The role of the Quality Improvement Organization.

Quality Improvement Organizations (QIOs) are an unbiased source of quality improvement support and expertise for health care professionals and institutions across the nation. The Carolinas Center for Medical Excellence, the QIO in North Carolina and South Carolina, is supporting the advancement of the National Quality Strategy.

The quality of medical care.

This article classifies the major approaches to the assessment of the process and outcomes of medical care. The apparent need to safeguard and enhance the quality of care has led to the institution of mechanisms that subject care to constant review so that deficiencies may be found and corrected. The article reviews the developments that led to the involvement of the federal government in this activity through its sponsorship of professional standards review organizations (PSRO's). The major features of the PSRO's are described and their possible effects discussed. It is too early to say how the PSRO's will fare, but should they fail to accomplish their objectives the pressure for more radical solutions will be difficult to resist.

Changes in average length of stay and average charges generated following institution of PSRO review.

A five-year review of accounting data at a university hospital shows that immediately following institution of concurrent PSRO admission and length of stay review of Medicare-Medicaid patients, there was a significant decrease in length of stay and a fall in average charges generated per patient against the inflationary trend. Similar changes did not occur for the non-Medicare-Medicaid patients who were not reviewed. The observed changes occurred even though the review procedure rarely resulted in the denial of services to patients, suggesting an indirect effect of review.

Peer review organization payment denials: comparative analysis of emergency department and non-emergency-department admissions.

The Health Care Financing Administration has contracted with regional peer review organizations to review Medicare admissions and to deny payment for hospital admissions that fail to meet peer review organization criteria. The purpose of this study was to compare emergency department admissions with non-emergency-department admissions with respect to rates of peer review organization denial and the reasons for those denials. All hospital Medicare admissions between January 1984 and April 1987 were retrospectively reviewed. Patients were excluded if they received peer review organization pre-authorization prior to admission. The rest were classified by 1) source of admission (emergency department or non-emergency department), 2) peer review organization decision, 3) reason for peer review organization denial, 4) whether the denial was appealed, 5) the results of appeal. Chi-square or Fisher's Exact Test analysis was performed, and P less than 0.05 was considered to be significant. During the 40-month study period, there were 19,847 emergency department Medicare admissions and 19,752 non-emergency-department Medicare admissions. Of the non-emergency-department admissions, 7887 received pre-authorization. None of the emergency department admissions received pre-authorization. Of the 19,847 emergency department admissions, 433 (2.23%) were denied. Of these denials, 269 (60.7%) were appealed by the hospital; 136 (50.5%) successfully. Of the 11,865 non-emergency department, non-pre-authorized admissions, 333 (2.81%) were denied. Of these denials, 174 (52.2%) were appealed, 76 (43.6%) successfully. Overall, emergency department admissions were significantly less likely to receive peer review organization denial than non-emergency-department, non-pre-authorized admissions (P less than 0.003).(ABSTRACT TRUNCATED AT 250 WORDS)

The historical precedents for quality assurance in health care.

The evolution of quality assurance as an essential component of a scientific, objective approach to health care delivery, and its implications for the profession of occupational therapy are presented. A review is made of the economic, ethical, psychological, and legislative forces that have influenced the development of quality assurance over the past century, a development that has seen times of strong emphasis on quality assurance functions, as well as periods of minimal support and, even, obstacles to any activity. Quality assurance standards established by both The American Occupational Therapy Association and the Joint Commission on Accreditation of Hospitals (JCAH) are discussed. Results of commitment to these standards include improved effectiveness and efficiency of health care, better coverage and reimbursement from third-party payors, and greater professional growth. The need for commitment by occupational therapists to the most effective forms of quality assurance is recommended.

Quality oversight: how much is too much?

Concern for quality, which has created $1 billion/year quality oversight businesses, has affected health care organizations financially in different degrees. The most costly is the JCAHO accreditation process. Health care organizations have the power to control these businesses and expenditures.

Health Care Financing Administration--PSRO hospital review; financing of activities. Final regulation.

This regulation establishes a new method for reimbursing the cost of hospital review conducted under the authority of Professional Standards Review Organizations (PSROs). It applies to review of hospital care provided to patients eligible under the Medicare, Medicaid, and Maternal and Child Health and Crippled Children's (MCH-CC) programs. It further implements Sections 1152(b), 1155(e), 1155(f), 1168, 1815(b), and 1861(w)(2) of the Social Security Act.

Health Care Financing Administration--Medicaid provider records and grants to Professional Standard Review Organizations: technical amendments. Final regulations.

These technical amendments reflect minor editorial changes in regulations relating to Medicaid agency recordkeeping and grants to Professional Standards Review Organizations. The amendments also delete various provisions which reiterate requirements now contained in 45 CFR Part 74, "Administration of Grants." These amendments are part of an HEW project to conform individual grant program regulations to the HEW-wide Grant regulations found in 45 CFR Part 74.

Medicare program; payment to hospitals for furnishing photocopies to peer review organizations--HCFA. Final rule.

This final rule amends the regulations governing Utilization and Quality Control Peer Review Organizations (PROs) to provide for a uniform methodology for determining payment to hospitals for the costs of furnishing photocopies of medical records of Medicare beneficiaries to PROs. We also are establishing the rate of payment for these costs at $.07 per page. This amount includes payment for labor and supply costs, but not the costs of equipment and overhead, which are already otherwise paid under the Medicare program.

Financially viable nurse-managed centers.

Nurse managed centers play an important role in the health service delivery system; often serving those in greatest need, while struggling to remain financially viable. This article discusses the role of a Financial Advisory Committee (FAC) and the process of financial peer review in academic nurse-managed centers to improve financial outcomes. Advanced practice nurses may find the identified strategies for financial sustainability useful in their own practices.

Providers question PROs' effectiveness. Critics contend peer review organizations are too costly and fail to improve the quality of care.

The Health Care Financing Administration (HCFA) established physician review organizations (PROs) to ensure that Medicare recipients receive care that is medically necessary, of high quality, and provided in the appropriate setting. While arguing that oversight is necessary, many healthcare professionals believe PROs do not accomplish what they were set up to do because physicians focus on the possibility of being penalized rather than on improving patient care. PRO critics claim that the program's peer reviewers are not peers of the physician under review and that, to be effective, they should come from the same local area. They contend the best peer review is conducted within the hospital. They believe intrafacility review can be more effective at bringing about improvement because hospital peer reviewers act as supportive, nonthreatening consultants. The confidentiality of the physician-patient relationship is another issue PRO critics raise. HCFA staffers say hospitalized Medicare patients are required to sign a waiver allowing inspection of their charts, but critics counter that waivers are only for the release of records for payment claims. Changes encouraging cooperation between PROs and hospitals could improve the PRO program and enhance quality of care.

Current and future state of FDA-CMS parallel reviews.

The US Food and Drug Administration (FDA) and the Centers for Medicare and Medicaid Services (CMS) recently proposed a partial alignment of their respective review processes for new medical products. The proposed "parallel review" not only offers an opportunity for some products to reach the market with Medicare coverage more quickly but may also create new incentives for product developers to conduct studies designed to address simultaneously the information needs of regulators, payers, patients, and clinicians.