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1 Four components affect quality health that can identified: pay­ are organization, third-party care review, and the individual health profes­ ers, peer is placed on the role of the Emphasis sional. health professional and on the partici­ individual of professional organization in guiding the pation enhancing the quality of health care. and u frequently has care ealth I I Downloaded from https://academic.oup.com/ptj/article-abstract/50/1/34/4595972 by guest on 11 May 2019 been and appraised as if it were considered utilized in a vacuum. This approach may be occasion, appropriate and commendable on but has immediate practical value. I will, little therefore, set the following realistic dimen­ sional limitations and make the following rea­ assumptions: sonable of Components United delivered 1. the care will be in The States under our present form of govern­ Quality Care Health and present economic system. ment our Health care, although one of the largest 2. of will country, industries not change this economic therefore, any the system; system must health-care to the eco­ adapt nomic system. 3. The ultimate judge and jury of the health­ ROYCE B.A. P. NOLAND, system will be the pub­ care increasingly than people rather and organiza­ the lic, provide the care. who tions Our society has, by desire or default, made 4. irreversible determination health an that be care through a system arranged will for third-party payers, with (or nonsystem) of major role. playing government a basis of these On four im­ the limitations, components which can par­ portant emerge health both quality ticularly influence care, positively. and are: (1) or­ negatively They (2) third-party payers; (3) peer ganization; and the individual health profes­ review; (4) In discussing these four, however, pass­ sional. reference should to one other com­ ing be made Discussion education education. of ponent: deferred, not will it has low priority, be because rather because it has the highest but priority and could not be adequately con­ therefore in prerequi­ paper. Education is a sidered this health rather site, component, of quality than a care. 34 PHYSICAL THERAPY

2 stability of bastion the been have associations ORGANIZATION for decades. many system health-care our in or­ society is Our inherently motivated to stabiliz­ a has that organization any However, over- ganize anything we do. We also tend to also have influence. stifling a can influence ing or­ to the extent that eventually the organize to contribute to are health If organizations of instead service, the rules ganization the care, health (1) develop: must they quality ruling service organization. Overorganiza- the personnel health to adaptability more their and weaken rather than improve the to tends tion more (2) of ease needs; for simplicity under­ service. quality of by standing the patient; and (3) more flexibility health organi­ our structure we Furthermore, needs. Health adjusting in to local community understandable to them make zations not to like be should organizations con­ in chameleons then the public, but to make understandable to forming to surroundings. their the administrators at the top. The organization Downloaded from https://academic.oup.com/ptj/article-abstract/50/1/34/4595972 by guest on 11 May 2019 beneficial often of the hospital complex is more PAYERS THIRD-PARTY to the people admin­ there and to the working the to majority of patients. The istrators than more With payers, with third-party more and cramming Medicare concept of all health ser­ government payer, third-party a federal the into three "provider" categories was de­ vice involving now care health a of percent with 80 arrangement an because not veloped would such third-party payer, the inevitable result will be health of system better a to lead necessarily funds available and a greater that be more will administrators the pro­ of care, but because the of Our quantity purchased. be will care health that found gram understandable. more structure feel society seems deficit quality a when that to group A in not, it­ does medicine of practice of doses large inject must we exists, quantity. better ensure self, prac­ Group care. medical seem but works, rarely method This de­ we only if the individual physicians tice better is and termined to try it again again. We pour practitioners. superior are group the in Health billions system the into dollars of each year, organizations will contribute to quality care the Yet amounts are increasing and each year. that cause the to only they the other degree are of not even approaching that basic goal we The better. function to components fun­ most bringing that system; the into people the is, Does damental question to ask is: the organi­ care, need who those all the need they time at or patients into need in bring system the zation need. it, are for the services they and Dollars that system in the best way? people in need not to deterrent principal the procedures, forms, and even the Regulations, the health-care the entering system; nor is into often of place physical are system the entry princi­ the available services health of amount greater potential and needy pa­ inhibitors to pal quality optimum attaining to impediment fundamental treat­ tients than the fear of the health our has Rarely care. any­ wanted society was the itself. Ask any ment patient what get, did we not quantitative a in that thing of hospital and most irritating stay, his part We have apparently chosen the third- sense. more than often not, he will cite his experience the paying party of health for as payer method admission desk. the at be probably will care health More care. the meant are comments These to imply that not result, in less be will patient the but involved is hospitals of organization unnecessary. The quantity the for, need and the determining supportive voluntary and this country and their nature and receives. he care health the of, But how third-party payers influence do quality? the most talked-about third- Certainly party payer these days is the federal govern­ ment Security the Social through provisions. Director Noland California the of Executive was Mr. This effort program greatest the represents by Association of the American Physical Therapy Chapters Di­ now Executive this paper was prepared. when He is third-party standards enhance to payer one any American Physical Therapy Association, rector the of care. payers, third-party many so Unlike of 1740 Broadway, New York, New 10019. York from a presented at the Forty-fifth Adapted paper An­ merely pouring than more the program is doing American the Conference of nual As­ Therapy Physical that dollars into the health-care system, and is July Illinois, Chicago, sociation, 1968. 35 Volume 50 / Number 7, January 1970

3 cumbersome regulations that surround our pro­ the program will be­ commendable. In time, vision of services. quantity, on influence major largest the come peer In the presence of third-party payers, and a quality. be on influence could major In is it desirable; than more is review mandatory. advance an effort the service, of quality the to has time The so, appropriately and passed, new many introduced has program important health of provider the when patient the and care it emphasis major placed has on but concepts, get together, determine the quantity of could of the institution or the agency as the guardian of the care, the cost the of nature the care, and a have will approach This bene­ major quality. those all dictate then and care, determinations effect but on minimal standards, ficial basic On payer. third-party the to other no hand, the will emphasis this when only quality improve one made accept determinations would solely individual health professional. the is shifted to Thus, so­ logical the payer. third-party the by be The the center, the focal point must core, Downloaded from https://academic.oup.com/ptj/article-abstract/50/1/34/4595972 by guest on 11 May 2019 peer-review is lution bodies. neutral, voluntary the perform the who services, people coupled and be will review However, peer effective of system a with review. peer review a that: just it when only valuable of is persons by services especially knowledgeable QUALITY PEER REVIEW AND services must be about the service. Physician by therapists Physical physicians. reviewed it review has Peer existed for some time but review the in involved be ther­ physical of must practical, been has more of an exercise than a apy services. meaningful force. The Medicare program has, impact on Peer review a will have beneficial for indeed, recognized and provided peer re­ is review peer however, field, the in view; when of simply quality the present approach peer reducing quantity is altered. Effective superficially the treated like cousin, country rec­ peer has Nor ignored. generally but ognized review be involved not only with over- must from attention adequate the review received on under- counsel give must but utilization, also more health professions. We should do than It appro­ the judge only not must utilization. full peer review; we should demand its accept the of be also must but care, advocate priateness of gain implementation. We have the most to care. optimum and lose most implementation its from to the The relationship will be­ physician-patient its forcefully and Effectively absence. ad­ from of physician-patient-third-party come a triangle elimi­ peer review ministered, could the justify for payer, and a similar triangle must emerge generally the of many of nation and ineffective other professions. The peer-review body health must be the arbitrator, the proponent of tem­ perate, care. health quality value-defendable, role this Abdicating especially else, anyone to of will paralyze the advancement government, re­ motivation, quality, and will destroy the Cm( are to con­ organizations If health * and initiative of the individual. sponsibility, health they quality to tribute care, must develop: (1) more adaptability to INDIVIDUAL THE PROFESSIONAL HEALTH and personnel health (2) needs; their the The individual health professional is more simplicity for ease of understand­ component indispensable only quality health of is statement This care. not intended down­ to by more (3) ing and patient; the flexi­ the other A components. the value of grade bility community local to adjusting in reveals review of organization standards clearly should organizations Health be needs. that those standards are, essentially, a com­ of standards the of health various the posite like chameleons conforming to their in professions. what are these standards of But 55 surroundings. professions? are obvious ones the laws The ethical the Although I recognize and principles. for need and will later emphasize their these PHYSICAL THERAPY 36

4 value and these standards are aimed importance, at that 5 at bottom, principally the "miserable which, either health all of percent" professions 66 wanted society any­ our has Rarely lack fail to provide by intent or a of ability, service. meaningful reasonable, For valuable, get, quanti­ not did we that thing a in legal, sometimes these percent, 95 other the have We sense. tative apparently little voluntary sometimes guidelines serve as the the as payer third-party chosen than occasional reminders. The vast ma­ more of aware intuitively are therapists physical jority health for method of paying care. not only of of right and wrong, but also good More care will probably be the health mes­ and better. Our greatest enemy is being patient the result, in­ less be will but The force by merized inhibiting greatest habit. Downloaded from https://academic.oup.com/ptj/article-abstract/50/1/34/4595972 by guest on 11 May 2019 to individual is care health quality acceptance for, in determining the need volved the of as traditional of quo, status methods the and the quantity and nature of, alone let adequate, being exceptional. 55 health he receives. care specifying Before of the ways the in­ some dividual physical therapist can influence quality health some comments should be made care, blew the team approach. An ill wind about into terminology our vocabulary. The this games, phrase team approach implies coaches, rela­ and players. Interprofessional captains, on too often lean the phrases "It's what the by tions are hurt this shuffle of determining ordered" directions" doctor or "just following who not do professionals True what. will be inter­ to activities. No their rationalize sane such need work to motivations childlike to­ relationship on based professional can be is what Interaction we gether. are seeking: are in­ performing or directing services which group recognizing its each professional need appropriate. But more than that, physical the de­ its and of, competencies special for, of should be the chief proponents therapists on, Our groups. other the will goal pendence will, occa­ improving service. This activity on scoreboard. a Our goal on not be expressed conflict be sion, cause them to only not in will comprehensive health care. This goal is with also but structure, the with medical the be participant individual each when achieved administrative may conflict The structure. even has the is given, and competence to accept, situation But positions. their them cost any needs the of singular responsibility for the performance at demands than optimum that less sphere. within patient professional his thera­ Physical position. worthwhile not is a can How physical therapists, as individual collaborators a form of fraud. in are pists human care, ad­ components of quality health some that hospital all We departments know the many this elusive concept? Three vance of little day-care centers for malin­ than more are are: (1) ways self-exertion; (2) exemplary and gerers some that home-care do agencies self-regulation. and behavior; (3) little more tangibly than the local welcome Self-exertion nursing Some wagon. 50 to 40 have homes physical for patterns utilization percent direct mean expression self-exertion does not The therapy Some work therapists physical service. should attempt as­ to therapists physical that with facilities extended-care in full time fewer of service any role, any task, or any phase sume is that about as jus­ one hundred beds, which than exceeds their competence. On the whole, tifiable nursery in teaching Kerr a Clark as they do not enough backbone in saying display school. when no they in treat­ involved are and witness these The which are less than adequate. fact that ment situations procedures are legal, and that third-party such as Medicare, may payers, Physical therapists need to be more masters the these does patterns, encourage inadvertently for of that service, responsible their and liable who not participate therapists physical justify service Therapists it is appropriate. not when Volume / Number I, January 1970 50 37

5 cal therapy profession's high standards of com­ in can only decry them. therapists Collectively, because petency and practice are high therapists stop can therapist individual the Only them. situation, community, them, and, in in his his them are standards ethical Their be. caused to specifically, situation. work own his in more chose stringent because they and they alone practice level of self-discipline. The this acts Some forces, supposedly legitimate organiza­ government components, tions, agencies, and requirement for rela­ a the include that referral quality from and demean therapists care. detour careful and physicians with tionship delineation But therapy service occurs only poor physical of scope service, consistent with educational of were preparation, therapists. upon inflicted not without and therapist, the of presence the in can He, cease. will him he, and only cause laws themselves chose that these They exist to poor service to stop—or improve. and provision. restrictive their on insisted Physical have also provided the therapists Downloaded from https://academic.oup.com/ptj/article-abstract/50/1/34/4595972 by guest on 11 May 2019 Behavior Exemplary practical leadership in the development and a to propagate is profession of purpose One maintenance of educational standards. This the improve to itself, order in thera­ If breed. stated the with friction cause to not is fact pists quality are to be participants in advancing respected and honorable profession medicine, of who health care, they must be sure that those therapists enjoy group with whom physical a them follow not are. they as good as merely are exceptionally but to empha­ amicable relations, the not is Education better. be must They end, a the fact size that therapists have heritage rich con­ of this process. The but just the beginning of professional obligation to pro­ their fulfilling education, mo­ the patterns, habit tinuing the high-quality vide competent, appropriate, care. among tivation to make good practices better heritage places the demand therapists, This on originate with those entering the profession will promulgation and the continue to collectively, optimum enhancement of standards of practice they therapists. The today's question is, Are and, individually, to recognize extraordinary exemplary? that individually self-discipline of belonging part as conduct and dis­ to reason more have therapists Physical a to profession. The learned health professions play and leadership in the area of rehabilitative the tolerate weak the protect cannot incom­ or than services restorative else. They anyone reason rather than hub have every the to be unscrupulous. petent and the for not wheel, the of spoke the of purpose value its and shell, a but is institution The the people who fill it. shell depends on The but self-gratification simply because they have must be flexible, able to adapt to the community general anyone than offer to more a As else. who in health the and function it. personnel accrued and more have they rule, experience quality hinder or help can payers Third-party knowledge this area, and yet they share that in health either. do to have not should They care. with others less than most other knowledge of would groups. The cause quality care health richly therapists shared some of if enhanced be Much of their knowledge they the knowledge. granted take for many by interpreted be would other edifica­ significant as professionals health tion. 66 and adminis­ forcefully Effectively Self-regulation peer could justify the tered, review laws are and vital ingredients, Self-regulation and each profession must promote them. of elimination generally of many the its medicine Whether any of organized or cumbersome and ineffective regula­ else, anyone or components, im­ the carries that of provision our surround tions responsible pression were for that they estab­ 9 )') services. ethical lishing physical therapy's high standards, principles, or legal limitations is unimportant. that What is important is that therapists know do The groups had little to those with it. physi­ PHYSICAL THERAPY 38

6 This responsibility and should be belongs to, by, the health professions totally assumed collective peer review, professional through 66 Physical therapists have more rea­ competence. individual standards, and organize, can therapists Physical interact, son area the in leadership display to subordi­ regulate, institutionalize, teams, form ser­ restorative and rehabilitation of cooperate, more. nate, administer more, spend than anyone else. They have vices activities some value in have pro­ may All these viding the However, care. health high-quality than rather hub the be to reason every component high- of indispensable one only because merely spoke of the wheel, the health individual competent the quality is care than they have more to offer anyone atmo­ He must, however, work in an therapist. Downloaded from https://academic.oup.com/ptj/article-abstract/50/1/34/4595972 by guest on 11 May 2019 sphere that does not group him into a faceless quality of cause The else. care health when care High-quality each occur will maze. physical if advanced richly be would individual the to function can participating therapists shared knowl­ of some their of capacity competency. Equally important, his .55 edge constantly be exposed to the scrutiny he must peers, of public and his the so that he is indi­ to personally challenged and vidually function at his best. young Physical therapy is a relatively profes­ sion, and learn the meaning of the word must authority, before competency and of the word Hale Nathan "I am well: question that answer service before status. The prime mover of only everything, do can't I one. am I but one, quality care is the individual health health that do— can I What something. do can I but maximum his exerting professional potential do. I ought to What I ought to do, by the judicious under indi­ can What the restraint. grace of God, I will do." health vidual of The do? professional words author the P. Noland is a graduate of Whitman College in Walla Walla, Royce and holds certificate in physical therapy from Stanford Washington, a Palo a California. He has been in member of the University Alto, Directors of the California State Health Manpower Council, Board of consultant to the California State Departments a Public Health and of of Care Services, and a member of the Public Health League Health California. executive is now of director of the American Physical He Association. Therapy 39 Volume 50 / Number 1, January 1970

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