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Community Health Centers and Quality ofCare: A Goal to Provide Effective HealthCare to the CommunityEvelyn E. St. MartinPublished online: 07 Jun 2010.

To cite this article: Evelyn E. St. Martin (1996) Community Health Centers and Quality of Care: A Goalto Provide Effective Health Care to the Community, Journal of Community Health Nursing, 13:2, 83-92,DOI: 10.1207/s15327655jchn1302_2

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JOURNAL OF COMMUNITY HEALTH NURSING, 1996,13(2), 83-92 Copyright @ 1996. Lawrence Erlbaum Associates, Inc.

Community Health Centers and Quality of Care: A Goal to Provide Effective Health Care to the

Community

Evelyn E. St. Martin, RN, MS University of Maryland at Baltimore

The uniqueness of community health centers provides for a sound environment for total quality management (TQM). Structure, process, and outcome are valued equally under TQM. With strong management leadership and a framework for quality of care, community health care specialists (e.g., advanced practice nurses) can easily incorporate the TQM measurement criteria in their daily practice routines. By applying the principles of TQM, the community health center will advance toward its goal of enhancing the effectiveness of health care delivery to a community and its members in partnership with the community.

Come, give us a taste of your quality-Shakespear Hamlet

The community health center is a nonprofit health care agency concerned with health promotion and primary prevention goals for specific populations. Populations may include the homeless, minorities, Medicaid recipients, migrant/seasonal farmworkers, persons infected with HIVIAIDS, the underinsured, and the uninsured. Community health centers are funded by the Bureau of Primary Health Care, U.S. Public Health Service, U.S. Department of Health and Human Services, via grant money and are located in designated medically underserved areas. The National Association for Community Health Centers and state associations for community health centers are advocates for the local centers.

Community health centers are unique in that they employ community health care specialists (e.g., family practice physicians and advanced practice nurses); they provide accessible primary care preventive health services; their clients include the individual, family, and community; and they have a partnership relationship with the community.

Community health centers, in their mission of providing health promotion and primary prevention, are concerned with access, cost, and quality issues. This article specifically

Requests for reprints should be sent to Evelyn E. St. Martin, RN, MS, 1226 Wild Rose Court, Mani- ottsville, MD 21 104.

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84 St. Martin

addresses the following quality care issues: (a) concepts, (b) standards, (c) measurement criteria, and (d) direction of quality care for the community health center.

Palmer (1991) stated that quality of care is the "production of improved health and satisfaction of a population within the constraints of existing technology, resources, and consumer circumstances" (p. 27). Quality care implies co-ownership. The American Nurses Association (ANA; 1991), in Nursing's Agenda for Health Care Reform, stated:

Consumers must assume more responsibility for their own care and become better informed about the range of providers and the potential options for services. Working in partnership with providers, consumers must actively participate in choices that best meet their needs. (p. 8)

As a management approach, quality care is a guarantee for cost-effective, accessible care. A study completed by Starfield et al. (1994) concluded that for those individuals whose health care is covered by Medicaid funds, there is a "generally higher quality of care for patients in medium-cost community health centers" (p. 1903).

With regard to quality of care in community health centers, the goal should be to enhance the effectiveness of health care delivery to a community and its members in partnership with the community. In order to accomplish this goal, community health centers should clearly define the mission, assess both agency and community values and goals, define quality of care as it relates to health, and follow a framework for quality of care.

CONCEPTS

Concern for quality in health care is nothing new; however, more attention is warranted. Shamansky (1991) noted, "the new focus on quality does indeed represent a paradigm shift in the most fundamental sense from a concentration on assessment and monitoring . . . and from a provider and process orientation, to a customer and outcome orientation" (p. 145). In this article the following key concepts, related to quality, are discussed: (a) quality assurance (QA), (b) peer review, (c) continuous quality improvement (CQI), and (d) total quality management (TQM).

Quality Assurance

QA is a traditional evaluation activity that is cyclic, intermittent, and retrospective. The ANA (1 986) defined QA as "activities to estimate and increase the level of excellence in the alteration of the health status of consumers, attained through review of providers' performance of diagnostic, therapeutic, prognostic, or other health care activities" (p. 18). More specifically, Jennison (1991) described QA as "the search for performance outliers" (p. 423). QA focuses on the measurement of structure, process, and outcome criteria by a designated QA team. In community health settings, QA traditionally includes:

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Community Health Centers 85

1. Meeting the requirements of regulatory agencies on a yearly schedule. 2. Performing utilization review on a quarterly schedule. 3. Performing peer review on an ongoing schedule. 4. Supervising staff on an ongoing schedule. 5. Learning through continuous internal and external continuing educationlprofes-

sional development.

Peer Review

With respect to nursing, peer review is one aspect of QA and is the "process by which nurses actively engaged in the practice of nursing appraise the quality of nursing care in a given situation in accordance with established standards of practice" (ANA, 1986, p. 18). Peer review is an internal evaluation activity that is usually subjective in nature. Kitson (1986) stated that for peer review "to work there must be mutual trust and respect, an awareness of one's professional accountability and a recognition of one's own responsibility to continue learning and not persist with outmoded practice" (p. 33).

Continuous Quality Improvement

CQI acknowledges the importance of structure and outcome criteria, but it focuses on process. By doing so, CQI essentially becomes part of the agency's organizational policy. CQI depends heavily on both administrative and clinical staff involvement to function. O'Leary (1990) stated, "CQI is built from the foundation of the positive aspects of QA but seeks to redirect the focus of organizational attention on quality of care issues" (p. 2).

CQI is a prospective, employee-focused evaluation process. In addition to a broader intemal focus, CQI has an external focus, too. Jennison's (1991, pp. 425-430) approach to quality improvement involves the following six principles:

1. Emphasize system analysis and process improvement. 2. Know who the customers are and understand their needs and expectations. 3. Know where to direct scarce time and resources for QA, 4. Let people know their performance and intentions are respected. 5. Reward people for their efforts to improve. 6. Involve the workers in a particular process in quality design and improvement.

Total Quality Management

Like CQI, TQM is a part of everyday functioning for all members in a health care agency; TQM is proactive. Moran and Johnson (1992) stated, '"TQM and CQI are generally considered broader concepts than QA ... and include the attainment of standards; the

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resolution of problems; and the identification, implementation, and evaluation of system- atic changes to improve the process and outcome of services" (p. 45). Sahney and Warden (1991, pp. 8-13) described 12 key concepts of the quality management process at the Henry Ford Health System (HFHS) as:

1. Top management leadership (p. 8). 2. Creating corporate framework for quality (pp. 8-9). 3. Transformation of corporate culture (p. 9). 4. Customer focus (pp. 9-10). 5. Process focus (pp. 10-1 1). 6. Collaborative approach to process improvement (p. 12). 7. Employee education and training (p. 12). 8. Learning by practice and teaching (p. 12). 9. Benchmarking: A process designed to assess the competition in comparison to the

organization's own performance (p. 13). 10. Quality measurement and statistical reports at every level (p. 13). 11. Recognition and reward (pp. 13-14). 12. Management integration (p. 14).

TABLE 1 Total Quality Management Framework of Henry Ford Health System and

Community Health Center: A Sideby-Side Comparison

Henry Ford Health System Community Health Center - - - -

1. Top management leadership 2. Creating corporate framework for

quality 3. Transformation of corporate culture

4. Customer focus

5. Process focus

6. Collaborative approach to process improvement

7. Employee education and training

8. Learning by practice and teaching

9. Benchmarking

10. Quality measurement and statistical reports at every level

1 1. Recognition and reward 12. Management integration

1. Management leadership -clear mission 2. Creating structure for measurement of

quality 3. Community assessment and education

in regard to role in quality care 4. Client focus: individual/family/

community 5. Focus on interrelation of structure,

process, and outcome 6. Collaborative approach to process

improvement 7. Continuing education and training for

staff 8. Following standards of practice for

health professionals 9. Collaboration and communication with

other community health centers 10. Quality measurement and evaluation

processes at every level 11. Recognition and reward 12. Management integration

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Community Health Centers 87

These concepts can be used as a baseline for designing a framework for TQM in the community health center. See Table 1 for a side-by-side comparison of HFHS and the proposed framework for the community health center.

The structure and function of the community health center is such that the framework of TQM provides for an easy fit. Because of a commitment to agency mission, collabo- rative relationships, community focus, standards of practice for health professionals, and effective communication, the community health center may already be practicing some of the principles of TQM.

STANDARDS

Standards of care need to be considered both internally and externally in the community health center. Internal standards are concerned with the community health center and its administrative and clinical staff. External standards reflect issues at the local, state, and federal levels. Standards specifically refer to licensure, certification, accreditation, or a combination of these issues.

Internal

The community health nurse is an integral part of the interdisciplinary team of the community health center. The founder of community health nursing in the United States, Lillian Wald (1936), stated, "I hope I shall not be charged with lacking a sense of proportion if I stress the purpose, the growth, and the importance of the public health nurse in the general progress of the public health" (p. 72). According to Freeman and Heinrich (198 1):

The goal of community health nursing is to enable people to cope with the discontinuities in and threats to health in such a way as to maximize their potential for high-level wellness as well as to promote reciprocally supportive relationships between people and their physical and social environment. (p. 37)

The ANA (1986) stated that standards "reflect the current state of knowledge in the field and are therefore professional, dynamic, and subject to testing and subsequent change" (p. 1). In community health nursing, quality care measurement is a catalyst for changing standards through structure, process, and outcome measurements. Mills (1 992) noted that "every nurse is responsible for continuous quality improvement" (p. 32). Standards have been developed by the ANA (1986, pp. 5-15) for various specialty areas in nursing. For community health nurses, in general, standards are as follows:

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88 St. Martin

Standard I. Theory: The nurse applies theoretical concepts as a basis for decisions in practice (p. 5).

Standard 11. Data Collection: The nurse systematically collects data that are com- prehensive and accurate (p. 6).

Standard III. Diagnosis: The nurse analyzes data collected about the community, family, and individual to determine diagnoses (p. 7).

Standard IV. Planning: At each level of prevention, the nurse develops plans that specify nursing actions unique to client needs (p. 8).

Standard V. Intervention: The nurse, guided by the plan, intervenes to promote, maintain, or restore health; to prevent illness; and to effect rehabilitation (p. 10).

Standard VI. Evaluation: The nurse evaluates responses of the community, family, and individual to interventions in order to determine progress toward goal achievement and to revise the database, diagnosis, and plan (p. 11).

Standard VII. Quality Assurance and Professional Development: The nurse partici- pates in peer review and other means of evaluation to assure quality of nursing practice. The nurse assumes responsibility for professional development and contributes to the professional growth of others (p. 13).

Standard VIII. Interdisciplinary Collaboration: The nurse collaborates with other health care providers, professionals, and community representatives in assessing, planning, implementing, and evaluating programs for community health (p. 14).

Standard IX. Research: The nurse contributes to theory and practice in community health nursing through research (p. 15).

Because community health centers function with interdisciplinary teams, standards of each professional group must be acknowledged when considering quality care measure- ment. Boland (1991) described six quality indicators that should be considered as part of performance standards for health providers:

1. Process of care through review of medical records. 2. Provider's conformance with appropriateness standards. 3. Impact of medical encounters on the well-being of patients. 4. Efficiency of diagnostic and other therapeutic settings. 5. Intensity of services adjusted for type of patient or case. 6. Patient satisfaction, based on survey results. (p. 10)

These quality indicators were designed for an acute care system, but they are flexible enough to conform to the structure of a community health center.

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Community Health Centers 89

External

Palmer (1991) stated that external QA is "used by a regulator, accreditor, or purchaser of health care to stimulate better internal efforts" (p. 40). The U.S. Public Health Service of the U.S. Department of Health and Human Services evaluates community health centers on a yearly basis. Similar to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the Primary Care Effectiveness Review (PCER) outlines stand- ards of care or indicators expected to be found in community health centers. Community health centers may opt to receive the accreditation of the JCAHO in addition to that of the PCER.

MEASUREMENT OF QUALITY

Quality care is measured by evaluating structure, process, and outcome. Flynn and Ray (1987) stated, "none of these dimensions exist alone; structure, process, and outcome are all interacting with one another and with the environment of which they are a part" (p. 189). The measurement criteria incorporate input from the community health center's staff members (professionals and nonprofessionals), clients, other community members, and payers of health care.

Structure

Structure refers specifically to the organization providing health care services. Structure is concerned with the resources and system design of a health care agency. Flynn and Ray (1987) stated, "characteristics of structure include staffing patterns, programs, finances, facilities, and size of an organization" (p. 188).

In the community health center, an organizational analysis should be done to reaffirm (a) agency mission and objectives, (b) current organizational table, (c) job descriptions of all staff, (d) management style of the organization, (e) agency committees and decision making abilities, and (f) previous and current community task forces.

Process

''Examining what must happen when, by whom, and in what sequence is the nature of process" (Widtfeldt & Widtfeldt, 1992, p. 315). Palmer (1991) stated that process data are "decisions made and actions taken on behalf of the patient by the provider and the providing organization, as well as information exchanged between patient and provider"

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90 St. Martin

(p. 57). Process is the interaction among staff and client (i.e., individuals, family, and community) in the community health center.

Nursing is both an art and science. Flynn and Ray (1987) described process as "the art of care" (p. 193). Freeman and Heinrich (1981) described the community health nurse's role as "provider of personal care, advocate, teacher, counselor, observer, potentiator, organizer, and decision-maker" (p. 53). The community health nurse facilitates these roles through the nursing process in collaboration with the client. The nursing process consists of assessment, diagnosis, planning, implementation, and evaluation activities.

Processes take place in both the administrative and clinical areas in the community health center. In addition, processes that affect health care outcomes take place on a daily basis internal and external to the community health center. Processes are the core of the community health center's functions.

Outcome

Outcomes are the products of the processes in a health care agency. Outcomes are research oriented. The ANA (1986) defined outcome criteria as a

focus on the end results of nursing care; a measurable change in the state of health of the community, family, or individual; the end product of a professional process; a change in the environment or in the attitude of the client toward health care. (p. 18)

Zlotnick (1992) noted that "outcomes are particularly difficult with public health, since public health often directs its services to health promotion and disease prevention" (p. 134). On a large scale, strategic planning objectives are anticipated outcomes of the processes of the community health center. As structure and process criteria are trans- formed in the present health care services milieu, research will focus on measurable outcomes for community health centers.

CONCLUSION

TQM is "a term to cover three types of activities: quality planning, quality measurement, and quality improvement" (Palmer, 1991, p. 58). Organizationally, TQM functions from the bottom up, with a total commitment from administration. Strategic planning provides for evolving processes and measurable community outcomes.

In striving to meet the goal of effective health care in a community, the community health center would benefit from the proactive framework of TQM. However, "providers must first be sure that their culture and climate are ready to accept an aggressive quality

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Community Health Centers 91

monitoring, management, and marketing program" (Nathanson, 1991, p. 416). According to Nathanson, the following elements must occur:

1. Agreement on what quality is and how it should be monitored (p. 416). 2. A shared perception that management and professional staff are serious about

dealing with quality problems (p. 416). 3. Open, honest, constructive communication (p. 416). 4. Enough of the right staff (p. 416).

Social advocacy may be added as an additional element. Community health centers are actively addressing access, cost, and quality issues in

providing health care services to the community. Quality of care should be incorporated in the mission of providing health promotion and primary prevention services to clients of a community health center.

Future

Health care is focusing more and more on primary care and the interaction of access, cost, and quality issues in an attempt to decrease fragmentation and increase effectiveness. Starfield et al. (1994) stated, "the finding of generally higher quality in moderate-cost CHC's [community health centers] is interesting and deserves study" (p. 1907). Perhaps research generated on the standards, process, and outcome criteria of TQM in community health centers can be a valuable tool to other health care service agencies whose goal it is to enhance the effectiveness of health care.

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Journal of Community Health Nursing, 4,187-197. Freeman, R. B., & Heinrich, J. (1981). Community health nursing practice. Philadelphia: Saunders. Jemison, K. (1991). Organizational dynamic of quality control. In P. Boland (Ed.), Making managed

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