From the Texas Medical Foundation, Austin, Texas.

The authors highlight 2 critical aspects of successful quality improvement initiatives: engaging physicians as quality leaders and using a multidisciplinary team approach. Because physicians manage patient care and determine therapeutic interventions, they have significant control over resource utilization. It is critical, therefore, to engage physicians in quality improvement efforts. A key step in engaging physicians is to focus on critical aspects of care for relevant clinical topics. Towards this end, the Health Care Financing Administration (HCFA) and the peer review organizations (PROs) introduced the health care quality improvement program (HCQIP) in 1992 (1). HCQIP represents a shift from individual case review looking for the “bad apples” to profiling of population-based patterns of disease-specific care in an effort to identify unintentional variations in care. This new approach assigns no blame. Instead, it looks for process changes within systems of care that will produce improved outcomes (2).

To focus HCQIP, 6 topics were chosen for national quality improvement efforts. To be included, a clinical topic must impact a large number of Medicare beneficiaries and cause significant morbidity or mortality. Next, scientific evidence must exist that links selected quality measures to improved outcomes and identifies valid and reliable data collection methodologies. Last, there must be evidence supporting variation in the actual application of these selected quality measures and an indication that Medicare PROs, working with their partners, can positively improve the selected measures (3). Even meeting these criteria, HCFA recognizes that a quality indicator cannot be applied to all patients. As such, extensive exclusion criteria have been utilized to ensure that physicians have the freedom to use clinical judgment in decision making.

As the state PRO, Texas Medical Foundation (TMF) has a role in the HCQIP process: to help Texas providers build the capacity to conduct their own data-driven improvement projects, while at the same time encouraging the use of processes that help them achieve benchmark performance for all of the quality indicators. TMF focuses on the systems approach to quality improvement. Because a system is defined as any set of processes linked together to produce an outcome, changing any process in a system will modify the outcome for better or worse. As such, prior to implementing any process change, an organization must understand the process steps in its current system and have baseline data documenting the performance of that system. Once a process change is implemented, data must be collected to ensure that the change positively impacted the desired outcome. A single process change rarely produces the degree of desired improvement; therefore, it is critical to undertake multiple quality improvement cycles to reach benchmark levels.

When analyzing a system, it is obvious that many health care professionals affect the delivery of care provided to patients. This highlights the authors' second point. Quality improvement cannot be performed by a single group of professionals (e.g., physicians, pharmacists, or nurses). As such, the authors are correct in identifying the need for a multidisciplinary approach to quality improvement. Only by engaging all groups who provide patient care can the quality improvement process be successful.

The Texas baseline ranks for the HCQIP quality indicators cannot be explained by inappropriate topic or quality indicator selection. They cannot be explained by a failure to recognize necessary exclusions. These data represent a call to action for all health care providers in Texas and throughout the nation. TMF supports and applauds the quality improvement efforts undertaken by BHCS. Through their efforts, and the quality improvement efforts of many similar health care providers throughout the state, Texas will meet the challenge and respond fully to this call to action. To learn more about the services and resources available from TMF, call 1-800-725-9216.

1. Jencks SF, Wilensky GR. The health care quality improvement initiative. A new approach to quality assurance in Medicare. JAMA 1992;268:900-903.
2. Pendergrass PW, Abel RL, Bing M, Vaughn R, McCauley C. Methodology of quality improvement projects for the Texas Medicare population. Tex Med 1998;94:54-60.
3. Jencks SF, Cuerdon T, Burwen DR, Fleming B, Houck PM, Kussmaul AE, Nilasena DS, Ordin DL, Arday DR. Quality of medical care delivered to Medicare beneficiaries: A profile at state and national levels. JAMA 2000;284:1670-1676.