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As physical therapists, we have an obligation to understand quality assurance and our role in it,
and to recognize that objective self-determination is a necessary extension of our service as
professionals. A functional quality assurance system can improve the physical therapy manager
and practitioner as well as improve physical therapy care.

A review of structure is an assessment of organization, staffing and staff qualifications, rules and
policies governing professional work, records, equipment, and physical facilities. The assessment
may include a judgment of the adequacy as well as the presence of the element of structure being

Process assessment is based on the degree or extent to which the physical therapist conforms to
accepted professional practices in providing services. The various approaches to care, their
application, efficacy, adequacy, and timeliness are considered. A process review requires that
considerable attention be given to developing and specifying the standards to be used in the

Outcome assessment is based on the condition of the patient at the conclusion of care relation to
the goals treatment. Assessment outcomes provide a means of reviewing the practitioner, the
services, and events which led to the results of care. The results of outcome assessment ultimately
may lead to the evaluation of the basic treatment procedures and modalities of the physical
therapy and validation of the approaches to patient care. Outcomes are the ultimate manifestations
of effectiveness and quality of care.


As early as 1863, Florence Nightingale proposed a system for collecting hospital statistics. She
realized that the availability of such information could make it possible to systematically improve
hospital treatment. Her efforts to implement a widespread system for collecting data were only
partially successful.

Shortly after World War I, Ernest Codman made a major effort to encourage his fellow
physicians to analyze the ³end results´ of their activities in order to determine their strong and
weak points and to use this analysis direct their care of patients. Codman believed that physicians
should provide care to only those patients for whom they cared well, and that they should avoid
providing care to those patients for whose care they were not qualified. Codman¶s efforts to
encourage his colleagues to adopt his method of ³end result´ analysis were unsuccessful.

In 1952, the Joint Commission on Accreditation of Hospitals (JCAH) was established to take over
the standard setting function from the American College of Surgeons. The standards established
by the JCAH were also directed to minimal achievement of environmental requirements.

During the period from the mid-1950s into the early 1970s, America entered the ³Age of
Consumerism´. The public gradually demanded a more active role in guiding its destiny and
protecting its future. It was inevitable that public attention and skepticism relating to expert
opinion and authority would also focus in on health care. Aided by the ever increasing media
coverage of health care events and accomplishments, the public became better informed about the
capabilities and the problems of modern medicine and the health care industry.

In 1965, the courts held that a hospital was responsible for the quality of care rendered by a
member of the medical staff. The landmark Darling V. Charleston Community Memorial
Hospital case uprooted the time honored charitable immunity that had been granted to hospitals.
The 1965 Medicare legislation set out the conditions of participation for health care providers in
federally funded programs. The conditions incorporated many structure and process elements.
One of the conditions was utilization review, the objective of which was to assure that the level of
hospital care was medically necessary and that the quality of care met the expectations of the
medical staff. The focus at that time was less on the cost of health care and more on the purchase
of health care services that were appropriate, timely and adequate.

In 1967, government began to realize that the cost of the federally funded health care programs
was exceeding earlier estimates. So, stricter utilization review requirements
Were established that were also applied to the Medicaid program. At this point, many health care
professionals began questioning government¶s intent in the implementation of programs proposed
to measure the quality of care.

By the early 1970s, it had become apparent that the revised utilization review requirements were
not totally successful in meeting the objective of controlling costs or in measuring the quality of
care. The Congress of the United States responded to this state of affairs in 1972 through passage
of the Bennett Amendment to Title VI of the Social Security Act. This amendment provided for
the establishment of Professional Standards Review Organizations (PSROs), which were to
review and exercise greater control over the costs and the quality of care for patients covered
under federal programs: Medicare, Medicaid, Maternal and Child Health and Crippled Childrens
programs. This legislation also provided for the review of non-physician health care services and
for local review, in the sense that health professionals who provide a specific service are to be
involved in reviewing that service. The legislation specifically mentioned physical therapy as on
of the examples of the non-physician services that should be involved.

In 1971, the JCAH revised its hospital standards and directed increased emphasis on quality
maintenance activity. Various quality review mechanisms were in use at this time, and many of
these mechanisms had been stimulated by the Medicare Law which required medical evaluation.

These quality review mechanisms suffered additional shortcomings. Some mechanisms consisted
of a subjective, unsystematic review of small numbers of randomly selected patient charts, in
which one physician reviewed one patient chart at a time using his own implicit criteria. Validity
and reliability were suspect in almost all the quality review mechanisms, and not until recently
was there any systematic programmed action to correct problems unless the problems were so
gross that the need for correction was readily apparent.

Taken together, these shortcomings in the quality review mechanisms prompted the development
of the Performance Evaluation Procedure (PEP) by the JCAH. The PEP provided a structured
mechanism by which the effects of actual performance could be assessed. Designed primarily to
assess care provided by the physician, the PEP required modification to meet the needs of
physical therapists who wished to use the method.

Early in the 1970s, the Board of Directors of the American Physical Therapy Association (APTA)
adopted standards for physical therapy services and standards for the physical therapy
practitioner. These standards were subsequently updated, adopted by the APTA¶s House of
Delegates in 1975, and last revised in 1980. The APTA has defined these standards as, V 


 , the APTA states, V 


The early development of the APTA¶s standards documents created a basis for the establishment
of guidelines for developing a system of peer review, adopted by the House of Delegates in 1975.
The system of peer review addressed in these guidelines is voluntary, educative, and nonpunitive
and includes assessment of structure, process, and outcome.
While APTA was developing its standards and peer review documents, some individual physical
therapists were actively developing methods of patient care.

The two major forces that are influencing quality assurance development in the United States
today are the Joint Commission on Accreditation of Hospitals (JCAH), a voluntary but quasi-
public accrediting agency, and the federally mandated Professional Standards Review
Organizations (PSROs).

In April 1979, the JCAH revised its quality assurance standard for hospital accreditation. This
revision stimulated feverish activity by hospitals to understand the new quality assurance standard
and to assure compliance with it. The standard states:






The V

  addresses the hospital as a whole. This part of the
standard requires a written, fully integrated quality assurance program that ultimately reports
quality assurance results to the Board of Trustees of the hospital. The physical therapy quality
assurance program must be an integral part of this whole program.

The JCAH dropped its requirements that a certain number of reviews (medical audits) be done
annually per hospital, but this does not affect the frequency of physical therapy service reviews.
Standard I of the section on Rehabilitation Services/Programs in the JCAH Accreditation Manual
requires a quarterly review of physical therapy services.

In physical therapy, as specified under Standard I of the section on Rehabilitation

Services/Programs in the JCAH Accreditation Manual, the reviews must be conducted with pre-
determined criteria and demonstrate input from an appropriate physician group.

The use of the words V 

  in the JCAH quality
assurance standard is not fully explained by JCAH. The implication is clearly one that points
toward important patient related problems and activities that have significant potential to improve
the quality of patient care.

The last part of the standard requires the correction of any problems identified by the quality
assurance program. Planning is underway to revise this Standard in the 1983 Accreditation
Manual for Hospitals.

In the last few years, the PSROs began to focus their quality assurance reviews on identifying and
solving problems, and on using a variety of methods for identifying, analyzing, and solving these
problems. The new wave of PSRO reviews relies on analysis of accurate and up-to-date data
bases. The previous health practitioner apathy or resistance in some cases has begun to turn to
active support for theses activities.

The Social Security Act, as amended in 1972, requires that physicians and hospitals that choose
to participate in the Medicare or Medicaid programs comply with three obligations:

1.p To order or furnish only care that us medically necessary

2.p To furnish care that meets professionally recognized standards of quality
3.p To provide such documentation of the medical necessity and quality of care provided as
the PSRO may reasonably require
The PSRO requirements for medical care evaluation are in a state of change.

The Health Care Financing Administration (HCFA) acting on reports submitted by PSROs may
invoke sanctions against physicians and hospitals that give Medicare and Medicaid patients¶
excessive or poor quality care. The regulations specifying the procedures to be used for invoking
these sanctions, published in the February 20, 1980, Federal Register, authorize HCFA to exclude
physicians and hospitals permanently or temporarily from participation in Medicare and Medicaid
or to assess a fine of up to $5000 in addition to restitution of any improperly paid claims.

The major thrust of the PSROs continues to be toward review of care provided by physicians, but
many PSROs are initiating review of care provided by non-physicians, as was called for in the
1972 legislation.


A system for quality assurance should have the capability to monitor, assess, and improve the
patient care results obtained by the department. The physical therapy department¶s quality
assurance system should be developed and implemented with the following objectives:
Ôp Evaluate the level of patient care results for the department
Ôp Evaluate the level of patient care results of each physical therapist
Ôp Related patient care results to specific diagnostic groups, therapeutic activities, and
intensity of services
Ôp Relate level of patient care results to productivity information
Ôp Improve documentation
Ôp Assist in management¶s decision-making process

Ò    ! "


One of the first decisions to be made is that of including in the data collection either the total
patient population or a sample of the patient population seen in the physical therapy department.
The most desirable system is one that includes all patients and has the capability of identifying
and retrieving data on specific groups of patients.

The items in the data base should include those that are consistent across all types of patients and
that will yield data that can be realistically and meaningfully summarized.

The goals of treatment are operationally defined to include the full range of patient variables
important in physical therapy and to permit the rating of achievement of the goals in a uniform

A distinct advantage of the goal list and the three-category rating scale is one of placing
all important patient outcome variables on the same results-oriented scale of measurement. This
approach permits summarizing both the absolute numbers and the percentage of goals achieved,
partially achieved, and not achieved, either in particular groups of patient or in all patients.
 !  " # 
Treatment outcomes or the achievement of selected goals may vary as the result of
several contributing factors over and above what is done to or with patients in a treatment
program. We believe that the data base for monitoring the results of care should include data on
these contributing factors, as well as on the elements of the physical therapy program and the
achievement of goals.
These summary reports are useful in monitoring and assessing the results of care on all patients,
bit our proposed system needs yet to describe how to use data on goal achievement to select
charts for the audit process.

!  " $# ! %

The retrospective patient care audit is the heart of assessing the result of care. This
process requires examination, retrospectively, of particular cases. The implication, then, is that
some defensible method for screening and selecting charts for in-depth study is needed.
 ! Ò   Ò !%
It is possible to establish other monitoring methods that less comprehensive than the
goal-achievement patient data collection system. To monitor, by definition, is to watch, check, or
keep track of for a special purpose. Monitoring is a process in which criteria or standards are used
to review actual practice in order to identify those areas requiring in-depth study, or to determine
the results of corrective action. We should monitor an area if it appears to be a problem or if there
is significant potential for improving patient care.
There are a number of potential elements that could be monitored in the physical therapy
department using sources that are readily available. The keys to successful monitoring are regular
performance and annual reappraisal to determine the value of the monitor.
  &   '
Once the questionable charts have been identified through the goal achievement
monitoring system, assessing the results of care through the retrospective patient care audit can
proceed. If a simpler monitoring method is used, the area of concern becomes the audit topic. The
audit topic is an area with significant potential for improving the quality of patient care, or a
problem area, identified through monitoring.
The audit topic can be a disease, an operative procedure, a special evaluation, or a
problem. Although any topic can be selected, it should be relevant to the patient population being
served, and it should have significant potential to improve the quality of care provided.
The physical therapy audit attempts to determine the quality of patient care through
reviews of the patient record. The audit provides an orderly, structured method of comparing
actual practice as revealed by the patient record to the expected level of quality of care.
Since most audits are retrospective, appropriate records of discharge diagnose of
operative procedures can be obtained from hospital summaries. The study should include records
from at least a six-moth method to represent a diverse sample. If the time period is too long, say,
more than two years, the information in the sample may be contaminated by therapeutic or
institutional changes. The actual number of records reviewed will depend upon the monitoring
system used, the topic selected, the hospital size, and available personnel.
The audit includes four distinct steps (1) Development of screening criteria, (2) Data
retrieved, (3) data display, and (4) data analysis. Before the first step is undertaken, however, the
objectives of the audit-the reasons why it is to be conducted-must be defined and agreed by the
committee. The previous monitor can provide much of the information needed to define the
objectives of the audit. Discussion of the monitoring information allows the committee to decide
which objectives are most appropriate. Once the objectives are defined, it is easier to develop and
apply appropriate screening criteria.

# "  
Development the screening criteria is not only the most important part of the audit, but
also the most difficult. Decisions made at this point carry through and influence the entire study.
The criteria should be designed to screen out records most likely representing acceptable patient
care from direct physical therapist review. Only those records that do not satisfy one or more
screening criteria should be reviewed by the therapist. If a record fails a screening criterion, it
does not necessarily imply poor care but means only that the record will be returned for review.
Variations from screening criteria can represent acceptable patient care, but this decision must be
made by the physical therapist.

The following guidelines will be helpful when developing screening for the first time.
1. Specifically what are you looking for?
2. Do you know why you looking for it?
3. Does it really make a difference in patient care?
4. Can it be measured in the existing medical record?
5. Can two or more persons, particularly medical data analysts, read the criterion and come to the
same interpretation.
The elements of the screening criteria usually fit into one or another of the categories
shown below, and in general one or more elements are developed for each category:
Physical therapy procedure
Discharge status
Other indicators
 The adult procedure reduces the number of records requiring complete physical therapist
review either by pinpointing the variations within each record or by assessing the entire record as
satisfactory and therefore not requiring therapist review. The medical data analyst performs the
time-consuming tasks of obtaining records for the study and then abstracting and summarizing
the information from these records. Because the abstracting is completed according to the
components developed by the physical therapists and specified on the Screening Criteria form, it
does not require clinical judgement. This adds an element of objectivity since a non-involved
person actually reviews the records.
The data analyst codes the results of reviewing each record on special forms. The codes
indicate whether the record satisfied the element, the exception, or neither for each screening
criterion. Data retrieval forms are used to total the results for all records and provide a subtotal for
each physical therapist.

# #
 The data display summarizes the medical data analyst¶s review of all records. It includes
the total number of records reviewed, the age and sex distribution of the patients, and the
distribution of records for each physical therapist. Specific information collected from the records
is arranged into meaningful categories by:
1.p Listing the total number of records and the percentage rate satisfying each criterion;
2.p Listing individual chart numbers of records not satisfying each criterion;
3.p Identifying the physical therapists for these records;
4.p Pointing out additional information, including the correlation of multiple criteria for the same

The physical therapist must review the data display and the records that did not satisfy
the screening criteria in order to determine the quality of care. This review may indicate that the
care was acceptable or that there were deficiencies. When deficiencies are identified, their cause
must be determined. Deficiencies may be related to care or to the criteria and method of the
audit. If related to care, appropriate actions can involve procedural changes, continuing
education, or other corrective actions. If related to the criteria and methods, appropriate changes
should be made. The physical therapists¶ judgements and recommendations concerning the study
are then sent to other professional and administrative staff members responsible for the care
given by the institution.

Ò( &   '
The third and final stage is improving the care provided. The monitoring process enables
focusing limited resources on problem areas or areas that have significant potential to improve
the quality of patient care. The assessment process enables the in-depth study of these areas to
determine the nature of the problem and what corrective action can best be applied to fix it. Then
of course, the corrective action must be implemented. To have a quality assurance system, it is
inherent that the care is not only studied, but also corrected when found to be deficient.