2

Determining What to Monitor

30 AN INTRODUCTION TO QUALITY ASSURANCE IN HEALTH CARE

I
shall deal with my first subject, which is determining or finding what
to monitor, by going through a series of logical steps toward making
that determination.

Externally Required Monitoring Activities

Quite often, and increasingly so, certain monitoring activities are required
by governmental agencies that provide care, directly or indirectly; pay for
it; and assume responsibility for its quality. When private insurance is
available, the insurers themselves may require certain kinds of monitoring
to control the cost of care and possibly also to supervise its quality. It is
obvious that any monitoring system will find it necessary to comply with
such requirements. But, in my opinion, the more important and mean-
ingful activities are those that the providers of care establish and carry out
themselves as part of their own responsibility to provide good care.

Internally Motivated Monitoring Activities

It is the purpose of all monitoring activities to identify instances or situ-

ations where the quality of care falls below the level expected or desired.
These pose a "problem" to be solved. Some have wished, rather, to focus
not on "problems" but on so-called "opportunities for improvement." Pos-
sibly the difference is more a matter of words than of realities; or this
phrase could represent a meaningful difference in orientation. In the first
instance we could be saying: "We are not doing well; we should correct
our errors." In the second instance we could be saying: "We are doing
well, but could we be doing better?" I shall leave it to the reader to decide
if the difference is important or not. As I proceed, I shall deal with both
problems and opportunities, but most of the time I shall use "problems"
to stand for both.
I conceive of problem identification to be of two kinds. The first I
shall call troubleshooting, a popular American expression to denote action
Determining What to Monitor 31

in response to a clear problem by someone qualified to solve it. In this

case the problem imposes itself; it finds us.
The second approach to identifying problems or opportunities for
improvement I shall call planned reconnaissance. This means that we take
action to find such problems and opportunities that we did not know
about or we only suspected but needed to confirm and document.

Troubleshooting
Troubleshooting is the action taken by clinicians or administrators
when a problem is presented to them by some untoward event. Things
go wrong; people complain; there are unpleasant, even tragic, events.
When a seemingly healthy person unexpectedly dies or the wrong limb
is amputated, the problem arrives at our doorstep unsolicited. But to en-
courage the reporting of other, less notable adverse events, it is important
to establish an environment conducive to reporting.
To create such an environment, we should be prepared to ask ques-
tions, and when told we should be willing to listen. The reporting of
problems, whether solicited or unsolicited, should never be met with im-
mediate denial, displeasure, anger, argumentation, accusation, retaliation,
or punishment. One should listen, explain if there has been only a mis-
understanding, or promise to investigate when this seems justified. I be-
lieve it would be helpful to ask the bearer of the report his or her view
of how the problem may have arisen and how it might have been pre-
vented. When possible and appropriate, the person reporting could be
invited to participate in the investigation that follows. At the very least,
those who have made a report should be informed of what the subsequent
investigation has revealed and what corrective action has been taken. If
this procedure is ignored, reports and suggestions will simply cease, even
as dissatisfaction and apathy persist and grow.
When adverse events are reported, there is pressure to deal with each
event as it arises. But it is important, at the same time, to try to understand
the more general significance of discrete events. One should look for the
possible presence of a "mechanism" that may underlie a series of events,
and if so, aim to deal with that root cause.
32 AN INTRODUCTION TO QUALITY ASSURANCE IN HEALTH CARE

Planned Reconnaissance
I have already defined planned reconnaissance as action taken to reveal
problems or opportunities for improvement. In this case, we take the
initiative to find the problems or opportunities. The kinds of action we
might take can be classified as problem identification (1) by group dis-
cussion and study, and (2) by routine surveillance.

Problem identification by group discussion and study. Small

groups of health-care professionals, joined perhaps by administrators and
other support personnel, can meet to review the work of a department or
unit and to suggest ways that may improve performance. Such groups
have been called "quality circles" or "quality improvement teams," or
given other names as the fashion of the times dictates.
A quality circle was intended by Ishikawa,10 the originator of this
social device, to be a rather small group of not more than ten workers,
all in the same workshop, who meet voluntarily at least twice a month,
under a leader whom they themselves elect, to study the principles and
methods of quality monitoring in general, and to engage in quality control
activities specific to their own work. These activities include identifying
problems of quality, understanding their causes, proposing and imple-
menting corrective action, and evaluating the results of such action.
Although the activities of each group are limited to a small unit in
the organization and are ostensibly voluntary, the activities of the several
quality circles in an organization are promoted, supported, and coordi-
nated by the quality assurance directorate of that organization. Moreover,
the quality circles in any one organization interact with the quality circles
in other similar organizations through a national organization of quality
circles and its regional branches. Thus, quality circles assume the char-
acter of a movement whose purpose is to enhance the self-image and
status of line workers through their involvement in quality improvement
activities.
Because this model was developed for industrial settings, such as
factories, its applicability to the health-care system might be questioned,
unless the model is significantly modified. Perhaps for that reason, or out
Determining What to Monitor 33

of a lack of vision, I know of no instances of the model's thoroughgoing

application to health care. Nowadays, almost any group that undertakes
quality improvement activities, even if it does not comply to the original
model, can be called a "quality circle" or some other corresponding name.

Routine surveillance. The second form of planned reconnaissance

can be called routine surveillance, a category that includes two subdivi-
sions: opinion surveys and performance monitoring.
Opinion surveys are an established method of social research. There
could be surveys of the opinions of patients, other clients, practitioners,
managers, and anyone else who can contribute to an understanding of
how a health-care system has performed. Surveys may be conducted by
telephone, mail, or personal interview, using highly structured or loosely
structured questionnaires. The former asks for answers to specific ques-
tions by providing spaces which a respondent checks. The latter allows
opportunities for the respondents to describe their thoughts or experi-
ences. The survey can be conducted at home or during a visit to a health-
care facility; and it can pertain to different periods in the course of the
care received. However it is conducted, the design and interpretation of
a survey, if it is to be free of error and bias, requires advice and direction
from a qualified social scientist.
As to performance monitoring, the second category subsumed by
planned reconnaissance, it is perhaps useful to think of it as taking one
of two forms: "clinical or anecdotal" or "statistical or epidemiological."
Clinical or anecdotal monitoring takes the form of case reviews such
as clinical audits. One example would be the review of medical charts by
a group of physicians in order to see if the care, as recorded, has been
acceptable or, in some respects, could have been improved.
The other form of performance monitoring, the form I have called
"statistical or epidemiological," envisages a flow of information regarding
critical activities and significant outcomes of care, so that unusual patterns
can be detected and studied.

The "tracer method" as an example of planned reconnais-

sance. The tracer method begins with an assumption that the quality of
34 AN INTRODUCTION TO QUALITY ASSURANCE IN HEALTH CARE

a bundle of related clinical activities can be represented by one activity

in the bundle or, at most, by a very small number. If this is true, one can
select one tracer, or a few, to represent the entire category they belong
to. For example, one could select screening for visual defects in children
to represent the entire category of screening activities in children. Simi-
larly, immunization against measles, for example, could stand for all im-
munizations. And in adults, screening for breast cancer in women and
for prostate cancer in men could stand for case-finding as a whole.11
In order to use this presumption to map the quality of care in a
larger context, one would need, as a first step, to construct a matrix, or
map of the terrain to be explored. In the above-mentioned examples, I
have assumed that care could be divided into preventive and therapeutic,
into care for children and adults, and, among adults, into care for males
and females. This illustration of mapping is, of course, only an example.
The "terrain of care," if one can use the term, can be mapped in a large
variety of ways, depending on what precisely the objectives of monitoring
are. I shall now offer a more fully developed application of the tracer
method.
We shall assume that our object is to monitor the quality of care in
the emergency service of a hospital. If so, one might begin by visualizing
what activities go on in such a setting, perhaps by constructing a diagram
that represents the flow of these activities. Such a diagram, offered merely
as an illustration, is shown in Figure 2.1.
The figure is constructed by assuming that patients come to the
emergency service in one of two ways: by walking in or by ambulance.
For simplicity, I shall follow the progress of the walk-in patient. First,
there is a sorting process (or triage) that separates out patients who need
immediate stabilization (which is carried out) and those who do not. This
is the first phase. In the second phase, a diagnosis is made and interim
treatment started accordingly. In Phase III, after the patient's progress has
been observed, more definitive (basic) treatment decisions are made; and
subsequently, in Phase IV, a decision is made as to whether the patient
is discharged or, alternatively, referred to one of the facilities shown in
the figure.
Having constructed such a flow-diagram one can begin to consider
Figure 2.1. One possible representation of the progression of care in a hos-
pital's emergency unit. (From Rhee, K. J., Donabedian, A., and Burney,
R. E., "Assessing the Quality of Care in a Hospital Emergency Unit: A
Framework and its Application," Quality Review Bulletin, January, 1987.)

35
36 AN INTRODUCTION TO QUALITY ASSURANCE IN HEALTH CARE

what the objectives of care are at each phase of a patient's progression

and, in general, throughout all phases. In Table 2.1 there is an illustrative
listing of such objectives. These are used to indicate the basic aspects of
care that should be considered in making a judgment about quality.
In Table 2.2 one finds an illustration of one possible tracer matrix;
many other mappings are possible. In this partial mapping, the stub of
the table shows the "phases" in the flow of patients, as well as the activities
during each phase, as already described. The headings of the table specify
aspects of care as "physical-physiological," "psychological," and "social-
environmental." Let me again emphasize that many other headings could
have been devised.
The intersection of the categories in the stub of the table with those
in the headings creates a matrix of 24 cells. Now we can select in each
of the cells a tracer or tracers that are important on their own account
and moreover are thought to represent other conditions in that cell.
The next step could be to select cases that fall in any one of the
cells of the matrix, and, based on a review of the patients' medical records,
by direct observation, or in some other way, we can obtain information
about what was done, how promptly, and with what results, using the

Table 2.1. Possible Objectives of a Hospital Emergency Unit

1. Expeditiousness, timeliness, and duration of care.
2. Appropriateness of diagnostic and therapeutic interventions as judged by the greatest
net benefit at the lowest cost.
3. The validity of diagnostic decisions.
4. Skill in the execution of diagnostic and therapeutic interventions.
5. Reliability and validity of diagnostic information and monitoring data.
6. Appropriateness of referral.
7. Maintenance of continuity-in-care through linkage and transfer of adequate information
to a more stable source of care.
8. Appropriate recording and management of information.
9. Patient education and motivation with a view to prevention.
10. Discharge of legitimate organizational and social obligations with due regard to respon-
sibilities toward individual patients.
From Rhee, K. J., Donabedian, A., and Burney, R. E., "Assessing the quality of care in a hospital emer-
gency unit: a framework and its application." Quality Review Bulletin, January, 1987.
 Table 2.2. An Illustrative Tracer Matrix for Assessing the Quality of Care in a Hospital Emergency Unit
Aspects of Illness, Health and Health Care
Phases and Components of the
Process of Care Physical-Physiological Psychological Social, Environmental
Phase I: Sorting and stabilization Cardiac arrest, multiple trauma Acute behavioral disturbance Acute behavioral disturbance
Phase II: Diagnosis and interim
management
Interim treatment Cardiac arrest, multiple trauma Acute behavioral disturbance Acute behavioral disturbance
Diagnosis Chest pain, abdominal pain, muscu- Depression, acute psychosis, Child abuse, bronchial
loskeletal pain, sick child bronchial asthma asthma
Phase III: Basic treatment
decisions
Therapeutic Bronchial asthma, poisoning, upper Bronchial asthma, poisoning Bronchial asthma, rape,
respiratory, infections, lacerations assault
Preventive Poisoning, foreign body, hypertension Poisoning, foreign body, Poisoning, foreign body, bron-
bronchial asthma chial asthma, child
abuse, spouse abuse
Phase IV: Completion of
disposition
Referral-linkage Any of the above, specified illness Any of the above vulnerable Any of the above, vulnerable
among vulnerable population population groups population groups, sub-
groups (e.g., aged, poor, isolated) stance abuse
Societal functions Reportable infections, conditions re- Cases requiring commitment Child abuse, spouse abuse,
quiring genetic counseling, acts rape, assault, suicide
of violence, motor vehicle acci-
dents
Information management Any of the above Any of the above Any of the above
From Rhee, Donabedian, and Burney, Quality Review Bulletin, January 1987.
38 AN INTRODUCTION TO QUALITY ASSURANCE IN HEALTH CARE

objectives of care listed in Table 2.1 as a guide. Clearly, to explore the

entire matrix as depicted would be a horrendous task. I know of no in-
stance of such a complete exploration. What is more likely to be done is
to select only a few conditions to begin with and perhaps at some later
date to select a few others. The task of selection is made easier by ob-
serving that some conditions appear in several of the cells of the matrix
and, therefore, can cast light on more than one aspect of emergency care.
But even then, one needs to know what is more important and what is
less, the more important being a candidate for immediate attention and
the less important postponed. To this pressing subject of importance rat-
ing we must now turn.