Journal explores internists' implementation of total quality management - The Internist: Health Policy in Practice

Health Care Financing Review, Spring, 1993

The much-heralded "quality revolution" is a well-known phenomenon in the business world. Less well known, but just as revolutionary, are the steps that health care providers are taking to improve the quality of their product. From administrators in large hospitals to internists in solo practice, a growing legion of providers are extolling the virtues of "total quality management" (TQM), also known as "continuous quality improvement" (CQI). The theory behind, and the application of, TQM are explored in the March issue of The Internist: Health Policy in Practice, the magazine of the American Society of Internal Medicine (ASIM).

An overview of TQM is provided by Donald M. Berwick, M.D., a Boston pediatrician and one of the best-known proponents of TQM in the health care arena. Dr. Berwick believes quality management techniques can eliminate a great deal of inappropriate medical care, while streamlining the bureaucracy that makes for ineffecient delivery of care. TQM, he says, allows greater understanding of a system, which in turn provides the framework for useful and wise actions to make it better."

A practical example of the efficacy of quality management theory is given by Brent C. James, M.D., the executive director of the Institute for Care Delivery Research at Intermountain Health Care, a Utah-based hospital chain. Dr. James shows how a continuous examination of health care delivery can yield significant improvements. To illustrate, he recounts how the application of TQM resulted in a 50-percent drop in postsurgical infection at LDS Hospital in Salt Lake City.

Dr. James says clinical researchers at LDS painstakingly examined each step of the pre-operative, surgical, and postoperative process to determine the point at which patients were at greatest risk of developing postoperative wound infections. Through a process of testing and elimination, researchers eventually narrowed their investigation to the pre-operative delivery of prophylactic antibiotics. By determining the time during which the delivery of antibiotics would yield an optimum amount of protection, the research team was able to modify surgeons' ordering practices and dramatically reduce the risk of postoperative infection.

Internists in a variety of practice settings are also adopting quality management techniques. In an article featuring ASIM members on the quality bandwagon, Austin internist Peggy Russell, M.D., describes how she and her staff use TQM to keep her new solo practice competitive. "Efficiency throughout the work day and effective communication are the things that will make or break you in private practice," Dr. Russell says. She meets on a regular basis with her three-person staff to discuss office problems and brainstorm for solutions.

Another management theory in vogue these days is "managed competition," the vessel that may ultimately be used as the basis for reform of the health care system. In a "Where We Stand" editorial, ASIM says managed competition is "not perfect, but promising." The editorial specifies the elements of managed competition that ASIM can support, while noting areas of concern that would need to be addressed to ensure patient choice and health care quality.

Health care reform is also the topic of discussion in this month's "Innerview" with Senator Dave Durenberger (Republican, Minnesota). Durenberger, the ranking member of the Senate Finance Committee's Medicare Subcommittee, says he's wary of attempts to provide universal health care coverage while simultaneously implementing cost controls. "Regardless of what kind of reform you pass, there is no way to obtain sufficient, immediate savings to pay for covering the uninsured. We must focus first on containing costs," he says.

For a copy of the issue The Internist: Health Policy in Practice, send $3 to ASIM, 2011 Pennsylvania Avenue, Suite 800, Washington, DC 20006. A 1 -year subscription costs $24. For more information, contact Alex Gramling at (202) 466-0281.