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INTRODUCTION

QA [quality assurance] used to be completely reactive, with incident reports. There would be a review to determine injury or no injury. QA is more real-time now, not so reactive. But we don't have a full system in place. It's evolving. … It's not cross-functional yet. Usually, I take the nurses and the chief of the service takes the physicians. There is finger-pointing.

Even when problems are systemic and collective in nature, performance measurement systems often assign accountability to individual functions. Classical organizational theorists James March and Herbert Simon found that this kind of functional accountability encourages people to "subgoal optimize"—to focus on optimizing the outcomes of their own jobs, even at the expense of the larger goal. Indeed, this is a common flaw of bureaucratic organizations. But there are better ways to measure performance. In particular, shared forms of accountability encourage people to adopt a broader systems perspective and to focus on achieving goals that transcend their own individual function.87

The purpose of quality improvement programs is to identify the faulty systems and processes that underlie errors and to set up cross-functional teams to recommend process improvements that can prevent the occurrence of errors in the first place. These changes in performance measurement are expected to improve coordination among workers by creating a sense of shared accountability for outcomes, thereby encouraging a move away from finger-pointing toward problem solving.88 Approaches to performance measurement that focus on problem solving have been found to preserve and strengthen working relationships, whereas the reactive assignment of blame has been found to promote silo mentalities.89 A shared approach to performance measurement is particularly important when tasks are part of a highly interdependent work process, as they are in healthcare.90

Healthcare organizations typically use two different kinds of performance measurement systems: quality assurance for monitoring the quality of care and utilization review for monitoring the efficiency of resource utilization. The central task of quality assurance and utilization review is to identify errors after the fact and assign accountability for those errors. Quality assurance often is tied organizationally to the legal department, or risk management, where malpractice issues are addressed. Quality assurance committees typically are established separately for the physicians and for other hospital personnel and conducted along the lines of professional peer review. Incident reports are reviewed by the quality assurance committee, which hears the evidence and determines whether an injury has occurred and then determines which party was responsible for the injury.

Utilization review departments are staffed with nurses specially trained to review medical records for unnecessary admissions, excessive lengths of stay, and unnecessary tests or procedures. Excess utilization typically is defined through comparison to clinical protocols developed internally by clinicians or externally by clinicians working for payers and consultants, which are intended to represent an acceptable standard of care, adjusted for the severity of a patient's condition. Utilization review nurses ...

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