Roanoke Times
Copyright (c) 1995, Landmark Communications, Inc.
DATE: SUNDAY, April 29, 1990 TAG: 9005080048
SECTION: NURSES PAGE: N21 EDITION: METRO
SOURCE: Sarah Cox
DATELINE: LENGTH: Medium
The results come in the form of more crisis intervention work, more outpatient surgery, intensified efforts while patients are in the hospital and more ambulatory care.
It also has resulted in the growth of quality assurance and utilization review programs. From 1979 on, the Joint Commission on Accreditation for Health Care Organizations required quality-assurance programs in hospitals. The Commission accredits hospitals that meet minimum standards - and it looks at everyone, every department, every functioning part.
"The object, said Jeanette Miller, quality assurance coordinator for nursing service at the Veterans Administration Medical Center, "is to identify problems in patient care and take corrective actions. Over the years, the Commission has changed - it publishes new standards every year."
The standards are specific to different kinds of health care - for instance, long-term, psychiatric or ambulatory care.
Pressure also has arrived in the form of diagnosis-related groups (DRGs) which have evaluated average lengths of stays for various causes, and arrived at a "suitable" time, in order to reduce health care costs.
Ten years ago, said Miller, when misuse of Medicare escalated medical costs, the crunch began.
"It gets into dollars and cents, and intervenes into quality assurance programs. DRGs have been positive in making people look at a practice and how to cut costs. But it was set up for physicians admitting and discharging patients. There was little connection in between diagnosis and nursing care. They have not well-served nurses. Nursing care is not a true part of that - we face an increasing acuity. Patients are sicker. Insurance is encouraging a climate where patients leave sooner and are not as well," she said.
There is also a big move toward ambulatory care and outpatient surgery. This can be seen in the fully developed systems hospitals now have for outpatient surgery, and in the nurses' resources for ambulatory patients.
Miller said that quality assurance comes into play here - it evaluates how patients are doing, and what the consequences are of this type of health care. "If someone who has outpatient care is admitted to the hospital three days later, we screen that. Why did that happen? Nurses struggle without having, within their system, a great deal of attachment. The diagnosis doesn't account for nurses. There is a lot of pressure for turnover - admit, treat, get them home. Nurses are looking at a shortage, anyway," she said. And standards of patient care are always haunting them, measuring how nurses meet these criteria.
Utilization review checks complications that may arise - if a patient received the wrong medication - and determines the sources of the problem. Miller's job is to research, then share this information with other support services within the hospital. It is a system, she said, of delivering patient care, knowledge and performance.
"You sort all this data, look at trends and look at risk management. Patients are at risk of having a fall, getting the wrong medication and getting an infection. You might see trends change," she said. Her job is to catch them at the pass.
"Nurses have a big concern. We're pulled between caring for a patient at the bedside and documenting the case. There never seems to be enough time - that's one of the ways they're pulled."
An outgrowth of nursing shortages and utilization review is the new systems being developed to handle alternative health care - home health care, for instance. And the seriousness with with quality assurance is being taken.
"It's taken the Joint Commission 10 years to get real systematic about it. They're focusing on the outcome. Historically, there was lip service. We've come so far with quality assurance."
Miller's job entails looking at policies and procedures of nursing care; nurses requesting clinical privileges and how that reflects standards; safety issues and policies; developing standards of patient care, and monitoring them; reporting problems; and looking at the educational needs of staff and providing quality assurance education.
She examines the results of nursing shortages and the pressures DRGs are putting on patient care.
"Quality assurance should identify problems; management has a responsibility to use that information to provide care. Nurses are working very hard, and there are a lot of ethical concerns. I do not want nursing practices to be governed by insurance companies."
by CNB