Decision making involves the comparison of the analyzed data with appropriate standards to determine what problems, if any, exist. The goals and techniques of the quality control program must reflect the criteria found in the standards. There are three sources of standards:
1. legally imposed duties
2. standards imposed by professional organizations
3. rules specific to the institution
Failure to adhere to any of these standards may result in various sanctions, including the loss of accreditation, financial losses from litigation, and even prison sentences for violating certain drug laws. Given these potentially severe penalties, it is critical that the standards be carefully observed. Unfortunately, they are often too general to apply directly to day-to-day problems. This requires the administrator to develop a set of detailed protocols that reflect the intent of the standards. The protocols then can serve as yardsticks to measure the raw data.
The most important consideration in developing the protocols is to ensure that legally imposed duties (especially drug laws) are strictly observed. The broad outlines of these duties are uniform from state to state, but the details must be drawn from the laws of the state where the provider is located. These legal duties are of two types: (1) very specific laws governing the reporting and treatment of drug-related illness and public health diseases, and (2) very general laws governing the provider-patient relationship (such as the requirement for consent to medical treatment). Because of their specificity, incorporating the drug and public health laws into the quality control program is straightforward. However, incorporating the general duties requires the development of detailed protocols to guide the hospital personnel and to provide quality control benchmarks.
Violation of the standards promulgated by professional organizations does not carry any direct legal penalty (unless the violation also breaches a legal duty), but it can result in the loss of the endorsement of the professional association. In a hospital, the most important of these professional associations is the Joint Commission on Accreditation of Hospitals (JCAH). To qualify for JCAH accreditation, a hospital must adhere to a broad-based, detailed set of standards embodied in the Accreditation Manual for Hospitals. The JCAH standards demand a higher degree of management control over quality assurance and risk management activities than most facilities currently provide.
The managerial objective in developing detailed protocols is to reduce the number of situations that requires administrative decisions. The reduction of such decisions helps to avoid delays in needed medical care that arise because the person with the authority to authorize the care is unavailable. For example, emergency room personnel should be allowed to transfer patients who need care that the hospital cannot provide. Requiring an administrator to ratify such a decision could result in a patient injury as a result of delaying necessary medical care.
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