Initial Assessment

The first step in establishing a comprehensive quality control program is to determine the structure of the existing management system. While the JCAH has issued guidelines only on the evaluation of quality assurance activities, these guidelines are equally applicable to risk management activities. The JCAH discusses the objectives of this initial assessment in the QA Guide: A Resource for Hospital Assurance:

This assessment is conducted to identify the scope, purpose, and effectiveness of current activities; to ascertain whether such activities meet all JCAH requirements for review and evaluation; to identify strengths and weaknesses in the overall quality assurance program; to determine whether duplication in activity, overlap in authority and responsibility, or unnecessary expenditures in staff time and resources exist; and to determine whether expansion, reorganization, or streamlining of the current program is necessary and appropriate.

Included in the assessment should be medical staff functions such as departmental meetings, continuing medical education, and credentialing; departmental activities such as emergency services, nursing, and anesthesiology reviews; and hospital-wide activities such as risk control, safety programs, and infection control. Although difficult, it might be useful to identify the cost and time spent in the conduct of quality assurance activities. The cost of an activity might be measured by calculating and then multiplying those hours by a predetermined dollar value. Costs can also be determined by calculating the number of manhours and multiplying that number by the hourly salary of paid personnel. However, the latter approach does not account for the time and cost of nonsalaried committee members.

You might wish to estimate the productivity of effectiveness of a quality assurance activity by viewing the impact of the activity on care in relation to the time, effort, and dollars expended. This approach tends to be subjective but can prove helpful by identifying areas in which changes may be indicated.

The goals of the initial evaluation should be the development of a detailed flow chart of all the tasks and personnel involved in quality control activities. The flow chart should include all lines of responsibility and authority, as well as the job descriptions and qualifications of all personnel involved in the various functions. This will facilitate the definition of each of the tasks that is currently part of the quality control activities. Once these tasks are defined, they may be analyzed to determine if the proper management controls are in place. It should be emphasized that, as this analysis is performed, it will be necessary to update the chart as previously unrecognized lines of authority and responsibility are delineated.