A comparison of implicit and explicit methods of process quality assurance for blunt trauma patients

We compared explicit (objective) and implicit (subjective) methods of process quality assurance to understand how the findings of each method are related. The charts of 100 blunt trauma patients who were admitted to the ICU, underwent surgery, or died in the emergency department were reviewed for compliance with six explicit process-of-care criteria previously established by the ED faculty. The results of this explicit review were compared with the results of an ongoing quality assurance program that uses implicit review. In the implicit review, a faculty member reviewed patients' charts and responded to three questions regarding the process of care. All blunt trauma patients who met the admission criteria were to be included in this review. Only 44 of the 100 charts were subjected to implicit review. Of these, 26 were judged satisfactory by both methods, two were judged unsatisfactory by both methods, two failed only the implicit review, and 14 failed only the explicit review. The null hypothesis, that the two methods were equivalent, was rejected (McNemar's test, P less than .003). These results suggest that process-of-care assessments of the quality of care must be interpreted with caution as they are method dependent and may not correlate with patient outcomes.