BOOKS OF RtfiDIfGS - PAHO/WHO

- 135 -
The fourth requirement is largely met in
that the assessment method traces the care
received throughout an episode and relates
it temporally to health status. However,
causal linkages between process and
health status are not established by the assessment
and so outcome of care is not
established. The number of health conditions
available to use as tracers is expanded
greatly by examliiiting only segments of the
process of care rather than the entire process
for every tracer, although this limits the
conclusions that can be drawn about the
continuity of the entire procer. jf care because
the functions are not independent of
one another. More work is needed to understand
clearly how changes in one function
influence the performance of others.
The fifth requirement established
criteria for the selection of tracers. These
criteria have been met with the exception
that the representativeness ofithe tracers as
a group has not been demonstrated, as
noted above.
The sixth requirement establishes
criteria for defining standards of care for'"
the tracers. The standards established
were both minimal and agreed upon by the
local practitioners. The work of Brook 24
suggests that because the assessment
method uses explicit standards for the
process of care rather than implicit judgments
or indicators of outcome, the absolute
performances will be relatively low.
However, this is not important so long as
the performance indicators are consistent
over time and across comnponents, functions
and consumer groups and their statistical
attributes are not relatively worse than
methods using implicit judgments or outcome
indicators. More investigation of
these assumptions is needed.
Although the assessment method identifies
areas of major deficiencies, it has not
demonstrated that it systematically identifies
remedial deficiencies, as called for in
the seventh requirement. In order to determine
if the deficiencies uncovered are
able to be corrected, the assessment must
be imbedded in an effective assurance
process. Alternative possible remedies
must be identified and evaluated and then
implemented successfully. This is the
point where other assessment methods
have encountered the most difficulty, and
it is widely recognized that assessments
have not reliably led to improvements in
quality.' 3 . 16.S4.25
The eighth requirement deals with cost.
Our experience indicates that the cust of
employing this method in IHS service
units is modest. Nonprofessionals were
used successfully to collect and tabulate
data from the nonstandardized health records
currently found in Indian Health Service.
In 10 service units it took 13 data
collectors and two supervisors a total of 291
working days to identiiy the cohorts and
abstract data from the health records, plus
another 69 working days to tabulate the
data. Thus an average of 36 nonprofessional
days was required to collect and
tabulate the data per service unit. Each
worker also spent eight days in training.
On the average, data were abstracted from
3.4 different health records for each consumer,
with study cohorts of approximately
50 consumers for each of nine tracers. This
produces an average time for data collection
and tabulation of 38.4 minutes per
episode of care studied and 11.3 minutes
per record abstracted.
Others have also reported on the cost of
data collection by nonprofessionals for
episodes of care using explicit standards.
Some agree with our experience that the
cost is modest7 ' ' 0 while others have found
it expensive."'16 Recent work by Albrecht
and Kessner :t suggests that while the cost
of abstracting may be modest, the' fixed
1 Although not reflected in the above cost estimate,
IHS is implementing a computerized health
information system which integrates data from all the
health records maintained for a given consumer. Once
in operation, this system should significantly increase
the efficiency of the assessment through its use of
standardized encounter forms, a well-defined list of
consumers from which to draw cohorts, and identification
of the location of all relevent records.