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Key Terms

Quality assurance

Small qa

Large QA

Continuous Quality Improvement

Total Quality Management

Clinical pathways

Care paths


Practice guidelines


Chapter Outcomes

  • Differentiate among the levels of quality assurance and management approaches.

  • Relate the processes of outcome measurement to the processes of quality improvement.

  • Describe the application of outcome measurement to development of clinical pathways.

  • Relate the role of benchmarking to outcome measurement.

The focus of this book has been on the use of outcome measurement to improve the quality of one clinician’s practice; that is, to develop an individual’s skills as a reflective practitioner. Previous chapters introduced some of the ways that outcome data can influence daily practice routines, professional development, and documentation processes in a single setting. This chapter shifts the focus from the individual practitioner to a system of service delivery. It introduces quality assurance processes that ensure ongoing, cyclical review of practice expectations. The focus of data collection is expanded to include multiple outcomes, or collection of data from multiple clinicians. It is then used for ongoing internal review, for development of clinical pathways or guidelines, and for benchmarking against known standards of excellence.


Quality assurance is a process used to monitor whether predetermined standards of service delivery are met in daily practice. The standards may reflect expectations for documentation or procedural routines. Typical documentation standards include recording such items as the date of an evaluation, a patient’s referral source, and the signature and license number of the therapist. Examples of documented procedural routines include annual safety electrical inspections of machines, application of universal precautions, and training staff in Health Insurance Portability and Accountability Act regulations.

For most documentation formats, a checklist of the expected practice standards is developed, and medical records are reviewed against that checklist. Rates of missing or incorrectly recorded items are calculated to determine if adequate levels of compliance have been met.

Quality assurance processes have traditionally emphasized the correction of errors or the identification of poor performers. They do not typically address the processes that underlie the errors (Coleman & Endsley, 1999; McKinley, et al., 1998). Checklists for documentation standards are easily constructed from practice standards published by professional or accrediting organizations or by government agencies. Record reviews often happen in locations separate from practice locations, such as in records departments or conference rooms. Thus, knowledge of the processes contributing to frequent errors is not likely to be reviewed.

The parties that set standards for practice vary. They include individuals and/or administrators within a practice setting, external organizations such as accrediting bodies, and government regulatory agencies. Settings such as a hospital department may have practice standards defined by several of these parties.

Chart reviews may be conducted by a clinician from within the clinical setting, or ...

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