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› Accessibility
› Accountability
› Continuity
› Comprehensiveness
› Coordination
› Compassion
› (NO) Conflict of interest
› References and Further Reading

Quality of Care

A definition of quality of care, the measurement of quality, and the process of continuous improvement are currently undergoing intensive study and debate in the health care industry. The following is a summary to begin a dialogue between our patients and physicians.

Patients and physicians are partners in promoting quality of care. Below are essential aspects of insuring quality of care in Primary Care Medicine as outlined by the Institute of Medicine and expanded by two groups of researchers. The first group (Drs. Safran, Tarlov, and Rogers -- see references) have expanded the key indicators first set forth by the Institute of Medicine and it is their structuring of how to look at quality of care in institutions which forms the basis of the presentation of this information for our patients. The second group (Drs. Emanuel and Dubler -- see references) direct their published studies and reviews on the patient-physician relationship and we have included aspects of their important work for your review. Please be sure to review the references at the end of this section to obtain further information to enhance your understanding of this important topic.

Follow the links outlined to review how you can play a vital role in defining and ensuring quality of care in Primary Care Services.

Accessibility (Financial and Organizational)

The primary care practice must be accessible with the least barriers as possible for patients to access care (organizational) at a cost we can all afford (financial).

Suggested ways to work on accessibility are as follows:

What you can do
Learn about appropriate means of accessing care during clinic hours and after hours.Partner with your physician in choosing cost-effective diagnostic and treatment modalities.		 Provide feedback to SMG concerning organizational barriers to your care.
SMG Accessibility of Care Commitment
We will monitor clinic access and study innovative practice arrangements to optimize your access to care.Work with health plans and our sponsoring institutions to provide cost-efficient care.		 Utilize the process of continuous quality improvement in monitoring organizational access for our patients.

Accountability (Financial and Professional)

Primary Care practices are accountable for both the financial aspects of their work and on a professional basis to our patients, health plans, and sponsoring institutions.

Suggested ways we can work on accountability are as follows:

What you can do Learn how your health care is financed from both the perspective of your health plan andphysician. Learn about your physician's training background and current educational strategy. Request quality of care results from your healthplan and sponsoring institution.
SMG Accountability of Care Commitment We will promote the hiring and continual nurturing of the highest quality of physicians. We will work with our sponsoring instutitions and health plans to provide cost-effective care. We will work on reporting key quality of care indicators to health plans and institutions and on developingmore meaningful information to help you understand issues regarding quality.

Continuity of Care

Perhaps the key component in the generalist physician-patient relationship is the nurturing over time of a relationship which empowers the patient to take responsibility for his/her health utilizing the physician as a guide, resource, and companion.

We can promote this together as follows:

What you can do Establish with a physician at SMG either by making a general medical appointment orcontacting the physician's practice coordinator. Coordinate your visits with your physician's practice coordinator. Always identify your primary physician when receiving health care at Stanford Hospital and Clinics(SHC).
SMG Continuity of Care Commitment We will schedule all visits with your physician as possible. Coordinate communication between your physician and our other physicians in your doctor's absence. Work with our practice coordinators and SHC to place highest priority on continuity of care.

Promoting Comprehensiveness of Care

Comprehensive medical care of the highest quality requires both generalist and specialist physicians, working together to define a scope of practice which enables the patient to achieve her or his health care goals. In addition, a committment to lifelong learning is essential if the generalist-physician is to maintain competence and continuous innovation of practice.

We can ensure that Comprehensiveness is optimized by the following:

What you can do Anchor your health care by maintaining a relationship with a generalist physician. Work with your physician team to learn how each physician contributes to your care. Participate in innovate health care programs and provide feedback concerning your experiences with your care.
SMG Comprehensiveness Commitment Continually update our medical knowledge, skills, and attitudes through self-directed learning. Partner with our specialist colleagues in defining the scope of generalist and specialty practice. Expand and innovate primary care practice through research and education of physicians in training at Stanford.

Coordination of Care

Generalist physicians are interested in the whole patient and coordinating your care is a key element of providing quality care. Collecting data, analyzing changes, and making further adjustments in your diagnostic and therapeutic regimen based on specialty evaluations can occur only when the generalist physician is an integral member of your health care team.

We can ensure that coordination is optimized by the following:

What you can do Ask the specialist to send your SMG physician a copy of their consultation. When changes are made in your medication regimen by a referring physician, please notify us so we can immediately update your chart. Please notify us if you are ever admitted to the hospital.
SMG Coordination Commitment Monitor specialist referrals for links in communication. Coordinate all medication changes and diagnostic testing for our patients. Monitor hospital admission activity for patient admissions.

Compassion


Latin - com (together) and - pati (to suffer)

Oxford English Dictionary "suffering together with another, participation in suffering, fellow-feeling"

Perhaps not a point of arrival but of departure? 1

1An idea based on '...is humanity as a reality and as an idea a point of departure or a point of arrival? In. Berger, John, Mohr, Jean. A Fortunate Man. Pantheon Books. New York. 1967. page 167.

(NO) Conflict of interest

An excellent review of trust in the patient-physician relationship is outlined by Pellegrino, ED, Thomasma, DC. The Virtues in Medical Practice ( page 68 - see references).

Some of the elements of trust as outlined by Drs. Pellegrino and Thomasma are:

  • "...to trust that the physicians possess the capacity to help and heal." "we must place our trust in the person of the physician...neither intruding nor presuming too much nor undertaking too little."
  • "We must trust also that our vulnerability will not be exploited for power,profit, prestige, or pleasure."

The Stanford Medical Group physicians are committed to providing efficient, patient-centered health care. We do not receive additional compensation for withholding tests, writing prescriptions for any type of prescription, or for restricting use of hospital resources or specialty referrals.

References and Suggestions for Further Reading

A variety of sources are available for further reading with regards to the patient-physician relationship and quality of care in primary care. The Stanford Health Library can provide some references, while others are available at local libraries or at Lane Library on the Stanford campus. Suggestions to get started are as follows:

  • Safran, EG, Tarlov, AR, Rogers, WH. Primary care performance in fee-for-service and prepaid health care systems JAMA 1994;271:1579-1586.
  • Institute of Medicine. Report of a study: a manpower policy for primary health care. Washington D.C.:National Academy of Sciences; May 1978.

This important study expands the previous defined indicators set forth by the Institute of Medicine in 1978 (accessibility, continuity, comprehensiveness, coordination, and accountability) to include both financial and organizational aspects of accessibility and both technical and interpersonal accountability. We have utilized this framework in presenting this information for our patients on quality of care. This ongoing longitudinal study of primary care is important for patients to review as it is partly based on patient-provided information and we encourage you to read the entire study.

  • Emanuel, EJ, Dubler, NN. Preserving the physician-patient relationship in the era of managed care. JAMA 1995;273:323-329.

These researchers have written extensively about the physician-patient relationship and this article is an excellent starting point for their studies. In this discussion, we have added two of their five "C's" (compassion, and (no) conflict of interest) to the quality indicators set forth by Drs. Safran, Tarlov, and Rogers. The remaining indicators: choice, competence, and communication are included in the areas of accessibility, accountability, and coordination. This article is an excellent starting point for study in the area of managed care and the physician-patient relationship and to the body of work by these authors.

  • Pellegrino, ED, Thomasma, DC. The virtues in medical practice. Oxford University Press. New York 1993.

This book provides an outstanding overview of a virtue-based ethic for medicine. Discusses are the following virtues: fidelity to trust, compassion, phronesis, justice, fortitude, temperance, integrity and self-effacement. The theory and practice of these virtues as it pertains to all health professionals is extensively discussed.

  • Blumenthal, D. Part 1: Quality of care - What is it? N Engl J Med 1996;335:891-894. Brook, RH, McGlynn, EA, Cleary, PD. Part 2: Measuring quality of care. N Engl J Med 1996;335;966-970.
  • Chassin, MR. Part 3: Improving the quality of care. N Engl J Med 1996;335:1061-3. Blumenthal, D. Part 4: Origins of the quality of care debate. N Engl J Med 1996;335:1146-1149.
  • Berwick, DM. Part 5: Payment by capitation and the quality of care. N Engl J Med 1996;335:1227-1231.

This was a recent excellent series which reviews the current status of quality of care theory, measurement, and future studies required before continuous improvement can occur in health care.