Complying with JCAH Quality Control Standards

Abstract

JCAH guidelines on quality control state that allied health personnel share responsibility for evaluating effectiveness of services they provide. The Respiratory Therapy Department at Henry Ford Hospital (Detroit, Michigan) has developed a retrospective audit mechanism for this purpose and to use to help educate the medical staff. Therapeutic objectives for clinical procedures were developed; methods for evaluating achievement of the objectives were developed; criteria were established for retrospective audits; a pilot audit was performed. Audits are conducted by a Medical Audit Committee that includes technical personnel; this committee periodically evaluates quality of care for a chosen clinical procedure as recorded in 10 to 25 pertinent patient charts. Peer review is also conducted, as respiratory therapy management reviews one to three procedures monthly. For audit, data are collected to learn how well care criteria have been met, and variations from policies are calculated and examined for causes and for justification, and they are classified by type. As a result of audit, the Committee may recommend counseling of persons responsible for unacceptable variations from policy and procedure standards. Awareness of audit has encouraged technical staff to observe patients more closely; marginal-quality care has been upgraded and adequate care has often been improved. Audit caused immediate improvement in charting and departmental morale and pride. "Selling" the audit to physicians is important; improvement of order forms and chart forms may help. Audit and review are time-consuming, and initial ambition about frequency and volume of auditing may be too high. But experience provides wisdom, and the process identifies problems and can lead to better patient care.