BOOKS OF RtfiDIfGS - PAHO/WHO

NUTTING ET AL.
sought care for specific health problems.
Most emphasize only diagnostic and
treatment functions.
More comprehensive methods are
needed. This article presents an approach
to quality assessment 'which tralcks members
of the community into and through
episodes of care provided by various parts
of the medical care system.
Requirements for Quality Assessment
in the Indian Health Service
The Indian Health Service (Department
of Health and Human Services) has
evolved a complex system of health services
delivery. Charged by Congress to assure
comprehensive health services to
more than 600,000 American Indians and
Alaskan Natives, the Indian Health Service
(IHS) has developed and is operating
more than 85 local comprehensive health
care systems, called Service Units. The
typical Service Unit serves a dispersed
population, often scattered over severaithousand
square miles. It usually consists
of a 30-50 bed hospital and outpatient department
staffed by a variety of health professionals
and administrative staff. The
main Service Unit facility serves as a referral
center and administrative base for
one or more full or part-time field clinics,
public health nurses, environmental engineers,
health educators, and a variety of
problem-specific health programs (nutrition,
mental health, maternal and child
health, alcoholism, etc.) operated by the
tribal government. Each Service Unit can
also refer patients to secondary and tertiary
care centers, either operated by the Indian
Health Service or through contract within
the private sector.
As Service Units have grown more complex
and Indian communities have become
more mobile and more active in health delivery
programs, the methods traditionally
used by IHS to assess and assure the
quality of care have become i. adequate.
Therefore, the Indian Health Service has
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undertaken a long-term research and development
effort in the assessment and
assurance of quality.
In an earlier study in one Service Unit,
patients were tracked through episodes of
ambulatory care for several prevalent
health problems. 7 The study demonstrated
that 1) explicit criteria for minimal care
could be defined by the Service Unit
physicians; 2) reliable data could be collected
retrospectively from medical records
by nonphysicians; 3) failures in the
process of care could be identified; 4) the
failures tended to occur at the same places
in the process of care for different health
problems; and 5) this information caused
the Service Unit to take action aimed at
correcting the problems.
As a result of this experience, eight requirements
were defined which, it was
felt, would make the assessment method
applicable throughout Indian Health
Service.
First, the assessment must examine the
performnance of the total health system.§
All facilities, organizational subunits, and
programs providing health services within
the community should be included
whether or not the individual components
consider themselves as a part of a "system."
The contribution of physician extenders,
pharmacists, public health nurses and
community health personnel as well as
phSysicians should be included. The combined
effect of consumer and provider on
system performance should be measured.
Second, the assessment must examine
the care received by all members of the
community, both patients and nonpa-
4 The total health system contains the consumer
subsystem and the provider subsystem. Much of our
attention focuses on the medical care system, which
we define as that part of the provider subsystem providing
medical care. Components refer to the varinous
parts of the two subsystems. For example, the assessment
examines three types of components in the medical
system. including facilities, organizational subunits
and professional disciplines, although other
components could also be identified.