"In order to fashion an integrated approach, the BPHC is committed to a single set of performance measures that integrates measurements important for the health care industry with measurements that are essential to document improvements in health status of the underserved."

--BPHC Improvement Collaborative RFP, April 1998

"There are only two things in life you can count on: death and taxes." So goes the saying. But for primary care centers, there’s another: Performance measures.

Unfortunately, this whole discussion is bedeviled by varying usage of some of the key terms. The purists insist on very specific definitions of the terms "structure", "process", and "outcome". For them, performance measures are the same as process measures. See Chapter 4 "What is HEDIS?" in "Clinician Skills for Managed Care" for a discussion using that approach. But in this discussion we are referring to a broad set of requirements imposed on primary care centers by outside agencies. Some of these are "structural," requiring the presence of certain staffing, facilities, committees and systems. Some of them are clinical quality indicators.

These external requirements fall into two broad categories:

• Those that are comprehensive, dealing with the overall primary care program such as are found in the PCER, the JCAHO accreditation, and the HEDIS (the Health Plan Employer Data Information Set, applied to managed care companies seeking NCQA accreditation). The PCER and the JCAHO accreditation process are discussed in detail below.
• Those related to categorical health programs such as Family Planning, EPSDT, Black Lung and School-based Health. These measures are often in the form of audit checklists to determine if the various required elements of the service have been completed and recorded on the proper form. A compilation of these is presented in Table 2.1.

A major challenge for primary care centers is how to integrate these external requirements into the internal QI life of the organization. We can and should make these measures work for us. If we treat them simply as bureaucratic busywork to be sent in, filed, and forgotten, we are missing an important opportunity. They are mostly well chosen and right on target with respect to important clinical and administrative issues.

Management teams and QI committees should review the sets of performance measures that apply to them and adjust both the Quality Improvement Policy and the Annual Plan accordingly. The Policy should include the quality improvement structure and processes as well as the specific audits required by the relevant external measures.

The Annual Plan should include objectives related to establishing certain policies, procedures or systems of care to meet the external performance standards. For example, if a performance measure is the provision of certain adult preventive health screening, and the health center is not satisfied that it has a medical record form that collects the needed information easily, the Annual Plan could include an objective for a team or person to develop a screening instrument that will facilitate compliance with the measure, and an objective for the QA/QI Committee to audit this indicator.

Comprehensive Measures

JCAHO Accreditation

Given the direction of the Bureau regarding accreditation and given the potential competitive benefits, health centers may want to consider aligning their quality program with the JCAHO standards even if accreditation is not sought immediately. The quality improvement sections of the JCAHO accreditation process for ambulatory care focus almost exclusively on process and structural standards and are consistent with sound management practices. JCAHO standards do not include specific clinical outcome measures (e.g. percent of patients with cardiovascular risk assessments), such as are included in the PCER, although the health center’s QI process will include setting or identifying appropriate specific performance standards. On the other hand, the JCAHO standards are explicit and demanding regarding the administrative systems and processes that must be in place and operational. The JCAHO 1996 Accreditation Manual for Ambulatory Care-Standards Section covers quality improvement in the sections dealing with Organizational Performance and Leadership and call for the following systems and processes related to quality improvement:

• A plan in place for process design, performance assessment and improvement;
• Explicitly described processes of care to assure that standards are met;
• Measurement of processes of care is carried out systematically;
• Conclusions are drawn about the measurement of performance; and
• Systematic improvement of performance and a clear record of improvements.

The standards also require evidence that certain leadership responsibilities are carried out related to quality improvement including:

• An organizational plan is developed and communicated throughout;
• A planning process that includes setting performance improvement priorities;
• An annual budget is prepared and budget performance is monitored;
• There is a process for monitoring variations in patient care;
• A program exists for recruitment and developing and educating staff;
• There is a process for credentialing and authorizing professionals to perform specific procedures and services;
• Make formal arrangements for needed services not provided by the organization; and
• Promote cooperation and communication throughout the organization.

Primary Care Effectiveness Review (PCER)

The clinical section of the PCER is actually much more specific in its requirements for health centers than the JCAHO standards. It also includes administrative requirements but, in addition, requires specific tracking processes and, of course, detailed clinical outcome measures. The PCER reflects the fact that the BPCH has set specific clinical outcomes for the various life cycles for health center users and has specific population-based objectives such as the improvement of immunization and HIV case finding rates. JCAHO, on the other hand, is focused almost entirely on the process of care for the individual patient and the organizational structure within which that care is provided and leaves it to the practice to set any specific clinical objectives.

The PCER quality requirements are more easily understood if they are organized into the three types of quality measures: Organizational, Process and Clinical Outcomes. (Note that this is not how they are organized in the Bureau’s protocol.)

Organizational Measures:

• Services, hours, and staffing meet program requirements;
• There is a Health Care Plan, that is comprehensive in that it deals with all lifecycles and with community health needs, and that is monitored by the quality management program of the center.
• There is committee that is charged with implementing the quality management program and functions according to a relatively formal structure and there is a record of its work and decisions;
• The organization has established functioning workgroups or teams that carry out work, that meet regularly to set objectives and evaluate progress, that coordinate with management and each other, and that have both an external and internal customer focus;
• Formal linkages or arrangements with outside resources and referral services; and
• Organizational and policy standards are met for ancillary services including pharmacy, radiology, laboratory, dental and hospital care.

Process Measures:

• A credentialing process that meets FTCA requirements;
• A patient complaint procedure is in place;
• Patient Tracking and Recall systems for over 20 different clinical situations;
• Preventive health schedules and strategies for the five life cycles and oral health, immunizations, violence and abuse, TB, HIV and other STD screening and treatment;
• Clinical protocols are in place for certain chronic and acute diseases;
• Medical Record format and use meets detailed standards; and

• A professional orientation and continuing education program is ongoing that covers specified topics and access to needed clinical information by center providers is assured.

Outcome Measures:

• Waiting time;
• Clinical Outcome Measures are evaluated for the five lifecycles -- perinatal, pediatric, adolescent, adult, and geriatric; and
• Reports on the performance of the tracking systems.

Categorical Measures

The quality measures for categorical health service programs are usually embodied in checklists used either by outside or in-house auditors who review a portion of the charts of patients who have received the categorical health service. Family planning, EPSDT, Breast and Cervical Cancer Screening are examples of programs using such audit checklists. The health centers face a challenge in meeting the service requirements of all these preventive health programs while integrating them into a seamless system of comprehensive primary care services. Each program has special requirements in the following categories: patient assessment including medical history, testing and physical exams; health education and/or anticipatory guidance; follow-up on identified problems; and record keeping. The challenge presented by these requirements can be met by creating a simple system of care. Although the System of Care model is discussed more fully in Chapter 3, for categorical programs the process of establishing a system that meets the standards efficiently and with high patient satisfaction involves the following five steps:

• Management creates a Team (e.g., the Family Planning Redesign Team) that includes staff involved with providing the services from providers to front desk people and gives the team a "charge" (objective), a deadline, and provides time and resources for the team work;
• The Team reviews the program performance standards and evaluates the present health center process for providing the service, using flow charts, etc., and identifies problems and opportunities for improvement;
• The Team designs a process to meet the standards and satisfy patients (should address delegation of tasks, staff training needed, forms and other tools needed);
• The new process is given a trial run, evaluated by objective and subjective means, and modified as needed;
• Redesigned process put into service and the Team meets periodically to assess performance.

Table 2.1 presented here lists the various sets of performance measures related to categorical programs. Specific requirements and formats for these reports can and should be obtained from the specific funding agencies.

Table 2.1

Quality Improvement/Assurance Requirements for Primary Care Centers

A Glimpse of the Future

As indicated by the quote at the start of this chapter, the leadership of the federal Bureau of Primary Health Care (BPHC) is grappling with how to develop and deploy a single set of performance measures and how to teach the best available quality improvement practices and tools to help health centers survive. Toward these ends they are investing in at least two major quality strategies:

1. The merger of the Bureau’s PCER with a national accreditation process (JCAHO) as a way to provide health centers with additional standing or credibility with managed care companies and consumers; and
2. Providing assistance to clusters or networks of health centers in developing systems of care (reengineering) to enable them to meet important clinical objectives and improve their competitive position.

"Breakthrough Collaboratives" are one form of this re-engineering approach. The purpose of the "Breakthrough Collaboratives" is for groups of health centers to work together to radically change the process by which certain care is provided to achieve dramatic improvements in patient satisfaction and clinical performance. Breakthrough Collaboratives have been launched to address diabetic care and to redesign the patient visit for the purpose of dramatically reducing waiting time. Others are envisioned for infant mortality, adult and pediatric immunizations, cardiovascular disease, HIV, and cancer prevention.

The Breakthrough Collaboratives are organized by the Quality Center of the BPHC with technical assistance from the Institute for Healthcare Improvement of Boston. Implicit in this initiative is that the Bureau has concluded that significant improvements in health center services require substantial effort in designing and implementing new processes of care (involving more delegation, systematic approaches to assessment and patient education, and appropriate use of new technologies.) Furthermore, such efforts require central support and technical assistance and the sharing of experience and insights among several centers. We would say they are identifying and redesigning key processes and fitting them together to form systems of care (SOCs). Chapter 3 presents this SOC approach in detail.

Go to Chapter 3