PRO changes under the fourth scope of work for Medicare.

The Fourth Scope of Work for the Medicare Program will become effective on December 1, 1991. This program will change the methodology utilized by peer review organizations throughout the country in performing federally mandated review of the medical care provided to Medicare patients.

Administración de la asociación / Administration of the asociation

La administración es una empresa compleja que requiere la aplicación de teorías sobre el tema; el uso de apropiadas herramientas administrativas y el desempeño de las funciones inherentes a la misma. Cada asociación debe contar con un documento constitutivo para formalizar su misión y modus operandis. Estructurar la organización según el principio de grupos facilita la administración e influye en el funcionamiento de sus órganos esenciales (juntas, comisiones, formuladores de la política a seguir). Toma de decisiones, planificación, control y coordinación son algunas de las funciones administrativas más importantes de la ANE y el buen administrador, se esforzará continuamente para ampliar sus capacidades. El trabajo y mérito de un administrador calificado no debe sobrevalorarse. Las ANEs que obtienen resultados positivos son aquellas que trabajan en la consecución de sus responsabilidades administrativas

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.

Quality assurance and development of criteria and standards.

This article considers some fundamental considerations in developing criteria and standards for use in a formal quality assurance program. These include the purpose of the review system, the types of problems being addressed, the availability of data, and the time and money that can be devoted to improving clinical performance.

The PSRO hospital review system.

The 1972 Social Security amendments contained the landmark Professional Standards Review Organization (PSRO) provisions as well as several sections upgrading existing utilization review (UR) requirements under Medicare and Medicaid. With issuance of the PSRO Program Manual and the recent publication of the new UR regulations, HEW for the first time has brought Medicare and Medicaid hospital review requirements into conformity and made them compatible with and supportive of the PSRO program. This article defines the PSRO hospital review system, describes how the three major components-concurrent review, medical care evaluation studies, and profile analysis-interrelate and provides examples of each of these components. Under utilization review requirements or PSRO, hospitals will be required to implement an integrated system of review designed to assure appropriate utilization practices and improve the quality of care. These aims are to be accomplished through the application of concepts of peer review, the use of norms, criteria, and standards, the identification of deficiencies in the quality, administration, or appropriateness of health care services, and their correction through linkage with programs of continuing medical education. Although PSROs are initially responsible for review in hospitals, they will likely provide the locus for a community-wide system of peer review for all services provided under National Health Insurance.