Presentación desde la FELAQ / Presentation from FELAQ

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Capítulo de Quemaduras de FILACP Actualización en el tratamiento del paciente quemado / FILACP Burns Committee Update in the treatment of the burned patient

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The relationship of community mental health centers to the professional standards review organizations program.

Given the realities of the professional standards review organization (PSRO) program and the necessity for accountability on the part of all health service providers, community mental health centers (CMHCs) should begin now to take an active role in planning their involvement in the PSRO program. The author points out the need for both psychiatrists and nonphysician professionals to become involved. There are many types of mental health services delivered in a given area, and the active involvement of CMHCs can be a major determinant of the shape and direction of this impact.

Effectiveness research and assessment of clinical outcome: a review of Federal Government and medical community involvement.

Because of their concern about the increasing costs of health care, industry and government contractors for health care will attempt to control health-care costs for the foreseeable future. New proposals for cost containment include those that are focused on cost alone--for example, expenditure limits--and those that propose to control costs by limiting medical interventions to those of known efficacy. This latter attempt has come to be known as "effectiveness research." Herein, we briefly review the history of quality assurance and cost-containment efforts in the United States, giving special attention to the current initiative based on effectiveness research. Although the effectiveness research initiative has shortcomings (for example, it will not provide guidance when data are not available), it seems to be superior to the current peer review system because it encourages the development of a knowledge base and deemphasizes punitive measures as a way to ensure quality and control costs. The Omnibus Budget Reconciliation Act of 1989 (Public Law 101-239) establishes a federal agency, the Agency for Health Care Policy and Research, within the Public Health Service to focus on effectiveness research.

Analysis of variations in hospital use by Medicare patients in PSRO areas, 1974-1977.

A study of the use of short-stay hospitals in PSRO areas by Medicare enrollees aged 65 and over for the period 1974 through 1977 revealed that discharge rates increased, average length of stay (ALOS) decreased, and days-of-care rates remained relatively constant in nearly all of the PSRO areas. The data show large variations in hospital use in PSRO areas within States and HEW regions, and suggest that factors within the area are critical determinants of hospital utilization. This study presents important implications for PSRO program policy for it suggests that factors other than physician and hospital behavior should also be considered when setting objectives for reducing misutilization and improving the quality of health care.

Toward a 21st century quality-measurement system for managed-care organizations.

As the Nation's largest managed-care purchaser, the Health Care Financing Administration (HCFA) is working to develop a uniform data and performance-measurement system for all enrollees in managed-care plans. This effort will ultimately hold managed-care plans accountable for continuous improvement in the quality of care they provide and will provide information to consumers and purchasers to make responsible managed-care choices. The effort entails overhauling peer review organization (PRO) conduct of health maintenance organization (HMO) quality review, pilot testing a new HMO performance-measurement system, establishing criteria for Medicaid HMO quality-assurance (QA) programs, adapting employers' HMO performance reporting systems to the needs of Medicare and Medicaid, and participation in a new alliance between public and private sector managed-care purchasers to promote quality improvement and accountability for health plans.

What's happening in quality improvement at the local hospital: a state-wide study from the Cooperative Cardiovascular Project.

The objective of this study was to investigate what happened to improve the quality of care for acute myocardial infarction (AMI) at all 32 nonfederal hospitals in Connecticut and to assess the impact of the Cooperative Cardiovascular Project (CCP) on quality improvement (QI) activities for AMI. We performed a questionnaire study with secondary analyses using the CCP database. On-site interviews were conducted with QI directors at all 32 Connecticut nonfederal hospitals that participated in the Health Care Financing Administration's Cooperative Cardiovascular Project (CCP) in 1992-93 and 1995. The interviews sought information about the makeup of QI departments, specific approaches used to improve the care of patients with AMI, and the perceived value of the CCP to each individual hospital. Results showed that the number of full-time equivalents (FTEs) and FTEs per beds employed in QI departments ranged from 1 to 30 and from 0.4 to 7.9, respectively, with a registered nurse most often serving as the department head (27/32). Over half of the departments (17/32) had additional responsibilities. The majority (25/32) used some combination of physician champions, multidisciplinary QI teams, standing orders, or critical pathways to effect change in AMI care. Finally, 26 of the 32 hospitals believed the CCP was valuable because it provided credible benchmark data, a catalyst for change, or a specific focus on processes of care needing improvement in AMI. Despite great variability in institutional resources, all 32 hospitals used a similar combination of QI approaches to effect change in AMI care. However, there is variable scientific evidence supporting these approaches. Externally sponsored projects such as the CCP appear to play a useful role for individual hospitals. Defining the optimal methods of QI is difficult given that hospitals are using complex combinations of nonstandardized improvement interventions.

Setting program standards for New York State's periodic medical review.

This article describes the methodology used to develop program standards for a new periodic medical review/independent professional review (PMR/IPR) in New York State nursing homes. The new program consists of two stages: a first, cursory stage for the purpose of identifying patients to be subjected to a more thorough process review in the second stage. Program standards consist of (1) norms for the percentage of patients failing Stage 1 before a second stage is undertaken in a nursing home and (2) norms for the percentage of patients failing the second stage before the home is subject to corrective action. The actual standards that were developed are also presented.

Quality improvement for pressure ulcer care in the nursing home setting: the Northeast Pressure Ulcer Project.

OBJECTIVES: The objectives of this study were to evaluate the impact of a collaborative model of quality improvement in nursing homes on processes of care for the prevention and treatment of pressure ulcers. STUDY DESIGN: The study design was experimental. SETTING: We studied 29 nursing homes in New Jersey, Pennsylvania, and Rhode Island. PARTICIPANTS: Participants consisted of pressure ulcer quality improvement teams in 29 nursing homes. INTERVENTION: Quality improvement teams attended a series of workshops to review clinical guidelines and quality improvement principles and to share best practices, and worked one-on-one with mentors to implement quality improvement techniques and to collect data independently. MEASUREMENTS: We calculated process measures based on the Agency for Healthcare Research and Quality (AHRQ) guidelines. Process measures addressed each facility's processes of care for the prevention and treatment of pressure ulcers at baseline and after 12 months of intervention. Prevention measures focused on recent admissions and high-risk residents; treatment measures focused on patients newly diagnosed with pressure ulcers and all patients with pressure ulcers. RESULTS: Overall, 6 of 8 prevention process measures improved significantly, with percent difference between baseline and follow up ranging from 11.6% to 24.5%. Three of 4 treatment process measures improved significantly, with 5.0%, 8.9%, and 25.9% difference between baseline and follow up. For each process measure, between 5 and 12 facilities demonstrated significant improvement between baseline and follow up, and only 2 or fewer declined for each process measure. CONCLUSION: Improvement in processes of care after the use of a structured collaborative quality improvement approach is possible in the nursing home setting.

Professional self-regulation: peer review.

Dentistry, in fulfilling its responsibility for self-regulation, has established a highly specific and formalized method of peer review. Its primary purpose is to mediate problems between patients, dentists, and third parties relative to the quality of treatment and appropriateness of care. It is a confidential service provided to the public and profession at no cost and accomplished with the voluntary cooperation of all parties involved. Decisions of peer review committees are advisory in nature but offer an alternative to legal resolution of misunderstandings and problems in patient care. The profession, by continually refining peer review and by educating its members and the public to its function, is providing a unique and valuable service to patients, dentists, and third parties. The objective and consistent application of this self-monitoring process is but one mechanism by which dentistry seeks to serve the public and perpetuate its high standard of care.

Health Care Financing Administration--Professional Standards Review; redesignation of PSRO areas in California. Final regulation.

This regulation redesignates Professional Standards Review Organization (PSRO) areas in California in order to combine PSRO Areas XIX and XXIII. This redesignation will facilitate initiation of PSRO activity in the currently uncovered area of Los Angeles, California, formerly designated as Area XIX. In addition, the redesignation results in a higher degree of congruence with the Health Service Areas (HSA) designations and in more effective coordination with Medicare intermediaries and carriers and Medicaid fiscal agents.

Medicare program; peer review organizations; area designation--HCFA. Final notice with comment period.

This notice announces the redesignation of an area consisting of the State of Hawaii and the territories of American Samoa, Guam and the Commonwealth of the Northern Mariana Islands as a single Utilization and Quality Control Peer Review Organization (PRO) review area. Presently, the State of Hawaii comprises one review area and the listed territories another review area. This change will enhance the efficiency and effectiveness of the administration of PRO activities.

Health Services Review Organization--Veterans Administration. Final regulations.

These regulations define the VA's Medical Quality Assurance program, Health Services Review Organization (HSRO), and provide confidentiality for certain quality assurance records and documents. The regulations also set forth the methods for disclosure and access to confidential and privileged HSRO records and documents. The regulations are intended to implement a change enacted by the Veterans Disability Compensation and Housing Benefits Amendments of 1980.

Medicare program; Peer Review Organizations: revised scopes of work for the District of Columbia, Puerto Rico, the Virgin Islands, and all states except Delaware, Florida, Missouri, Montana, Nebraska, Nevada, Oklahoma, Rhode Island, South Carolina, Washington, and Wyoming--HCFA. Final notice.

This notice describes requirements for the review activities of Utilization and Quality Control Peer Review Organizations (PROs) under contract extensions of the Scope of Work for the District of Columbia, Puerto Rico, the Virgin Islands and all States except Delaware, Florida, Missouri, Montana, Nebraska, Nevada, Oklahoma, Rhode Island, South Carolina, Washington, and Wyoming. Section 1153(h)(1) of the Social Security Act requires us to publish any new policy or procedure adopted by the Secretary that affects substantially the performance of PRO contract obligations at least 30 days before the date the policy or procedure is to be used. Specifically, this notice describes the way in which PRO contract requirements are changed and explains significant changes in the PRO program (e.g., the way in which cases will be selected for review) and also describes continuing requirements. This notice also implements provisions of the Omnibus Budget Reconciliation Act of 1990.

Medicare program; peer review organization contracts: solicitation of statements of interest from in-state organizations--Alaska, Delaware, the District of Columbia, Hawaii, Idaho, Illinois, Kentucky, Maine, Nebraska, Nevada, South Carolina, Vermont, and Wyoming--HCFA. Notice.

This notice, in accordance with section 1153(i) of the Social Security Act, gives at least 6 months' advance notice of the expiration dates of contracts with out-of-State Utilization and Quality Control Peer Review Organizations. It also specifies the period of time in which in-State organizations may submit a statement of interest so that they may be eligible to compete for these contracts.

Health reform and the quality assurance imperative.

The administration's blueprint for healthcare reform contains a number of positive features, including a national healthcare information database, quality "report cards," and state-based patient complaint offices. Missing from the plan, however, is "an active quality monitoring system that holds health plans and providers publicly accountable for improved performance," says Andrew Webber, Executive Vice President of the American Medical Peer Review Association, the national association of Peer Review Organizations (PROs). His antidote includes the creation of an independent, state-based network to coordinate quality assurance activities; a program to monitor compliance with practice guidelines; and a quality foundation to measure, manage, improve, and oversee quality.

The internal review process: implications for the novice clinical researcher.

The purpose of this article, directed at first-time clinical researchers, is to describe the internal review board process of one clinical research facility and to provide an example of its protocols for conducting clinical research. After a brief history depicting the need for Internal Review Boards, the review process itself, is discussed. Emphasis is placed on the patient's medical/legal rights and safety. Equipped with an understanding of why the review process is necessary and with examples of the review board criteria, the nurse researcher has the tools to begin the research project.

[Towards an accreditation system for the Dutch hospitals]. / Op weg naar een accreditatiesysteem van Nederlandse ziekenhuizen.

The development of the Netherlands system for accreditation of hospitals started in 1989 in the Pilotproject Accreditation (PACE). This resulted in the establishment of the Netherlands Institute for Accreditation of Hospitals (NAIH) early 1999, by the Dutch Association of Hospitals, the Dutch Association of University Hospitals, the Dutch Organisation of Medical Specialists and the PACE foundation. Dutch hospitals may request (voluntary) for an accredition for their whole organisation or for parts of it, independent of the used quality system. An accreditation assesses whether organizational requirements are available for quality assurance. Accreditation is not primarily aimed to account for organizational quality, but rather to find points for improvement. The survey is carried out by peers: experts from other Dutch hospitals. The frame of reference used in accreditation is composed of 35 departmentwise standards and a hospitalwide standard 'Quality system'. All standards are developed by people in Dutch hospitals. NIAH can accept certificates for parts of the hospital (e.g. laboratoria) issues by organisations. The system is complementary to the 'visitities' which are organized by the medical specialist societies in the Netherlands. From 1996-1998 trial accreditations were carried out in 19 Dutch hospitals. These showed that the accreditation system has an added value for Dutch hospitals.