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Dynamic Chiropractic – November 6, 1995, Vol. 13, Issue 23

Practice 2000 -- Chiropractic Opportunities for the Millennium

Quality Assurance in the Office: The CA as a QA Specialist

By Daniel Hansen, DC
Editor's note: "Practice 2000 -- Chiropractic Opportunities for the Millennium" is a new feature in "DC" that offers insights and ideas from a variety of columnists on advancing chiropractic into the health care mainstream, and helping doctors prepare for the changes in health care. Dr. Hansen is chairman of the quality improvement committee of Chiropractic Network Services, an IPA in Washington state.

Future Practice 2000 topics will include: capitation vs. fee-for-service; credentialing for HMOS/PPOS; recordkeeping and practice accountability; quality improvement; information technology; technology assessment; vertically integrated health systems; and how global supply and demand economics affect the chiropractor in practice.

The delivery of health care and reimbursement for health care services are changing. The expected accountability of physicians, including chiropractors, is changing. National and community standards are being applied to practices and clinics that participate in managed care settings. There is an increasing demand for physicians and clinic staff members to be trained and competent in quality assessment and quality assurance, consistent with current recommendations. With the public expectation for appropriately trained clinic personnel, chiropractors would do well to seek appropriately trained personnel or seek quality assurance training for existing clinic staff. The chiropractic colleges or national/state trade organizations could respond to the growing demand by providing education consistent with established national standards on quality assurance directed to the experienced chiropractic assistant.

We're over halfway through the decade of the '90s, and for those of us that are active in providing care to patients and meeting the needs of the patient, we are encountering many significant changes. Are these changes good or bad? Well, there's probably a little of both, depending on your vision of the future. We do know that the people that are paying the bills for health care are making stronger demands for assurances of quality for those services they purchase.

The people that pay the bills are obviously important customers. And while we may think that this customer base is mostly composed of managed care organizations and insurance companies, the patients and their families still comprise a significant chunk of our revenue. Their attitude about these changes continues to grow stronger. They want assurance that the care they purchase is appropriate and not wasteful. They expect that the care they receive is of the highest quality possible. These purchasing groups are subscribing to quality standards much like the manufacturing industries have done with their ISO-9000 standards, standards emerging from OSHA, and other related government agencies. The day has come when the service and product turned out by our offices will be compared against national and regional standards for quality.

Is this just a manifestation of these managed care groups trying to tighten down on providers? No, not really. This action is really a response to the expectations in the modern health care market place. There are now clear market indications that within two years, all of the health care purchased by many of the nations largest employers will be consistent with quality standards as outlined by the National Commission on Quality Assurance (NCQA). This isn't idle talk anymore. Managed care organizations all across the country that are competing for the business from these large employers are mobilizing their efforts to comply with standards such as these: thus the growing expectation that doctors, clinics, and hospitals that want to participate in these modern reimbursement systems will also acknowledge these standards and seek compliance.

Chiropractors who are now actively involved in managed care organizations are starting to feel the effects of these expectations almost on a day-to-day basis. Practices are gradually shifting from solo to group practices, facilitating reduction in costs for care by sharing overhead and staff resources. With this trend, facility-based quality management creates the opportunity for a new office staff position with a unique set of job duties in quality assurance (QA) and continuous quality improvement (QI) obligations.

There is a growing need for a member of the physician's office to be conversant with quality management. Ideally, this specialized staff person oversees all aspects of quality management, at the same time being accountable to the physician staff. For example, the QA staff completes compliance reports to MCO networks or other credentialing organizations, thereby reducing the burden on the doctor. A sample set of duties is given in Table I.

This specialized staff position could be responsible for management of clinical outcome instruments, assuring proper instructions to patients, scoring and recording the results. One of the key functions would be to manage quality related to patient records, such as overseeing recordkeeping for completeness, confidentiality, and storage.

TABLE 1: Suggested Duties for QA Specialist in the Chiropractic Office

  • Trained in quality assessment and quality assurance


  • Trained in continuous quality improvement


  • Inspect clinic facilities for safety compliance (OSHA, ADA, local codes) - x-ray and darkroom - diagnosis and treatment equipment (maintenance, calibration)


  • Manage outcome instruments
  • instruction to patients
  • assurance of compliance
  • Oversee recordkeeping (completeness, confidentiality, storage)


  • Witness sensitive chiropractic procedures in

examination/treatment rooms
  • informed consent
  • procedures of risk
  • patients at risk
  • Assist chiropractor in utilization management for MCOs


  • Assist in assuring patient compliance with treatment recommendations

The QA specialist also may serve as protection against some risk management issues. For example, staff attendance for sensitive examination and treatment procedures places a witness in the room in the event of a subsequent allegation against the doctor and acknowledges the patient's informed consent. This is quite important, especially for procedures of risk and patients at risk.

Some questions might be asked, "Does all of this really have application in the chiropractic office?" "What if our office chooses not to be involved in any of those managed care programs?" "If it is important, and if it can really reduce the hassles to the doctor, how can one of my office staff get this training?" Likely, many chiropractic offices that choose to integrate into managed care programs will realize benefits of a specialized QA staff member. Some managed care organizations may actually require appropriate QA staffing for the larger clinic facilities. Certainly if an office chooses not to be responsive to quality of care concerns or participate in managed care programs, this issue may be moot.

Fundamental training for the QA staff position will include instruction in quality assessment, quality assurance, quality improvement, safety, regulation and compliance, and legal responsibility. Currently, there are no formal programs for such training in chiropractic venues other than through select managed care organizations. Elements of the QA staff education may be available through local community college nursing programs or medical assistant programs. Do the chiropractic colleges or state/national associations have responsibility for this element of education? Maybe not, but there is certainly an opportunity for some associations and institutions to assist the profession to adapt to the changing elements in health care.

The office of the future ... will need to be compliant with the expectations of the public for providing cost effective quality care that is assured and accountable.

Portions of this article are exerpted from the book chapter: Hansen DT, Triano JJ. "Applications of Quality Assurance in Chiropractic Practice" In: Lawrence D (Ed): Advances in Chiropractic, Volume 2. Chicago, IL, Mosby-Year Book; 1995. (Available September 1995.) Used with permission.

Daniel Hansen, DC
Olympia, Washington

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