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A DISCUSSION OF METHODS* Panel Discussion

CONRAD ROSENBERG, M.D., moderator

Medical Director Community Health Program of Queens-Nassau, Inc. New Hyde Park, N.Y.

AVEDIs DONABEDIAN, M.D., SIDNEY M. GREENBERG, M.D., JOHN K. GUCK, M.D., FREDERICK H. SILLMAN, M.D., RICHARD KNUTSON, M.D., STANLEY REICHMAN, M.D., AND MILDRED A. MOREHEAD, M.D.

R. CONRAD ROSENBERG. This question is addressed to Dr. Donabedian. Structure and process are measurable indicators of the environment and manner in which care is given, but outcome would seem to be the best ultimate indicator of quality. However, it may turn out that the process of care has little or no relation to its outcome, which would lead to the question of whether much of the medical process is necessary. If outcome and indeed process are unrelated, why are we fussing with the process? Might this be an underlying reason for physicians' lack of enthusiasm for patient-care review? DR. AVEDIs DONABEDIAN. This is a difficult question, which would take a long time to explore in detail. The time has come to examine very carefully our norms of practice, to relate them to outcomes, to study alternative ways of achieving desirable outcomes, and to choose those alternatives that are most efficient and socially acceptable. The costs of medical care are increasing, the available technology is increasing, and the range of things one can possibly do to and for patients is becoming large and costly. We need to begin to study which procedures are the most effective for achieving the desired goals. If an additional laboratory test will not yield additional information-or if it yields additional information which cannot be acted upon or used in a way that is meaningful to the desired outcome-it should not be done.
*Presented in a panel, A Discussion of Methods, as part of the 1975 Annual Health Conference of the New York Academy of Medicine, The Professional Responsibility for the Quality of Health Care, held April 24 and 25, 1975.

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We have to search for efficient strategies of management; that is where research is needed. In the meantime, we have no alternative but to what wise and competent doctors tell us is appropriate. These norms themselves need to be researched systematically and related to outcome, efficiency, the allocation of resources, problems of social equity, and a variety of additional factors that enter the picture-all of which make for an extremely complex problem. We have to prepare for the future in terms of evaluating the quality of care, and there is much that we can do now with some simple tools that we already have. The tools we have are good enough to find out what is wrong with medical care today. The important needs are for more sharp and potent tools for evaluation and for the will to make them work properly. We need to develop immensely and to bring to much higher levels of sophistication our concepts of quality and our tools for assessment. DR. SIDNEY M. GREENBERG. We have not yet analyzed how many hours of labor are required for our 22i-bed hospital. There are four people in the Office for Quality Control at LaGuardia Hospital. One nurse spends full time monitoring infections in the hospital and seeing to it that steps are taken to reduce the incidence. We also have a program coordinator and an administrative assistant. The entire staff, including myself, fulfills a major responsibility to auditing charts. DR. JOHN K. GUCK. Dr. Greenberg's remarks imply another question: How do you select the physicians to make the audits-how do you judge who are going to be good auditors? DR. GREENBERG. In arriving at the composition of the committee, we try to expose as many people as possible. We prefer people who have been associated with the institution long enough so that we can observe their abilities. Membership is on a rotation basis. DR. ROSENBERG. Dr. Sillman, with regard to the lack of action taken by Kings County Hospital on the findings of your committee and your suggestion that a lack of resources is largely responsible for its problems, to what extent does your committee or hospital administrator consider an internal redeployment of existing resources to improve the effectiveness and quality of a program? DR. FREDERICK H. SILLMAN. Our committee is more of a staff than a line committee, and it has very little enforcement power. The only time that our committee wields power is when the threat of losing our
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titles funds becomes a reality. At present this big club is rather ethereal. In the meantime, we are providing whatever stimuli we can. For example, I mentioned that our record system has been a basic problem. We have invited speakers, including Dr. Weed, to talk about problemoriented records and we have sponsored other educational programs. Within the city hospitals of New York there is a tremendously complicated bureaucracy, which involves not only our administrations but also the New York City Health and Hospitals Corporation. We have met with representatives of the corporation and they have been kind and attentive, but not responsive. DR. ROSENBERG. Dr. Knutson, what responsibilities have been given to administrators which you feel physicians should have retained? Do you think that physicians have the training and time to handle administrative functions while delivering medical care? DR. RICHARD KNUTSON. I think that decision-making power in most hospitals has been taken away from physicians to a great degree. This is true of other professionals in hospitals as well. This power to make an important decision is zero. Interesting meetings of medical boards, executive committees of the medical boards, Professional Standards Review Organizations (PSROs) and other groups are being held every week. But nothing done by these groups makes any difference because the administrators tell them that their ideas cannot be implemented, that these are not part of the grand scheme. Everything is five years away on the planning board; they will even show plans which cost $50,000 or $75,000 to design. In the meantime, you have a nonfunctioning electrocardiograph and five patients died last night. This does not matter to the administrators. We are frequently expected to serve on many committees. This is less true in training situations than in private hospitals. There it is mandated that the physician who does not serve on committees loses his privileges. As professionals, we need some way to implement our decisions. Dr. Sillman pointed this out very carefully. I was a little less kind. The system is rotten-not only in the city hospitals, but in most of the hospitals in the city. What is needed to improve the system? The answers are always the same: a few more people, the right equipment, and more cleanliness. You do not need a $50,ooo survey to learn that sort of thing. You can simply walk through a hospital and ask the patients and the people who
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work there. Implementing any program requires cash. Everyone talks about controlling quality and cutting costs, but nothing is done about it. If the importance of such action gets across, then we shall have succeeded here. We are not doing the job that we are supposed to be doing. I invite anyone who believes that we can improve our performance to serve with me at night to see how we can do so. DR. STANLEY REICHMAN. The statements that are being made emphasize the challenge that exists. It was pointed out earlier that for the Internal Revenue Service the purpose of auditing is to gain dollars from the money that is being spent. If utilization review is considered a form of audit, the hope is that we shall reduce costs by changing the form of utilization. The challenge to do this or the requirement to do it offers an immense opportunity for us to point out where the responsibility lies. If this responsibility belongs at the level of the board of trustees because there are not enough ophthalmoscopes and the physicians think that this is important, then there is a problem in the administrative structure. By proper use of the audit we can document where the structure is at fault -whether it is in the number of man-hours being provided or in the number of personnel that provides the care for a particular group of patients. Then changes may be begun through the mechanism of accountability. It is the role of physicians and all professionals to point out through the audit that administrators and trustees are increasingly responsible, on a legal as well as a sociological level, to provide improvements in structure which will improve the outcome of care significantly. DR. ROSENBERG. Dr. Morehead, you suggested that outcome might be an inappropriate focus for attention in the evaluation of chronic disease. What might the auditor focus on that would be more appropriate for evaluating diseases such as hypertension and diabetes? DR. MILDRED A. MOREHEAD. The problem is in the evaluation of chronic disease. It is a question of time. Many hospitals evaluate patients on the day of discharge. That is clearly not relevant to the patient. Some hospitals evaluate patients on the first return visit or two months after discharge. One difficulty with this method is that interview surveys usually have to be performed to find the patients who are being evaluated. Eventually, we shall have to try to perform evaluations on a
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periodic basis. You cannot say that the outcome of a diabetic patient is favorable six months, a year, or even five years after you first saw him because of what you have done for him. The government's desire for instant policy changes and innovative programs and academia's desire for instant publication has meant that we do not have funding for long-term programs to follow chronic diseases over io or I5 years. DR. ROSENBERG. Gentlemen, would each of you answer this plaintive request-it is so direct and relevant: "Please summarize what was taught or agreed upon here today." What was it all about? DR. GUCK. We are beginning to establish home guidelines for assessing the quality of care. Judging by the pace with which the medical societies have been moving in the past, what we have done in the past two or three years-including the development of the PSROrepresents a tremendous change. It also represents a tremendous growth of responsibility on the part of the medical profession to see that the altruistic ideas which have always been latent might perhaps be implemented. DR. SILLMAN. For better or worse, we are stuck with evaluations and audits. We can merely go through the motions of these exercises or we can view them as opportunities to improve the quality of our care. We should keep the latter ideal foremost in our minds; this is what evaluation is mainly about. Health-care professionals should take up this cause because there will be plenty of others to complain about the costs. We should not focus all of our attention on the process of health care to the extent of sacrificing what we are really trying to do. If we keep the quality of health care in mind and constantly searchthrough research and every other way we can-for the means to improve it, then we shall be doing our best to achieve our goal. DR. GREENBERG. I cannot avoid commenting about the extraordinarily limited vision which has been exhibited today. No one has talked about society at large. We have been talking about the health services as if they exist in a vacuum. The same problems exist in education, employment, housing, etc. We have trouble with our value system, and this is being exhibited very much in the field of health services. In health services, the object of value-the product-is an individual and his health status. Yet we hear that Kings County Hospital has more than 20 different kinds of records. How long have we known about
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unit-record systems? What has happened to our value system whereby people have become less important than things? We have to look at this question not so much as health professionals but as citizens. The problem exists throughout our society. Health care is a $Ioo billion industry, the second or third largest in the country. It reflects all our national problems. DR. DONABEDIAN. What I said was based on an implicit prior observation, namely, that for the last 10, 20, or more years no new methods of evaluating the quality of medical care have appeared. We have been refining essentially the same kinds of approaches. I have been wondering in what direction we should go in the future to find something new, more effective, and more relevant. It seemed to me that we should study much more carefully the clinical process -clinical judgment and clinical decision-making-and after we understand it we should evaluate it in terms not only of individual objectives but also of aggregate social objectives. One ultimate objective should be the achievement of the largest increment of health for the largest number of people; this should be equitably distributed in a manner that meets our standards of social justice. This is my general perspective DR. MOREHEAD. I am very pragmatic. I do not worry much about the problems and the techniques. The application of any method is better than none at all. In relation to the horror of 28 different records at Kings County Hospital, I recall that for a few years it was predicted that everything would be solved by computers. This prediction fell to pieces. That kind of thing can happen with auditing. If we aim for the perfect system to answer everything, if we depend too much on techniques to solve basic problems that could be handled more simply in more practical ways, it will be a long time before we are able to affect the pressing problems on the medical scene today. DR. ROSENBERG. Dr. Donabedian, since the record is so important, why has there been no attempt to develop and enforce a universal set of forms, etc? DR. DONABEDIAN. Every time someone asks me to support a universal anything-PSRO forms or whatever-something very conservative in my background, which I thought I had left behind, says, "Beware." Do we really know enough to impose something like this on everyone?
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There is a great deal of duplication in medicine. We have mentioned the various requirements of the many regulatory and review agencies, the various insurance companies (for claims), and so on. We should try as hard as we can to reduce unnecessary duplication to arrive at some kind of uniformity, but at the same time I would hate to see uniformity made mandatory, so that everyone would have to do the same thing. That would destroy innovation. Maybe that is a very conservative view and not a very reasoned one, but it is my emotional reaction. I do not like to see anything imposed on people unless I am absolutely certain that it is the right thing. As an academician, if I were certain that anything was right, I imagine that I would immediately lose my tenure and be discharged from my university. So there is always the need for doubt and the need to use care before imposing anything on everyone. DR. ROSENBERG. I believe it was Voltaire who said that to be in doubt is disturbing but to be certain is ignorance.

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