Quality assessment program in primary care clinics: a tool for quality improvement
Mục lục
Abstract
Background. Assessment of quality of health care is a major ongoing project of the Israeli Defense Forces (IDF) medical corps.
Objectives. (i) To describe mechanisms of quality assessment (QA) in IDF primary care clinics; (ii) to compare quality of care in different types of primary care clinics; and (iii) to test the hypothesis that implementation of the QA program results in improved quality of care.
Research design. A prospective, single-blinded, uncontrolled, non-randomized study.
Measures. Teams of two physicians carry out the QA process once or twice a year according to clinic size. Five areas were evaluated: (i) physician–patient interaction; (ii) medical chart evaluation; (iii) high-risk patients management; (iv) medical care provided by specialists; and (v) medical staff guidance. Clinics were classified in two groups: single-physician clinics (battalion troop clinics) and multi-physician clinics (home-front base clinics). General Linear Models were used for analysis. A P-value <0.05 was considered significant.
Results. In 2000 and 2001, 99 primary clinics and 162 primary care physicians were assessed. Seventy-four (45%) physicians were evaluated twice. Single-physician clinics scored higher than multi-physician clinics on most QA parameters. Physicians had significantly better QA results at the second encounter, regardless of the type of clinic.
Conclusions. A primary care medicine QA system is feasible in the IDF. It allows for standardized, reliable, and comprehensive assessment of primary care across the military clinics. We postulate that the increase in QA assessment scores from one examination to the next one indicates an improvement in quality due to the QA program.
Quality assessment (QA) in primary care is a process of planned activities whose ultimate goal is to achieve a continuous improvement of medical care through the evaluation of structure, process, and outcome measures [1–4].
The practice of health care in the Israeli Defense Forces (IDF) is similar in many aspects to that of civilian health systems. It is essentially based upon primary care clinics, and also upon secondary specialist centers, and civilian hospitals and facilities. Yet the military milieu is different from other clinical setups in various aspects [5–7]: (i) pre-recruiting screening examinations select draftees that are healthier than the general population; (ii) there is an abrupt change in lifestyle of young adults recruited in the army; and (iii) military constraints may conflict with proper medical decision making. Over the years, the medical corps has created a primary care system that is highly accessible and available, leading to an average of seven to eight visits per soldier per year (according to unpublished internal IDF data). In this health system, primary care physicians (PCPs) include board-certified physicians in general medicine (general practitioners) that serve either on active duty or as civilians employed by the army or as reservists. The differences between these groups might be fundamental with respect to knowledge, skills, motivation, and the sense of identification with the medical corps. The characteristics of the military medical establishment make it mandatory to develop a comprehensive system able to identify variations in quality of care and to study the impact of corrective measures.
The purposes of this study were: to describe the mechanisms of QA in the primary care clinics of the IDF; to describe the results of QA studies conducted from the implementation of the program, on 1 January 2000, to 31 December 2001 in primary care clinics; to compare the quality of care provided by the different types of primary care clinics and physicians; and to analyze the preliminary impact of the QA program upon quality of primary care. We hypothesized that the implementation of the QA program within the IDF results in improved quality of care and that evaluation of a specific PCP within the framework of the QA program results in an improved score of the PCP during a second evaluation.
Methods
Definitions
For the purpose of this analysis, the various PCP units evaluated were classified as follows: (i) ‘single-physician medical clinics’ were those primary care clinics located at field units, serving deployed troops, in mobile clinics, either during deployment or during training. In this setting, primary care is provided by a single general practitioner, with no level of support from other health care providers except for military medics. These military medics provide only elementary medical care and are responsible for administrative functions as well. All these unit clinics have a restricted pharmacy on site (capable of providing basic medications). Physiotherapy and mental health services are not available on site. (ii) ‘Multi-physician medical clinics’ were those primary care clinics located in home-front bases, which employed between two and 10 PCPs and were supported by medics and nurses, which increases the number of available clinical staff. In addition, full laboratory, pharmacy, and radiology services are usually available on site or near by. Most centers also have physiotherapy and mental health services, while others include various specialists’ services in the same building. Some centers also have in-patient facilities. In addition, most of these primary care clinics function in the evenings and at weekends for urgent visits.
Physician assessors
In the IDF, several teams of two experienced physicians carry out the QA system. In each team there is at least one board-certified family physician. The teams use a detailed, prospectively established QA protocol, where the emphasis is placed on medical records. The assessment uses both specific obligatory markers of adequate medical evaluation and treatment (an explicit quality assessment method), and a direct inspection of the primary physician (an implicit quality assessment method). Identification and management of population at risk, further medical training and guidance, and medical administration with a direct effect on the quality of care are also evaluated. Each item is subcategorized and is given a specific score. The score reflects the relative importance of the item in question, as determined (by consensus) by a committee composed of the Surgeon General and the IDF scientific committee. The QA forms that the assessors fill in are shown as Supplementary data (available at IJQHC Online), and include both the variables studied and their scoring assessment (maximum score).
Inspection
A board-certified family physician inspects the patient–physician interaction (directly, in a live performance) and examines the following characteristics: (i) medical history taking: is the past medical history properly studied? Are the correct questions about the present illness asked? (ii) Physical examination: is a thorough physical examination performed? (iii) Discussion: the assessor discusses the case for differential diagnosis, further evaluation option and suggested treatment. (iv) Follow-up: evaluation of the follow-up that is offered to the patient. (v) Communication: the communication between the physician and the patient during the interaction and the psychosocial approach are evaluated. Finally, (vi) a general impression of the assessor on the interaction is given.
Medical record audit
The medical record is the soldier’s medical file, which consists of past medical history data, previous referrals to military unit clinics, laboratory results, and tests. In addition, the patient chart may be used as a legal tool. The medical record is tested using three criteria. (i) ‘Medical data’, which provide global, yet important, medical information that must be included in the medical chart. These data include medical rating, information about drug allergy, an active medical problem list, and past hospitalizations record and vaccine status. (ii) ‘Chart arrangement’ is evaluated by the percent of medical charts found on request, chronological continuity of the chart, presence or absence of physician signature after each visit, and order and clarity of the charts. (iii) ‘Analysis of the medical chart’ by the assessors—examination of the written data inside 10 different records, according to problem-oriented medical writing principles (the S.O.A.P. acronym: subjective, objective, assessment, therapeutic and evaluative plan). In addition, five frequent (based on the army’s yearly statistical report; internal unpublished data) medical conditions (respiratory tract infection, urinary tract infection, abdominal pain, headache, and low back pain) and one chronic condition (asthma) are evaluated. At least three different physician–patient interactions for each condition are analyzed. In order to address this part of the QA program prospectively, teams of board-certified specialists analyzed each of these conditions, and defined the necessary actions that must be taken for their evaluation.
High-risk patient surveillance
Patients at high risk in the army are those soldiers whose medical problems are either dynamic and may lead to serious complications, or subjects with chronic illnesses. In this field, two QA criteria are examined: (i) the initial surveillance of follow-up examinations of those patients at risk and the existence of appropriate medical records for such examinations; and (ii) the implementation of periodic follow-up examinations and recommendations.
Complementary medical services
Evaluation of the medical services that relate to the physician–patient interaction is effected according to the following criteria: (i) appropriate drug supply; and (ii) secondary health care characteristics. The latter is the interaction between the primary physician and the secondary physician, which is examined in terms of: (i) the proportion of referrals from the total visits in the primary clinic; (ii) the quality of the referral letter; (iii) the justification of the referral and the attitude of the primary care physician in regard to the specialist’s recommendations; (iv) the availability of the medical services (determined by the average waiting time in the clinic, the waiting list management system, and the priority order); (v) the efficacy of the administration procedures; and (vi) the evaluation of the in-patient rooms in the units.
Guidance
An important aspect of preventive medicine is patient education and continuous medical education of the medical staff. Thus, the following characteristics were recorded: lectures to the soldiers, knowledge of the medical staff and the medical orderly, reserve army medical guidance, and the existence of updated medical references.
Weighting of the results
Each item was ranked and subranked according to its importance to the QA committee. Individual scores for each item were determined by consensus, and may be seen in the Supplementary data. The quality assessment of the clinic was arbitrarily scored according to an internal weighting system, where each component was weighted as a percentage of the total score, as follows: the medical record, 35%; inspection of the PCP, 20%; high-risk patient management, 15%; the medical services, 25%; and guidance, 5%. In addition, a separate mark was given to the physician, which included a score for the inspection and a score for the markers. Each physician was given a final mark and his or her achievements were calculated, also on a percentile of all military-physicians. The score for the inspection is expressed as such, as a percentile of military physicians, but also as a percentile related to the specific assessor team.
Every clinic in the IDF is evaluated once or twice a year, depending upon patient load. High volume clinics, where the total physician–patient interactions exceed 1000 per month, are evaluated twice a year. In order to avoid bias, the assessors’ teams were not kept aware of the results of the previous evaluations. The results are stored in a computerized data bank and analyzed using special software specifically designed for this project. After analysis of the results, two feedback reports are sent to the physicians and to the clinic managers, separately. The PCP receives the feedback from the inspection and from the tracers that were analyzed. The primary care clinic’s manager receives the whole quality assessment feedback. In addition, a yearly executive report is presented to the surgeon general command.
Statistical analysis
General Linear Models (SAS Institute Inc., Cary, NC) were used for analysis. Student’s t-tests were used to determine differences in scores by clinics. In addition, paired t-test analysis was used to evaluate the differences between first and second assessment of physicians. Stepwise logistic regression was performed when needed. A P-value of <0.05 was considered significant.
Results
During the period 1 January 2000 to 31 December 2001, 99 primary care clinics were evaluated. Fifty-five clinics (56%) were single-physician medical clinics (unit troop clinics) and 44 (44%) were multi-physician medical clinics (home-front clinics). One hundred and sixty-four PCPs were evaluated during this period: 52 (32%) worked in single-physician medical clinics and 112 (68%) worked in multi-physician medical clinics.
Table 1 depicts score differences by type of clinic (single-physician versus multi-physician clinics), evaluated using the implicit method (inspection). Scores ranged from 0 (lowest quality assessment) to 5 (highest quality assessment). In general, PCPs working in single-physician medical clinics scored significantly higher than PCPs working in multi-physician medical clinics in every single assessment criterion examined: medical history taking, physical examination, discussion, program, communication, assessor’s impression, and mean score (Table 1).
Table 1
.
Single-physician medical clinics
.
Multi-physician medical clinics
.
History taking 4.04 ± 0.009 3.52 ± 0.008 Physical examination 3.69 ± 0.011 3.09 ± 0.009 Discussion 4.01 ± 0.009 3.47 ± 0.009 Program 4.17 ± 0.007 3.54 ± 0.008 Communication 4.24 ± 0.008 3.75 ± 0.007 Impression 4.17 ± 0.007 3.66 ± 0.007 Mean score 4.05 ± 0.007 3.50 ± 0.007
.
Single-physician medical clinics
.
Multi-physician medical clinics
.
History taking 4.04 ± 0.009 3.52 ± 0.008 Physical examination 3.69 ± 0.011 3.09 ± 0.009 Discussion 4.01 ± 0.009 3.47 ± 0.009 Program 4.17 ± 0.007 3.54 ± 0.008 Communication 4.24 ± 0.008 3.75 ± 0.007 Impression 4.17 ± 0.007 3.66 ± 0.007 Mean score 4.05 ± 0.007 3.50 ± 0.007
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Table 1
.
Single-physician medical clinics
.
Multi-physician medical clinics
.
History taking 4.04 ± 0.009 3.52 ± 0.008 Physical examination 3.69 ± 0.011 3.09 ± 0.009 Discussion 4.01 ± 0.009 3.47 ± 0.009 Program 4.17 ± 0.007 3.54 ± 0.008 Communication 4.24 ± 0.008 3.75 ± 0.007 Impression 4.17 ± 0.007 3.66 ± 0.007 Mean score 4.05 ± 0.007 3.50 ± 0.007
.
Single-physician medical clinics
.
Multi-physician medical clinics
.
History taking 4.04 ± 0.009 3.52 ± 0.008 Physical examination 3.69 ± 0.011 3.09 ± 0.009 Discussion 4.01 ± 0.009 3.47 ± 0.009 Program 4.17 ± 0.007 3.54 ± 0.008 Communication 4.24 ± 0.008 3.75 ± 0.007 Impression 4.17 ± 0.007 3.66 ± 0.007 Mean score 4.05 ± 0.007 3.50 ± 0.007
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Table 2 depicts the score differences by type of clinic (single-physician versus multi-physician clinics), evaluated using the explicit method (markers of adequate medical evaluation and treatment). Scores ranged from 0 (lowest quality assessment) to 100 (highest quality assessment). The data shown in the table are the data obtained at the first assessment only. Multi-physician medical clinics scored higher than single-physician medical clinics in terms of high-risk patient surveillance, but not in terms of medical record assessment, complementary medical services, or guidance (Table 2).
Table 2
.
Single-physician medical clinics
.
Multi-physician medical clinics
.
P-value
.
Medical record assessment 79.22 ± 1.2 76.75 ± 1.01 NS High-risk patient surveillance 56.93 ± 2.24 71.67 ± 2.68 <0.008 Complementary medical services 86.72 ± 1.23 83.77 ± 1.01 NS Guidance 71.34 ± 2.3 72.9 ± 3.4 NS
.
Single-physician medical clinics
.
Multi-physician medical clinics
.
P-value
.
Medical record assessment 79.22 ± 1.2 76.75 ± 1.01 NS High-risk patient surveillance 56.93 ± 2.24 71.67 ± 2.68 <0.008 Complementary medical services 86.72 ± 1.23 83.77 ± 1.01 NS Guidance 71.34 ± 2.3 72.9 ± 3.4 NS
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Table 2
.
Single-physician medical clinics
.
Multi-physician medical clinics
.
P-value
.
Medical record assessment 79.22 ± 1.2 76.75 ± 1.01 NS High-risk patient surveillance 56.93 ± 2.24 71.67 ± 2.68 <0.008 Complementary medical services 86.72 ± 1.23 83.77 ± 1.01 NS Guidance 71.34 ± 2.3 72.9 ± 3.4 NS
.
Single-physician medical clinics
.
Multi-physician medical clinics
.
P-value
.
Medical record assessment 79.22 ± 1.2 76.75 ± 1.01 NS High-risk patient surveillance 56.93 ± 2.24 71.67 ± 2.68 <0.008 Complementary medical services 86.72 ± 1.23 83.77 ± 1.01 NS Guidance 71.34 ± 2.3 72.9 ± 3.4 NS
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Table 3 depicts score differences between the first and the second assessment, evaluated using the implicit method (inspection). Seventy-four PCPs (46%) were evaluated twice. In univariate analysis using paired t-tests, there was a significant improvement in mean scores of the PCPs in four out of the six fields studied. The improvement was significant in terms of discussion, program, communication, and impression. Although the scores were also higher at the second assessment in terms of history taking or physical examination, the difference between the two assessments was not statistically significant (Table 3). We used backward stepwise multiple regression analysis to study the effect of potential confounders (type of clinic, year of study, and assessor team) on the ‘improvement’ between the two assessments. It allowed us to confirm that a statistically significant improvement had indeed occurred in terms of discussion, program, communication, and impression, but not in terms of history taking or physical examination.
Table 3
.
First assessment
.
Second assessment
.
P-value
.
History taking 3.39 ± 0.09 3.61 ± 0.09 NS Physical examination 3.11 ± 0.11 3.24 ± 0.1 NS Discussion 3.29 ± 0.09 3.65 ± 0.08 <0.003 Program 3.33 ± 0.09 3.67 ± 0.08 <0.005 Communication 3.67 ± 0.08 3.99 ± 0.08 <0.004 Impression 3.48 ± 0.09 3.78 ± 0.08 <0.008
.
First assessment
.
Second assessment
.
P-value
.
History taking 3.39 ± 0.09 3.61 ± 0.09 NS Physical examination 3.11 ± 0.11 3.24 ± 0.1 NS Discussion 3.29 ± 0.09 3.65 ± 0.08 <0.003 Program 3.33 ± 0.09 3.67 ± 0.08 <0.005 Communication 3.67 ± 0.08 3.99 ± 0.08 <0.004 Impression 3.48 ± 0.09 3.78 ± 0.08 <0.008
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Table 3
.
First assessment
.
Second assessment
.
P-value
.
History taking 3.39 ± 0.09 3.61 ± 0.09 NS Physical examination 3.11 ± 0.11 3.24 ± 0.1 NS Discussion 3.29 ± 0.09 3.65 ± 0.08 <0.003 Program 3.33 ± 0.09 3.67 ± 0.08 <0.005 Communication 3.67 ± 0.08 3.99 ± 0.08 <0.004 Impression 3.48 ± 0.09 3.78 ± 0.08 <0.008
.
First assessment
.
Second assessment
.
P-value
.
History taking 3.39 ± 0.09 3.61 ± 0.09 NS Physical examination 3.11 ± 0.11 3.24 ± 0.1 NS Discussion 3.29 ± 0.09 3.65 ± 0.08 <0.003 Program 3.33 ± 0.09 3.67 ± 0.08 <0.005 Communication 3.67 ± 0.08 3.99 ± 0.08 <0.004 Impression 3.48 ± 0.09 3.78 ± 0.08 <0.008
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Table 4 depicts score differences between the first and the second assessment, evaluated using the explicit method. There were no statistically significant differences between the two assessments in terms of any of the parameters studied, i.e. medical record assessment, high-risk patient surveillance, complementary medical services, or guidance.
Table 4
.
First assessment
.
Second assessment
.
P-value
.
Medical record assessment 77.19 ± 2.39 75.66 ± 2.18 NS High-risk patient surveillance 53.26 ± 7.06 64.20 ± 5.67 NS Complementary medical services 84.54 ± 3.20 83.59 ± 2.11 NS Guidance 81.54 ± 6.97 83.81 ± 4.49 NS
.
First assessment
.
Second assessment
.
P-value
.
Medical record assessment 77.19 ± 2.39 75.66 ± 2.18 NS High-risk patient surveillance 53.26 ± 7.06 64.20 ± 5.67 NS Complementary medical services 84.54 ± 3.20 83.59 ± 2.11 NS Guidance 81.54 ± 6.97 83.81 ± 4.49 NS
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Table 4
.
First assessment
.
Second assessment
.
P-value
.
Medical record assessment 77.19 ± 2.39 75.66 ± 2.18 NS High-risk patient surveillance 53.26 ± 7.06 64.20 ± 5.67 NS Complementary medical services 84.54 ± 3.20 83.59 ± 2.11 NS Guidance 81.54 ± 6.97 83.81 ± 4.49 NS
.
First assessment
.
Second assessment
.
P-value
.
Medical record assessment 77.19 ± 2.39 75.66 ± 2.18 NS High-risk patient surveillance 53.26 ± 7.06 64.20 ± 5.67 NS Complementary medical services 84.54 ± 3.20 83.59 ± 2.11 NS Guidance 81.54 ± 6.97 83.81 ± 4.49 NS
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Discussion
Our first aim was to describe the mechanisms of QA in the primary care clinics of the IDF. We showed that such a QA program was feasible in a military setting, geographically distributed over a whole country, despite operational constraints.
The results of this study supported our hypothesis that the quality of primary care provided in single-physician medical clinics, such as is found in troop clinics, was higher than that provided in multiple-physician medical clinics, such as in home-front base clinics. This was true in terms of most of the parameters studied, except for high-risk patient evaluation, which scored better in multi-physician than single-physician medical clinics. We speculate that the reasons for this finding are multiple. It might be that the IDF primary care physicians are medical officers who graduate from a medical school, an officer academy, and a military medical academy. They are then sent to unit troops clinics for periods of 12–18 months. In contrast, PCPs serving in home-front bases, where several PCPs work in the same clinic, are more likely to be civilian physicians hired by the IDF or military reserve physicians. Thus, the degree of motivation and identification with the organization goals and values may be different between these groups, and thus may render quality of medical care uneven. Another potential reason is that the setting of a field unit is similar to that of a small community, in which the PCP is familiar with the population and in terms of military medicine, with the tasks of the unit as well; thus, it helps the PCP to perceive his/her role as a ‘family’ practitioner and assures continuity of care by the same physician. Moreover, since a unit troop clinic serves a smaller population than that of a home-front clinic, the patient load, a parameter that may affect quality, is respectively lower, and thus the measured quality of primary care is higher. A similar finding was made by Campbell and colleagues [9], who stratified a random sample of 60 general practices in six areas of England and identified factors associated with high quality care. They found a significant association between size of practice and quality of care. Smaller practices scored better than larger ones for access to care, but for diabetes care larger practices had higher scores than smaller ones. The authors concluded that no single type of practice has a monopoly on high quality care; different types of practice may have different strengths. In our study, an analogy to Campbell’s statement was that only a single parameter (high-risk patient surveillance) scored higher in larger practices than in smaller ones.
The QA program that we described was effective in that it improved primary care per physician examined in nearly all aspects of the assessment. We believe that the improvement was true in nature, and did not reflect only the experience of the PCP in ‘passing’ the inspection. Indeed, while the part of the assessment under direct inspection may be influenced by the previous experience of the physician assessed, the part of the assessment that relates to the quality of the chart evaluates continuous care rendered while the physician is not under investigation. Similar positive impact of QA programs, leading to improvement of care as judged from improved outcomes or processes, has been demonstrated in various settings, such as the emergency department [10], the hematology/oncology day unit [11], among pneumonia patients in very small hospitals [12], or in hemodialysis units [13].
There are several possible limitations to our study. Firstly, we conducted it in a military setting. Although the nature of medicine is at times similar in civil clinics and in military clinics, some characteristics of military medicine are unique [5–7], thus the interaction between the PCP and the patient may be different. A study comparing this QA program between military and civil clinics has not yet been conducted. Such a study may be useful in determining this system’s capabilities and may offer a standardized tool for the assessment of quality of care in primary care clinics. Secondly, we evaluated PCPs over a limited period of 2 years, and the long-term impact of our QA program cannot be evaluated at this point in time. Furthermore, the financial cost/benefit aspects of this QA program have not been calculated. In a country such as Israel, such a QA program is feasible for several reasons: (i) the physician-per-capita ratio is one of the highest in the world [14]; and (ii) there is mandatory conscription of the whole population, with continued military periods for physicians until 45–51 years of age. In contrast, such a program may be prohibitive in countries with a lower physician density, or whose army physicians are only hired.
When placed into the general context of the recently published recommendations of the Committee on Quality of Care in America (CQCA) (of the Institute of Medicine for quality of medical care improvement [15,16]), our program addressed many, but not all of the issues raised there. The CQCA defined six major aims for the 21st century health care system, and recommended that it be ‘safe, effective, patient-centered, timely, efficient, and equitable’. In terms of safety, our QA program verified that appropriate records be kept, and appropriate steps be taken for several specific tracers. The program was not primarily designed to assess effectiveness, in that mortality or specific morbidities were not measured, while the major aim of the program was to assess the process of rendering care rather than outcomes. The program examined specific aspects of patient-centered care, as it may be noted that all variables studied were done so for the benefit of the patient, and did not address whether it would be to the benefit of the IDF. Timeliness was studied in terms of physician availability, availability of specialists and waiting time at the clinic. In terms of efficiency of care, aspects such as appropriate use of specialists’ services and in-patient services were examined. And finally, a major variable examined in this report, i.e. variability of quality of care by geographic location, was a measure of the equitable nature of care in the IDF.
In conclusion, this study confirms that a wide variation in the quality of care exists in IDF general practice. The study also allowed us to confirm that evaluation of primary care clinics and primary care physicians is feasible, and leads to an improvement in the quality of primary care in the military setting. We believe that our program should help us to meet a major challenge raised by the CQCA, i.e. the incorporation of performance and outcome measurements for improvement and accountability.
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International Journal for Quality in Health Care vol. 16 no. 2 © International Society for Quality in Health Care and Oxford University Press 2004; all rights reserved
