t was against t h i s p o l i t i c a l - e c o n o m i c backdrop that the Q u a l i t y A s s u r a n c e S t a n d a r d w a s i n t r o d u c e d by the CCHA, a n a t i o n a l s e l f - r e g u l a t i n g body which i s not r e s p o n s i b l e to any g o v e r n m e n t a l a u t h o r i t y . However, the CCHA i s a v o l u n t a r y agency t h a t i s w i d e l y a c c e p t e d and has d e v e l o p e d s t a n d a r d s based on peer judgement. Demographic C h a r a c t e r i s t i c s C h a p t e r 1 h o l d s the d e f i n i t i o n of " s m a l l e r " h o s p i t a l s used i n t h i s s tudy. Some demogr a p h i c s are p r e s e n t e d so t h a t some c h a r a c t e r i s t i c s of these h o s p i t a l s are understood. The h o s p i t a l s s e l e c t e d f o r the sample are s c a t t e r e d t h r o u g h o u t t h e p r o v i n c e of B.C. The p o p u l a t i o n of t h e p r o v i n c e i s e s t i m a t e d a t 2,910,000 i n 1985 as b a s e d on p r o j e c t i o n s from 1981 census data. Most of the h o s p i t a l s are found i n r u r a l a r e a s . These a r e a s have a p o p u l a t i o n t h a t v a r i e s between 2,000 to 10,000. Some of the h o s p i t a l s are i s o l a t e d from l a r g e r secondary c e n t e r s by many m i l e s and hours of t r a v e l . Some of the h o s p i t a l s are r e l a t i v e l y c l o s e to l a r g e r s e c o n d a r y c e n t e r s . T h o s e h o s p i t a l s t h a t a r e c l o s e r t o o t h e r h e a l t h c a r e 38 with other f a c i l i t i e s f o r shared s e r v i c e s . There are 105 predominantly acute-care h o s p i t a l s i n B.C. There are 80 (76%) of t h e s e h o s p i t a l s a c c r e d i t e d . There are 17 f a c i l i t i e s i n the p r o v i n c e which meet the c r i t e r i a f o r smaller h o s p i t a l s as def i n e d i n Chapter 1. The s t a n d a r d s of c a r e p r o v i d e d i n the h o s p i t a l s depend upon the c o n d i t i o n s t r e a t e d at the h o s p i t a l and the a t t i t u d e of t h e p r o f e s s i o n a l s . Many of t h e a d m i n i s t r a t o r s a r e concerned about being able to work w i t h i n the budget and many are i n a d e f i c i t budget. There i s a general concern that they may not be a b l e to meet the n e c e s s a r y m i n i m a l s t a n d a r d s yet a l o n e the o p t i m a l q u a l i t y a s s u r a n c e s t a n d a r d i f the budgets are reduced any f u r t h e r . 39 CHAPTER I I I Methodology T h i s c h a p t e r d e s c r i b e s how the e m p i r i c a l d a t a were c o l l e c t e d i n order to meet the second and t h i r d o b j e c t i v e : - to determine the purpose, goals and o b j e c t i v e s of the s m a l l e r h o s p i t a l s ' q u a l i t y a s s u r a n c e program as based on e m p i r i c a l f i n d i n g s . - to d e t e r m i n e the components of a q u a l i t y a s s u r a n c e program f o r the s m a l l e r h o s p i t a l as based on e m p i r i c a l f i n d i n g s . Four a r e a s w i l l be i n v e s t i g a t e d : board, d i e t a r y , nursing and pharmacy. The Sample The study i s concerned with determining s e l e c t e d q u a l i t y assurance components f o r h o s p i t a l s . The s u b j e c t s chosen were those a d m i n i s t r a t o r s of c u r r e n t l y a c c r e d i t e d , 20-50 bed p u b l i c g eneral h o s p i t a l s i n B.C. (see f u l l d e f i n i t i o n i n Chapter 1). R a t i o n a l e f o r S e l e c t i o n of t h i s Sample T h i s p a r t i c u l a r group of h o s p i t a l s ( a d m i n i s t r a t o r s ) were chosen f o r study f o r a number of reasons. F i r s t , p r e l i m i n a r y 40 i n t e r v i e w s w i t h t h e s e a d m i n i s t r a t o r s i n d i c a t e d t h a t many s m a l l e r h o s p i t a l s are hindered i n developing the components of a q u a l i t y a s s u r a n c e p l a n due to the l a c k of a v a i l a b l e r e s o u r c e s . Second, because of the l i m i t e d r e s o u r c e s , the s m a l l e r h o s p i t a l must use a l t e r n a t i v e methods i n me e t i n g the CCHA standards. This f a c t i s acknowledge by the CCHA and addressed i n the supplement to the Standards c a l l e d "An I n t e r p r e t a t i o n With S p e c i a l Reference to the Needs of Small Acute Health Care F a c i l i t i e s . . . " . T h i r d , the a d m i n i s t r a t o r s and/or t h e i r d e l e g a t e s were s e l e c t e d as s u b j e c t s because they are the managers who are o p e r a t i o n a l l y r e s p o n s i b l e to implement a q u a l i t y a s s u r a n c e program i n the h o s p i t a l . Fourth, only h o s p i t a l s that are c u r r e n t l y a c c r e d i t e d were chosen. Those h o s p i t a l s that have not r e c e i v e d the r e s u l t s of an a c c r e d i t a t i o n survey i n d i c a t i n g that they have met minimal r e q u i r e m e n t s of q u a l i t y s e r v i c e were r u l e d out because they were p e r c e i v e d as h a v i n g d i f f i c u l t y m e e ting the m i n i m a l Standards. T h i s study i s concerned with an optimal Standard. F i f t h , o n l y h o s p i t a l s i n B.C. were s e l e c t e d . S m a l l e r h o s p i t a l s i n other provinces were not in c l u d e d because of the problems and c o s t s r e l a t e d to c o o r d i n a t i n g l a r g e r groups which are widely d i s p e r s e d . 41 The four areas chosen f o r study are: the h o s p i t a l board, n u r s i n g , pharmacy and food s e r v i c e s . These areas were chosen b e c a u s e t h e y r e p r e s e n t e d a c r o s s - s e c t i o n of t h e m a i n f u n c t i o n a l areas: i.e. a d m i n i s t r a t i o n and management, p a t i e n t c a r e s e r v i c e s , and h o s p i t a l s e r v i c e s . A r e a s s u c h as l a b o r a t o r y and maintenance were r u l e d out because many q u a l i t y c o n t r o l r e g u l a t i o n s are already i n p l a c e . Having presented the r a t i o n a l e f o r the s e l e c t i o n of t h i s p a r t i c u l a r sample, i t i s a p p r o p r i a t e at t h i s time to d i s c u s s the assumptions of t h i s study. Assumptions 1. The s i n g l e most c o n f o u n d i n g f a c t o r a s s o c i a t e d w i t h the s e l e c t i o n of the sample i s d e t e r m i n i n g who i s an e x p e r t . There i s a tremendous d i f f e r e n c e between a panel of 15 to 20 a d m i n i s t r a t o r s and a p a n e l of 100 q u a l i t y a s s u r a n c e "co-o r d i n a t o r s " a n d / o r q u a l i t y of c a r e r e s e a r c h e r s . The a d m i n i s t r a t o r s were c o n s i d e r e d e x p e r t s f o r the s t u d y on the b a s i s t h a t they are e d u c a t e d i n and e x p e r i e n c e d w i t h s m a l l e r h o s p i t a l management. 2. The h o s p i t a l s are a l r e a d y engaged i n q u a l i t y a s s u r a n c e a c t i v i t i e s and the a d m i n i s t r a t o r s can determine the p r i o r i t y of the q u a l i t y assurance f u n c t i o n s . 42 P r o j e c t Methodology The o r i g i n a l c o n c e p t of t h i s s t u d y was to d e t e r m i n e the components of a q u a l i t y a s s u r a n c e program i n a s m a l l e r h o s p i t a l f o r f o u r a r e a s : b o a r d , d i e t a r y , n u r s i n g and pharmacy. The i n t e n t was to conduct a r e g i o n a l (B.C.) s u r v e y to determine o p t i m a l and minimal q u a l i t y assurance components f o r t h e s e a r e a s , and then c o n d u c t more i n t e n s i v e r e s e a r c h i n these areas. The methodology was to use m u l t i p l e i t e r a t i o n s of a q u e s t i o n n a i r e . A s u b m i s s i o n was made to the U n i v e r s i t y of B r i t i s h Columbia B e h a v i o r a l Sciences Screening Committee f o r Research and other s t u d i e s i n v o l v i n g human s u b j e c t s . The experimental procedures proposed f o r t h i s study were found to be e t h i c a l l y a c c e p t a b l e by t h i s committee and a c e r t i f i c a t e of approval was i s s u e d (see Appendix 111). Round 1 A p i l o t t e s t was i n i t i a t e d the f i r s t week of March, 1985. S i x s u b j e c t s were c o n t a c t e d by l e t t e r f i r s t and then by t e l e p h o n e c a l l on March 14 to e x p l a i n the i n t e n t of the q u e s t i o n n a i r e . A l e t t e r of s u p p o r t by Mr. F r a n c i s B r u n e l l e ( V i c e - p r e s i d e n t , A d v i s o r y S e r v i c e s , B r i t i s h C o l u m b i a H e a l t h A s s o c i a t i o n ) was sent out with the q u e s t i o n n a i r e . 43 I n s u m m a r y , t h e q u e s t i o n n a i r e r e q u e s t e d s u b j e c t s : 1. t o i d e n t i f y t h e p u r p o s e , g o a l s and o b j e c t i v e s o f t h e h o s p i t a l s ' q u a l i t y a s s u r a n c e p r o g r a m . 2. t o i d e n t i f y m i n i m a l a n d o p t i m a l q u a l i t y a s s u r a n c e f u n c t i o n s f o r e a c h s u b j e c t a r e a and d e t e r m i n e t h e p r i o r i t y o f t h e s e f u n c t i o n s . T h e f o u r s u b j e c t a r e a s w e r e : b o a r d , d i e t a r y , n u r s i n g and p h a r m a c y . One a d m i n i s t r a t o r r e f u s e d t o p a r t i c i p a t e w i t h t h e s t u d y a t t h e o n s e t a n d l e f t t h i s m e s s a g e w i t h h e r s e c r e t a r y . T w o a d m i n i s t r a t o r s r e t u r n e d c o m p l e t e d q u e s t i o n n a i r e s by t h e t h i r d week o f M a r c h . The t w o r e m a i n i n g a d m i n i s t r a t o r s r e p o r t e d t h a t t h e y h a d t r o u b l e f i n d i n g t h e t i m e t o c o m p l e t e t h e q u e s t i o n n a i r e b u t a g r e e d t o a p e r s o n a l i n t e r v i e w . The i n i t i a l p r e - t e s t i n d i c a t e d t h a t t h e r e was a p o t e n t i a l f o r f a t i g u e i n o r d e r t o c o m p l e t e t h e q u e s t i o n n a i r e . Y e t , t h o s e a d m i n i s t r a t o r s i n t e r v i e w e d i n p e r s o n n o t o n l y c o m p l e t e d t h e q u e s t i o n n a i r e b u t g a v e a d d i t i o n a l i n f o r m a t i o n a b o u t t h e h o s p i t a l ' s q u a l i t y a s s u r a n c e , p r o g r a m . F o r e x a m p l e , d a t a was g i v e n a b o u t t h e p r o t o c o l s h e e t s u s e d f o r c o n d u c t i n g n u r s i n g a u d i t p r o c e d u r e s , a n n u a l r e p o r t s a b o u t m e d i c a l a u d i t p r o c e d u r e s , and m i n u t e s o f q u a l i t y a s s u r a n c e m e e t i n g s . D i s c u s s i o n s w i t h t h e f i r s t f i v e a d m i n i s t r a t o r s l e d t o v o l u n t a r y d i s c l o s u r e s by t h e m a b o u t t h e i r o p i n i o n s o f t h e 44 Q u a l i t y A s s u r a n c e S t a n d a r d . I n f a c t , many o f t h e a d m i n i s t r a t o r s seemed more comfortable d i s c u s s i n g the i s s u e s concerned with implementing the Standard than with answering the q u e s t i o n n a i r e . A l l of the s u b j e c t s r e p o r t e d t h a t they were developing t h e i r q u a l i t y assurance programs but had not c o m p l e t e d an o v e r a l l p l a n . They a s s u r e d me t h a t t h e i r h o s p i t a l s were p r o v i d i n g q u a l i t y s e r v i c e s . The q u e s t i o n n a i r e was e d i t e d on the b a s i s of the feedback of the f i r s t respondents. The request to d i s t i n g u i s h between op t i m a l and minimal q u a l i t y assurance f u n c t i o n s was removed and the f o l l o w i n g questions were added to the q u e s t i o n n a i r e : 1. Does your h o s p i t a l have an o v e r a l l q u a l i t y assurance plan? 2. Who i s p r i m a r i l y r e s p o n s i b l e f o r t h e q u a l i t y assurance program and who i s o p e r a t i o n a l l y r e s p o n s i b l e f o r the q u a l i t y assurance program i n the four areas? 3. What are the p r o b l e m s and b e n e f i t s d e r i v e d when t r y i n g to implement a q u a l i t y assurance program? 4. What i s the a d m i n i s t r a t o r s ' o p i n i o n of the new q u a l i t y a s s u r a n c e r e q u i r e m e n t s f o r a c c r e d i t a t i o n ? (see Appendix I V ) . The remaining ten a d m i n i s t r a t o r s were contacted by l e t t e r and by telephone. Attempts were made to have as much personal c o n t a c t w i t h t h e a d m i n i s t r a t o r s as p o s s i b l e . A l l t h e 45 a d m i n i s t r a t o r s were s u r v e y e d over the phone about t h e i r p e r c e p t i o n s of the Q u a l i t y Assurance Standard. The resear c h e r met w i t h n i n e a d m i n i s t r a t o r s p e r s o n a l l y , f o u r at t h e i r r e s p e c t i v e h o s p i t a l s and f i v e i n Vancouver. Upon r e c e i v i n g twelve responses (one a d m i n i s t r a t o r i s the a d m i n i s t r a t o r f o r two of the h o s p i t a l s ) , the Round I I q u e s t i o n n a i r e was designed and p r e - t e s t e d at the beginning of June, 1985. F o l l o w i n g t h i s , another completed Round I q u e s t i o n n a i r e was r e c e i v e d . In a d d i t i o n , t h i s a d m i n i s t r a t o r submitted the newly approved h o s p i t a l ' s Q u a l i t y Assurance P l a n . Round II The responses from the Round I i n d i c a t e d a wide range of f u n c t i o n s f o r e a c h s u b j e c t a r e a . On a v e r a g e , e a c h a d m i n i s t r a t o r i n d i c a t e d f i v e or s i x major q u a l i t y a s s u r a n c e f u n c t i o n s per area. C o l l e c t i v e l y these responses made up 16 to 19 f u n c t i o n s per area. A second q u e s t i o n n a i r e was designed that l i s t e d a l l these f u n c t i o n s and requested the s u b j e c t s to a s s i g n the p r i o r i t y of these f u n c t i o n s (see Appendix V). The i n t e n t of t h i s q u e s t i o n n a i r e was to obt a i n f u r t h e r v a l i d a t i o n about the f u n c t i o n s and to o b t a i n a co n s e n s u s about the p r i o r i t y of these f u n c t i o n s . Given the competing demands f o r the a d m i n i s t r a t o r s ' time, the t h e s i s members recommended a r e - s u r v e y i n g of only some of 46 the a d m i n i s t r a t o r s . Those t h r e e a d m i n i s t r a t o r s who had not p a r t i c i p a t e d i n Round I were r e - s u r v e y e d as were t e n o t h e r a d m i n i s t r a t o r s . The o t h e r t en a d m i n i s t r a t o r s were s e l e c t e d a c c o r d i n g t o a s t r a t i f i e d s a m p l e b a s e d on r e g i o n a l r e p r e s e n t a t i o n . A l l of t h e a d m i n i s t r a t o r s r e t u r n e d a completed q u e s t i o n n a i r e by the end of J u l y , 1985. L i m i t a t i o n s As with a l l survey techniques there are questions r e l a t e d t o r e l i a b i l i t y and v a l i d i t y . Two i m p o r t a n t q u e s t i o n s c o n s i d e r e d d u r i n g the d e s i g n i n g of the q u e s t i o n n a i r e were: does the i n s t r u m e n t a c t u a l l y measure what i s p l a n n e d to be measured and do t h e s e d a t a r e a l l y r e p r e s e n t r e a l i t y ? The f o l l o w i n g l i s t i d e n t i f i e s those major r e l i a b i l i t y and v a l i d i t y concerns f o r t h i s study. 1) The a d m i n i s t r a t o r s were e x p e c t e d to c o m p l e t e the q u e s t i o n n a i r e i n c o n s u l t a t i o n with the Chairman of the Board, the d i e t i t i a n , the D i r e c t o r of Nursing, and the pharmacist. I do not know to what extent these persons were co n s u l t e d e i t h e r f o r m a l l y or i n f o r m a l l y . 2) The s u b j e c t s were s u r v e y e d d u r i n g the t i m e of many other h o s p i t a l management a c t i v i t i e s such as year end budget a p p r a i s a l s , a u d i t programs, a n n u a l s o c i e t y m e e t i n g s , and 47 p r e p a r a t i o n f o r a c c r e d i t a t i o n . In a d d i t i o n , many of the a d m i n i s t r a t o r s were s u r v e y e d d u r i n g v a c a t i o n and e d u c a t i o n leaves. Subsequently, there were long periods of w a i t i n g f o r r e t u r n s of the q u e s t i o n n a i r e s . 3) T h e s e a d m i n i s t r a t o r s were s u r v e y e d by o t h e r i n v e s t i g a t o r s at the same t i m e ; at l e a s t two o t h e r s u r v e y s were b e i n g c o n d u c t e d ( t h e s e s u r v e y s were not about q u a l i t y a s s u r a n c e ) . Ongoing s u r v e y i n g of t h e s e a d m i n i s t r a t o r s o n l y serves to f a t i g u e and anger them. 4) Only one person d i d the e d i t i n g and content a n a l y s i s of the raw d a t a . The d a t a from Round I were e d i t e d so t h a t statements of s i m i l a r meaning were condensed to one statement. The a n a l y s i s c o u l d have been improved i f t h e r e were more i n v e s t i g a t o r s i n v o l v e d i n the process. C o n s i d e r a b l e time was spent r e - a s s e s s i n g the e d i t i n g and a n a l y s i s . 5) The r e l i a b i l i t y of the i n s t r u m e n t has not been e s t a b l i s h e d . I t i s not c e r t a i n i f the r e s p o n d e n t would mark t h e q u e s t i o n n a i r e i n t h e same way i f g i v e n t h e same q u e s t i o n n a i r e f o r a second time. 6 ) T h i s type of s t u d y does not p r o v i d e answers to the consequences of undertaking the " q u a l i t y " assurance f u n c t i o n s as d e s c r i b e d by the respondents. 7) I t w i l l not be c o n f i r m i n g whether or not t h e s e q u a l i t y assurance f u n c t i o n s are r e a l l y done i n the h o s p i t a l s . 8) The viewpoints of the p a t i e n t s w i l l not be s o l i c i t e d . 48 CHAPTER IV Res u l t s T h i s c h a p t e r p r e s e n t s the e m p i r i c a l f i n d i n g s from the s u r v e y s of t h e s u b j e c t s . T h e s e d a t a a r e p r e s e n t e d i n r e l a t i v e l y raw f o r m so t h a t t h e r e m a r k s made by t h e a d m i n i s t r a t o r s are c l e a r to the r e a d e r . These d a t a are organized under three major headings. An a n a l y s i s and summary f o l l o w s each major h e a d i n g . T h i s a n a l y s i s a t t e m p t s to meet the o b j e c t i v e of c o m p a r i n g the n o r m a t i v e s t a n d a r d s w i t h the e m p i r i c a l f i n d i n g s . Purpose, Goals, and O b j e c t i v e s of the Smaller H o s p i t a l s ' Q u a l i t y Assurance Program The h o s p i t a l s have M i s s i o n Statements which d e l i n e a t e the goals of the h o s p i t a l . The M i s s i o n Statement i d e n t i f i e s the h o s p i t a l board as having the r e s p o n s i b i l i t y to provide q u a l i t y care. In a d d i t i o n to the M i s s i o n Statement, three h o s p i t a l s have a w r i t t e n q u a l i t y a s s u r a n c e p l a n t h a t d e s c r i b e s the q u a l i t y a s s u r a n c e program. S i x h o s p i t a l s d e s c r i b e d the purpose, g o a l s and o b j e c t i v e s of t h e i r q u a l i t y a s s u r a n c e program using the q u e s t i o n n a i r e provided. Most of the h o s p i t a l s a re i n the f o r m a t i v e s t a g e s of t h e i r q u a l i t y assurance plans. The h o s p i t a l s are at d i f f e r e n t 49 s t a g e s of s p e c i f y i n g t h e i r q u a l i t y a s s u r a n c e components. Vague, s p e c i f i c and mediocre statements of purpose, goals and o b j e c t i v e s f o r the h o s p i t a l s ' q u a l i t y assurance program. Two parameters of these statements are summarized below. 1. Vague statements: Purpose: To achieve and maintain optimum p a t i e n t c a r e . G o a l s : To d e v e l o p and implement a s t u d y , r e v i e w and adjustment mechanism that w i l l be d i r e c t e d towards the above purpose. O b j e c t i v e s : To monitor p a t i e n t care from medical p r a c t i c e t h r o u g h n u r s i n g , t h e r a p e u t i c t r e a t m e n t s , n u t r i t i o n and c l e a n l i n e s s of environment,comfortable and safe accommodation through a w e l l maintained f a c i l i t y , courteous, sympathetic and h e l p f u l a t t e n t i o n to a l l p a t i e n t needs. 2. S p e c i f i c statements: P u r p o s e : To meet the r e a l and p e r c e i v e d needs of the community by p r o v i d i n g optimum c a r e c o n s i s t e n t w i t h the g e o g r a p h i c a l l o c a t i o n , s p e c i a l requirements both i n d u s t r i a l and demographic through the e f f i c i e n t and e f f e c t i v e use of the resources a v a i l a b l e . Goals: To e s t a b l i s h and maintain a p p r o p r i a t e methods to review and evaluate c a r e / s e r v i c e s provided by the h o s p i t a l so that problems may be i d e n t i f i e d and r e s o l v e d . 50 O b j e c t i v e s : 1) To m a i n t a i n adequate a d m i n i s t r a t i v e / documenting systems; medical and other records; n u r s i n g care; p o l i c i e s , procedures, p r o t o c o l s . 2) To maintain r e c r u i t m e n t , o r i e n t a t i o n , documentation of a l l personnel i n c l u d i n g medical s t a f f . 3) To m a i n t a i n a c c r e d i t a t i o n b o t h g e n e r a l and s p e c i f i c (Lab, CCHA) and conform to a l l r e q u i r e m e n t s of ap p r o p r i a t e r e g u l a t i o n s and l e g i s l a t i o n (Workers' Compensation Act; Pressure V e s s e l s Act; P o l l u t i o n C o n t r o l ; E l e c t r i c a l , F i r e Safety Codes). 4) To maintain documented reviews of c l i n i c a l work of p h y s i c i a n s , nurses, p a t i e n t s e r v i c e s . 5) To maintain a communication and feedback system. In a d d i t i o n to the above s t a t e m e n t s , I a l s o r e c e i v e d statements c a t e g o r i z e d by one a d m i n i s t r a t o r as " p r a c t i c a l " and " t h e o r e t i c a l . " These s t a t e m e n t s e n u n c i a t e some of the f r u s t r a t i o n and c o n t r o v e r s y r e l a t e d to the CCHA S t a n d a r d . These statements are i n f o r m a l l y supported by at l e a s t h a l f of the s u b j e c t s . These statements are summarized below. 1. Purpose statements -T h e o r e t i c a l : To ensure that the care being provided i s of the h i g h e s t q u a l i t y p o s s i b l e w i t h i n our h o s p i t a l ' s f i s c a l framework. P r a c t i c a l : To r e t a i n our a c c r e d i t a t i o n s t a t u s . 2. Goal statements -T h e o r e t i c a l : E s t a b l i s h a r e p o r t i n g system ( w i t h a c t i o n 51 and feedback mechanism) that w i l l document the v a r i o u s q u a l i t y c o n t r o l measures already o c c u r r i n g and put these together i n an o r g a n i z e d manner to d e t a i l f o r the board how q u a l i t y i s being ensured. P r a c t i c a l : To t r y to get a l r e a d y o verworked p e r s o n n e l i n v o l v e d and motivated to t o l e r a t e more meetings and analyze f u r t h e r d o c u m e n t a t i o n t h a t i s c u r r e n t l y p r o v i d e d and won't l i k e l y change our methods a p p r e c i a b l y . 3. O b j e c t i v e s -To meet the above g o a l s w h i l e t r y i n g t o cope w i t h a d e f i c i t , t o t a l l a c k of s e c r e t a r i a l s t a f f and one of the most p r o d u c t i v e s m a l l e r h o s p i t a l s i n the p r o v i n c e , w h i l e h o p i n g CCHA w i l l one day awaken to the r e a l world. Summary An a n a l y s i s of t h e d a t a i n d i c a t e d a w i d e r a n g e of purpose, g o a l s and o b j e c t i v e s f o r the s m a l l e r h o s p i t a l s ' q u a l i t y a s s u r a n c e p r o g r a m s . I n t e r v i e w s w i t h t h e a d m i n i s t r a t o r s i n d i c a t e d that many of them were unsure as to how s p e c i f i c they needed to w r i t e t h e s e s t a t e m e n t s and some d i s c u s s e d f r u s t r a t i o n i n t r y i n g t o w r i t e m e a n i n g f u l s t a t e m e n t s . Some a d m i n i s t r a t o r s thought t h a t i t would be d i f f i c u l t to implement a q u a l i t y assurance program given the 52 c u r r e n t p r o v i n c i a l p o l i c y of f i s c a l r e s t r a i n t . The CCHA QA Standard does not provide a w r i t t e n plan f o r q u a l i t y a s s u r a n c e t h a t d e l i n e a t e s the purpose, g o a l s and o b j e c t i v e s of the program. The d e t a i l e d d e s c r i p t i o n s of q u a l i t y assurance programs are expected to be developed i n the f i e l d and w i l l not be imposed by CCHA. However, i n 1984, CCHA d e c i d e d to i n c l u d e the M i s s i o n S t a t e m e n t as one of the S t a n d a r d s under " G o v e r n i n g Body and Management" (see Appendix VI). Th i s Standard i d e n t i f i e s that an " o v e r a l l p l a n " i s needed to a d d r e s s the a c h i e v e m e n t of g o a l s and o b j e c t i v e s and t h a t t h i s p l a n i s to be s u b j e c t to r e g u l a r review and r e v i s i o n . The booklet of the Proceedings of the Q u a l i t y Assurance Seminars October 1983 - May 1984, CCHA suggests that q u a l i t y a s s u r a n c e has to s t a r t w i t h a d e f i n i t i v e M i s s i o n S t a t e m e n t . T h i s b o o k l e t gave an example of a M i s s i o n S t a t e m e n t t h a t i n c l u d e d the f o l l o w i n g components: - the p o p u l a t i o n that the h o s p i t a l serves. - the l e v e l of care that the i n s t i t u t i o n intends to d e l i v e r ( i . e . primary, secondary or t e r t i a r y ) . - the major s e r v i c e s to be p r o v i d e d i n s u p p o r t of the l e v e l of c a r e such as g e n e r a l m e d i c i n e , p e d i a t r i c s , o b s t e t r i c s , general surgery, pathology and r a d i o l o g y . - a d e f i n i t i o n of the i n s t i t u t i o n s ' s e c o n d a r y r o l e i n 53 r e l a t i o n to other l o c a l h e a l t h s e r v i c e s . - a statement of what the h o s p i t a l i s not going to provide - s t a t e m e n t s t h a t d e t e r m i n e the p e o p l e who are g o i n g to monitor the c a r r y i n g out of the s e r v i c e s . - a s t a t e m e n t on t h e m e d i c a l s t a f f ' s p r i v i l e g e s and c r e d e n t i a l s . A l l of the h o s p i t a l s ' M i s s i o n S t a t e m e n t s have most of these statements, although v a r y i n g i n degree of s p e c i f i c i t y . One h o s p i t a l had a l l these statements and added a few more to the above l i s t , these were: - the a u s p i c e s under which the h o s p i t a l i s o p e r a t e d and funded, i . e . a h o s p i t a l s o c i e t y and t h r o u g h an a n n u a l g r a n t from the M i n i s t r y of H e a l t h , payments of c o - i n s u r a n c e , f e e s from Worker's Compensation Board c l a i m a n t s , and f e e s from p a t i e n t s not covered by the M e d i c a l S e r v i c e s Plan of B r i t i s h Columbia. - the scope of the s e r v i c e s , f o r example the p r o v i s i o n of maternity and b i r t h i n g care f o r women e x p e r i e n c i n g a low r i s k pregnancy; the p r o v i s i o n of 24 hour emergency s e r v i c e s . - the Standards of Care, i . e . , CCHA Standards. - the Community R o l e , e.g.programs f o r the e d u c a t i o n and t r a i n i n g of h e a l t h workers and the r o l e i t p r o v i d e s as an economic c o n t r i b u t o r to the community. 54 A r e c e n t a r t i c l e added to t h i s g r o w i n g l i s t . T h i s a r t i c l e c l e a r l y makes the point that the goals and o b j e c t i v e s f o r the development of a h o s p i t a l - w i d e QA program be part of the M i s s i o n Statement ( C o c k e r i l l , 1985, p. 27). T h i s point i s n o t c l e a r f r o m r e a d i n g t h e M i s s i o n S t a t e m e n t , G o a l s , O b j e c t i v e s and Planning Standard (CCHA, 1985). Q u a l i t y Assurance Functions f o r the Board, D i e t a r y , Nursing  and Pharmacy Areas i n Smaller H o s p i t a l s Appendix VI holds a l l the t a b u l a t e d r e s u l t s of Round I I . The QA f u n c t i o n s i n Round II were p r i o r i z e d on a s c a l e of one to f i v e ; one r e p r e s e n t i n g f i r s t p r i o r i t y . For the purposes of c o m p i l i n g s c o r e s (13) i n t o c u m u l a t i v e s c o r e s , the p r i o r i t y r a t i n g s were reversed so that higher p r i o r i t y f u n c t i o n s would be represented by higher s c o r e s . The h i g h e s t p o s s i b l e s c o r e would be 65. The range of s c o r e s f o r the board f u n c t i o n s i s 40 to 60; d i e t a r y i s 43 to 54; n u r s i n g i s 31 to 61; and pharmacy i s 41 to 59. The t h r e e highest and three lowest scores f o r the f u n c t i o n s i n each area are d i s p l a y e d i n the f o l l o w i n g t a b l e s . 55 TABLE II The Three Highest Scores f o r the Q u a l i t y Assurance Functions i n Four Areas: H o s p i t a l Board, D i e t a r y , Nursing and Pharmacy. Chosen by 13 A d m i n i s t r a t o r s of Predominantly Acute-Care, A c c r e d i t e d 20-50 Bed H o s p i t a l s i n B r i t i s h Columbia June - J u l y 1985. Area F u n c t i o n Score Board Development of M i s s i o n Statement 60 CCHA survey recommendations 59 Appointment/review of medical s t a f f 56 Appointment/review of s e n i o r a d m i n i s t r a t i v e s t a f f 56 D i e t a r y F i n a n c i a l c o n t r o l s (budget, r e c o r d s ) 54 Cleaning schedules 54 Job d e s c r i p t i o n s 53 Care and maintenance of equipment 53 Performance a p p r a i s a l of s t a f f 53 System f o r handling p h y s i c i a n d i e t orders to ensure accuracy 53 Review and update of goals, o b j e c t i v e s , p o l i c i e s and procedures 51 S t a f f o r i e n t a t i o n and c o n t i n u i n g education 51 A p p l i c a t i o n of d i e t manual 51 Tray a u d i t 51 Nursing Review of p o l i c i e s and procedures 61 Establishment of goals and o b j e c t i v e s 58 Unusual i n c i d e n t / m e d i c a t i o n e r r o r r e p o r t i n g and follow-up 58 Safety Committee 58 Nursing Audit 56 Pharmacy W r i t t e n procedures f o r storage, p r e p a r a t i o n , a d m i n i s t r a t i o n and p r e c a u t i o n s 58 Report of medication e r r o r s 58 Development of h o s p i t a l formulary with r e g u l a r review 57 N a r c o t i c c o n t r o l and i n s p e c t i o n 56 56 TABLE I I I The Three Lowest Scores f o r the Q u a l i t y Assurance Functions i n Four Areas: H o s p i t a l Board, D i e t a r y , Nursing and Pharmacy. Chosen by 13 A d m i n i s t r a t o r s of Predominantly Acute-Care, A c c r e d i t e d , 200-50 Bed H o s p i t a l s i n B r i t i s h Columbia June - J u l y 1985 Area Function Score Board J o i n t Conference Committee 47 P a t i e n t s a t i s f a c t i o n p o l l 47 U t i l i z a t i o n review 45 Risk management 40 D i e t a r y P a t i e n t survey 44 S t a f f survey 44 Provide Meals on Wheels to the Community (Not a p p l i c a b l e f o r four h o s p i t a l s ) Nursing Nursing p r a c t i c e committee 40 Regional committee 33 P a t i e n t c l a s s i f i c a t i o n systems 31 Pharmacy P a t i e n t discharge c o u n s e l l i n g program 45 P a t i e n t s e l f - a d m i n i s t e r e d drug program 41 Drug documentation a u d i t (HMRI) 39 57 Summary T h i s study i l l u m i n a t e d components of a q u a l i t y assurance program f o r a s m a l l e r h o s p i t a l which are more s p e c i f i c than t h o s e found i n the CCHA S t a n d a r d s . The s t u d y i d e n t i f i e d s p e c i f i c q u a l i t y a s s u r a n c e f u n c t i o n s f o r f o u r a r e a s of a s m a l l e r h o s p i t a l . F urther, these f u n c t i o n s were p r i o r i z e d and c u m u l a t i v e s c o r e s computed. The h i g h e s t and l o w e s t s c o r e s have been p r e s e n t e d . C o n c l u s i o n s can be drawn about which f u n c t i o n s are n e c e s s a r y or e s s e n t i a l or which f u n c t i o n s are l e a s t important. The CCHA QA Standard does not provide a d e t a i l e d l i s t of QA f u n c t i o n s . The b o o k l e t about the P r o c e e d i n g s of the Seminars on Q u a l i t y Assurance holds l i s t s of q u a l i t y assurance a c t i v i t i e s p r e s e n t l y i n e f f e c t or p l a n n e d as i d e n t i f i e d i n v a r i o u s workshops. These a c t i v i t i e s are not p r i o r i z e d . For the most part these a c t i v i t i e s are s i m i l a r to those f u n c t i o n s i d e n t i f i e d by the s u b j e c t s w i t h some e x c e p t i o n s . The f o l l o w i n g Table shows those f u n c t i o n s that were not i d e n t i f i e d i n both l i s t s . 58 TABLE IV Quality Assurance Functions Unique to Administrators of Predominantly Acute-care, Accredited 20-50 Bed Hospitals in B.C, June - July 1985 or to the Proceedings of the Seminars on Quality Assurance, CCHA, 1984 Administrators CCHA Board Monitor a l l QA committee ac t i v i t i e s by reviewing the target for a l l department. Review adequacy of f a c i l i t y and equipment. Dietary Organized system for consultation with a qualified dietitian. System for handling doctors' orders to ensure accuracy, e.g., use of a kardex. Menu review and planning. Staff survey Providing Meals-on-Wheels to the community. Financial controls, e.g., budget, records. Nursing Staffing guidelines. Regional committee Board Trustee orientation. Periodic review of Mission Statement (yearly). Policies concerning job descriptions and performance. Monthly departmental budget reports for trends. Productivity standards. Dietary Therapeutics Committee. Nutritional support, committee — TPN etc. Dietary internship. Number of therapeutic diets compared with regular diets. Cost per patient per day. Utilization s t a t i s t i c s . Purchasing from approved sources. Tendering. Nursing CPR and annual review of competency Professional Responsibility Committee Pharmacy Review and update of the goals, objectives, policies and procedures. Written procedures for storage preparation, administration and precautions. Availability of up-to-date CPS and other references. Medical staff regulations re orders, etc. Staff education and supervision. Pharmacy Professional standards Pharmacy and Therapeutic Committee Additive program Security through "night cupboard" — assess number of times necessary to c a l l pharmacist or ask supervisor to enter pharmacy . . . . 59 Summary The survey of the a d m i n i s t r a t o r s about the f u n c t i o n s of a q u a l i t y assurance program y i e l d e d 18 to 22 f u n c t i o n s whereas the Proceedings . . . i d e n t i f i e d 18 to 25 f u n c t i o n s . The area of highest agreement f o r f u n c t i o n s i s nursing s e r v i c e s . I t i s not c l e a r as to why t h e r e are d i f f e r e n c e s i n the k i n d o f q u a l i t y a s s u r a n c e f u n c t i o n s i d e n t i f i e d by t h e a d m i n i s t r a t o r s or a t the CCHA Se m i n a r s . A r e a s o n c o u l d be t h a t the f u n c t i o n s a r e r e l e v a n t to both groups but p e o p l e f a i l e d to mention them when s u r v e y e d . A l s o , the d a t a were c o l l e c t e d at two d i f f e r e n t p o i n t s i n time. A l t e r n a t i v e l y , maybe there are r e a l d i f f e r e n c e s between the groups. I t could be that the CCHA seminars are dominated by p e o p l e from v e r y d i f f e r e n t i n s t i t u t i o n s , i . e . , l a r g e teaching h o s p i t a l s that have d i f f e r e n t p r i o r i t i e s than s m a l l e r h o s p i t a l s . I t i s not c l e a r as to why n u r s i n g s e r v i c e s have the highest r a t e of agreement between the two groups. I t could be t h a t n u r s i n g has e s t a b l i s h e d more commonly known and understood standards f o r q u a l i t y assurance. 60 A d d i t i o n a l E m p i r i c a l F i n d i n g s What i s the Stage of Development of the H o s p i t a l ' s Q u a l i t y Assurance Program? As s t a t e d before, most the h o s p i t a l s are i n the f o r m a t i v e s t a g e s of t h e i r q u a l i t y a s s u r a n c e p l a n . The f o l l o w i n g d a t a show some of the verbatim responses of the a d m i n i s t r a t o r s when asked the preceding question: "We don't have s p e c i f i c goals and o b j e c t i v e s ; there are g o a l s and o b j e c t i v e s f o u n d i n t h e c o n s t i t u t i o n of t h e h o s p i t a l . " "The board i s not v e r y i n v o l v e d . " ( T h i s r e s p o n s e was common to f i v e h o s p i t a l s ) "We a r e a t the p o i n t of d e v e l o p i n g a purpose and g o a l statement f o r a q u a l i t y assurance program although we haven't met y e t . " "There hasn't been any f o r m a l r e p o r t i n g t h r o u g h the q u a l i t y assurance committee to the Board." "We are not p r e s e n t l y f a r i n t o q u a l i t y , a s s u r a n c e , but ex p e c t t h a t i n the next c o u p l e of y e a r s we w i l l p r o b a b l y do more." "Our QA program was approved at the end of A p r i l . Given the r e s t r a i n t program, the h o s p i t a l c o u l d n ' t a f f o r d e x t r a s t a f f ; so we needed a plan that was simple and p r a c t i c a l . " 61 "We have made s e v e r a l a t t e m p t s to b r i n g t h i s program together. Lack of s t a f f and time prevents us from p u t t i n g i t a l l t o g e t h e r . " "Segments of QA are already i n p l a c e . " " O n l y t h e m e d i c a l s t a f f have a d e v e l o p e d q u a l i t y a s s u r a n c e program . . . . Other d e p a r t m e n t s are w o r k i n g on q u a l i t y assurance." Who i s O p e r a t i o n a l l y R e s p o n s i b l e f o r the Q u a l i t y A s s u r a n c e Program? The board i s u l t i m a t e l y r e s p o n s i b l e f o r the q u a l i t y a s s u r a n c e program. T h i s s t a t e m e n t i s s u p p o r t e d by the n o r m a t i v e s t a n d a r d s and the e m p i r i c a l f i n d i n g s . In the h o s p i t a l s , the r e s p o n s i b i l i t y f o r monitoring the program has been d e l e g a t e d to the a d m i n i s t r a t o r and/or the D i r e c t o r of N u r s i n g and/or to c o m m i t t e e s . The QA f u n c t i o n s may be assigned to already e x i s t i n g or newly created committees such as the P a t i e n t Care Committee and the J o i n t C o n f e r e n c e Committee. Membership of the J o i n t Conference Committee t y p i c a l l y c o n s i s t s of an equal number of board members, members of the m e d i c a l s t a f f as w e l l as r e p r e s e n t a t i v e s f r o m s e n i o r a d m i n i s t r a t i o n . Membership of the P a t i e n t Care Committee u s u a l l y c o n s i s t s of the a d m i n i s t r a t o r , D i r e c t o r of N u r s i n g , 62 C h i e f of M e d i c a l " s t a f f and v a r i o u s department heads. The amount of i n v o l v e m e n t of i n d i v i d u a l board members on th e s e committees v a r i e s from n i l to c h a i r i n g the QA committee. The r e s p o n s i b i l i t y f o r the day to day q u a l i t y a s s u r a n c e program i n the d i e t a r y department i s the food s u p e r v i s o r or head cook. The m a j o r i t y of t h e h o s p i t a l s m a i n t a i n c o n s u l t a t i o n with a d i e t i t i a n who r o u t i n e l y phones, v i s i t s or s e n d s i n f o r m a t i o n by m a i l . The d i e t i t i a n e s t a b l i s h e s t h e r a p e u t i c d i e t s and methods of e v a l u a t i n g the p r o v i d i n g high q u a l i t y food f o r p a t i e n t s and s t a f f . The D i r e c t o r of N u r s i n g (D.O.N.) or D i r e c t o r of P a t i e n t Care S e r v i c e s (as found i n one h o s p i t a l ) i s r e s p o n s i b l e f o r the q u a l i t y assurance program i n the nursing department. In two h o s p i t a l s , the D.O.N, p o s i t i o n i s c u r r e n t l y vacant, so the head nurses and a d m i n i s t r a t o r s are assuming the r e s p o n s i b i l i t y f o r the ongoing f u n c t i o n i n g of the q u a l i t y assurance program i n the n u r s i n g department. In e i g h t h o s p i t a l s , the D.O.N, i s oft e n r e s p o n s i b l e f o r other s e r v i c e areas such as pharmacy. Four h o s p i t a l s do not have a p h a r m a c i s t . The o t h e r h o s p i t a l s have a p a r t - t i m e or c o n s u l t a n t p h a r m a c i s t . The c o n s u l t a n t p h a r m a c i s t may be a h o s p i t a l or c o m m u n i t y p h a r m a c i s t . The a d m i n i s t r a t o r s u s u a l l y p r e f e r a h o s p i t a l pharmacist. U n d o u b t e d l y , the a d m i n i s t r a t o r i s the pe r s o n p r i m a r i l y 63 r e s p o n s i b l e f o r t h e o n g o i n g c o m m i t m e n t t o t h e q u a l i t y a s s u r a n c e program. T h i s r e s p o n s i b i l i t y o f t e n i n c l u d e s the sending out of n o t i c e s of the meetings, pr e p a r i n g the agenda, c h a i r i n g the meetings and w r i t i n g up the minutes. Many of the a d m i n i s t r a t o r s do not have s e c r e t a r i a l s t a f f to a s s i s t them i n t h i s process. What problems did the a d m i n i s t r a t o r s encounter when t r y i n g to implement a Q u a l i t y Assurance program? The f o l l o w i n g i s a l i s t of v e r b a t i m r e s p o n s e s from the a d m i n i s t r a t o r s : "We r e a l l y have no one on s t a f f with s u f f i c i e n t time and support s e r v i c e s to adequately handle the task " "There has been l a c k of d i r e c t i o n and lack of knowledge; with no lead from CCHA." "Funding i s i n s u f f i c i e n t f o r b a s i c s l e t alone QA." " I t i s d i f f i c u l t when there are the same people i n v o l v e d i n so many committees." "There has been problems i n g e n e r a t i n g e n t h u s i a s m ; d e s c r i b i n g and c o n v i n c i n g department heads of need and b e n e f i t s of QA." " G e t t i n g s t a r t e d i s a problem." "There i s a g e n e r a l l a c k of u n d e r s t a n d i n g ; we need to cut through the mysteries of the QA l i n g o . " 64 One a d m i n i s t r a t o r d e s c r i b e d the p r o c e s s of s e t t i n g up a q u a l i t y assurance program as thus: "Nobody had any idea what QA meant, or how a QA p r o g r a m s h o u l d work. We a l l ( a d m i n i s t r a t o r and department heads) had to r e v i e w the l i t e r a t u r e to a r r i v e at a common u n d e r s t a n d i n g of QA." They had to b u i l d up t h e i r knowledge base. The d e t e r m i n i n g of s p e c i f i c QA f u n c t i o n s and standards i n each department was a d i f f i c u l t process. The s t a f f were unsure as to what c r i t e r i a should be set f o r the study standards. The process of s e t t i n g up the q u a l i t y assurance program was very time consuming. There were unique problems a s s o c i a t e d with s e t t i n g up a q u a l i t y a s s u r a n c e p r o g r a m i n t h e d i e t a r y and p h a r m a c y departments. These problems r e l a t e d to the l a c k of f u l l - t i m e q u a l i f i e d p h a r m a c i s t s and d i e t i t i a n s . The a d m i n i s t r a t o r s managed with the problems as r e a l i s t i c a l l y as p o s s i b l e . Many of the a d m i n i s t r a t o r s delegated the r e s p o n s i b i l i t y f o r q u a l i t y a s s u r a n c e i n t h e p h a r m a c y d e p a r t m e n t t o t h e n u r s i n g department. Many of the a d m i n i s t r a t o r s u t i l i z e d s u r v e y s to determine the p a l a t a b i l i t y of the food f o r s t a f f and p a t i e n t s . I n t h e n u r s i n g d e p a r t m e n t , as i n some of t h e o t h e r departments, i t i s d i f f i c u l t to organize meetings because of the assignment of personnel to s h i f t work. Most s m a l l h o s p i t a l s r e q u i r e l o n g i t u d i n a l s t u d i e s i n order to o b t a i n adequate numbers of cases f o r t h e i r r e s u l t s to 65 be s i g n i f i c a n t . Some h o s p i t a l s may never get enough da t a on r a r e d i s o r d e r s or the t h e r a p e u t i c treatment may change before e f f i c a c y i s d e m o n s t r a t e d . The t i m e r e q u i r e d to c a r r y out these s t u d i e s r e p r e s e n t s more of a time commitment than other s t u d y d e s i g n s such as c r o s s - s e c t i o n a 1 which can be used i n l a r g e r c e n t r e s . Nor may the s t a f f have the t r a i n i n g or the i n c l i n a t i o n to do the necessary research. A common complaint by a d m i n i s t r a t o r s i s that there are no funds a v a i l a b l e f o r a t t e n d a n c e not o n l y at i n h o u s e q u a l i t y assurance meetings but a l s o f o r any job r e l a t e d conferences or q u a l i t y a s s u r a n c e s e m i n a r s which, because of demand, are u s u a l l y l o c a t e d i n l a r g e p o p u l a t i o n c e n t e r s . Thus, p a r t of the reason f o r t h i s l a c k of attendance i s because of the long d i s t a n c e s t h a t s t a f f have to t r a v e l on t h e i r own t i m e . In s h o r t , t h e d e v e l o p m e n t of a q u a l i t y a s s u r a n c e p r o g r a m r e p r e s e n t s an i n c r e a s e d expense f o r the s m a l l e r h o s p i t a l a d m i n i s t r a t o r . T h i s p r o v i d e s l i t t l e i n c e n t i v e f o r the v o l u n t a r y commitment to a c c r e d i t a t i o n . However, many of the problems r e l a t e d to monitoring the q u a l i t y of care d e l i v e r e d i n s m a l l e r h o s p i t a l s are overcome by a number of s p e c i f i c management t e c h n i q u e s . D a i l y c o n t a c t with a l l s t a f f i n a l l areas i s p o s s i b l e i n a s m a l l e r h o s p i t a l . Senior management i s able to observe d i r e c t l y and s u b j e c t i v e l y the s t a t e of c l e a n l i n e s s , the appearance of food and the need 66 f o r r e p a i r of the p h y s i c a l p l a n t . The c o m p l a i n t s of t i m e c o n s t r a i n t s by department heads i n order to meet a c c r e d i t a t i o n r e q u i r e m e n t s are c o u n t e r e d by a c o m b i n a t i o n of p r a c t i c a l a s s i s t a n c e and a s s e r t i o n of a u t h o r i t y . In any s m a l l e r h o s p i t a l , no c o m p l a i n t r a r e l y goes unreported because of the c l o s e work environment. Because of t h e c l o s e c o m m u n i t y t i e s , c o m p l a i n t s a r e i n v e s t i g a t e d immediately with a quick response to the complainant. What B e n e f i t s Have Been Gained From I m p l e m e n t i n g a Q u a l i t y Assurance Program? In s p i t e of a l l t h e s e problems l i s t e d above, t h e r e are b e n e f i t s a s s o c i a t e d w i t h i m p l e m e n t i n g a QA program. The f o l l o w i n g i s a l i s t of verbatim responses from a d m i n i s t r a t o r s : "There i s not a w e l l understood and able to be acted upon medical audit." "Good way to get work out of the board member who c h a i r s the QA committee." "Great improvement of h o s p i t a l manuals." " A u d i t r e s u l t s prove e x c e l l e n c e of s e r v i c e p r e v i o u s l y only ' f e l t ' . " "Brought i n t o the open i n t e r d e p a r t m e n t a l c o n f l i c t s . " "None yet." "We have a l l become more aware of what we s h o u l d be d o i n g and how w e l l i t should be done versus our a c t u a l performance." 67 " People have been f o r c e d to t h i n k about t h e i r j o b s and t h e i r performance and are t a k i n g more p r i d e i n themselves." What Are the A d m i n i s t r a t o r s ' R e a c t i o n s to the New Q u a l i t y Assurance Requirements f o r A c c r e d i t a t i o n ? The f o l l o w i n g l i s t s the a d m i n i s t r a t o r s responses: "The requirements are good. They c l e a r l y o u t l i n e what i s r e q u i r e d but l e a v e the 'how to' f o r each h o s p i t a l to f i g u r e out. T h i s f o l l o w s a p p r o p r i a t e r u l e s of delegation." " T e r r i b l e ! The requirements give no c o n s i d e r a t i o n to the c o s t , t h e d i f f i c u l t y of i m p l e m e n t a t i o n , t h e f a c t t h a t government does not s u p p o r t the program or t h a t CCHA do not themselves know what they want from QA." "Good. I t assures the p r o v i d e r and consumer that care i s being assessed and graded." "Object somewhat to i t s being mandatory but am pleased to see the i n t r o s p e c t i o n i t f o r c e s upon the h o s p i t a l . " "Both good and bad. Good — they make the p r o c e s s dynamic and r e q u i r e s y s t e m s to m a i n t a i n adherence to the Standards. Bad — created a new language system that seems to r e q u i r e a new p r o f e s s i o n to u n r a v e l the m y s t e r i e s to the unknowing." 68 Summary The d a t a show t h a t t h e r e a r e p r o b l e m s r e l a t e d to i m p l e m e n t i n g a QA program but at the same t i m e t h e r e are a number of b e n e f i t s r e l a t e d to the program. The v a r i e t y of responses of the a d m i n i s t r a t o r s to the QA requirements could represent the stage of acceptance or non-acceptance commonly experienced during a s i g n i f i c a n t change. The A p p l i c a t i o n of the D o l l and Donabedian Models The l a s t a r e a f o r a n a l y s i s i s to compare the two most popular q u a l i t y assurance models with the e m p i r i c a l f i n d i n g s . The Donabedian model was c o n s t r u c t e d as a framework to e v a l u a t e the methods f o r a s s u r i n g q u a l i t y of c a r e , i . e . , s t r u c t u r e , process and outcome. The D o l l model presents three elements of a model that d e f i n e q u a l i t y . These elements are m e d i c a l e f f i c a c y , s o c i a l a c c e p t a b i l i t y and e c o n o m i c e f f i c i e n c y . In C h a p t e r I I , i t was argued t h a t the D o l l model was more a p p r o p r i a t e f o r the c u r r e n t CCHA r e q u i r e m e n t s than the Donabedian model. the D o l l model i n c l u d e s more elements that are r e l e v a n t to the c u r r e n t p o l i c i e s of f i s c a l r e s t r a i n t by government and the requirements of a q u a l i t y assurance program by t h e CCHA. The p o l i c y of f i s c a l r e s t r a i n t c o u l d be 69 r e p r e s e n t e d i n the e l e m e n t of economic e f f i c i e n c y and the requirements of q u a l i t y assurance could be represented i n the e l e m e n t s of s o c i a l a c c e p t a b i l i t y and economic e f f i c i e n c y . Take as an example, some of the e m p i r i c a l q u a l i t y a s s u r a n c e f u n c t i o n s i d e n t i f i e d i n the d i e t a r y department. These f u n c t i o n s could i t i n t o the d o l l model as f o l l o w s : 1 . Medical e f f i c a c y would i n c l u d e : c l e a n i n g s c h e d u l e s , c a r e and m a i n t e n a n c e of equipment, t e m p e r a t u r e a u d i t s , p u b l i c h e a l t h and s a n i t a t i o n t e s t s , a p p l i c a t i o n of d i e t m a n u a l s , o r g a n i z e d system f o r c o n s u l t a t i o n w i t h a q u a l i f i e d d i e t i t i a n , e t c . 2. S o c i a l a c c e p t a b i l i t y would i n c l u d e : p a t i e n t and s t a f f surveys, t r a y a u d i t s . 3. Economic e f f i c i e n c y would i n c l u d e : s t o c k i n g and i n v e n t o r y , f i n a n c i a l c o n t r o l s , performance review of s t a f f , e t c . I t i s not d i f f i c u l t to convince the reader that the D o l l model i s a s u i t a b l e model f o r c a t e g o r i z i n g v a r i o u s q u a l i t y a s s u r a n c e f u n c t i o n s . The c h a l l e n g e i s to d e t e r m i n e i f the model can a l s o be used as a method to a s s e s s and m o n i t o r q u a l i t y assurance components. D o l l sees each element as being monitored i n terms of the outcome achieved or by the process i n which the outcome i s r e a c h e d . S i n c e D o l l uses the terms 70 common to Donabedian, i t seems a p p r o p r i a t e to combine the two models. The Donabedian model i s used as a broad framework to a s s e s s and m o n i t o r the e l e m e n t s t h a t d e f i n e q u a l i t y as suggested by D o l l . A s i m i l a r suggestion was made e a r l i e r by Donabedian (1982). The c o n j o i n t a p p l i c a t i o n of t h e s e two models i s d i s p l a y e d i n T a b l e V. The e m p i r i c a l q u a l i t y a s s u r a n c e f u n c t i o n s f o r the d i e t a r y department are used i n t h i s example. 71 Table V A Method f o r A s s e s s i n g and M o n i t o r i n g Q u a l i t y Assurance Components i n the D i e t a r y Department Q u a l i t y Approaches to Assessment and M o n i t o r i n g Assurance Elements Process Outcome Medical E f f i c a c y 1. A p p l i c a t i o n of d i e t manual. 2. Recording of d i e t a r y progress of p a t i e n t s . 3. C l e a n i n g schedules. 1. H e a l t h - e f f e c t s of e a t i n g the d i e t : as i n d i c a t e d by weight, e t c . 2. P u b l i c h e a l t h and s a n i t a t i o n t e s t s i n d i c a t e adequacy of schedules. S o c i a l A c c e p t a b i l i t y .1. P a t i e n t survey. 2. S t a f f survey. 3. Tray a u d i t . 1. P u b l i c s a t i s f a c t i o n or d i s s a t i s f a c t i o n . Economic Ef f i c i e n c y 1. F i n a n c i a l c o n t r o l s . 2. Stocking and Inventory 1. I n d i c a t o r s : w i t h i n budget or over the budget. 2. C r i t e r i a f o r determining i f stock i s w e l l u t i l i z e d . 7 2 F i n a l Summary and Conclusions T h i s c h a p t e r p r e s e n t e d the e m p i r i c a l f i n d i n g s from the surveys of the s u b j e c t s . The data were c o l l e c t e d i n order to determine what are the purposes, goals and o b j e c t i v e s of the s m a l l e r h o s p i t a l s ' q u a l i t y assurance program. T h i s data were analyzed and compared with the normative standards. I t i s not c l e a r from the CCHA s t a n d a r d s as t o what t h e s e s t a t e m e n t s s h o u l d i n c l u d e . However, the b o o k l e t of the " P r o c e e d i n g s of the Q u a l i t y A s s u r a n c e S e m i n a r s " . . . s u g g e s t s t h a t q u a l i t y assurance should s t a r t with a d e f i n i t i v e " M i s s i o n Statement." T h i s c h a p t e r has d e s c r i b e d c o m p o n e n t s f o r a " M i s s i o n S t a t e m e n t " b a s e d on n o r m a t i v e s t a n d a r d s and e m p i r i c a l f i n d i n g s . The r e v i e w of the l i t e r a t u r e showed t h a t t h e r e were no e x p l i c i t " G o l d S t a n d a r d s " ( i . e . , commonly a g r e e d upon s t a n d a r d s ) f o r s p e c i f i c f u n c t i o n s of the q u a l i t y a s s u r a n c e programs f o r s m a l l e r h o s p i t a l s . The survey data i n d i c a t e the most common and most s t r o n g l y or weakly agreed upon f u n c t i o n s f o r four areas: board, d i e t a r y , nursing and pharmacy. These f u n c t i o n s were compared with those f u n c t i o n s i d e n t i f i e d i n the CCHA Seminars and d i f f e r e n c e s were found. I t i s u n c e r t a i n as to why these d i f f e r e n c e s e x i s t . The l i t e r a t u r e r e v i e w a l s o i n d i c a t e d t h a t t h e r e were a 73 number of c o n t r o v e r s i a l i s s u e s a f f e c t i n g the implementation of the Q u a l i t y Assurance Standard and r a i s e d questions about the s i g n i f i c a n c e of the S t a n d a r d f o r the s m a l l e r h o s p i t a l s . A number of q u e s t i o n s were asked to d e t e r m i n e i f t h e r e were i s s u e s a f f e c t i n g the implementation of the q u a l i t y assurance program and an e v a l u a t i v e question to determine the stage of development of the q u a l i t y assurance program. The e m p i r i c a l data i n d i c a t e d some ambivalence and o b s t a c l e s to implementing a q u a l i t y a s s u r a n c e program. Yet, h o s p i t a l s were p r e c e d i n g with developing a q u a l i t y assurance program. As pointed out i n the l i t e r a t u r e , these o b s t a c l e s may be due to a response to change. The l a s t a r e a of a n a l y s i s was to d e t e r m i n e t h e c o m p a t i b i l i t y between the popular q u a l i t y assurance models and the e m p i r i c a l f i n d i n g s . The c o n c l u s i o n s are t h a t the two models can be used c o n j o i n t l y to d e t e r m i n e and a s s e s s the f u n c t i o n s of a q u a l i t y a s s u r a n c e program. However, i t i s s u g g e s t e d t h a t more r e s e a r c h be done i n a p p l y i n g the two models ass a method to a s s e s s and m o n i t o r q u a l i t y a s s u r a n c e components. The D o l l model i s a p p r o p r i a t e f o r implementing a QA p r o g r a m , i . e . , i d e n t i f y i n g t h e e l e m e n t s t h a t d e f i n e q u a l i t y . 74 CHAPTER V Conclusions and Recommendations The components of a q u a l i t y assurance program i d e n t i f i e d i n t h i s s t u d y has p r o d u c e d many i t e m s w h i c h m i g h t be c o n s i d e r e d o b v i o u s . However, the t e c h n i q u e of p o o l i n g together the f u n c t i o n s i d e n t i f i e d i n Round I and r e - s u r v e y i n g of s u b j e c t s i n Round I I i l l u m i n a t e d more q u a l i t y a s s u r a n c e f u n c t i o n s . There were approximately two times more f u n c t i o n s acknowledged by the a d m i n i s t r a t o r s i n Round I I . With some exceptions, the e m p i r i c a l data are c o n s i s t e n t with the normative standards. The i n t e n t of the study was not to e s t a b l i s h an i n s t i t u t i o n a l - w i d e QA program as s p e c i f i e d i n the S t a n d a r d s but to i d e n t i f y components s p e c i f i c to a QA program i n s m a l l e r h o s p i t a l s . The CCHA S t a n d a r d s do not i d e n t i f y the s p e c i f i c f u n c t i o n s of the QA program f o r s m a l l e r h o s p i t a l s ; t h i s study does. The f u n c t i o n s i d e n t i f i e d i n t h i s study are s p e c i f i c and a r e g e n e r a t e d by t h e a d m i n i s t r a t o r s who h a v e t h e r e s p o n s i b i l i t y f o r the ongoing o p e r a t i o n of the QA program. I t i s l i k e l y that the p r i o r i t y r a t i n g s of these f u n c t i o n s are u s e f u l f o r f o r w a r d p l a n n i n g when a l t e r n a t i v e s must be considered during t h i s time of f i s c a l r e s t r a i n t . The a d m i n i s t r a t o r s ' r e a c t i o n to the QA Standard could be 75 summarized i n one s t a t e m e n t : " Q u a l i t y i s good but at what c o s t ? " Although the QA Standard was developed i n response to s h i f t i n g p o l i t i c a l and p r o f e s s i o n a l p r e s s u r e s , i t may not f u l l y take i n t o a c c o u n t f o r m a l and i n f o r m a l r e s t r i c t i o n s to i n n o v a t i v e programs. These formal r e s t r i c t i o n s are resource l i m i t a t i o n s imposed by government and the i n f o r m a l r e s i s t e n c e to change by p r o f e s s i o n a l s . The CCHA Standards appear to be overwhelming to s m a l l e r h o s p i t a l a d m i n i s t r a t o r s . T h i s study has demonstrated that the h o s p i t a l s can i d e n t i f y many components of a QA program but may not be able to i n t e g r a t e them i n t o an o v e r a l l QA program. R e l i a b i l i t y and V a l i d i t y of the Study Many of the r e l i a b i l i t y and v a l i d i t y i s s u e s have been d i s c u s s e d i n C h a p t e r I I I ; some of t h e s e i s s u e s d e s e r v e f u r t h e r d i s c u s s i o n now that the study i s completed. The method of e n q u i r y used i n a stud y w i l l i n e v i t a b l y a f f e c t the r e s u l t s . T h i s k i n d of stud y i s based on human o p i n i o n and judgement. I t does not provide s c i e n t i f i c t r u t h s . I t only took i n t o account those components i d e n t i f i e d by the a d m i n i s t r a t o r s who p a r t i c i p a t e d i n the study. Those who were chosen and agreed to p a r t i c i p a t e d i n t h i s s t u d y w i l l be d i f f e r e n t from those who d i d not p a r t i c i p a t e . The v a l i d i t y ( a c c u r a c y ) or the study c o u l d be c o n f i r m e d by 76 r e p e a t i n g t h e s t u d y w i t h a d i f f e r e n t g r o u p , d i f f e r e n t o b s e r v e r , or by a d i f f e r e n t method. One method would be to use a committee as the p a r t i c i p a n t group. I t i s unsure i f a committee would have the patience or time to generate such a comprehensive l i s t of f u n c t i o n s and vote on these f u n c t i o n s . The l i t e r a t u r e i n d i c a t e s t h a t t h e r e l i a b i l i t y ( r e p r o d u c a b i l i t y ) of the i n f o r m a t i o n i s i n c r e a s e d by h a v i n g more Rounds. The i m p r e s s i o n i s t h a t the r e l i a b i l i t y of the i n f o r m a t i o n would decrease with subsequent rounds because of the p o t e n t i a l f o r f a t i g u e of the p a r t i c i p a n t s . A l a r g e r number of p a r t i c i p a n t s would have meant a l t e r i n g the sample c r i t e r i a or s e l e c t i n g p a r t i c i p a n t s from out of the p r o v i n c e . The r e l i a b i l i t y and v a l i d i t y of the study was improved by the high r a t e of r e t u r n s of the q u e s t i o n n a i r e s and by the use of random sampling with the p r e - t e s t and s t r a t i f i e d sampling with Round I I . Recommendations On the b a s i s of an a n a l y s i s of the l i t e r a t u r e and the e m p i r i c a l data, the f o l l o w i n g recommendations are suggested. 1) I t i s recommended t h a t the h o s p i t a l e s t a b l i s h a Q u a l i t y Assurance Plan that i n c l u d e s the f o l l o w i n g elements: purpose, philosophy, o r g a n i z a t i o n a l s t r u c t u r e and r o l e s , goals 77 and o b j e c t i v e s . The p u r p o s e o u t l i n e s t h e i n t e n t of t h e p l a n . The philosophy i d e n t i f i e s the guid i n g p r i n c i p l e s and b e l i e f s f o r the conduct of the QA program. The o r g a n i z a t i o n a l s t r u c t u r e and r o l e s i d e n t i f i e s the l i n e s of a u t h o r i t y and r e s p o n s i b i l i t y of the p e o p l e i n v o l v e d i n the QA program. The r o l e s of the board, medical s t a f f , s e n i o r a d m i n i s t r a t i v e s t a f f and h o s p i t a l s t a f f need to be d e f i n e d . The g o a l s t a t e m e n t s g u i d e t h e d e v e l o p m e n t of t h e o b j e c t i v e s . The g o a l s a re s t a t e m e n t s of r e l a t i v e l y broad s c o p e and need t o be s p e c i f i e d i o n m e a s u r a b l e t e r m s . O b j e c t i v e s are narrower than goals and more s p e c i f i c i n scope. O b j e c t i v e s a r e m e a s u r a b l e , a c h i e v a b l e , t i m e - r e l a t e d , understandable and s p e c i f i c . The d i f f e r e n c e between goals and o b j e c t i v e s i s i l l u s t r a t e d i n the f o l l o w i n g example. The h o s p i t a l ' s g o a l i s to p r o v i d e h i g h q u a l i t y c a r e ; one of i t s o b j e c t i v e s i s to comply with CCHA Standards. 2 ) A d m i n i s t r a t o r s who are d e v e l o p i n g t h e i r QA program should be aware of t h i s study. The QA components d e v e l o p e d i n t h i s study would be of i n t e r e s t to l a r g e r and s m a l l e r , a c c r e d i t e d and non-accredited h o s p i t a l s . The QA f u n c t i o n s i d e n t i f i e d i n t h i s study a re s i m i l a r to th o s e i d e n t i f i e d i n the CCHA s e m i n a r s , w i t h some exceptions. These exceptions help d i s t i n g u i s h those q u a l i t y assurance f u n c t i o n s which are unique to s m a l l e r h o s p i t a l s . 7 8 3) A d m i n i s t r a t o r s s h o u l d be aware of f u n c t i o n s i d e n t i f i e d as high and low p r i o r i t y . T h i s i n f o r m a t i o n would be of i n t e r e s t i n p l a n n i n g a QA program and f o r determining p r i o r i t i e s f o r the QA program. 4) Recommend t h a t s u i t a b l e models f o r i m p l e m e n t i n g QA are developed and u t i l i z e d . Government p o l i c i e s , a l o n g w i t h the s t r o n g v o l u n t a r y support of a c c r e d i t a t i o n programs, make i t v i t a l l y important t h a t s u i t a b l e models f o r i m p l e m e n t i n g QA are d e v e l o p e d . As argued i n t h i s s t u d y , the D o l l model i s s u g g e s t e d as a b a s i s f o r i m p l e m e n t i n g QA. G i v e n the c o m p e t i t i o n f o r h e a l t h s e r v i c e s r e s o u r c e s , h e a l t h p l a n n e r s and h o s p i t a l a d m i n i s t r a t o r s can i l l a f f o r d to i g n o r e a model which might p r o v i d e g r e a t e r b e n e f i t s t h r o u g h the i n c l u s i o n of more elements. 5) Recommend t h a t where geography p e r m i t s , groups of h o s p i t a l s pool together t h e i r resources and conduct QA s t u d i e s j o i n t l y . One component of the d o l l model i s the mounting of r e g i o n a l m o r b i d i t y and m o r t a l i t y s u r v e y s to d e t e r m i n e need. Another component i s to conduct c o n t r o l l e d t r i a l s i n l i m i t e d s e t t i n g s . F o l l o w i n g a r e v i e w of t h e s e components and the e m p i r i c a l data, the preceding recommendation was formulated. T h i s recommendation seems a p p r o p r i a t e , p a r t i c u l a r l y f o r 79 s m a l l e r h o s p i t a l s where t h e r e are l i m i t e d r e s o u r c e s both m a t e r i a l and human. 6) Recommend that a c l e a r methodology f o r a s s e s s i n g the q u a l i t y of care be developed. T h i s study disc u s s e d the numerous meth o d o l o g i c a l problems a s s o c i a t e d w i t h a s s e s s i n g q u a l i t y of c a r e . In a d d i t i o n , the a d m i n i s t r a t o r s v e r b a l i z e d t h a t t h e r e i s a g e n e r a l l a c k of d i r e c t i o n and l a c k of knowledge about how to c a r r y out a QA program. Also, t h i s study suggested the use of the D o l l model and the Donabedian as a methodology f o r a s s e s s i n g the q u a l i t y of care. T h i s methodology needs to be f u r t h e r t e s t e d i n order to determine i t s u s e f u l n e s s . I t i s i m p o r t a n t t h a t a methodology be d e v e l o p e d t h a t i s r e l a t i v e l y p r a c t i c a l , t i m e l y , inexpensive and not d i s r u p t i v e to the c u r r e n t system. The methodology s h o u l d be w i d e l y a c c e p t a b l e to the p e o p l e who work i n the h o s p i t a l and the community at l a r g e . The methodology should be c o n s i s t e n t and o b j e c t i v e so that i t can be a p p l i e d r e p e a t e d l y using the same ground r u l e s . F i n a l l y , the methodology should be d i r e c t l y or i n d i r e c t l y r e l a t e d to outcome. 7) Recommend that s m a l l e r h o s p i t a l s use more q u a l i t a t i v e methods r a t h e r than q u a n t i t a t i v e methods to e v a l u a t e the q u a l i t y of c a r e . There was some concern expressed by a d m i n i s t r a t o r s that there i s l a c k of adequate numbers f o r the s m a l l e r h o s p i t a l to 80 conduct meaningful s t u d i e s . One way to deal with t h i s problem i s to f o c u s on b r o a d e r , g e n e r i c t o p i c s t h a t c u t a c r o s s a v a r i e t y of s i t u a t i o n s . These t o p i c s c o u l d i n c l u d e the s t a f f and p a t i e n t s ' o p i n i o n s about the q u a l i t y of the f o o d , the e f f e c t i v e n e s s of discharge planning and the e f f e c t i v e n e s s of o u t - p a t i e n t care. 8) Recommend t h a t a d m i n i s t r a t o r s e l i m i n a t e redundant committees and c o n s o l i d a t e a c t i v i t i e s that can be c a r r i e d out by small s t r u c t u r e d groups. Some a d m i n i s t r a t o r s were concerned about the redundancy of meetings and the same people having to spend time a t t e n d i n g numerous m e e t i n g s . A l t e r n a t i v e l y , o t h e r a d m i n i s t r a t o r s e x p r e s s e d a c o n c e r n t h a t t h e r e was o f t e n j u s t one or two people who are c a r r y i n g . t h e r e s p o n s i b i l i t y of the Qa program. The documentation process demands a l o t of time. Decreasing the frequency of meetings and e l i m i n a t i n g redundant meetings c o u l d l e a d to more m e a n i n g f u l s t a f f i n v o l v e m e n t i n the i n s t i t u t i o n - w i d e QA program. Con c l u s i o n T h i s study was c o n c e r n e d w i t h a p r i m a r y o b j e c t i v e : to d e t e r m i n e the components of a Q u a l i t y A s s u r a n c e program. Along with t h i s o b j e c t i v e , other o b j e c t i v e s and questions were g e n e r a t e d . A major a s s u m p t i o n made at the b e g i n n i n g of the 81 s t u d y was t h a t h o s p i t a l s a r e a l r e a d y e n g a g e d i n QA a c t i v i t i e s . T h i s a s s u m p t i o n was s u p p o r t e d by the e m p i r i c a l data, a The o b j e c t i v e s were met and the questions researched. In comparison to other e f f o r t s to improve the q u a l i t y of c a r e , the QA s t a n d a r d i s more c o m p r e h e n s i v e . However, many s m a l l e r h o s p i t a l a d m i n i s t r a t o r s expressed t h e i r concern about being able to f u l l y meet the requirements of the QA standard. The i n f o r m a t i o n d e r i v e d from t h i s study could be used as a b a s i s f o r forming a QA program i n a h o s p i t a l . Areas f o r F u r t h e r Research and Development Many of the i s s u e s d i s c u s s e d i n the study are not new. Research i n t o the methodology used i n q u a l i t y measurement and a s s u r a n c e n e e d s t o be c o n t i n u e d . R e s e a r c h n e e d s t o be c o n t i n u e d about methods of r e t r a i n i n g and r e - o r i e n t a t i n g people who are i n v o l v e d i n QA at the s e r v i c e l e v e l . There i s a need to i n v e s t i g a t e the e f f e c t s of environment and o r g a n i z a t i o n a l s t r u c t u r e on the q u a l i t y of c a r e . The o p e r a t i o n a l and c o n c e p t u a l s i d e s of o r g a n i z a t i o n a l b e h a v i o r need to be i n v e s t i g a t e d . Having i d e n t i f i e d s p e c i f i c components f o r QA, i t would be i n t e r e s t i n g to examine s p e c i f i c h o s p i t a l s to see whether these QA f u n c t i o n s are b e i n g c a r r i e d out, what p r i o r i t y t h e s e QA f u n c t i o n s have and to what e x t e n t the QA program i s c a r r i e d 82 out. The h o s p i t a l s examined could be l a r g e or s m a l l , r u r a l or u r b a n , a c u t e c a r e or e x t e n d e d c a r e . O t h e r h o s p i t a l departments and the medical s e r v i c e could be i n v e s t i g a t e d too. There i s a need to i n v e s t i g a t e the e f f e c t s of environment and o r g a n i z a t i o n a l s t r u c t u r e on the q u a l i t y of c a r e . The o p e r a t i o n a l and c o n c e p t u a l s i d e s of o r g a n i z a t i o n a l b e h a v i o r need to be r e s e a r c h e d and d e v e l o p e d i n o r d e r to f u r t h e r our u n d e r s t a n d i n g about q u a l i t y a s s u r a n c e . T h i s s t u d y and the CCHA s t a n d a r d l e a v e s us somewhat u n c l e a r a b o u t t h e o r g a n i z a t i o n a l dimensions of QA programs. An i m p o r t a n t r e s e a r c h q u e s t i o n i s : how much are we w i l l i n g to spend on h e a l t h c a r e and f o r what amount of q u a l i t y . A n other q u e s t i o n i n v o l v e s the r e l a t i v e c o s t and b e n e f i t s of i n d i v i d u a l QA f u n c t i o n s . With l i m i t e d amount of r e s o u r c e s , how much a r e h o s p i t a l s w i l l i n g t o s p e n d on a s s e s s i n g the q u a l i t y of h e a l t h s e r v i c e v e r s u s the a c t u a l p r o v i s i o n of QA? Another more g l o b a l p o l i c y i s s u e i s : s h o u l d h e a l t h s e r v i c e resources go towards a s s e s s i n g the d e l i v e r y of care or s h o u l d money go towards c h a n g i n g people's l i f e s t y l e s ? The L a l o n d e R e p o r t was one f e d e r a l r e p o r t t h a t c h a l l e n g e d the p o l i c y of f o c u s s i n g r e s o u r c e s on h e a l t h c a r e o r g a n i z a t i o n s . A l m o s t a l l of the f e d e r a l h e a l t h s e r v i c e e x p e n d i t u r e s go towards h e a l t h c a r e o r g a n i z a t i o n s , whereas the l a r g e s t 83 s h o u l d money go towards c h a n g i n g people's l i f e s t y l e s ? The L a l o n d e R e p o r t was one f e d e r a l r e p o r t t h a t c h a l l e n g e d the p o l i c y of f o c u s s i n g r e s o u r c e s on h e a l t h c a r e o r g a n i z a t i o n s . A l m o s t a l l of the f e d e r a l h e a l t h s e r v i c e e x p e n d i t u r e s go t owards h e a l t h c a r e o r g a n i z a t i o n s , whereas the l a r g e s t percentage of c u r r e n t m o r b i d i t y and m o r t a l i t y can be r e l a t e d to l i f e s t y l e . 84 REFERENCES A b e l - S m i t h , B. 1964. The H o s p i t a l s , 1800-1948. London: Hei nemann. Act to Regulate the Q u a l i t y of P r a c t i t i o n e r s i n Medicine and S^rg^er_y_. 1858. S t a t u t e s of the U n i t e d Kingdom, Grea t B r i t a i n and I r e l a n d , 22 V i c t o r i a : Chapter XC. Agnew, G.H. 1974. Canadian H o s p i t a l s 1920-1970: A D ^ m a t i c Half Century. Toronto: U n i v e r s i t y of Toronto P r e s s l Ainsworth, T.H. 1984. Q u a l t i y assurance i n the p r o v i s i o n of h o s p i t a l care -- t r u s t e e s , the u l t i m a t e r e s p o n s i b i l i t y . H o s p i t a l s , 49. A l i s o n , S h e i l a & K i n l o c k , Kathy. 1981. Four s t e p s to q u a l i t y assurance. Canadian Nurse, 77 (11), p. 36-42 "A S e n i o r A d m i n i s t r a t o r ' s Response to F a c i l i t y P l a n n i n g by Government." 1984. Handout from the c o u r s e i n h e a l t h p l a n n i n g g i v e n i n the Department of H e a l t h Care and E p i d e m i o l o g y , U.B.C. Baker, Frank. 1983. Q u a l i t y assurance and program e v a l u a t i o n . E v a l u a t i o n and the Health P r o f e s s i o n s , 6^  (2), p. 149-160. B e n n e t t , J.E. & Krasny, J. 1980. Time to f a c e up to the h e a l t h c a r e c r u n c h . In P e r s p e c t i v e s on C a n adia n H e a l t h and S o c i a l S e r v i c e P o l i c y : H i s t o r y and Emerging Tren d s , M e i l i c k e , C.A. & S t o r c h , J.L. (eds.). M i c h i g a n : Health A d m i n i s t r a t i o n Press. B e r l i n e r , H. 1975. A l a r g e r p e r s p e c t i v e on the F l e x n e r Report. I n t e r n a t i o n a l J o u r n a l of Health S e r v i c e s , _5 (4), p. 573-592. B r a d l e y , L.O. 1972. S t a n d a r d s i n h e a l t h c a r e . H o s p i t a l A d m i n i s t r a t i o n i n Canada, August. Brooks, R.H. & Appel, F.A. 1973. Q u a l i t y of care assessment; choosing a method f o r peer review. New England J o u r n a l  of Medicine, 288, p. 1323-1329. 85 Brooks, R.H. 1972. A Study of Me t h o d o l o g i c a l Problems Assoc-i a t e d w i t h Assessment of_ Q u a l i t y of Care. B a l t i m o r e : John Hopkins U n i v e r s i t y , S c h o o l of Hygiene and P u b l i c Health. C a l d w e l l , George B. J u l y 1981. Use of employee s u r v e y s i n q u a l i t y assurance programs. QRB, p. 19-23. Canadian C o l l e g e of Health S e r v i c e s Executive. November 1984. Canadian C o l l e g e of Health S e r v i c e s E x e c u t i v e s , Q u a l i t y  Assurance Workshops. Vancouver, B.C. Canadian H o s p i t a l s . 1984. Handout from the course i n h e a l t h p l a n n i n g g i v e n i n the Department of H e a l t h Care and Epidem i o l o g y , U.B.C. C a r r o l l , Jean Gayton. 1984. R e s t r u c t u r i n g Q u a l i t y Assurance,  The New Guide f o r Health Care P r o v i d e r s . Homewood, I l l i n o i s : Dow Jones-Irwin. C l a r k , S.D. 1976. Ca n a d i a n S o c i e t y i n H i s t o r i c a l P e r s p e c - t i v e . Toronto: McGraw-Hill. Coburn, D., D'Arcy, C , New, P., & T o r r a n c e , G. (Eds.). 1981. Health and Canadian S o c i e t y : S o c i o l o g i c a l P e r s p e c t i v e s . Toronto: F i t z h e n r y and Whiteside. C o c k e r i l l , A.W. 1985. S u c c e s s f u l QA programs; commitment i s the key. H o s p i t a l T r u s t e e , 9 (3), p. 26-27. C r i c h t o n , A. January 1976. From e n t r e p r e n e u r i a l to p o l i t i c a l power i n the Canadian h e a l t h system. S o c i a l Science and  Medicine, p. 59-67. C r i c h t o n , A. 1980. Health P o l i c y Making: Fundamental Issues  i n the United S t a t e s , Canada, Great B r i t a i n , A u s t r a l i a . Ann Arbor, Michigan: Health A d m i n i s t r a i t o n Press. Current Issues i n Health P o l i c y Making f o r the Government of J3_r i t^ j 3 h_C^l__u _ia.. Autumn 1982. A c o l l e c t i o n of Occ a s i o n a l Papers, Health Management Forum. Daze, A. & S c a n l o n , J. August 1983. A QA program i n a s m a l l r u r a l h o s p i t a l . QRB, p. 233-235. D o l l , S i r R. 1974. S u r v e i l l a n c e and m o n i t o r i n g . I n t e r -n a t i o n a l J o u r n a l of Epidemiology, 3, p. 305. 86 D e l b e c q , A.L., Van de Ven, A.H., & G u s t a f s o n , D.H. 1975. Group Techniques f o r Program Planning: A Guide to  Nominal Group and Delphi Processess. Glenview, I l l i n o i s : S c o t t , Foresman and Company. Donabedian, Avedis. 1969. A frame of r e f e r e n c e . A Guide to Medical Care A d m i n i s t r a t i o n , Volume I I : Medical Care  A p p r a i s a l - Q u a l i t y and U t i l i z a t i o n . New York: APHA. Donabedian, Avedis. 1966. E v a l u a t i n g the q u a l i t y of medical c a r e . M i l b a n k M e m o r i a l Fund Q u a r t e r l y , 4-4- ( P a r t 2), p. 166-206. Donabedian, Avedis. 1982. E x p l o r a t i o n s i n Q u a l i t y Assessment  and M o n i t o r i n g , V o l . I: The D e f i n i t i o n of Q u a l i t y and Approaches to I t s Assessment. Ann A r b o r , M i c h i g a n : Health A d m i n i s t r a t i o n Press. Donabedian, Avedis. 1982. E x p l o r a t i o n s i n Q u a l i t y Assessment  and Monitoring, V o l . I I : The C r i t e r i a and Standards of  Q u a l i t y . Ann A r b o r , M i c h i g a n : H e a l t h A d m i n i s t r a t i o n Press. D o n a b e d i a n , A v e d i s . 1968. P r o m o t i n g q u a l i t y t h r o u g h e v a l u a t i n g the p r o c e s s of p a t i e n t c a r e . M e d i c a l Care, VI. (3), p. 181-201. Fink, A., K o s e c o f f , J. C h a s s i n , M., & Brooks, R.H. 1984. Consensus methods; c h a r a c t e r i s t i c s and g u i d e l i n e s f o r use. AJPH, 74 (9), p. 979-983. F i n n i e , C a r o l J . 1985. Q u a l i t y a s s u r a n c e f o r s m a l l e r h o s p i t a l s : A f e a s i b i l i t y model. U n p u b l i s h e d paper, 1985. F l e x n e r , A. 1910. M e d i c a l E d u c a i t o n i n the U.S. and Canada. C a r n e g i e F o u n d a t i o n f o r the Advancement of T e a c h i n g , B u l l e t i n No. 4, New York. G i l b a l d i , J. & A r c h t e r t , W.S. 1984. Handbook f o r W r i t e r s of R e s e a r c h Papers. Second e d i t i o n . New York: Modern Language A s s o c i a t i o n . Gold smith, D. 1978. A Study of the R e l a t i o n s h i p between the H o s p i t a l and the R u r a l Community. U n p u b l i s h e d M.Sc. t h e s i s . U n i v e r s i t y of B r i t i s h Columbia (Health S e r v i c e s P l a n n i n g ) . 87 Graham, Nancy. 1984. Q u a l i t y A s s u r a n c e i n H o s p i t a l s : S t r a t e g i e s f o r Assessment and Implementation. G a i t h e r s -burg, Maryland: Aspen P u b l i c a t i o n s . Greene, R. 1976. A s s u r i n g Q u a l i t y i n Medical Care, The State  of the A r t . Cambridge, Mass.L B a l i n e r P u b l i s h i n g Co. Greenspan, Jack. 1980. A c c o u n t a b i l i t y and Q u a l i t y Assurance  i n H e a l t h Care. Bowie, M a r y l a n d : The C h a r l e s P r e s s , Robert J . Brady Co. Guide to H o s p i t a l A c c r e d i a t i o n . 1972. C a n a d i a n C o u n c i l on H o s p i t a l A c c r e d i t a t i o n , Ottawa. H a e g e r t y , J . J . F e b r u a r y 1934. The development of p u b l i c h e a l t h i n Canada. CJPH, H a s t i n g s , J.E.F. F e d e r a l and p r o v i n c i a l i n s u r a n c e f o r h o s p i t a l and p h y s i c i a n s c a r e i n Canada. I n t e r n a t i o n a l  J o u r n a l of Health S e r v i c e s , 1^ , p. 398-414. H e a t h e r i n g t o n , R.aW. 1982. Q u a l i t y a s s u r a n c e and o r g a n i z a t i o n a l e f f e c t i v e n e s s i n h o s p i t a l s . H e a l t h  S e r v i c e s Research, 17, p. 185-201. H i l l , L. & B u r t o n , H. 1958. A r e v i e w of the H o s p i t a l Survey and C o n s t r u c t i o n A c t , 1946, C o u n c i l on M e d i c a l S e r v i c e . J o u r n a l of the American Medical A s s o c i a t i o n . I n t e g r a t i o n Issues i n Q u a l i t y Assurance. 1980. QRB, S p e c i a l Issue. Jackson, R.A. 1983. A model of q u a l i t y pharmaceutical care: Structue, process and outcome. i n Handbook of I n s t i t u - t i o n a l Pharmacy P r a c t i c e . Smith, M.C. & Brown, T.R. (Eds.). B a l t i m o r e : W i l l i a m s & W i l k i n s . J e s s e e , W i l l i a m F. J u l y 1981. Approaches to i m p r o v i n g the q u a l i t y of h e a l t h c a r e : O r g a n i z a t i o n change. QRB, p. 11-17. J e s s e e , W.F. 1984. I d e n t i f i y i n g H e a l t h Q u a l i t y Problems, A P r a c t i c a l Manual f o r PSROs and H o s p i t a l s . C h i c a g o , I l l i n o i s : The H o s p i t a l Research and E d u c a t i o n a l T r u s t . Jessee. W.R. 1984. Q u a l i t y of Care I s s u e s f o r the H o s p i t a l Trustee, A P r a c t i c a l Guide to F u l f i l l i n g Trustee Respons- i b i l i t i e s . Chicago, I l l i n o i s : The H o s p i t a l Research and E d u c a t i o n a l T r u s t . 88 J o i n t Commission on the A c c r e d i t a t i o n of H o s p i t a l s . 1981. A c c r e d i t a t i o n Manual f o r H o s p i t a l s . Chicago, I l l i n o i s . J o i n t C o m m i s s i o n t h e A c c r e d i a t i o n of H o s p i t a l s . 1980. The QA Guide: A Resource Manual f o r H o s p i t a l Q u a l i t y  Assurance. Chicago, I l l i n o i s . Laframboise, H.L. Health p o l i c y : breaking the problem down i n t o more manageable segments. CM.A. J., 108, p. 3 88-393. LaLonde, M. 1975. A New P e r s p e c t i v e on the Health of Canadians. Ottawa: Information Canada. L a n g e n f e l d , M. & Rzasa, C B . December 1984. A model f o r i n t e g r a t i n g the q u a l i t y assurance a c t i v i t i e s of two s m a l l h o s p i t a l s . QRB, p. 423-427. L a r s o n , E. & E w e r t , B. S e p t e m b e r 1983. I n t e g r a t i n g a h o s p i t a l QA program. QRB, P. 275-276. Levy, M.G., C o v a l e s k i k , M.A. & Johnson, A.C S p r i n g 1982. I n t r a - o r g a n i z a t i o n a l s t r a t e g i c d e c i s i o n model i n the c e r t i f i c a t e - o f - n e e d a p p l i c a t i o n process. HCM Review, p. 25-36. L i m o n g e l l i , F. 1985. S t a t e m e n t of m i s s i o n — a v a l u a b l e working t o o l H o s p i t a l Trustee, 9_ (3). p. 24-25. Lindeman, C.A. 1975. Delphi survey of p r i o r i t i e s i n c l i n i c a l research. Nursing Research, 24 (6), p. 434-441. Luke, R.D. & B o s s , R.W. 1981. B a r r i e r s l i m i t i n g t h e i m p l e m e n t a t i o n o f q u a l i t y a s s u r a n c e p r o g r a m s . Health Ser. Res., 16 ( 3 ) . Luke, R o i c e & Modrow, Robert. 1982. Q u a l i t y A s s u r a n c e an a c c o u n t a b i l i t y model. Health S e r v i c e Research. Marsh, L.A. 1983. Q u a l i t y a s s u r a n c e a c t i v i t i e s i n a s m a l l community h o s p i t a l . QRB, _9.(3), p. 77-80. M c A u l i f f e , W.E. 1979. Measuring the q u a l i t y of medical care: Process versus outcome. Milbank Memorial Fund Q u a r t e r l y , 57 (1), p. 118-152. M c L a c h l i n , G. (Ed.). 1976. A Q u e s t i o n of Q u a l i t y . London, England: Oxfored U n i v e r s i t y Press. 89 M e i l i c k e , C.A. & S t o r c h , J.L. (Eds.). 1980. P e r s p e c t i v e s on Canadian Health and S o c i a l S e r v i c e P o l i c y : H i s t o r y and  Emerging Trends. Michigan: Health A d m i n i s t r a t i o n Press. M e i s e l , Steven. May 1983. A pharmacy-based q u a l i t y assurance program. QRB, p. 147-148. Meisenheimer, C.G. 1983. I n c o r p o r a t i n g JCAH standards i n t o a q u a l i t y a s s u r a n c e p r o g r a m . N.u.£^iHE._AjiiS.iili^.t_Il^.t.i°.il Q u a r t e r l y , 7_ (30), p. 1-8. Modrow, R. & Luke, R.D. The 'new' a c c o u n t a b i l i t y and the r o l e of the nurse a d m i n i s t r a t o r . Health Forum, p. 13-14. M u l h o l l a n d , A.V., Wheeler, S.G. & H e ieck, J.J. 1973. M e d i c a l a s s e s s m e n t by a D e l p h i group o p i n i o n t e c h n i c . The New England J o u r n a l of Medicine, 288, (4), p. 1272-1275. Mus t a r d , J.F. Summer 1980. H e a l t h i s s u e s i n the 1980s. Health Management Forum, p. 301-306. Neuhaser, D. 1971. The r e l a t i o n s h i p between a d m i n i s t r a t i v e a c t i v i t i e s and h o s p i t a l p e r f o r m a n c e . R e s e a r c h S e r i e s . 28. C h i c a g o : U n i v e r s i t y of C h i c a g o C e n t e r f o r H e a l t h A d m i n i s t r a t i o n Studies. N u r s i n g r e v i e w : c r i t e r i a f o r e v a l u a t i o n and a n a l y s i s of p a t i e n t care. 1982. QRB. S p e c i a l Issue. O a k l e y , R.S. & Bradham, D.D. 1983. R e v i e w of q u a l i t y a s s u r a n c e i n h o s p i t a l pharmacy. A m e r i c a n J o u r n a l of  H o s p i t a l Pharmacy, 40 (1), p. 53-63. P a l l e n , P. & Layton, D. 1979 B r i t i s h Columbia H o s p i t a l Role  Study, Phase I. M i n i s t r y of Health, V i c t o r i a . Pena, J.J., Rosen, B., H a f f n e r , A.N., & L i g h t , D.W. 1984. H o s p i t a l Q u a l i t y Assurance, Risk Management and Program  E v l u a t i o n . R o c k v i l l e , Maryland: Aspen Systems Co. Phaneuf, Maira C. & Wandelt, Mabel A. 1981. Obstacles to and p o t e n t i a l s f o r nursing q u a l i t y a p p r a i s a l . QRB, p. 2-5. P i l l , J . 1971. The D e l p h i method; S u b s t a n c e , c o n t e x t , a c r i t i q u e and an a n n o t a t e d b i b l i o g r a p h y . S o c i o - E c o n .  P l a n . S c i . , 5, p. 5 7-71. 90 P o l i c y S t a t e m e n t s H e a l t h Care, I t s Need f o r New D i r e c t i o n s , The P roposed Canada H e a l t h Act. J u l y / A u g u s t 1983. RNABC News B.C., Proceedings of the Seminars on Q u a l i t y Assurance. 1984. Ca n a d i a n C o u n c i l on H o s p i t a l A c c r e d i t a t i o n , Ottawa: CCHA. P r i o r , J. May/June 1985. Q u a l i t y assurance f o s t e r s improved management c o n t r o l . H o s p i t a l Trustee, p. 19. Q u a l i t y A s s u r a n c e . November 1981. Top. Hosp. Pharm. Managte., I (3), p. 1-99. Q u a l i t y Assurance Plan. 1985. A s h c r o f t and D i s t r i c t General H o s p i t a l . A s h c r o f t , B.c. Regi s t e r e d Nurses A s s o c i a t i o n of B r i t i s h Columbia. September 1977. Q u a l i t y Assurance Manual. R e s t u c c i a , J o seph D. & H o l l o w a y , Don C. 1982. Methods of c o n t r o l f o r h o s p i t a l q u a l i t y a s s u r a n c e s y s t e m s . Health S e r v i c e s Research, 17 (3), p. 241-251. R o b e r t s , M.D., Grimes, R.M., M o s s e l e y , S.K. & Bruhn, J.G. February 1985. Development of i n d i c e s of e f f e c t i v e n e s s ; A q u a n t i f i c a t i o n of a c c r e d i t i n g p r o c e s s . J o u r n a l of  A l l i e d Health, p. 13021. Room, F.J. & Hulka, B.S. 1977. D e v e l o p i n g c r i t e r i a f o r a s s e s s m e n t : E f f e c t o f t h e D e l p h i t e c h n i q u e . Health S e r v i c e s Research, 14 (4), p. 309-312. S a b a t i n o , Frank G. 1979. Toward a c o m p r e h e n s i v e q u a l i t y assurance program. QRB, S p e c i a l Issue, p. 2-3. S a n a z a r o , P.J. 1980. Q u a l i t y a s s e s s m e n t and q u a l i t y a s s u r a n c e i n m e d i c a l c a r e . Ann. Rev. P u b l i c H e a l t h , 1_, p. 37-68. S c h u l b e r g , F. & Baker, 0. 1979. Program E v a l u a t i o n i n the Health F i e l d s , Vol. I I . New York: Human Sciences Press. Shanahan, Maryanne. 1983. The q u a l i t y assurance standard of t h e JCAH: A r a t i o n a l a p p r o a c h t o p a t i e n t c a r e e v a l u a t i o n . In O r g a n i z a t i o n and Change i n Health Care  Q u a l i t y A s s u r a n c e , L i k e , R.D., Krueger, S. & Modrow, R. (Ed s . ) . R o c k v i l l e , Maryland: Aspen. 91 S h o r t e l l , S.M., B e c k e r , S., & N e u h a u s e r , D. 1976. The e f f e c t s of management p r a c t i c e s on h o s p i t a l e f f i c i e n c y and q u a l i t y of c a r e . In O r g a n i z a t i o n R e s e a r c h i n Hos-ja i_ _t a Is . ( I n q u i r y M o n o g r a p h ) . C h i c a g o : B l u e C r o s s A s s o c i a t i o n . S i l v e r s t e i n , Gary H. 1981. C h o o s i n g an o r g a n i z a t i o n a l s t r u c t u r e f o r a q u a l i t y assurance program at Rockingham M e m o r i a l H o s p i t a l . A p r o j e c t f o r the degree Master of Health A d m i n s i t r a t i o n , Richmond, V i r g i n i a . Slee, V e r g i l , H. A u g u s t 1977. The q u a l i t y a s s u r a n c e f u n c t i o n . CPHA. Standards f o r A c c r e d i t a t i o n of Canadian Health Care F a c i l -d^t^e^. 1985. C a n a d i a n C o u n c i l on H o s p i t a l A c c r e d i t a t i o n , Ottawa. Swanson, A.L. 1984. Q u a l i t y C o n t r o l A p p r a i s a l and Assurance  f o r Q u a l i t y Management i n Health Care I n s t i t u t i o n s . U.B.C. Health Sciences Centre H o s p i t a l , Vancouver, B.C. T a y l o r , M. 1978. H e a l t h I n s u r a n c e and C a n a d i a n P u b l i c  P o l i c y . I n s t i t u t e of P u b l i c A d m i n i s t r a t i o n . Montreal: Queens P r e s s / M c G i l l U n i v e r s i t y Press. T u r n e r , G.P. & Mapa, J. ' March 1984. Q u a l i t y a s s u r a n c e : A new approach. Dimensions, p. 12-14. T u r n e r , J. 1958. The H o s p i t a l I n s u r a n c e and D i a g n o s t i c S e r v i c e s A c t : I t s i m p a c t on h o s p i t a l a d m i n i s t r a t i o n . CMAJ, LXXVII, p. 768-778. Vanagunas, A., E g e l s t o n , E.M., Hopkins, J., & Walczak, R.M. 1979. P r i n c i p l e s of q u a l i t y a s s u r a n c e . QRB, S p c i a l E d i t i o n , p. 4.7 Vanagunas, Audrone. 1979. Q u a l i t y a s s e s s m e n t : A l t e r n a t e approaches. QRB, S p e c i a l E d i c t i o n , p. 8-11. Van Loon, R.J. 1978. From s h a r e d c o s t to b l o c k f u n d i n g and beyond, the p o l i t i c s of h e a l t h i n s u r a n c e i n Canada. J o u r n a l of Health P o l i t i c s , P o l i c y and Law, p. 454-478. W e l l e r , G.R. W i n t e r 1977. From ' p r e s s u r e group p o l i t i c s ' to ' m e d i c a 1 - i n d u s t r i a 1 c omplex': The d e v e l o p m e n t of a p p r o a c h e s to the p o l i t i c s of h e a l t h c a r e . J o u r n a l of  Health P o l i t i c s , P o l i c y and Law. 92 Wendorf, Barbara. February 1981. Is q u a l i t y assurance r e a l l y w orth i t ? QRB, p. 23-28. W i l l i a m s , K a t h l e e n H. & Brook, R.H. 1978. A r e v i e w of the r e c e n t l i t e r a t u r e ; Q u a l i t y measurement and a s s u r a n c e . Health & Medical Care S e r v i c e s Review, _1, (3), p. 2-15. APPENDIX I QUALITY ASSURANCE 93 PRINCIPLE THE HEALTH CARE FACILITY SHALL DEMONSTRATE A CONSISTENT ENDEAVOUR TO DELIVER OPTIMAL PATIENT CARE. A MAJOR COMPONENT IN THE APPLICATION OF THIS PRINCIPLE IS THE OPERATION OF A QUALITY ASSURANCE PROGRAM. QUALITY ASSURANCE IS THE ESTABLISHMENT OF HOSPITAL-WIDE GOALS, THE ASSESSMENT OF THE PROCEDURES IN PLACE TO SEE I F THEY ACHIEVE THESE GOALS AND, IF NOT, THE PROPOSAL OF SOLUTIONS IN ORDER TO ATTAIN THESE GOALS. THE QUALITY ASSURANCE PROGRAM SHOULD BE INTERNAL, INTERNALLY-ADMINISTERED, ONGOING, SPECIFIC TO THE INSTITUTION, STRUCTURED AND COORDINATED WITHIN THE FACILITY. STANDARD I ESSENTIAL COMPONENTS A QUALITY ASSURANCE PROGRAM MAY USE MULTIPLE APPROACHES AND METHODOLOGIES TO DETECT AND ASSESS PROBLEMS, PLAN MEASURES TO REDUCE OR ELIMINATE SUCH PROBLEMS, AND EVALUATE AND MONITOR THE EFFECTIVENESS OF IMPLEMENTED CHANGES. I n t e r p r e t a t i o n The o v e r a l l program s h o u l d i n c l u d e : P e r i o d i c r e v i s i o n of the m i s s i o n of the h e a l t h c a r e f a c i l i t y . C o o r d i n a t i o n of d e p a r t m e n t a l g o a l s w i t h t h o s e of the h e a l t h c a r e f a c i l i t y . E v a l u a t i o n of human and p h y s i c a l r e s o u r c e s . P roblem d e t e c t i o n t h r o u g h : m o n i t o r i n g of s t a t i s t i c s and i n d i c a t o r s a u d i t i n g e x t e r n a l r e v i e w s and c o n s u l t a t i o n s . O b j e c t i v e assessment and i n v e s t i g a t i o n of i d e n t i f i e d p r o b l e m s . Recommendations f o r r e s o l u t i o n of these p r o b l e m s . I m p l e m e n t a t i o n of a c t i o n s and measures to overcome p r o b l e m s . M o n i t o r i n g a c t i v i t i e s d e s i g n e d t o a s s u r e t h a t the d e s i r e d r e s u l t has been a c h i e v e d and s u s t a i n e d . D o c u m e n t a t i o n t h a t s u b s t a n t i a t e s the e f f e c t i v e n e s s of the o v e r a l l program t o enhance p a t i e n t c a r e and t o a s s u r e sound c l i n i c a l p e r f o r m a n c e . STANDARD I I ORGANIZATION AND ADMINISTRATION THERE SHALL BE A CURRENT WRITTEN PLAN DESCRIBING THE ORGANIZATION AND IMPLEMENTATION OF A QUALITY ASSURANCE PROGRAM DESIGNED TO ENHANCE PATIENT CARE. Board Approved September 1984 45 SOURCE: S t a n d a r d s f o r A c c r e d i t a t i o n of Canadian H e a l t h Care F a c i l i t i e s CCHA QUALITY ASSURANCE I n t e r p r e t a t i o n The b o a r d , h a v i n g the o v e r a l l r e s p o n s i b i l i t y f o r the conduct of the h e a l t h c a r e f a c i l i t y , s h a l l i n i t i a t e and s u p p o r t the development of a f a c i l i t y -wide q u a l i t y a s s u r a n c e program to a s s u r e the a t t a i n m e n t of the g o a l s of the h e a l t h c a r e f a c i l i t y i n s u p p o r t o f the board approved m i s s i o n s t a t e m e n t . The development and c o o r d i n a t i o n of the q u a l i t y a s s u r a n c e program may be a c c o m p l i s h e d t h r o u g h a committee, group or i n d i v i d u a l . The o r g a n i z a t i o n a l s t r u c t u r e s h a l l be d e t e r m i n e d by the board on the a d v i c e of the a d m i n i s t r a -t i o n and the p r o f e s s i o n a l and o t h e r s t a f f s of the h e a l t h c a r e f a c i l i t y . The w r i t t e n p l a n f o r q u a l i t y a s s u r a n c e s h a l l d e s c r i b e the mechanisms used t o : D e l e g a t e r e s p o n s i b i l i t y f o r the v a r i o u s a c t i v i t i e s t h a t c o n t r i b u t e t o the program. A s s u r e c o m p l e t e n e s s and i n t e g r a t i o n of a l l components of the program. D e f i n e r e p o r t i n g c h a n n e l s f o r p r o f e s s i o n a l and o t h e r d e p a r t m e n t a l q u a l i t y a s s u r a n c e a c t i v i t i e s . E x i s t i n g p r o f e s s i o n a l q u a l i t y a s s u r a n c e a c t i v i t i e s d e t a i l e d i n o t h e r s e c t i o n s o f t h e s e s t a n d a r d s , s u c h as m e d i c a l s t a f f c r e d e n t i a l l i n g and d e l i n e a t i o n o f p r i v i l e g e s , d e a t h and c o m p l i c a t i o n r e v i e w , i n f e c t i o n c o n t r o l , t i s s u e r e v i e w and s t r u c t u r e d a u d i t programs, and n u r s i n g s t a f f i n c i d e n t r e v i e w s , p a t i e n t c l a s s i f i c a t i o n programs and n u r s i n g a u d i t programs, and f a c i l i t y - w i d e u t i l i z a t i o n r e v i e w s must be encouraged and i n t e g r a t e d i n the o v e r a l l h e a l t h c a r e f a c i l i t y q u a l i t y a s s u r a n c e program. O t h e r departments and s e r v i c e s s h a l l d e v e l o p a p p r o p r i a t e mechanisms to e v a l u a t e t h e i r degree of a t t a i n m e n t of t h e i r u n i t g o a l s . T e r m i n o l o g y used to d e s c r i b e s t u d i e s c o n d u c t e d or methods employed s h a l l be d e f i n e d i n w r i t i n g and be a v a i l a b l e to a l l . STANDARD III DIRECTION AND STAFFING IT IS EXPECTED THAT THE QUALITY ASSURANCE PROGRAM BE SUPPORTED BY DESIGNATION OF APPROPRIATE PERSONNEL ON EITHER A FULL-TIME OR PART-TIME BASIS TO THE ROLE OF QUALITY ASSURANCE COORDINATOR OR BY ASSIGNING RESPONSIBILITY FOR QUALITY ASSURANCE DIRECTION WITHIN THE EXISTING ORGANIZATIONAL STRUCTURE. I n t e r p r e t a t i o n The q u a l i t y a s s u r a n c e program may be c o o r d i n a t e d by a f u l l - t i m e or p a r t -t i m e q u a l i t y a s s u r a n c e c o o r d i n a t o r , o r by a s s i g n i n g q u a l i t y a s s u r a n c e r e s p o n s i b i l i t i e s to e x i s t i n g department and s e r v i c e heads or committees. Whatever the s t r u c t u r e used f o r c o o r d i n a t i o n , a l l d u t i e s and r e s p o n s i -b i l i t i e s s h a l l be c l e a r l y d e s c r i b e d i n w r i t i n g and agreed upon by a l l c o n c e r n e d . Board Approved September 1984 46 QUALITY ASSURANCE 95 If a f u l l - t i m e c o o r d i n a t o r i s a s s i g n e d , t h e i r r o l e may be tha t of: a r e s o u r c e p e r s o n , s t i m u l a t o r or a c t i v a t o r or i t may be that of a dat a c o l l e c t o r and correspondence s e c r e t a r y depending on the r o l e a s s i g n e d to department or s e r v i c e heads w i t h i n the o r g a n i z a t i o n a l s t r u c t u r e . If the q u a l i t y a s s u r a n c e program i s e n t i r e l y a s s i g n e d to e x i s t i n g s t a f f w i t h i n the e x i s t i n g o r g a n i z a t i o n a l framework, there may be no a d d i t i o n a l s t a f f a s s i g n e d to t h i s f u n c t i o n . STANDARD IV REPORTING FINDINGS OF QUALITY ASSURANCE ACTIVITIES THROUGHOUT THE FACILITY SHALL BE REPORTED BY THE PROFESSIONAL AND OTHER STAFF ORGANIZATIONS TO THE GOVERNING BODY AND MANAGEMENT BY A MECHANISM THAT DOES NOT CONFLICT WITH NORMAL EXECUTIVE REPORTING CHANNELS. I n t e r p r e t a t i o n The r e p o r t i n g mechanisms and ch a n n e l s s h a l l accommodate the p r e e x i s t i n g q u a l i t y a s s u r a n c e programs and a c t i v i t i e s of p r o f e s s i o n a l s t a f f s as w e l l as the d e v e l o p i n g programs i n o t h e r areas of the h e a l t h c a r e f a c i l i t y . The r e p o r t i n g mechanisms s h a l l be d e f i n e d i n w r i t i n g , and s h a l l i n c l u d e r e p o r t i n g s c h e d u l e s , and the format and c o n t e n t of r e p o r t s at v a r i o u s r e p o r t i n g l e v e l s . Department r e p o r t s may be p a r t of normal r e p o r t i n g mechanisms. STANDARD V EVALUATION THE QUALITY ASSURANCE PROGRAM SHALL BE APPRAISED ANNUALLY THROUGH A DESIG-NATED MECHANISM. I n t e r p r e t a t i o n The q u a l i t y a s s u r a n c e program devel o p e d by the h e a l t h c a r e f a c i l i t y s h o u l d be reviewed on an annual b a s i s f o r i t s e f f e c t i v e n e s s . T h i s r e a p p r a i s a l s h o u l d i d e n t i f y components of the q u a l i t y a s s u r a n c e program th a t need to be a l t e r e d or d e l e t e d . E v a l u a t i o n of the q u a l i t y a s s u r a n c e a c t i v i t i e s s h o u l d ensure t h a t the program i s ongoing, comprehensive, e f f e c t i v e i n i m p r o v i n g p a t i e n t care and c l i n i c a l performance, as w e l l as b e i n g conducted w i t h c o s t and time e f f i c i e n c y . THE HEALTH CARE FACILITY'S QUALITY ASSURANCE PROGRAM SHALL BE EMPHASIZED IN ©ETERMINING THE ACCREDITATION OF THE FACILITY. Board Approved September 1984 47 A P P E N D I X I I QUALITY ASSURANCE STANDARD I ORGANIZATION AND ADMINISTRATION 96 Every accredited health care f a c i l i t y must have an organized program of quality assurance which encompasses a l l the ac t iv i t i e s performed within the f a c i l i t y . The f i n a l responsibi l i ty for the creation and maintenance of such a program rests with the Board. The program must be so designed that the Board and, through the Board, the public may be assured that the health care f a c i l i t y is s tr iv ing to effectively provide the service l i s ted In the mission statement. The Board must be assured that the professional and support services are being continuously evaluated, corrected and improved where necessary. , An administrative structure to support the quality assurance program should be planned and implemented. In health care f a c i l i t i e s with adequate resources, this may be achieved through the formation of a raultidisciplinary quality assurance committee. In small health care f a c i l i t i e s the function may be assigned to an existing committee, such as a patient care committee, or to a particular individual such as the chief executive of f icer , chief of staff or director of nursing. A l l professional staff should contribute to the program with act iv i t i es both in the individual services and In multidiscipl inary studies.* An i n i t i a l step for most health care f a c i l i t i e s in setting up a faci l i ty-wide quality assurance program is to conduct an inventory of quality assurance act iv i t ies presently being conducted. In addition to the audits of the medical and nursing staffs and the quality control of the laboratory, most health care f a c i l i t i e s w i l l find there are many other act iv i t ies which may not have been thought of as quality assurance programs. These might include staff performance appraisals, safety inspections, monitoring by the infection control committee, and patient questionnaires. Once these programs have been identif ied and the ac t iv i t i e s documented, the responsible group or person should identify the gaps and weaknesses in the overall program and in i t ia te act iv i t ies to f i l l these gaps. Evaluation Requirement Program Design Program Structure Ini t iat ing a Program * The CCHA Quality Assurance Manual is available from CCHA offices and expands on methodologies for quality assurance programs. Board Approved September 1984 21 SOURCE: CCHA, 1984. QUALITY ASSURANCE 97 STANDARD II ESSENTIAL COMPONENTS After a potential problem has been identif ied by Evaluation individuals , groups, services, or others, the group Process or person who has the responsibil ity for the overal l quality assurance program should: (a) assess the problem; (b) assign i t a pr ior i ty ; (c) propose methodologies, and suggest and support appropriate studies; (d) establish a schedule; (e) suggest corrective measures; and, (f) assign follow-up studies. STANDARD III ISSUE/PROBLEM IDENTIFICATION No further interpretation is required. STANDARD IV ASSESSMENT When a problem is specific to a department of Responsibilities service, the methodologies chosen to study this of Staff problem must be studied within that department or service. If the subject to be studied is influenced by the ac t iv i t i e s of a number of professionals, a mult idiscipl inary approach is suggested. In either case, each group must be held responsible for carrying out the assessment of Its own a c t i v i t i e s . The creation of a faci l i ty-wide quality assurance program does not obviate the department/service responsibil ity for self-evaluation. STANDARD V IMPLEMENTATION OF RECOMMENDATIONS As a result of the studies carried out, suspected Evaluation problems can be dismissed as non-existent, or the Reporting deficiencies can be Identified. A summary of these Mechanisms studies and their results should be reported regularly to the responsible authorities including the Board. Recommendations for corrective measures should also be reported. Recommendations should not be viewed as necessarily d isc ipl inary. They may include recommendations for educational programs, additional resources or personnel, etc. B o a r d A p p r o v e d S e p t e m b e r 1984 22 QUALITY ASSURANCE After due consideration, the Board must ensure that these recommendations are implemented. Control studies, following a suitable interval of time, are mandatory to ensure that the original problem has been eliminated. STANDARD VI REPORTING No further interpretation is required. STANDARD VII EVALUATION The purpose of any quality assurance act iv i ty is to introduce a process whereby improvements can be made in a l l the ac t iv i t i e s of the health care f a c i l i t y . It is therefore necessary that an evaluation of the quality assurance program i t s e l f be conducted periodical ly to assess i ts effectiveness. A restructuring of the program may be required when deficiencies or weaknesses are identif ied through this evaluation. Board Approved September 1984 23 101 QUESTIONNAIRE THE COMPONENTS OF A QUALITY ASSURANCE PROGRAM FOR SMALLER HOSPITALS IN BRITISH COLUMBIA The p u r p o s e of t h i s s t u d y i s t o i d e n t i f y s e l e c t c o m p o n e n t s of a q u a l i t y a s s u r a n c e p r o g r a m f o r s m a l l e r h o s p i t a l s i n B r i t i s h C o l u m b i a . t h i s study i s an e s s e n t i a l part of my master's t h e s i s (U.B.C. — Health S e r v i c e s Planning and A d m i n i s t r a t i o n ) . A summary r e p o r t of the f i n d i n g s w i l l be made a v a i l a b l e to you upon completion of the study. I hope t h a t you a g r e e to p a r t i c i p a t e i n t h i s s t u d y by c o m p l e t i n g t h i s q u e s t i o n n a i r e . A r e f u s a l to p a r t i c i p a t e or withdraw at any time w i l l i n no way r e f l e c t a d v e r s e l y on you or y o u r h o s p i t a l . Names of t h e p a r t i c i p a n t s and t h e i n s t i t u t i o n s w i l l not be r e q u e s t e d , and o n l y I w i l l have access to your completed q u e s t i o n n a i r e . Please remember that t h i s q u e s t i o n n a i r e i s not a t e s t ; I am i n t e r e s t e d i n c a n d i d and r e a l responses to the questions. INSTRUCTIONS: Your h o s p i t a l i s a l r e a d y i n v o l v e d with q u a l i t y assurance f u n c t i o n s . The manner i n w h i c h y o u r d e p a r t m e n t s a r e organized, your everyday p r o b l e m - s o l v i n g a c t i v i t i e s and your performance reviews are a l l a form of q u a l i t y assurance. I am r e q u e s t i n g you to document here what those q u a l i t y assurance f u n c t i o n s are f o r : the board, d i e t a r y , medicine, nursing and pharmacy. Please f o l l o w these steps: I. F i r s t , does your h o s p i t a l have an o v e r a l l q u a l i t y a s s u r a n c e p l a n ? A. No B. Yes C. P a r t i a l l y developed I f no, d e s c r i b e i n the f o l l o w i n g space, the s t a g e of development of your h o s p i t a l ' s q u a l i t y assurance, i.e., who i s i n v o l v e d , what are the p l a n s , e t c . I f "yes" or i f your p l a n i s " p a r t i a l l y d e v e l o p e d " , p l e a s e answer the q u e s t i o n s as provided. • 102 A . I I . Do you have p u r p o s e , g o a l s and o b j e c t i v e s f o r your h o s p i t a l ' s q u a l i t y a s s u r a n c e program? Yes No . I f "yes", p l e a s e d e s c r i b e u s i n g t h e space p r o v i d e d on page 4. A l t e r n a t i v e l y , i f the q u a l i t y a s s u r a n c e g o a l s t a t e m e n t s a r e found i n the mission statement, please a t t a c h or d e s c r i b e . I I I . What i s your r e a c t i o n to the new q u a l i t y assurance 4 requirements f o r a c c r e d i t a t i o n ? 103 IV. P l e a s e i d e n t i f y f o r each s u b j e c t a r e a the q u a l i t y a s s u r a n c e f u n c t i o n s and d e t e r m i n e how i m p o r t a n t t h e s e f u n c t i o n s are (see Example I, page 5 and Importance Key at the end of page 5 and on page 4). P l e a s e use the q u e s t i o n s h e e t s provided. B. I f "yes", d e s c r i b e : l a . Who i s p r i m a r i l y r e s p o n s i b l e f o r t h e q u a l i t y assurance program? l b . Who i s o p e r a t i o n a l l y r e s p o n s i b l e f o r the q u a l i t y assurance program i n the f o l l o w i n g areas: ( i ) board ( i i ) d i e t a r y 1  ( i i i ) medicine ( i v ) n u r s i n g (v) - pharmacy 104 l c . What problems d i d you encounter t r y i n g to implement a q u a l i t y assurance program? Id. What b e n e f i t s have been gained from implementing a q u a l i t y assurance program? 1 0 5 QUESTIONNAIRE STEP I I : What a r e t h e p u r p o s e , g o a l s and o b j e c t i v e s of t h e h o s p i t a l ' s q u a l i t y assurance program? Purpose: Goals: O b j e c t i v e s : 106 QUESTIONNAIRE STEP IV SUBJECT AREA: MEDICAL RECORDS I I . Please l i s t a l l the q u a l i t y assurance f u n c t i o n s f o r t h i s s u b j e c t area and c i r c l e the l e v e l of importance: IMPORTANCE HIGH LOW 1. 1 2 3 4 5 2. • 1 2 3 4 5 3. 1 2 3 4 5 4. : 1 2 3 4 5 5. " 1 2 3 4 5 6. 1 2 3 4 5 7. 1 2 3 4 5 IMPORTANCE KEY What i s the importance of t h i s f u n c t i o n : 1 2 3 4 5 very important somewhat unimportant very important •' important unimportant 107 QUESTIONNAIRE STEP IV SUBJECT AREA: I I . Please l i s t a l l the q u a l i t y assurance f u n c t i o n s f o r t h i s s u b j e c t area and c i r c l e the l e v e l of importance: IMPORTANCE HIGH ... LOW 1. 1 2 3 4 5 2. 1 2 3 4 5 3. : 1 2 3 4 5 4. ' 1 2 3 4 5 5. 1 2 3 4 5 " 6. \ 1 2 3 4 5 7. 1 2 3 4 5 IMPORTANCE KEY What i s the importance of t h i s f u n c t i o n : 1 2 3 4 5 very important somewhat unimportant very important -'  important unimportant APPENDIX V 108 T H E U N I V E R S I T Y OF B R I T I S H C O L U M B I A Faculty of Medicine Department of Health Care and Epidemiology Mather Building 5804 Fairview Avenue Vancouver, B.C. V6T 1W5 (604)228-2772 May 30, 1985. Dear : Thank you f o r y o u r p a r t i c i p a t i o n i n my s t u d y w h i c h i s i n t e n d e d t o d e t e r m i n e t h e components o f a q u a l i t y a s s u r a n c e program f o r t h e c u r r e n t l y a c c r e d i t e d , p r e d o m i n a n t l y a c u t e - c a r e h o s p i t a l s o f 20-50 beds i n B.C. The r e s p o n s e r a t e t o the f i r s t q u e s t i o n n a i r e was a v e r y q r a t i f y i n g 75%. E n c l o s e d you w i l l f i n d summary l i s t s o f q u a l i t y a s s u r a n c e f u n c t i o n s f o r f o u r a r e a s : b o a r d , d i e t a r y , n u r s i n g and pharmacy. These f u n c t i o n s were i d e n t i f i e d as i m p o r t a n t by t h e p a r t i c i p a n t s o f t h e s t u d y . To f u r t h u r c l a r i f y a r e a s o f agreement and d i s a g r e e m e n t amongst p a r t i c i p a n t s , I am a s k i n g t h e p a r t i c i p a n t s t o r a n k t h e f u n c t i o n s . I n s t r u c t i o n s o f t h e r a n k i n g s c a l e i s a t t a c h e d . When c o m p l e t e d , p l e a s e r e t u r n t h e q u e s t i o n n a i r e t o me i n t h e stamped a d d r e s s e d e n v e l o p e by June 14. Once a g a i n , I want t o emphasize t h a t y o u r r e p l i e s s h a l l r e m a i n c o n f i d e n t i a l . I t t a k e s a p p r o x i m a t e l y 20 m i n u t e s t o c o m p l e t e t h e q u e s t i o n n a i r e . The t i m e you a r e t a k i n g t o p a r t i c i p a t e i n t h i s s t u d y i s g r e a t l y a p p r e c i a t e d . I w i l l keep you u p - t o - d a t e w i t h t h e f i n a l r e s u l t s of t h e s t u d y . Y o u r s s i n c e r e l y , C a r o l J . F i n n i e , B.S.N. 109 Q U E S T I O N N A I R E R o u n d I I THE COMPONENTS OF A Q U A L I T Y ASSURANCE PROGRAM FOR S M A L L E R H O S P I T A L S I N B R I T I S H COLUMBIA %he p u r p o s e o f t h i s s t u d y i s t o i d e n t i f y s e l e c t c o m p o n e n t s o f a q u a l i t y a s s u r a n c e p r o g r a m f o r s m a l l e r h o s p i t a l s i n B r i t i s h C o l u m b i a . t h i s s t u d y i s a n e s s e n t i a l p a r t o f my m a s t e r ' s t h e s i s ( U . B . C . — H e a l t h S e r v i c e s P l a n n i n g a n d A d m i n i s t r a t i o n ) . A s u m m a r y r e p o r t o f t h e f i n d i n g s w i l l be made a v a i l a b l e t o y o u u p o n c o m p l e t i o n o f t h e s t u d y . I h o p e t h a t y o u a g r e e t o p a r t i c i p a t e i n t h i s s t u d y by c o m p l e t i n g t h i s q u e s t i o n n a i r e . A r e f u s a l t o p a r t i c i p a t e o r w i t h d r a w a t any t i m e w i l l i n no way r e f l e c t a d v e r s e l y on you o r y o u r h o s p i t a l . N a m e s o f t h e p a r t i c i p a n t s a n d t h e i n s t i t u t i o n s w i l l n o t be r e q u e s t e d , a n d o n l y I w i l l h a v e a c c e s s t o y o u r c o m p l e t e d q u e s t i o n n a i r e . I N S T R U C T I O N S : The f o l l o w i n g l i s t s u m m a r i z e s t h e v i e w s e x p r e s s e d a s t o t h e c o m p o n e n t s o f a q u a l i t y a s s u r a n c e p r o g r a m f o r f o u r a r e a s : b o a r d , d i e t a r y , n u r s i n g and p h a r m a c y . P l e a s e r a n k e a c h s t a t e m e n t by c i r c l i n g t h e l e v e l o f i m p o r t a n c e a c c o r d i n g t o t h e f o l l o w i n g s c a l e ; i m p o r t a n t E X A M P L E : M e d i c a l R e c o r d s v e r y i m p o r t a n t s o m e w h a t i m p o r t a n t R e l e a s e o f i n f o r m a t i o n A c c u r a c y o f c o d i n g and a b s t r a c t i n g U s e r s a t i s f a c t i o n s u r v e y u n i m p o r t a n t v e r y u n i m p o r t a n t HIGH 1 1 1 2 2 2 3 3 3 LOW 4 5 4 5 4 5 M a s t e r L i s t B o a r d H I G H Review o f b o a r d s t r u c t u r e , c o m mittees and o v e r a l l h o s p i t a l o r g a n i z a t i o n s D e v e l o p m e n t o f m i s s i o n s t a t e m e n t 1 R e v i e w o f b y l a w s , g o a l s and o b j e c t i v e s _ 1 Review s o c i e t y membership and p u b l i c image 1 Review a d e q u a c y of f a c i l i t y and equipment 1 Review b u d g e t , c a s h f l o w , f i n a n c i a l r e c o r d 1 M o n i t o r a l l q u a l i t y a s s u r a n c e committee a c t i v i t i e s by r e v i e w i n g t h e t a r g e t s f o r a l l d e p a r t m e n t s A p p o i n t m e n t / r e v i e w of m e d i c a l s t a f f A p p o i n t m e n t / r e v i e w of s e n i o r a d m i n i s t r a t i v e s t a f f Review a d m i n i s t r a t o r s ( m o n t h l y ) b o a r d r e p o r t M a i n t a i n good c o m m u n i c a t i o n between h o s p i t a l and community 1 D i s a s t e r P l a n and F i r e P l a n 1 I l l HIGH LOW P a t i e n t s a t i s f a c t i o n p o l l CCHA survey recommendations J o i n t Conference Committee Comparative s t a t i s t i c s (with same s i z e f a c i l i t y ) U t i l i z a t i o n review Risk management committee 2 2 3 4 3 4 3 4 3 4 3 4 3 4 5 5 5 IMPORTANCE KEY What i s the importance of t h i s f u n c t i o n : very important important somewhat unimportant very important unimportant Any a d d i t i o n a l comments (please rank i f a p p r o p r i a t e ) Master L i s t Therapeutic Dietary/Food S e r v i c e s 112 HIGH LOW Review and update of g o a l s , o b j e c t i v e s , p o l i c i e s and procedures 1 2 3 4 5 P u b l i c h e a l t h and s a n i t a t i o n t e s t s 4 5 Temperature a u d i t s 1 2 3 4 5 Cleaning schedules 1 2 3 4 5 Care and maintenance of equipment 1 2 3 4 5 Organized system f o r c o n s u l t a t i o n with q u a l i f i e d d i e t i t i a n 4 5 S t a f f i n g g u i d e l i n e s 1 2 3 4 5 Job d e s c r i p t i o n s 1 2 3 4 5 Performance a p p r a i s a l of s t a f f 1 2 3 4 5 S t a f f o r i e n t a t i o n and c o n t i n u i n g education 3 4 Stocking and invent o r y 1 2 3 4 5 A p p l i c a t i o n of d i e t manual 1 2 3 4 5 113 HIGH LOW System f o r handling p h y s i c i a n d i e t orders to ensure accuracy, e.g., use of a Kardex 1 2 3 4 5 Menu review and planning 1 2 3 4 5 Recording of d i e t a r y progress of p a t i e n t s 1 2 3 4 5 P a t i e n t education r e : t h e r a p e u t i c d i e t s _ 1 2 3 4 5 Tray a u d i t 1 2 3 4 5 P a t i e n t survey 1 2 3 4 5 S t a f f survey 1 2 3 4 5 Provide Meals on Wheels to the community _ 1 2 3 4 5 F i n a n c i a l c o n t r o l s , e.g., budget, records 1 2 3 4 5 IMPORTANCE KEY What i s the importance of t h i s f u n c t i o n : 1 2 3 4 5 very important somewhat unimportant very important important unimportant Any a d d i t i o n a l comments (please rank): Nursing Master L i s t 114 HIGH LOW Establishment of goals and o b j e c t i v e s Review of p o l i c i e s and procedures Performance a p p r a i s a l of s t a f f S t a f f o r i e n t a t i o n and c o n t i n u i n g education S t a f f i n g g u i d e l i n e s Develop comprehensive standard care plans Nursing A u d i t Unusual i n c i d e n t / m e d i c a t i o n e r r o r r e p o r t i n g and follow-up I n t e r d i s c i p l i n a r y team conferences P a t i e n t c l a s s i f i c a t i o n systems Crash c a r t a u d i t Discharge planning ( i n c l u d i n g r e f e r r a l to community res o u r c e s ) 2 3 4 5 2 3 4 5 2 3 4 5 2 3 4 5 2 3 4 5 2 3 4 5 2 3 4 5 2 3 4 5 2 3 4 5 2 3 4 5 2 3 4 5 115 HIGH LOW P a t i e n t t e a c h i n g programs 1 2 3 4 5 T r a n s f e r of f u n c t i o n 1 2 3 4 5 Record a l l m e d i c a l - s u r g i c a l s u p p l i e s ordered ' 1 2 3 4 5 Committees: I n f e c t i o n c o n t r o l 1 2 3 4 5 Q u a l i t y Assurance 1 2 3 4 5 Nursing P r a c t i c e 1 2 3 4 5 Safety 1 2 3 4 5 Regional 1 2 3 4 5 P a t i e n t conference 1 2 3 4 5 If your n u r s i n g department does a u d i t s , please d e s c r i b e : IMPORTANCE KEY What i s the importance of t h i s f u n c t i o n : 1 2 3 4 5 very important somewhat unimportant very important important unimportant Any a d d i t i o n a l comments (p l e a s e rank): M a s t e r L i s t P h a r m a c y HIGH R e v i e w and u p d a t e o f t h e g o a l s , o b j e c t i v e s , p o l i c i e s a n d p r o c e d u r e s 1 W r i t t e n p r o c e d u r e s f o r s t o r a g e , p r e p a r -a t i o n , a d m i n i s t r a t i o n a n d p r e c a u t i o n s 1 P u r c h a s i n g and i n v e n t o r y r e c o r d s 1 E v a l u a t i o n o f : d r u g u t i l i z a t i o n 1 d r u g o r d e r s 1 d r u g r e a c t i o n • 1 c o s t e f f e c t i v e n e s s 1 D e v e l o p m e n t o f a h o s p i t a l f o r m u l a r y w i t h r e g u l a r r e v i e w 1 A v a i l a b i l i t y o f an u p - t o - d a t e CPS a n d o t h e r r e f e r e n c e s 1 D r u g p r o f i l e s on p a t i e n t s / r e s i d e n t s 1 I n t e r d i s c i p l i n a r y m e e t i n g s t o e v a l u a t e p a t i e n t s 1 M e d i c a l s t a f f r e g u l a t i o n s r e : o r d e r s , e t c . 1 R e v i e w o f o u t d a t e d s t o c k on w a r d a n d r e t u r n o f i t t b p h a r m a c y 1 117 HIGH LOW C o n s u l t a t i o n with pharmacist 1 2 3 4 5 Poison c o n t r o l 1 2 3 4 5 Drug documentation a u d i t (HMRI) 1 2 3 4 5 S t a f f education and s u p e r v i s i o n 1 2 3 4 5 N a r c o t i c c o n t r o l and i n s p e c t i o n 1 2 3 4 5 Report of medication e r r o r s 1 2 3 4 5 P a t i e n t discharge c o u n s e l l i n g program 1 2 3 4 5 P a t i e n t s e l f - a d m i n i s t e r e d drug program 1 2 3 4 5 Drug i n f o r m a t i o n s e r v i c e 1 2. 3 4 5 IMPORTANCE KEY What i s the importance of t h i s f u n c t i o n : 1 very important important somewhat unimportant very important unimportant Please add any a d d i t i o n a l comments and rank these comments: APPENDIX VI PRINCIPLE 118 THERE SHALL BE A GOVERNING BODY OR EQUIVALENT THAT HAS LEGAL AND MORAL RESPONSIBILITY FOR THE CONDUCT OF THE HEALTH CARE FACILITY IN ALL ITS ASPECTS AND, IN PARTICULAR, FOR MAINTENANCE AND IMPROVEMENTS IN STANDARDS OF PATIENT CARE. IT IS RESPONSIBLE TO THE PATIENT, THE COMMUNITY AND THE SPONSORING ORGANIZATIONS), IF APPLICABLE. ITS OFFICIAL REPRESENTATIVE IS THE CHIEF EXECUTIVE OFFICER. THE FUNDAMENTAL PRINCIPLES OF THE ORGANIZATION INCLUDE THE FOLLOWING: THERE SHALL BE A WRITTEN STATEMENT DESCRIBING THE MISSION OF THE HEALTH CARE FACILITY WHICH SHALL CLEARLY DEFINE ITS GOALS AND OBJECTIVES. THIS MAY BE TITLED THE MISSION STATEMENT. THERE SHALL BE DOCUMENTED EVIDENCE OF THE DEVELOPMENT OF A PLANNING PROCESS WHICH SHALL ENSURE REGULAR REVIEW AND REVISION OF GOALS AND OBJECTIVES. THE CLEARLY DELINEATED GOALS AND OBJECTIVES SHALL BE REFLECTED IN WRITTEN POLICIES, PROCEDURES AND ORGANIZATIONAL PLANS. THERE SHALL BE AN ADEQUATE AND COMPETENT STAFF AND MEMBERS OF EACH DISCIPLINE SHALL PRACTISE IN ACCORDANCE WITH THE PROFESSIONAL AND ETHICAL STANDARDS OF THEIR PROFESSION. THERE SHALL BE EFFECTIVE PROGRAMS AND MECHANISMS FOR SYSTEMATIC REGULAR REVIEW OF THE QUALITY AND QUANTITY OF SERVICE PROVIDED. THIS QUALITY ASSURANCE PROGRAM SHALL USE THE METHODOLOGIES OF STRUCTURED PATIENT CARE APPRAISAL AS WELL AS PROGRAM EVALUATION TECHNIQUES. THE MILIEU PROMOTED SHALL ENHANCE EFFECTIVE COMMUNICATION AMONG STAFF, PATIENTS AND FAMILIES. SERVICES PROVIDED SHALL BE COORDINATED WITH OTHER APPROPRIATE COMMUNITY RESOURCES, SHALL BE RESPONSIVE TO COMMUNITY NEEDS AND SHALL DEMONSTRATE CONTINUING PROGRESS IN MEETING THE NEEDS OF THEIR PATIENTS. THE PERSONAL DIGNITY OF THE PATIENT SHALL BE RESPECTED. THE RIGHTS OF THE PATIENTS AND THEIR FAMILIES, INCLUDING THEIR PERSONAL AND INFORMATIONAL PRIVACY, SHALL BE PROTECTED. PATIENTS SHALL BE MADE AWARE OF THEIR RESPONSIBILITIES DUE TO THEIR HOSPITALIZATION. NO INDIVIDUAL SHALL BE EXCLUDED FROM RECEIVING SERVICES, OR FROM MEMBERSHIP ON THE GOVERNING BODY OR STAFF OF THE HEALTH CARE FACILITY ON THE BASIS OF RACE, CREED, SEX OR NATIONAL ORIGIN. ATTAINMENT OF ACCREDITATION BY THE CANADIAN COUNCIL ON HOSPITAL ACCREDI-TATION SHALL BE A GOAL OF THE HEALTH CARE FACILITY AND THERE SHALL BE COMPLIANCE WITH COUNCIL STANDARDS WHICH HAVE BEEN DEVELOPED TO PROMOTE THE ESSENTIAL INTEREST OF QUALITY PATIENT CARE TOGETHER WITH A PROGRAM OF TEACHING AND RESEARCH APPROPRIATE TO THE HEALTH CARE FACILITY.* •Although i t s standards are comprehensive and applicable to a l l health care f a c i l i t i e s the methods used to meet standards may vary with the s ize , location and function of the f a c i l i t y . The Canadian Council on Hospital Accreditation uses pract ical judgment in evaluating the smaller f a c i l i t y in contrast to the large tert iary care f a c i l i t y . Board Approved September 1984 1 SOURCE: Standards for Accreditation of Canadian Health Care F a c i l i t i e s , CCHA, 1934 GOVERNING BODY AND ADMINISTRATION 119 The c h i e f e x e c u t i v e o f f i c e r and a d m i n i s t r a t i v e p e r s o n n e l s h a l l be enco u r a g e d to a t t e n d m e e t i n g s and s e m i n a r s r e l e v a n t to t h e i r f u n c t i o n s . STANDARD VII QUALITY ASSURANCE QUALITY ASSURANCE PROGRAM An i n s t i t u t i o n - w i d e q u a l i t y a s s u r a n c e program i s an e s s e n t i a l element f o r a c c r e d i t a t i o n . T h i s program must i n c l u d e r e v i e w and e v a l u a t i o n of m e d i c a l , n u r s i n g and o t h e r d i r e c t p a t i e n t c a r e d e p a r t m e n t s and a l s o e v a l u a t i o n of the d e l i v e r y o f s u p p o r t s e r v i c e s as w e l l as p e r f o r m a n c e a p p r a i s a l of p e r s o n n e l . The g o v e r n i n g body s h a l l be r e s p o n s i b l e f o r and s h a l l p r o v i d e the n e c e s s a r y r e s o u r c e s to c a r r y t h i s o u t . Through i n d i v i d u a l and/or committee r e p o r t i n g , the c h i e f e x e c u t i v e o f f i c e r e n s u r e s t h a t the g o v e r n i n g body r e c e i v e s r e g u l a r r e p o r t s on and r e s u l t s of a l l a s p e c t s of the q u a l i t y a s s u r a n c e program. A c t i o n s t a k e n as a c o n s e -quence of the program are a l s o r e p o r t e d to e n s u r e t h a t the g o v e r n i n g body f u l f i l l s i t s mandate i n e n s u r i n g and b e i n g a c c o u n t a b l e f o r the d e l i v e r y of o p t i m a l q u a l i t y c a r e . REVIEW OF GOVERNANCE The Board s h a l l d e v e l o p a methodology of e v a l u a t i n g its, own f u n c t i o n and the g o v e r n a n c e of the h e a l t h c a r e f a c i l i t y . M e t h o d o l o g i e s may i n c l u d e a s t r u c t u r e d s e l f - e v a l u a t i o n program or the use of o u t s i d e r e s o u r c e s t o e f f e c t a p e r i o d i c s t r a t e g i c r e v i e w of the m i s s i o n and f u n c t i o n s • of the h e a l t h c a r e f a c i l i t y . UTILIZATION REVIEW: MECHANISMS AND RESULTS There s h a l l be a p p r o p r i a t e r e v i e w methods and p r o c e d u r e s i n p l a c e to e n s u r e t h a t p a t i e n t c a r e r e s o u r c e s a r e u t i l i z e d e f f e c t i v e l y and e f f i c i e n t l y and t h a t p o t e n t i a l s f o r improvement are d i l i g e n t l y p u r s u e d . Dependent i n l a r g e measure upon the i n s t i t u t i o n ' s management i n f o r m a t i o n s y s t e m ( s ) , f o r m a l r e s o u r c e u t i l i z a t i o n r e v i e w mechanisms are now viewed as a h a l l m a r k c h a r a c t e r i s t i c o f r e s p o n s i b l e h e a l t h c a r e p r o v i d e r s . Such r e v i e w s a r e c l o s e a l l i e s o f q u a l i t y a s s u r a n c e programs g e n e r a l l y and m e d i c a l a u d i t a c t i v i t i e s i n p a r t i c u l a r . U t i l i z a t i o n r e v i e w i s c o n c e r n e d w i t h u n d e r u t i l i z a t i o n as w e l l as o v e r u t i l i z a t i o n . U t i l i z a t i o n r e v i e w w i t h i n c l i n i c a l d e p a r t m e n t s s h o u l d be an e x p e c t e d r e s u l t of the l e a d e r s h i p f u n c t i o n o f the c l i n i c a l c h i e f s . Review at s e n i o r a d m i n i s t r a t i v e and M e d i c a l A d v i s o r y Committee l e v e l s s h o u l d f l o w from the a c t i v i t i e s o f the h o s p i t a l ' s U t i l i z a t i o n Review Committee. The c o m p o s i t i o n of the l a t t e r s h o u l d i n c l u d e s e n i o r management r e p r e s e n t a t i v e s as w e l l as a broad s p e c t r u m r e p r e s e n t a t i o n of c l i n i c a l and l a b o r a t o r y p h y s i c i a n s . In a d d i t i o n t o making needed d a t a a v a i l a b l e t h e r e s h o u l d be e v i d e n c e o f management s u p p o r t of committee i n i t i a t i v e s i n the f o r m of a n a l y t i c a l a s s i s t a n c e and a s s i s t a n c e w i t h r e p o r t p r e p a r a t i o n . I t i s e s s e n t i a l t h a t the o b s e r v a t i o n s , comments and recommendations of t h e U t i l i z a t i o n Review Committee be r e p o r t e d to the i n s t i t u t i o n ' s g o v e r n i n g body. T h i s s h o u l d be accompanied, of c o u r s e , w i t h any a d d i t i o n a l i n f o r m a -t i o n o r recommendations the M e d i c a l A d v i s o r y Committee, or e q u i v a l e n t , may w i s h t o add. Board A p p r o v e d September 1984 13 120 APPENDIX VII BOARD P r i o r i t y Rating Development of mission statement 60 CCHA survey recommendations 59 Appointment/review of s e n i o r a d m i n i s t r a t i v e s t a f f 56 Appointment/review of medical s t a f f 56 Review of bylaws, goals and o b j e c t i v e s 55 Review adequacy of f a c i l i t y and equipment 55 Maint a i n good communication between h o s p i t a l and community 53 Review a d m i n i s t r a t o r s (monthly) board r e p o r t 52 Review of board s t r u c t u r e , committees and o v e r a l l h o s p i t a l s t r u c t u r e 51 Review budget, cash flow, f i n a n c i a l a u d i t 51 D i s a s t e r Plan and F i r e Plan 51 Monitor a l l q u a l i t y assurance committee a c t i v i t i e s by r e v i e w i n g the t a r g e t s f o r a l l departments 48 Review s o c i e t y membership and p u b l i c image 48 P a t i e n t s a t i s f a c t i o n p o l l 47 J o i n t Conference Committee 47 U t i l i z a t i o n review 45 Comparative s t a t i s t i c s (with same s i z e f a c i l i t y ) 40 Risk management 40 Note: Higher scores i n d i c a t e higher p r i o r i t y . 121 THERAPEUTIC DIETARY/FOOD SERVICE P r i o r i t y Rating C l e a n i n g schedules 54 F i n a n c i a l c o n t r o l s 54 Care and maintenance of equipment 53 Job d e s c r i p t i o n s 53 Temperature a u d i t s 53 Performance a p p r a i s a l s of s t a f f 53 System f o r handling p h y s i c i a n d i e t order to ensure accuracy e.g., use of a Kardex 53 Review and update of goals, o b j e c t i v e s , p o l i c i e s and procedures 51 S t a f f education and o r i e n t a t i o n 51 A p p l i c a t i o n of d i e t manual 51 Tray a u d i t 51 Organized system f o r c o n s u l t a t i o n with q u a l i f i e d d i e t i t i a n 50 P u b l i c h e a l t h and s a n i t a t i o n t e s t s 50 Stocking and inv e n t o r y 49 Recording of d i e t a r y progress of p a t i e n t s 49 P a t i e n t eduction r e : t h e r a p e u t i c d i e t s 46 S t a f f i n g g u i d e l i n e s 44 Menu review and planning 44 P a t i e n t survey 44 S t a f f survey 44 Provide Meals on Wheels to the community not a p p l i c a b l e f o r four h o s p i t a l s Note: Higher scores i n d i c a t e higher p r i o r i t y . 122 NURSING P r i o r i t y Rating Review of p o l i c i e s and procedures 61 Establishment of goals and o b j e c t i v e s 58 Unusual i n c i d e n t / m e d i c a t i o n e r r o r r e p o r t i n g and follow-up 58 Safety committee 58 Nursing a u d i t 56 Performance a p p r a i s a l of s t a f f 55 Develop comprehensive standard care plans 54 Crash c a r t a u d i t 53 S t a f f o r i e n t a t i o n and c o n t i n u i n g education 52 Q u a l i t y assurance committee 52 P a t i e n t teaching programs 51 T r a n s f e r of f u n c t i o n 51 Record a l l m e d i c a l - s u r g i c a l s u p p l i e s ordered 51 P a t i e n t conference 51 Discharge planning 50 I n t e r d i s c i p l i n a r y team conferences 49 I n f e c t i o n c o n t r o l 47 Nursing p r a c t i c e 40 Regional conference 33 P a t i e n t c l a s s i f i c a t i o n systems 31 Note: Higher scores i n d i c a t e higher p r i o r i t y . 123 PHARMACY P r i o r i t y Rating W r i t t e n procedures f o r storage, p r e p a r a t i o n , a d m i n i s t r a t i o n and p r e c a u t i o n s 58 Report of medication e r r o r s 58 Development of a h o s p i t a l formulary with r e g u l a r review 57 N a r c o t i c c o n t r o l and i n s p e c t i o n 56 Review and update of the goals, o b j e c t i v e s , p o l i c i e s , and procedures 54 Review of outdated stock on ward and r e t u r n of i t to pharmacy 54 A v a i l a b i l i t y of an up-to-date CPS and other r e f e r e n c e s 53 E v a l u a t i o n of drug orders 53 E v a l u a t i o n of drug u t i l i z a t i o n 52 Drug p r o f i l e s on p a t i e n t s / r e s i d e n t s 51 E v a l u a t i o n of drug r e a c t i o n 50 C o n s u l t a t i o n with pharmacy 50 Cost e f f e c t i v e n e s s of drugs 47 S t a f f education and s u p e r v i s i o n 47 I n t e r d i s c i p l i n a r y meetings to evaluate p a t i e n t s 47 Drug i n f o r m a t i o n s e r v i c e 47 Poison c o n t r o l 46 Medical s t a f f r e g u l a t i o n s r e : order, e t c . 45 PHARMACY P a t i e n t discharge c o u n s e l l i n g program P a t i e n t s e l f - a d m i n i s t e r e d drug program Drug documentation a u d i t (HMRI) 124 P r i o r i t y Rating 45 41 39 Note: Higher scores i n d i c a t e higher p r i o r i t y . 

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