The emphasis on quality is a national phenomenon that will only increase in the future. Payers, consumers, insurers, and practitioners are demanding assurance that the care they purchased or received was the best care and as good as the care provided anywhere else by any other provider. Although the Federal Government (CMS) has identified various quality indicators for providers, these indicators are outcome focused and not related to the process of care patients receive. To its credit, CMS hasn't told us how to practice-it doesn't want to-it shouldn't have to. That's what nursing and medical licenses are for.

McGlynn et al.'s (2003) recent study on physician care found that doctors, on average, provided appropriate healthcare only about 50% of the time. The percentage varied little among the chronic, acute, or preventive care categories. Other findings were equally startling:

* Patients with hypertension received only 65% of recommended care. Poor blood pressure control contributes to more than 68,000 preventable deaths annually.

* Only 45% of heart attack patients received beta-blockers, which have been proven to reduce the risk of death by 23%.

* Only one third of patients had been screened for colorectal cancer. Routine screening and follow-up care could prevent approximately 9,600 deaths annually.

This is not just about physicians, however. Many of us have cared for these patients unaware of best practices; or, if we've known the best care, we've been hesitant to question the physician's orders. Has any home care agency ever refused to admit a patient because the medical plan of care and/or the drug regimen for the patient was not appropriate? Are home care agencies having adverse events appearing on their report record when it's really due to incorrect physician treatment/medication orders?

One may argue, "We're nurses, and this is the physician's responsibility." As I recall, it's in our code of ethics and the reason we're licensed that we are expected to be knowledgeable enough to question physicians' orders.

We all need to be part of the process that solves the dilemma of how to keep professionals abreast of all the new evidence without experiencing overload. Patient care changes daily. For generalists like home care clinicians often there's simply too much to know and too little time to keep up. Computerized systems may be our hope to remind us and keep us up to date.

The bottom line is that inconsistent practices pose a threat to everyone's health. As home care clinicians we must enter the dialogue and help find solutions.

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