CHAPTER 31: Standards and Quality of Care
The term "standards" has two distinct meanings: a criterion for quality or acceptability, and the usual level of practice. The first meaning implies a test of acceptable practice established by a high authority, such as a government agency, a consideration of ethics, or the expectations of society or one's peers. The second meaning implies the minimum one can get away with without being perceived as inferior, as determined by usual custom and the actual practice of one's peers. Standards of practice may have aspects of both.
Standards in occupational medicine are not simple and direct, as in general health care. The physician in the occupational health care system is part of a much larger network which balances the legitimate interests of the five or six parties involved: the physician, the patient-employee, the employer, the workers' compensation carrier, the government (OSHA or its counterpart), and, often, the employee's union. The physician's traditional one-to-one relationship with the patient is modified into a hierarchy of responsibilities in which the relationship to the patient is primary but not exclusive, and may be governed in important respects by law, government regulation, fiduciary (financial) responsibility, and obligations to the other parties.
For legal purposes in deciding malpractice cases, the criterion employed is the standard of practice in the community. If a physician treats a patient in the same manner as most other physicians in a comparable area would, this fact is a defence against the liability of the physician for improper practice.
Quality of Care
Because the delivery of occupational health services is diffuse in the community or centralized only in special institutions such as industry or medical schools, it is more difficult for the busy practitioner to know whether he or she one is practicing at a suitable standard than when providing general medical care. This is particularly true when occupational medicine is only a small portion of the physician's practice. In general, the medical management of an occupationally-related case should be no different than that of a comparable case in general medical care. It is beyond the ability of any clinician to recall all the possible health effects of toxic exposures or the particulars of many industries. Knowing where to find this information and where to send the patient-employee for referral is a principal responsibility of any physician who deals with work-related disorders.
Faced with requests to provide services which are not medically indicated but which do not harm the patient, the physician should generally prepare a brief letter to the employer outlining one's reservations on medical grounds. In general, however, the employer's request should be honored. Screening in preplacement evaluations is notoriously slow to change and employers are reluctant to change a policy perceived as successful. Physicians should then interpret any abnormal findings on tests conservatively with due attention to the principles of diagnostic probability and should monitor usage to ensure that practices are not abused.
The situation is very different when the physician is asked to perform a study or to employ a treatment which is dangerous or unproven. Routine low back X-rays without a specific indication, for example, have a very low yield of pathology, are rarely helpful in predicting whether an employee will develop back pain, and expose the subject to significant radiation for no benefit. Certain therapies, such as chelation to lower blood lead levels, are dangerous and rarely indicated. In such situations the physician has a duty to explain in precise and logical terms understandable to the lay person why one is refusing and to explain the matter diplomatically to the employee. Usually, such issues arise because an employer is following obsolete guidelines or lacks a medical consultant with occupational health experience.
If a physician cannot provide a service or is not knowledgeable in an area in which one is asked to provide care, there is an absolute duty to either refer the case or to acquire the necessary skill at a level commensurate with one's responsibilities. A physician should not, for example, accept responsibility for screening for asbestos-related disorders without becoming familiar with the clinical aspects of asbestos-related diseases and the asbestos standard.
From the primary care physician's point of view, the occupational physician is interrupting continuity of care and encroaching on one's practice by providing direct care to employees. From the occupational physician's point of view, the primary care physician is unlikely to have the specialized knowledge needed to manage some uniquely occupational problems. It is very important that such disagreements be handled in a mature and rational manner because the employee's best interest is served when the two physicians work together. In general, it is better for the occupational physician to perform or arrange for routine screening tests for three reasons: 1) Primary care physicians may not have the background to interpret the implications of the findings with respect to a particular job. 2) Plant physicians are in part responsible for protecting the health of employees in their plants and must be personally satisfied with the evaluation. 3) A busy practitioner is often tempted to cut corners by substituting past examinations or recent lab tests or to bend guidelines to the benefit of one's personal patients. On the other hand, it is usually best for the private physician to handle treatment except in cases such as toxicity-related problems which fall outside primary care practice. When the employee's personal physician handles the management of the case, one should not take offense if the plant physician routinely sees the patient or calls to monitor progress. The decision to allow the patient-employee to return to work should be made jointly after mutual consultation.
Standards of Performance
"Standards of performance" refers to indicators of how well occupational health services are meeting the needs of employees in general and employers, as opposed to the individual patient. Performance can be categorized in many ways but here attention will focus on efficiency, cost, effectiveness, and administration. The discussion will first treat occupational health services in primary care practices, and will conclude with an outline of the evaluation of performance that applies to both.
Occupational health programs in industry are somewhat expensive to operate although less costly then dealing with major health problems. Whether a small-scale safety program or a complete corporate medical department, the employer must provide personnel, facilities, administrative support, overhead (expense of heating, maintenance, custodial services, and so forth), and equipment. Employers need to know that a program will be effective in its goals and need to run the program as efficiently as possible. This means closely monitoring costs and not committing a company to expensive programs unless a need for them can be demonstrated. This is a responsible, business-like approach from industry's point of view, consistent with the social purposes of industry in the first place: to create wealth and to provide goods and services needed by society. The problem with this approach is that it is often very conservative, especially in companies that are rapidly growing or are faced with financial problems. It is often impossible accurately to document the benefits of employee health protection. Preventive services can only be evaluated by predicting (usually on the basis of past experience) events that did not occur, such as accidents that did not happen or health problems that were avoided. Managers are usually skeptical of such estimates and rely on changes from year to year, which is often misleading because of the effect of other factors such as changes in hiring or retirement and because one or even ten years do not provide enough time for many health promotion activities to have an impact. Many secondary benefits of such programs are not reflected in financial terms or reduced risk of liability. Nevertheless, an increasing number of larger employers are taking a broader view of the health of their employees and are establishing offices to manage their human resources as well as they do their material resources. It is much harder for small companies to afford this, hence occupational health services are usually weakest in small businesses.
Performance in a private medical practice setting is more difficult to evaluate because the individual physician or clinic seldom covers all employees of a single plant and usually cannot easily retrieve the information needed. Certain indicators are useful, however. The delay between arrival of an employee for a visit and discharge is a crude indicator of efficiency. Excessive delays are a frequent complaint and may be caused by bottlenecks in obtaining lab tests or completing paperwork.
The flow of paperwork is another common problem. First reports and supplemental reports should be filed within 24 hours because the workers' compensation system depends on them for critical and expensive decisions about eligibility for compensation, duration of payment, and when to close out a case. Delayed reports are a major source of dissatisfaction.
Employers are also in need of information after an employee is evaluated. Is the employee fit for an assignment, how long will the employee be off work, will the work have to be modified? These are practical considerations that translate into practical concerns about scheduling work, reassigning personnel, or hiring a replacement. A simple telephone call or a handwritten note from the physician or nurse is very much appreciated. The vocabulary or workers' compensation is also important. When reports are vague or expressed in terms which are strictly medical, the system cannot interpret them. As indicated in Chapter 7, precise terms such as "temporary full disability" or "partial 30% impairment resulting from injury to the left hand" are preferred. The telephone should be used freely.
Return visits are a common source of problems. In general medical care it might be common practice to give a patient with low back pain conservative treatment and to reschedule a return in six weeks. From the point of view of workers' compensation or the employer, however, that may be evidence that the physician is not responsive to their needs. The patient-employee may be fit to return to work in four weeks or may have compounded the injury by a second back strain at two weeks that will require further temporary disability beyond six weeks. Thus, return visits should be scheduled as often as necessary to monitor the course of the employee's recovery until the recovery is either complete or stable. In some cases, this may be as often as daily, but usually will be weekly, even if the duration of the return visit is only a few minutes. It is much more expensive for workers' compensation for cases to drag on without a clear prognosis or for employees to return to work days after their recovery is complete than it is to pay for additional return visits and supplemental reports. It is also better for the employee to return to a normal life at full wages or salary than to stay off work indefinitely with an uncertain prognosis. This is an important difference between occupational health care and general ambulatory health care: Occupational health care requires frequent return visits with closer monitoring of even routine problems.
As occupational health services expand, two problems in maintaining quality arise: control over increasing numbers of staff and the stress placed on the entire system by an increasing caseload.
Quality control in occupational medicine is a major problem today. The field attracted many highly questionable practitioners in the past and is still saturated with physicians who practice it as a job to be done rather than as a specialty and commitment. Although developments at the "top" of the specialty are progressing very rapidly, clinical practice at the "bottom" remains mostly routine examinations and minor trauma, subject to slippage in quality due to boredom or bad habits. Client employers are not always informed or reasonable in their requests and it is often tempting to take the path of least resistance and to comply with ill-considered requests. Nonetheless, quality of care cannot be a variable. It must be a constant in an organization that cares.
Strategies for quality control among the medical staff do not have to be onerous or burdensome. Table 31.1 lists alternative strategies for quality control that might be adopted. These are classified by whether participation by the physician is voluntary or involuntary and by whether the strategy merely prevents or corrects poor practice or actually makes a substantial, constructive contribution to the practice of occupational medicine. Obviously, those strategies which are voluntary and constructive are much to be preferred to those which are coercive and only corrective. It should be emphasized that involvement in an academic program is a relatively painless way to promote quality control because it stimulates preparation for teaching, peer interaction, analysis of problematical cases, and chart reviews incidental to constructive purposes. It is highly appropriate for a major, diversified occupational health service to participate in a training program for occupational physicians, nurses, and mid-level health practitioners.
Quality control among support staff can be enhanced in somewhat the same way by promoting in-service training and dispensing recognition for good performance. Above all, the attitude should always be emphasized that occupational health is a valuable field contributing much to both the worker and the employer and that staff in the service are contributing substantially to the success of an important endeavor.
Table 31.1. Alternative Strategies for Quality Control In Occupational Health Services
Chart audits Case discussions*
Civil claims Continuing medical education programs*
Utilization monitoring Board certification requirements or preference for staff positions
Legal enforcement actions
Chart reviews for administrative Chart reviews for research and teaching*
purposes Postgraduate medical teaching*
Interviews with client employers Interaction with occupational medicine
(by marketing) physicians outside group*
Supervising professional training*
* Activities which form part of an active academic training program.