TITLE(s): The quality march: part three of a National Survey of Quality Improvement Activities. (medical care) illustration table graph Summary: Statistics from the National Survey of Hospital Quality Improvement Activities show a variable response to the survey's four assistance scales, which include training, patient data, incentives and clinical data. Hospitals without continuous quality improvement/total quality management (CQI/TQM) programs showed the most interest in the scales, especially the training scale. Response rates for CQI/TQM hospitals, system member hospitals, and hospitals by bed size and teaching orientation are provided. Hospitals & Health Networks p45(4) Jan 5 1994 v68 n1 DESCRIPTORS: Hospitals_Quality control Medical care_Quality control PART THREE OF A NATIONAL SURVEY OF QUALITY IMPROVEMENT ACTIVITIES This final article in the series (see the Dec. 5 and Dec. 20 issues) identifies areas where hospitals want assistance in order to further enhance their quality efforts, with particular emphasis given to clinical applications and greater physician involvement. Survey respondents were asked to indicate the extent to which 12 different items would assist their efforts to improve the quality of patient care on a scale of 1 (no or little assistance) to 7 (great assistance). Analysis resulted in four assistance scales involving training, patient data, incentives and clinical data. * The training assistance scale was calculated by averaging responses to the following: additional staff training in quality assurance, assessment and improvement; training in group processes; outside consultation on quality assurance/improvement functions and activities; and reorganization of current quality assurance/improvement functions and activities. * The patient data assistance scale was formed by averaging responses to items involving better data on patient satisfaction and better data on patients' needs and preferences. * The incentives assistance scale was created by averaging responses to changes in the budget process and changes in the employee evaluation/reward system. * Finally, the clinical data assistance scale averaged the items related to better methods to adjust data for disease severity and more opportunities to compare results with others. Overall results While all hospitals report that these measures would be of some assistance in their quality improvement efforts, hospitals without CQI/TQM generally perceive that they would be more helpful. For example, non-CQI/TQM hospitals perceive a greater need for training assistance (5.00 versus 4.41 on a 7-point scale) and incentives (4.29 versus 2.14) than do CQI/TQM hospitals. However, CQI/TQM hospitals rate of importance of better clinical data somewhat more highly than do non-CQI/TQM hospitals (5.07 versus 4.97). There was no significant difference between the two groups in regard to assistance with patient care data. For all types of hospitals, respondents differ significantly in their perceived need for training assistance by bed size, teaching orientation and system membership. Non-teaching hospitals find training measures to be of more assistance than do teaching hospitals (4.60 versus 4.46). Further, and somewhat surprising, system member hospitals perceive a greater need for training assistance than do non-system hospitals (4.68 versus 4.46). Not surprising, smaller hospitals report a greater need for training assistance than do the medium-sized and larger hospitals (4.74 versus 4.51 and 4.47, respectively). While there are no significant differences in response to the incentives assistance scale across hospitals by teaching scale across hospitals by teaching orientation or systems membership, opinion does differ by bed size. In this case, small and large hospitals perceive a greater need for changed incentives (4.23 and 4.31, respectively than do medium-size hospitals (4.11). This may reflect the fact that smaller hosptials have not yet initiated budgeting and performance appraisal systems that promote quality improvement efforts, while larger hospitals have difficulty implementing such changes due to their size. There are also significant differences in response to the clinical data assitance scale across hospitals by either bed size, teaching orientation or system membership. In general, the above differences by bed size, teaching orientation and system membership exist for the subsample of CQI/TMQ hospitals as well. Physician involvement Respondents were asked to indicate the number of active staff physicians who have participated in formal quality improvement training. CQI/TQM sites had a significantly higher percentage of trained physicians than did non-CQI/TQM hospitals (16.2 percent versus 9.5 percent). While there were no differences by teaching orientation or system membership, smaller hospitals by virtue of their smaller medical staffs had a higher percentage of physicians trained (23 percent) than either medium-size (13.9 percent) or large hospitals (10.6 percent). Respondents were also asked to indicate how many of their active staff physicians have participated in quality improvement teams. Again, a significantly higher percentage of physicians at CQI/TQM sites have participated in quality improvement teams than at non-CQI/TQM hospitals (10.1 percent versus 8.4 percent). There were also differences by bed size, teaching orientation and system membership. Due to smaller medical staff size, a higher percentage of physicans at the small hospitals (13.0 percent) have quality improvement team experience than at medium-sized (7.1 percent) and large hospitals (4.8 percent). Interestingly, the percentage of physicians with improvement team experience is somewhat higher at non-teaching hospitals (16.6 percent) than teaching hospitals (13.0 percent), and at system member hospitals (11.6 percent) than freestanding hospitals (8.3 percent). Clinical applications A list of 15 medical, surgical, obstetrical and outpatient conditions/procedures was provided (see table 1, page 46). For each condition treated or procedure performed, respondents were asked to indicate of quality of care data were being used by formally organized quality assurance/quality improvement project teams. On average, all hospitals use quality of care data in QA/QI project teams for 17.7 percent of the conditions/procedures performed by the hospital. For CQI/TQM hospitals this figure is 20.3 percent, versus 11.8 percent for non-CQI/TQM hospitals. Among CQI/TQM hospitals, the percentage of quality of care data used by AQ/QI project teams differ significantly by bed size but not teaching orientation or system membership. Project teams at larger hospitals are more likely to use quality of care data (23.7 percent) than at small (20.5 percent) and medium-sized hospitals (19.3 percent). For example, large hospitals are more likely than medium-sized and smaller hospitals to use quality of care data for hip replacements (47.0 percent versus 33.7 percent and 24.2 percent, respectively). This pattern also exists for angioplasty, where 36.6 percent of large and 38.2 percent of medium-size hospitals use such data in QA/QI project teams, versus only 22.2 percent of the smaller hospitals. Respondents were also asked to indicate whether they have developed or used clinical algorithms, practice protocols/guidelines or critical path-ways (see figure 1, page 47). Findings indicate that a much higher percentage of CQI/TQM hospitals use these than do non-CQI/TQM hospitals. Among CQI/TQM hospitals, the use of clinical algorithms varies by bed size, teaching orientation and system membership (see figure 2, this page). Large hospitals, teaching hospitals and system hospitals are more likely to use protocols and pathways. Results show that a much higher percentage of CQI/TQM hospitals use both clinical and cost data in reviewing physician privileges and credentials than do non-CQI/TQM hospitals (see figure 3). Among CQI/TQM hospitals, the use of clinical and cost data in reviewing privileges and credentials varies by bed size, teaching orientation and system membership (see figure 4). Larger hospitals, teaching hospitals and hospitals belonging to system are more likely to use these data. Summary Taken as a whole, these findings from the National Survey of Hospital Quality Improvement Activities provide important baseline information on the current status of hospital quality improvement efforts. They also indicate those areas where hospitals perceive the greatest need for assistance and fortell the much-needed expansion of CQI/TQM to clinical processes and activities involving a greater degree of physician participation.