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Total Quality Assurance: An Important Step in Improving Care for Older Individuals

1992; Wiley; Volume: 40; Issue: 9 Linguagem: Inglês

10.1111/j.1532-5415.1992.tb01999.x

1532-5415

John E. Morley, Douglas K. Miller,

Balance, Gait, and Falls Prevention

After World War II, an American, W. Edwards Deming, developed a new approach to improving the quality of products. In essence his system utilized statistical methodology of frequency of failure to pinpoint problems in production. Outcome evaluation was coupled to a process known as continuous quality improvement in which the team of workers continuously identify and correct problems, focusing on areas with the highest rates of identified deficiencies.1, 2 This system was rejected by American business, and Deming traveled to Japan where his system was widely embraced and turned Japan from the leading manufacturer of cheap, junk trinkets to the leading manufacturer of inexpensive, high quality industrial goods. The Deming approach has much in common with modern geriatrics, where we use interdisciplinary teams to identify and correct problems in a group of individuals at high risk of adverse outcome. It should therefore be easier for geriatricians than other physicians to embrace the Deming approach enthusiastically and, in doing so, provide a much enhanced quality of care for our older patients. A simple hypothetical example of the total quality assurance approach may help to elucidate the process. By monitoring the fall rate in a number of institutions it is noted that the rate is 10% higher in one institution than in all the others. This institution is determined to be a statistical outlier. A Pareto analysis is undertaken in this institution to pinpoint the major causes of falls. The Pareto analysis is based on the principle that a small number of causes will be responsible for the majority of cases as first demonstrated by Vilfedo Pareto, an Italian political economist, who showed that a small percentage of the population controls most of the wealth.3 Let us suppose that our analysis is similar to that of Robbins et al4 which found that most falls can be explained by either hip weakness, balance problems, or more than four medications. An interdisciplinary team is then called and shown three graphs. The first shows the increased frequency of falls in the institution compared to others, the second demonstrates the Pareto histogram of most common causes, and the third is a line graph for the next 12 months with a single point on it demonstrating the present fall rate. The team is then asked for possible solutions to reducing the fall rate. The pharmacist offers to monitor all persons on five or more medications (alone or in combination) and check whether the medications are causing postural hypotension5 or aggravating postprandial hypotension6 as a cause of falls. It is agreed that if potentially offending agents are identified, the patient's physician will be contacted immediately and permission obtained to discontinue as many of the implicated drugs as possible. The physical therapist offers to develop a hip muscle strengthening program utilizing leg weight lifting modeled on a proven protocol.7 The occupational therapist decides to work with the recreational therapist to develop a beach ball throwing game to enhance balance. The janitor remembers reading in the newspaper about a program in which walking chairbound residents improved their balance and offers to organize a group of his friends from the Elks to come in once a week and replicate this program.8 The engineer asks if there is any area in which falls are particularly prevalent and further analysis of the data shows an excess of falls in the bathroom area. The engineer suggests improving the lighting, increasing the height of the toilet seats, and adjusting the placement of grab bars. The team's plan is put into action, and the team meets once a month to observe decreases in the fall frequency, to be provided feedback on whether new major causes of falls are emerging, and to be proud of the result of their actions. The specific work process that leads to the decrease in patient falls having been identified, it can be monitored in the future for the purpose of maintaining the consistency of the program over time. This monitoring is accomplished with a specific work-sampling procedure that permits an ongoing analysis of factors that influence the variability of the direct care provider's ability to implement the fall prevention work process. Such a program would represent continuous quality improvement at its best. It should be noted that a key to total quality improvement is the commitment of management to give the team the authority to make these suggestions and then to implement them. Without commitment from the top to really make a change, the process is extraordinarily difficult, if not impossible. However, it should be recognized that physicians can exert leverage on hospital administration to embrace the process of total quality management. Dimant9 has described in detail how a total quality management system transformed a nursing home whose license had been revoked into an environment that provided high quality of care for residents and enjoyable employment for the staff. Use of continuous quality improvement methods have also been demonstrated to be effective in decreasing restraints10 and improving urinary continence in nursing homes.11 Due to the outstanding efforts of the RAND-UCLA group, the utility of outcomes research has been well established for identifying variations in practice procedures and appropriateness of these procedures in hospitals.12–14 Using the Delphi approach, they have suggested that total quality assurance approaches for older persons should focus on persons with congestive heart failure, hypertension, pneumonia, breast cancer, adverse effects of drugs, incontinence, and depression.15 In addition to in-patient care, they have suggested there should be a focus on hospital discharge planning, long-term-care facilities, home health care services, and case-management of functional disability16 and geriatric syndromes (dementia, depression, gait and balance problems, and malnutrition) in ambulatory older patients.17 Our recent editorial on life expectancy after 65 years of age has suggested that the United States does poorly in comparison to many other countries.18 Brook19 echoed this feeling in an article in which he questioned whether American physicians cared about the quality of care. It has been suggested that the average physician's response to total quality assurance is similar to an immune system response to a foreign antigen with the physician the “Natural Killer Cell” of the system.3 We believe that these attitudes can be reversed by an enthusiastic embracing of the principles of continuous quality improvement by the community of geriatric providers. Since most geriatricians already have experience working in interactive teams, the philosophy and methods of continuous quality improvement will seem quite natural. The potential benefits are many. Care can be delivered more efficiently, team members can gain greater job satisfaction by making valuable contributions to worthwhile projects, and, most importantly, the health of our older patients can be improved. As continuous quality improvement programs are implemented, these benefits need to be documented to convince health care institutions, third party payors, and the health care field in general of their value. Continuous quality improvement has much to offer the field of health care in general.20 Let us geriatricians lead the implementation of this potentially valuable system.