Quality, Accreditation, and the Patient-Centered Medical Home

Quality in a Tribal health program is more than a score on a report or a certificate on the wall. It is about whether the organization consistently provides safe, effective, accessible, and respectful care.

For a Health Director, quality is a management responsibility. Accreditation and the Patient-Centered Medical Home can provide useful frameworks, but they should support the health program rather than become ends in themselves.

Quality Is More Than a Score

Health programs measure many things: access, preventive services, chronic disease management, patient experience, clinical outcomes, referrals, staffing, and other indicators.

Measures are useful when they help the organization understand what is happening and decide what to do next.

A number by itself does not improve care. The important questions are:

What does the measure tell us?
Why is performance where it is?
Who is responsible for improvement?
What resources or changes are needed?
How will we know whether the change worked?

Quality improvement should therefore be connected to day-to-day management.

Quality Improvement Is Everyone’s Responsibility

Quality is sometimes treated as the responsibility of a quality department or a particular staff member. That is too narrow.

Clinical staff are responsible for clinical quality. Administrative staff affect access, scheduling, billing, and the patient experience. Health information staff affect the availability and accuracy of information. Managers affect staffing, supervision, communication, and follow-through.

The Health Director’s responsibility is to make sure these pieces work together.

A quality problem may not actually be a clinical problem. A missed appointment may reflect transportation or scheduling. Poor follow-up may reflect staffing or information systems. Low screening rates may reflect access rather than a lack of clinical knowledge.

The first question should often be: What is happening in the system?

Accreditation Can Strengthen a Program

Accreditation can provide an external framework for examining how a health program operates.

Depending on the organization and services provided, accreditation may address patient safety, clinical practices, documentation, infection prevention, credentialing, quality improvement, governance, and other organizational functions.

A good accreditation process can identify weaknesses that an organization has become accustomed to overlooking. It can also provide a common set of expectations for staff and leadership.

But accreditation is a means, not the purpose of the health program.

A program can become very good at preparing for an accreditation survey without necessarily becoming better at serving patients. The goal should be to build systems that work every day, not merely systems that look good when someone comes to inspect them.

The Patient-Centered Medical Home

The Patient-Centered Medical Home, or PCMH, is an approach to organizing primary care around the needs of the patient.

The basic idea is straightforward: primary care should be coordinated, accessible, comprehensive, and focused on the person rather than on individual departments or isolated visits.

For a Tribal health program, this approach can be particularly useful because patients may interact with many parts of the health system. Primary care may connect with behavioral health, dental care, pharmacy, public health, Purchased/Referred Care, community health representatives, and outside specialists.

The patient does not experience the organizational chart. The patient experiences the health program as one system.

Quality and Access Are Connected

A health program cannot provide high-quality care if people cannot get the care they need.

Long waits for appointments, difficulty reaching the clinic, inadequate transportation, limited specialty services, staffing shortages, and fragmented referrals can all affect quality.

This means that quality improvement should not focus exclusively on clinical measures. Access is itself an important part of quality.

The Health Director should be able to see where patients encounter barriers and determine whether those barriers can be addressed through changes in staffing, scheduling, services, facilities, technology, referrals, or partnerships.

Keep the Measures Manageable

There is a temptation to measure everything.

That can produce large reports without producing better management.

A useful management system should identify a manageable number of measures that tell leadership whether the program is accomplishing its most important objectives. The measures should be understandable to the people expected to act on them.

Tribal Council generally does not need a clinical quality dashboard with dozens of measures. Council needs to understand whether the program is meeting its responsibilities, where significant problems exist, and what resources or policy decisions may be required.

The Health Director and clinical leadership need more detailed information to manage the program.

Different levels of management need different levels of information.

Questions for Tribal Leadership

What does our health program mean by quality?
Are quality measures helping us improve care or simply producing reports?
What are the most important quality problems facing the program?
Are access and staffing problems affecting quality?
Is accreditation strengthening the organization or becoming an administrative burden?
Are primary care and other services working together around the patient?
Do we know where patients experience delays or gaps in care?
What information does the Health Director need from Tribal leadership to address quality problems?
Are we measuring enough to manage the program without measuring everything?

The Principle

Quality improvement is a management system, not a compliance exercise.

Accreditation and the Patient-Centered Medical Home can provide useful frameworks, but the real test is whether the Tribal health program consistently provides accessible, safe, coordinated, and effective care to the people it serves.

The objective is not to build a program that passes an inspection.

The objective is to build a health program that works.