Showing papers in "International Journal for Quality in Health Care in 2000"
TL;DR: All financial incentives that had been proposed, described, or used regardless of their initial objective were identified and, when possible, assessed to assess the results of these incentives on costs, process or outcomes of care.
Abstract: Objective. To identify all financial incentives that had been proposed, described, or used regardless of their initial objective and, when possible, to assess the results of these incentives on costs, process or outcomes of care. Material and methods. Systematic review of the literature. Databases searched were: Medline, Embase, Health Planning and Administration, Pascal, International Pharmaceutical Abstracts and the Cochrane Library. Search terms were: health professionals and type of practice, type of incentive, methodology, languages English or French, January 1993 to May 1999. Results. Financial incentives concerned the modalities of physician payment and financing of the health care system. Confounding factors included: age of the doctor, training, speciality, place and type of medical practice, previous sanctions for over-prescribing, type and severity of disease, type of insurance. Risks of financial incentives were: limited access to certain types of care, lack of continuity of care, conflict of interests between the physician and the patient. Any form of fund-holding or capitation decreased the total volume of prescriptions by 0–24%, and hospital days by up to 80% compared with fee-for-service. Annual cap on doctors’ incomes resulted in referrals to colleagues when target income is reached. Discussion. Financial incentives can be used to reduce the use of health care resources, improve compliance with practice guidelines or achieve a general health target. It may be effective to use incentives in combination depending on the target set for a given health care programme.
356 citations
TL;DR: It is asserted that quality can be measured, that quality of care varies enormously, that improvingquality of care is difficult, that financial incentives directed at the health system level have little effect on quality, and that there is a publicly available tool kit to assess quality.
Abstract: The modern quality field in medicine is about one-third of a century old. The purpose of this paper is to summarize what we know about quality of care and indicate what we can do to improve quality of care in the next century. We assert that quality can be measured, that quality of care varies enormously, that improving quality of care is difficult, that financial incentives directed at the health system level have little effect on quality, and that we lack a publicly available tool kit to assess quality. To improve quality of care we will need adequate data and that will require patients to provide information about what happened to them and to allow people to abstract their medical records. It also will require that physicians provide patient information when asked. We also need a strategy to measure quality and then report the results and we need to place in the public domain tool kits that can be used by physicians, administrators, and patient groups to assess and improve quality. Each country should have a national quality report, based on standardized comprehensive and scientifically valid measures, which describes the country's progress in improving quality of care. We can act now. For the 70-100 procedures that dominate what physicians do, we should have a computer-based, prospective system to ensure that physicians ask patients the questions required to decide whether to do the procedure. The patient should verify the responses. Answers from patients should be combined with test results and other information obtained from the patient's physician to produce an assessment of the procedure's appropriateness and necessity. Advanced tools to assess quality, based on data from the patient and medical records, are also currently being developed. These tools could be used to comprehensively assess the quality of primary care across multiple conditions at the country, regional, and medical group level.
318 citations
TL;DR: This monograph provides a sound rationale for the critical nature of medication administration and the importance of accurate and safe dosage calculations and medication administration.
Abstract: ■ Describe the consequences and costs of medication errors. ■ Cite the incidence of hospital injuries and deaths attributable to medication errors. ■ Explore evidence and rationale for the underreporting of medication errors. ■ Name the steps involved in medication administration. ■ Identify six common causes of medication errors. ■ Identify the role of the nurse in preventing medication errors. ■ Describe the role of technology and health care administration in medication error prevention. ■ Recognize examples of prescription, transcription, and recording notation errors. ■ Correct medical notation errors. ■ Describe the requirements of The Joint Commission to prevent medication errors. ■ Provide a sound rationale for the critical nature of medication administration and the importance of accurate and safe dosage calculations and medication administration.
296 citations
TL;DR: The concepts of a sequential analysis are introduced, the practical steps of setting up a data collection and monitoring performance for procedures in health care are dealt with and the methods used to achieve this result are explained.
Abstract: Continuous quality assurance (QA) in health care has necessitated the adoption of statistical methods developed as industrial process monitoring techniques. One such statistical technique is the cumulative summation (Cusum) methodology, which can monitor continuously a production process and detect subtle deviations from a preset defined level of achievement. The method is practical, simple to apply, easy to introduce and has proved popular with trainees in some specialities. This article introduces the concepts of a sequential analysis, deals with the practical steps of setting up a data collection and monitoring performance for procedures in health care.
244 citations
TL;DR: In The Netherlands many health care organizations apply the EFQM Model, which can be used as a self-assessment instrument on all levels of a health care organization and as an auditing instrument for the Quality Award.
Abstract: One way to meet the challenges in creating a high performance organization in health care is the approach of the European Foundation for Quality Management (EFQM). The Foundation is in the tradition of the American Malcolm Baldrige Award and was initiated by the European Commission and 14 European multi-national organizations in 1988. The essence of the approach is the EFQM Model, which can be used as a self-assessment instrument on all levels of a health care organization and as an auditing instrument for the Quality Award. In 1999 the EFQM Model was revised but its principles remained the same. In The Netherlands many health care organizations apply the EFQM Model. In addition to improvement projects, peer review of professional practices, accreditation and certification, the EFQM Approach is used mainly as a framework for quality management and as a conceptualization for organizational excellence. The Dutch National Institute for Quality, the Instituut Nederlandse Kwaliteit, delivers training and supports self-assessment and runs the Dutch quality award programme. Two specific guidelines for health care organizations, 'Positioning and Improving' and 'Self-Assessment', have been developed and are used frequently. To illustrate the EFQM approach in The Netherlands, the improvement project of the Jellinek Centre is described. The Jellinek Centre conducted internal and external assessments and received in 1996, as the first health care organization, the Dutch Quality Prize.
181 citations
TL;DR: Five methodological differences accounted for some of the discrepancy between the two studies and the remaining three-fold disparity are that quality of care was worse in Australia and that medical record content and/or reviewer behaviour was different.
Abstract: Objective. To better understand the differences between two iatrogenic injury studies of hospitalized patients in 1992 which used ostensibly similar methods and similar sample sizes, but had quite different findings. The Quality in Australian Health Care Study (QAHCS) reported that 16.6% of admissions were associated with adverse events (AE), whereas the Utah, Colorado Study (UTCOS) reported a rate of 2.9%. Setting. Hospitalized patients in Australia and the USA. Design. Investigators from both studies compared methods and characteristics and identified differences. QAHCS data were then analysed using UTCOS methods. Main outcome measures. Differences between the studies and the comparative AE rates when these had been accounted for. Results. Both studies used a two-stage chart review process (screening nurse review followed by confirmatory physician review) to detect AEs; five important methodological differences were found: (i) QAHCS nurse reviewers referred records that documented any link to a previous admission, whereas UTCOS imposed age-related time constraints; (ii) QAHCS used a lower confidence threshold for defining medical causation; (iii) QAHCS used two physician reviewers, whereas UTCOS used one; (iv) QAHCS counted all AEs associated with an index admission whereas UTCOS counted only those determining the annual incidence; and (v) QAHCS included some types of events not included in UTCOS. When the QAHCS data were analysed using UTCOS methods, the comparative rates became 10.6% and 3.2%, respectively. Conclusions. Five methodological differences accounted for some of the discrepancy between the two studies. Two explanations for the remaining three-fold disparity are that quality of care was worse in Australia and that medical record content and/or reviewer behaviour was different.
170 citations
TL;DR: This paper is a summary of the operation, findings and conclusions of a European Union project on external peer review techniques, termed 'ExPeRT', to research the scope, mechanisms and use of external quality mechanisms in the improvement of health care.
Abstract: This paper is a summary of the operation, findings and conclusions of a European Union project on external peer review techniques, termed 'ExPeRT', to research the scope, mechanisms and use of external quality mechanisms in the improvement of health care. Many of the themes outlined are described in detail in other papers that have been prepared specifically for this issue of The International Journal for Quality in Health Care. Although the emphasis of this project and of this issue of the Journal is on Europe, the conclusions are more widely relevant.
167 citations
TL;DR: Health care organizations have the technology to significantly improve their detection of ADEs, medication errors, and potential ADEs and should be adopted by organizations.
Abstract: Purpose. Adverse drug events (ADEs), or injuries due to drugs, are common and often preventable. However, identifying ADEs, potential ADEs, and medication errors can be a major challenge. In this review, we describe methodologies that have been used to identify these events and give strategies for identification in non-study settings.
Results. Methods such as voluntary reporting, chart review, and computerized monitoring for events have been most commonly used in studies of ADEs in inpatients. However, voluntary reporting, the method most hospitals currently use, has a very low yield of events. Chart review is much more sensitive but the costs are prohibitive. Computerized monitoring for ADEs (using rules or triggers) is a high yield and relatively inexpensive strategy that should be adopted by organizations. A limitation of this strategy, however, is that it identifies few medication errors and potential ADEs, which are also important. These can be captured through pharmacy logs, chart review, and direct observation. Once events have been identified, they can be classified by type of event, severity, and preventability. In non-study settings, the most practical method for identifying ADEs is computerized monitoring, and for identifying prescribing errors it is pharmacy logs of interventions. Once problems are found, a structure (either individual or committee) must be in place to classify them, identify opportunities for improvement, and carry out the necessary changes.
Conclusion. Health care organizations have the technology to significantly improve their detection of ADEs, medication errors, and potential ADEs. Identification and subsequent classification of events is crucial for quality efforts to improve patient safety.
145 citations
TL;DR: It is hypothesize that this disparity is due to different thresholds for admission and discharge and to a greater degree of under-reporting of certain types of problems as AEs by UTCOS than QAHCS reviewers.
Abstract: Objective. To better understand the remaining three-fold disparity between adverse event (AE) rates in the Quality in Australia Health Care Study (QAHCS) and the Utah-Colorado Study (UTCOS) after methodological differences had been accounted for. Setting. Iatrogenic injury in hospitalized patients in Australia and America. Design. Using a previously developed classification, all AEs were assigned to 98 exclusive descriptive categories and the relative rates compared between studies; they were also compared with respect to severity and death. Main outcome measures. The distribution of AEs amongst the descriptive and outcome categories. Results. For 38 categories, representing 67% of UTCOS and 28% of QAHCS AEs, there were no statistically significant differences. For 33, representing 31% and 69% respectively, there was seven times more AEs in QAHCS than in UTCOS. Rates for major disability and death were very similar (1.7% and 0.3% of admissions for both studies) but the minor disability rate was six times greater in QAHCS (8.4% versus 1.3%). Conclusions. A similar 2% core of serious AEs was found in both studies, but for the remaining categories six to seven times more AEs were reported in QAHCS than in UTCOS. We hypothesize that this disparity is due to different thresholds for admission and discharge and to a greater degree of under-reporting of certain types of problems as AEs by UTCOS than QAHCS reviewers. The biases identified were consistent with, and appropriate for, the quite different aims of each study. No definitive difference in quality of care was identified by these analyses or a literature review.
123 citations
TL;DR: The challenge for the years to come is to design strategies for quality improvement that integrate elements from the different models and to set the step from anecdotal evidence for these strategies to systematic evaluation in order to distinguish between faith and fact in the field of improving care.
Abstract: There is an increasing number of studies showing that patients often do not receive necessary care or receive care that is not needed, inefficient or even damaging. There is no lack of ideas and approaches on how to improve practice. In the last decades we have seen the rise of fascinating models for quality improvement, for instance Evidence Based Medicine, Total Quality Management and Patient Partnership. These models are interesting and potentially very valuable in improving patient care. However, the evidence for their (cost-) effectiveness is very limited. The challenge for the years to come is to design strategies for quality improvement that integrate elements from the different models and to set the step from anecdotal evidence for these strategies to systematic evaluation in order to distinguish between faith and fact in the field of improving care.
108 citations
TL;DR: The organizational accreditation model, such as the international accreditation program, provides a framework for the convergence and integration of the strengths of all the models into a common health care quality evaluation model.
Abstract: Objective. To describe the components of the new Joint Commission International (JCI) accreditation program for hospitals, and compare this program with the four quality evaluation models described under the ExPeRT project ( visitatie , ISO, EFQM, organizational accreditation). Results. All the models have in common with the JCI program the use of explicit criteria or standards, and the use of external reviewers. The JCI program is clearly an organizational accreditation approach with evaluation of all the «systems» of a health care organization. The JCI model evaluates the ability of an organization to assess and monitor its professional staff through internal mechanisms, in contrast with the external peer assessment used by the visitatie model. The JCI program provides a comprehensive framework for quality management in an organization, expanding the boundaries of the quality leadership and management found in the EFQM model, and beyond the quality control of the ISO model. The JCI organizational accreditation program was designed to permit international comparisons, difficult under the other models due to country specific variation. Conclusion. We believe that the organizational accreditation model, such as the international accreditation program, provides a framework for the convergence and integration of the strengths of all the models into a common health care quality evaluation model.
TL;DR: Although a general convergence between the four models can be observed, actual convergence will depend on their adoption in specific health system contexts.
Abstract: Accreditation, ISO, EFQLM and visitatie are, in essence, control mechanisms in health care systems. An analysis is provided of the way the four models have been adopted and adapted in European health care systems over the past decade. After a short discussion of the major reforms in the European health care systems in the direction of regulated markets, deregulation and decentralization, the features of the four models are highlighted and it is explained how each of them can help to fill the 'accountability gap' between health care providers on the one hand and patients, financiers and governments on the other. The quality system perspective of ISO, the quality management development perspective of EFQM, the health care organization perspective of accreditation and the professional perspective of visitatie can each be appropriate given the balance of power between parties in the health care system and the focus and scope of accountability. Although a general convergence between the four models can be observed, actual convergence will depend on their adoption in specific health system contexts. Potential pitfalls for further convergence are the differences in distribution of responsibilities for quality of care among the various European countries, the drift away from clinical decision making, bureaucratic tendencies and too much focus on efficiency and patient empowerment compared with attention to medical effectiveness.
TL;DR: It is concluded that clinical pathways, when implemented in the context of an acute care hospital, can result in improvements in the care delivery process.
Abstract: A critical or clinical pathway defines the optimal care process, sequencing and timing of interventions by doctors, nurses and other health care professionals for a particular diagnosis or procedure. Clinical pathways are developed through collaborative efforts of clinicians, case managers, nurses, pharmacists, physiotherapists and other allied health care professionals with the aim of improving the quality of patient care, while minimizing cost to the patient. The use of clinical pathways has increased over the past decade in the USA, the UK, Australia, and many other developed countries. However, its use in the developing nations and Asia has been sporadic. To the author's knowledge, there is to date, no published literature on the use and impact of clinical pathways on the quality and cost of patient care in the Asian health care setting. This paper provides a qualitative account of the development and implementation of a clinical pathway programme (using the example of patients with uncomplicated acute myocardial infarction) in an acute care general hospital in Singapore. The paper concludes that clinical pathways, when implemented in the context of an acute care hospital, can result in improvements in the care delivery process.
TL;DR: Patient satisfaction with family practice care in Slovenia was shown to be relatively high and can be compared to other European countries, but areas in which quality improvement is required are shown: organizational changes to shorten the waiting time in the waiting room and greater emphasis on communication skills.
Abstract: Objective. To describe the level of patient satisfaction with family practice in Slovenia. Design. An internationally developed instrument for patients’ evaluations of general practice care was used in a postal survey. Setting. A representative sample of 36 family practices in Slovenia. Study participants. Sixty consecutive patients in every practice were approached and offered a self-administered questionnaire. A total of 2160 questionnaires were handed out. Main outcome measure. Percentages of patients reporting level of satisfaction on a 5-point Likert scale for the items in the questionnaire. Results. On average 58.2% of respondents rated the level of care received as excellent. Waiting in the waiting room was the item rated poorest (26.0%). Participants were also less satisfied with perceived time during the consultation (51.6%) and with connectional aspects of care: the feeling that family practitioners showed interest in their personal situation (46.5%); the feeling that family practitioners made it easy to explain problems (49.1%). On the other hand patients praised many other aspects of family practice care in Slovenia: confidentiality of medical records (77.0%); listening capacity of their family physicians (69.4%); being able to speak to the family practitioner on the ’phone (72%). Conclusions. Patient satisfaction with family practice care in Slovenia was shown to be relatively high and can be compared to other European countries. The results showed areas in which quality improvement is required: organizational changes to shorten the waiting time in the waiting room and greater emphasis on communication skills.
TL;DR: The Care Evaluation Program (CEP) of clinical performance measures in its accreditation program remains unique in the scope of the medical disciplines covered and in the formal provider involvement with indicator development.
Abstract: The Australian Council on Healthcare Standards (ACHS) established the Care Evaluation Program (CEP) of clinical performance measures in its accreditation program to increase the clinical component of that program and to increase medical practitioner involvement in formal quality activities in their health care organizations. From the introduction of a set of generic indicators in 1993 the program expanded through all of the various medical disciplines and from January 2000 there will be 18 sets (well over 200 indicators) in the program. More than half of Australia's acute hospitals (covering the majority of patient separations) are monitoring the indicators and reporting clinical data twice yearly to the ACHS. In turn they receive a 6-monthly feedback of aggregate and peer comparative results. The ACHS policy had no specific requirement for a set number of indicators to be monitored and it was not mandatory to achieve any specific data threshold to be accredited. However, where an organization's results differed unfavorably from those of its peers some action was expected. Qualitative information is also sent to the CEP and this has enabled a determination of the effectiveness of the indicators. There is documented evidence of improved management and numerous examples of improved patient outcomes. The program remains unique in the scope of the medical disciplines covered and in the formal provider involvement with indicator development. Both the clinical component of accreditation and clinician involvement in quality activities have been increased in an educational process. However, not all of the indicators are of equal value and a reduction in the number of indicators to a 'core' group of the most reliable and responsive ones is in process.
TL;DR: It is demonstrated that in principle, convergence of the four main models in order to gain from each model's key strengths is feasible and whether convergence is practical, depends upon the willingness of governments, health service providers, health care quality professionals and organizations to come together and adopt the recommendations of the ExPeRT project.
Abstract: Objective This paper aims to evaluate the use and development of external peer review models and to identify where the main models are used in European Union member states and countries with reciprocal research agreements with the European Union Design The ExPeRT (external peer review techniques) project research team conducted a series of fact-finding missions to all participating European nations Study participants I Blomberg, Sweden; L Bohigas, Spain; S Cucic, The Netherlands; P Morosini, Italy The Project is led by C Shaw, UK and is managed by C Heaton, CASPE Research Results We identified four main external peer review models aimed at measuring the quality of service management and delivery: health care accreditation, the International Organization for Standardization ISO 9000 standards, the European Foundation for Quality Management Excellence Model and visitatie , which is Dutch for «visitation» or peer review-based schemes Discussion ExPeRT has demonstrated that in principle, convergence of the four main models in order to gain from each model's key strengths is feasible Whether convergence is practical, depends upon the willingness of governments, health service providers, health care quality professionals and organizations to come together and adopt the recommendations of the ExPeRT project
TL;DR: The relationships with the nursing and medical personnel appear to be the major determinants of both patient treatment satisfaction and patients' reception of adequate information about their condition and its treatment.
Abstract: Objective. To investigate prospectively which medical, psychosocial or treatment-related factors predicted treatment satisfaction and to evaluate the adequacy of a preceding retrospective study which had examined the same factors. Furthermore, to examine the predictors and the stability of the major determinants of patient treatment satisfaction.
Design. Assessments made before admission, at discharge and 2 and 4 months after discharge were used to predict both the level and the rate of change in satisfaction with different aspects of treatment.
Setting. Three surgical departments at a University Hospital.
Study participants. Four-hundred and eighty-two patients electively admitted for several surgical conditions.
Results. The central treatment-related measures were the same in the retrospective and prospective studies: global satisfaction with treatment (GS), perceived quality of contact with the nursing (QCN) and medical staff (QCM) and provision of adequate treatment information (INF). More of the variance in GS was explained in the prospective study (48.7% versus 36.3%). GS was most influenced by treatment-related factors with QCN as the strongest predictor in both studies. Only a small portion of the variance in QCN and QCM could be accounted for by the characteristics of the patients. INF was predicted by characteristics of the patients, their illness and life situation and by treatment-related factors. QCN was the strongest predictor of INF. The relationships with the nursing and medical personnel appear to be the major determinants of both patient treatment satisfaction and patients' reception of adequate information about their condition and its treatment.
TL;DR: This experience in the USA suggests that over time successful external quality evaluation mechanisms throughout the world will involve representatives of the public, purchasers, and government in establishing standards and setting policies.
Abstract: The Joint Commission on Accreditation of Healthcare Organizations, the oldest health care accrediting body in the world, currently accredits almost 20000 organizations in the USA. Although continuing to be professionally-sponsored, accreditation's rapid growth in recent years has been driven by the external users of accreditation--government, purchasers, and public--rather than by the original users, the professionals themselves. This experience in the USA suggests that over time successful external quality evaluation mechanisms throughout the world will involve representatives of the public, purchasers, and government in establishing standards and setting policies. Without this involvement, these stakeholders are unlikely to find the mechanisms credible in addressing their needs, and will seek alternatives--adding cost and duplication to the external quality evaluation system. Successful mechanisms are also likely to provide more detailed information about an organization's performance to the public, purchasers, and the government, while creating evaluation processes that provide for innovation and support improvement in efficiency, as well as quality, through incorporation of aspects of the Baldrige and European Foundation for Quality Management approaches to organizational excellence. Finally, successful evaluation mechanisms are likely to create a special focus on the safety of care, incorporating aspects of the International Organization for Standardization's ISO 9000 approach to quality management. While the specific nature, priority, and timing of these changes will differ from country to country, they are likely to influence the evolution of external quality evaluation throughout the world. External evaluation of health care organizations' quality holds great promise, but its long-term success depends on responding to all those who will want to depend on it.
TL;DR: How Estonian people evaluate the changes in primary health care (PHC), how they perceive the acceptability of the new PHC system, and patients' satisfaction with primary care doctor are evaluated are found.
Abstract: Since the early 1990s, the Estonian health sector has been undergoing a number of reforms. At the same time, a number of legislative acts have also been established, forming a new legal basis for the health system. The introduction of a social health insurance in 1992 was the first reform in the Estonian health sector reorganisation, followed by a primary health care (PHC) reform, a hospital reform and a number of public health reforms. The aim of this thesis is to analyse these health sector reforms in Estonia, focusing on the outcomes of the health system from the population’s perspective. Proceeding from this general aim, the specific objectives of the thesis are as follows: 1) To analyse the PHC reform in terms of the access to the health services and the acceptability and satisfaction with these services. 2) To analyse the health insurance reform in terms of the acceptability and satisfaction with the new system. 3) To analyse the public health reforms and their impact on the health of the population. The empirical data were gathered with the following research methods: reviews of official health statistics and population surveys in 1998, 2002 and 2005 based on face-to-face interviews using structured questionnaires. The main results can be summarised in relation to the objectives of the thesis: 1) The primary health care reform has been implemented and most of the objectives have been achieved. In general, people accept the changes in the PHC system and the satisfaction with the family doctors has increased. Access to the PHC services is good. Based on the results of a population study in 2002 and 2005, more than half of the respondents could see the family doctor on the same day they made an appointment. Almost a half of the respondents (49%) were satisfied with the access to the health services. Satisfaction with the PHC services and family doctors were found to have positive effects on satisfaction with access to health services. Although people with chronic conditions were less satisfied with the access to the health services they did not experience organisational barriers in their access to such services. 2) The health insurance reform has been implemented and a high level of financial protection has been maintained. The solidarity principle of the health insurance system guarantees access to health services for all the insured people. About half of the population is satisfied with the present system. Compared to 2002, the percentage of satisfied people has increased in 2005, while the percentage of very dissatisfied persons has decreased. The most important predictor of satisfaction with the health insurance was the satisfaction with the existing PHC system. The satisfaction with the health insurance was higher in 2002 as well as 2005 among those respondents who had visited a family doctor or a specialist or were admitted in a hospital during the last 12 months before the survey, but lower among those who had visited a dentist. A small majority preferred the solidarity principles and comprehensive financing of health service by health insurance. The attitudes regarding financing principles were related to the personal contacts with the health services. The respondents who had used the PHC or ambulance services preferred a more comprehensive financing of health services, while those who had had contacts with a specialists or dentists would prefer less comprehensive financing if the waiting lists were short. More than three quarters of the respondents were informed about their rights concerning the access to the health services. Personal contacts with family doctors and specialists had positive impact on the level of awareness. 3) Some progress has been made in connection with the public health reforms. A number of national programs and projects to prevent the most essential health risks have been initiated. As a result, there is some evidence of a positive impact on the health of the population – positive trends in dietary habits and decreasing infant mortality, number of abortions, and incidences of sexually transmitted infections and tuberculosis. At the same time, however, the proportion of smokers and consumers of strong alcohol has not decreased. Moreover, there has been an explosive increase of new cases of HIV-infections in 2000, which is one of the most serious public health problems today. Greater progress has been achieved in the areas where health promotion and health education activities have been supported by political decisions to make a healthy choice for the population easier. However, a comprehensive national health policy and strategy is still lacking in Estonia. In public health, this is evidenced by a lack of long-term planning and understanding of the significance of intersectoral co-operation. Discussion. Up to now, the major reforms in the Estonian health system have been implemented. However, the environment is changing and the health system has to respond to these changes. The next step should therefore be to reach a public agreement about the common values of the health system and setting long-term health policy goals. To improve the effectiveness of policy implementation and reform, the importance of systematic research and evaluation should also be stressed.
TL;DR: For overall patient satisfaction, it is essential to satisfy specific items related to the aspect of hospital care emphasized by the patient, irrespective of the patients' emphasis.
Abstract: Objective The objective of this study was to detect whether there was any difference among the characteristics of patient satisfaction between two patient emphasis groups: patients demanding technical elements of hospital care and patients demanding interpersonal elements Design and setting The sample for this study was drawn from in-patients discharged from 77 voluntarily participating hospitals throughout Japan The relationship between overall satisfaction with hospital care and patient satisfaction, and the evaluation of a hospital’s reputation, was explored by stepwise multiple regression analysis of 33 variables relevant to aspects of hospital care for each patient group Results In the interpersonal emphasis (IE) group, ‘nurse’s kindness and warmth’ was associated significantly with overall satisfaction, while ‘skill of nursing care’ and ‘nurse’s explanation’ were significant predictors of overall satisfaction in the technical emphasis (TE) group On the other hand, ‘doctor’s clinical competence’, ‘recovery from distress and anxiety’, and items pertaining to the hospital’s reputation were significantly related to overall satisfaction in both emphasis groups Conclusion For overall patient satisfaction, it is essential to satisfy specific items related to the aspect of hospital care emphasized by the patient Specific significant predictors of overall satisfaction (eg ‘doctor’s clinical competence’) were indispensable measures of professional performance in hospital care, irrespective of the patients’ emphasis A positive perception of hospital reputation items might increase overall patient satisfaction with Japanese hospitals
TL;DR: From examination of the six identified guideline documents, the claim that ISO 9000 introduces quality systems which are comparable from one country to another is unfounded in the acute health care sector.
Abstract: Objective. This paper aims to address two questions related to the implementation of the ISO 9000 Quality Management System standard in the acute health care sector: which countries have developed specific nationwide guidelines/interpretations? and what variances exist between the different interpretations of the ISO 9002 standard? Design. The study was carried out via an assessment of the available guideline documents for the use of ISO 9000 in the acute health care sector. The interpretation of each document was examined for common elements and deviations from the commonly agreed terms. Setting. Worldwide in the acute health care sector (excluding that of laboratories). Study participants. Eighty-two international ISO members and/or quality health care organizations. Results. The results showed variation in the interpretations of the ISO 9000 standard. In total, 16 of the clauses/subclauses note distinct variations, between one or more of the documents, which could alter the perception of the system. Conclusion. From examination of the six identified guideline documents, the claim that ISO 9000 introduces quality systems which are comparable from one country to another is unfounded in the acute health care sector.
TL;DR: It is concluded that formal process analysis techniques are suited to improve processes in the intensive care unit and resulted in a significant reduction of 'door-to-needle time'.
Abstract: Objective. To assess and reduce delays in coronary thrombolysis in patients with acute myocardial infarction. Design. Prospective, descriptive study using statistical process control. Setting. Interdisciplinary intensive care unit of a 300-bed community hospital. Subjects. Thirty-seven consecutive patients with acute myocardial infarction who were receiving thrombolytic therapy. Interventions. To perform an interdisciplinary formal process analysis aimed at detecting delay-causing factors, review of existing house rules, generation and implementation of new practice guidelines. Main outcome measures. Comparison of «door-to-needle times» of patients admitted before, during and after formal process analysis and implementation of new guidelines. Results. Mean «door-to-needle time» fell significantly from 57 minutes (±25.4) in 16 patients studied before, to 32 minutes (±9.0) in 16 patients studied after the formal process analysis and the implementation of new guidelines ( P < 0.002). An even more pronounced but transient decrease to 24 minutes (±3.8) was observed in five patients studied during the phase of formal process analysis ( P < 0.004). Delay-causing factors were identified in the areas «communication», «people» and «methods/rules/guidelines». Equipment failure was never responsible for delays. Conclusions. Formal process analysis, followed by implementation of revised guidelines resulted in a significant reduction of «door-to-needle time». An initial dramatic but transient reduction of «door-to-needle time» was considered observational and must not be mistaken as the definite new level of performance. We conclude that formal process analysis techniques are suited to improve processes in the intensive care unit.
TL;DR: The RAYS scale demonstrated high internal consistency and significant discriminative value, and is thus a suitable disease-specific tool for measuring QoL in MS.
Abstract: Objective. To develop a self-administered rating scale for quantifying quality of life (QoL) in multiple sclerosis (MS) patients. Methods. The RAYS scale items were derived from a source of 600 questions composed by our Centre's experts from commonly used instruments that assess physical, psychological, and social–familial dimensions. Prior to finalization of the RAYS QoL, candidate items were administered to 15 health rehabilitation professionals. Clarity, importance, relevance and specificity were graded for each item by every professional independently. Items chosen for the final version were graded as good or excellent on all these aspects. The Medical Outcome Study Short Form-36 (SF-36) was used to compare health appraisal with the RAYS scale. Results. Each of the three subscales of the RAYS covers a different dimension (physical, psychological, and social–familial) and each includes 15 self-report items scored from 1 (best) to 4 (worse), focusing on the preceding week. Validation was achieved through administration of the scale to 50 randomly selected MS patients and to 50 age-, sex-, education- and family status-matched healthy controls. All RAYS dimensions among MS patients reached a Cronbach's coefficient α > 0.8. Mean values for all dimensions were greater in patients than in controls ( P < 0.002). Patients scored below norms for the general population in the majority of the SF-36 subscales (on average 32% lower). Significant correlation was found between the two scales especially in the physical and social functioning subscales. Conclusion. The RAYS scale demonstrated high internal consistency and significant discriminative value, and is thus a suitable disease-specific tool for measuring QoL in MS.
TL;DR: To compare the methods used by external evaluators of health care institutions in Europe, a common framework for analysis was designed by the authors and shared among the members of the ExPeRT Project.
Abstract: Objective. To compare the methods used by external evaluators of health care institutions in Europe. Methods. A common framework for analysis was designed by the authors and shared among the members of the ExPeRT Project. Each member prepared a description of a model and the results were compared in two workshops. Results. Programmes share similarities in the methods used, but they differ in the focus and purpose of the evaluation. Differences in focus included whether a part or the whole of the institution is analysed and whether the review is patient or system centred. Different purposes of the programmes are reflected in the emphasis and use of the methodological tools: for instance, the appeal system is used only in the programmes that provide a certificate to the institution audited.
TL;DR: patient satisfaction ratings were higher for providers who had received the training and providers reported training to be relevant and useful, and further validation of IPC skills and simplification of assessment methods are needed.
Abstract: Objective. To evaluate the impact of interpersonal communication (IPC) training on practice and patient satisfaction and to determine the acceptability of this training to providers in a developing country. Design. The study used a pre–post design with treatment and control groups. Data collection methods included interaction analysis of audio-taped clinical encounters, patient exit interviews, and a self-administered questionnaire for health providers. Study participants. Interaction analysis was based on an experimental group of 24 doctors and a control group of eight (with multiple observations for each provider). Exit interviews were carried out with 220 pre-test patients and 218 post-test patients. All 87 health providers who received training responded to the self-administered questionnaire. Intervention. A brief in-service training programme on interpersonal communications was presented in three half-day sessions; these focused on overall socio-emotional communication, problem solving skills and counselling. Main outcome measures and results. The IPC intervention was associated with more communication by trained providers (mean scores of 136.6 versus 94.4; P=0.0001), more positive talk (15.93 versus 7.99; P=0.001), less negative talk (0.11 versus 0.59; P=0.018), more emotional talk (15.7 versus 5.5; P=0.021), and more medical counselling (17.3 versus 11.3; P=0.026). Patients responded by communicating more (mean scores of 113.8 versus 79.6; P=0.011) and disclosing more medical information (54.7 versus 41.7; P=0.002). Patient satisfaction ratings were higher for providers who had received the training and providers reported training to be relevant and useful. Conclusions. Further validation of IPC skills and simplification of assessment methods are needed if IPC is to be an area for routine monitoring and quality improvement.
TL;DR: It is concluded that ultrasound and computed tomography investigations on patients with suspected appendicitis are of great value and in fertile women, where unnecessary surgery is best avoided, they are better alternatives to surgical intervention.
Abstract: Objective. To study the sensitivity and the specificity for ultrasonography and computed tomography in patients with suspected appendicitis, and their value to the clinician.
Design. Retrospective study.
Setting. Teaching hospital, Sweden.
Main outcome measures. The negative appendectomy rate and the sensitivity and the specificity for ultrasonography and computed tomography in patients with suspected appendicitis.
Results. The diagnostic accuracy was 88% (men 95%, women 80%). Two hundred and thirty-nine patients were examined by ultrasonography preoperatively. The sensitivity for ultrasonography was 0.82 and the specificity was 0.97. Forty-nine patients were examined by computed tomography preoperatively. The sensitivity for computer tomography was 0.88 and the specificity was 0.95.
Conclusions. We conclude that ultrasound and computed tomography investigations on patients with suspected appendicitis are of great value. Computed tomography seems to have a higher sensitivity than ultrasound and a high specificity. In fertile women, where unnecessary surgery is best avoided, we believe that computed tomography investigation or ultrasound examination are better alternatives to surgical intervention.
TL;DR: The findings suggest that the antipsychotic dose performance measure may be useful for monitoring quality and is likely to improve patient outcomes.
Abstract: Objective. This report describes the development, application, and exploratory evaluation of a clinical performance measure based on recently published schizophrenia guidelines for antipsychotic dose. Design, setting, participants. The performance measure, which assesses adherence to antipsychotic dose recommendations for acute schizophrenia treatment, was calculated at hospital discharge for 116 patients with schizophrenia who had participated in a 6-month outcomes study. Main outcome measure. The Brief Psychiatric Rating Scale (BPRS) was used to assess symptom severity at 6-month followup. Results. At discharge, almost one-half of the patients were prescribed doses outside the recommended range. For the entire sample, linear regression models showed that the performance measure variable was not significantly associated with followup symptom severity (BPRS total scores). However, a significant association was observed for patients prescribed oral antipsychotics only (n=69). Patients prescribed recommended doses had lower adjusted mean BPRS totals than patients prescribed doses either greater than (P < 0.05) or less than (P < 0.05) recommended. Conclusions. Our findings suggest that the antipsychotic dose performance measure may be useful for monitoring quality. It assesses a modifiable aspect of care for which clinical improvement is needed, and such improvement is likely to improve patient outcomes. Future research is needed to confirm our findings and to develop and test interventions to improve the quality of care for schizophrenia that incorporate this clinical performance measure.
TL;DR: Hospital accreditation programmes or systems have been established in several countries or areas such as: Taiwan (1978), Korea (1981), Mainland China (1989), New Zealand Governance and policies (1990), Japan (1995), The Philippines (1999), Malaysia (1999) [16,25,26].
Abstract: Health service accreditation systems have had extraordinarily of China, began its hospital accreditation system in 1978 operated jointly by the Ministry of Education and the Derapid growth and development worldwide in the past decade [1–17]. Currently 28 countries have established their own partment of Health (DOH) [25–27]. In 1986, with the promulgation of the Medical Care Act (MCA), Taiwan’s hospital hospital accreditation systems. The international accreditation feasibility paper of the International Society for Quality in accreditation programme was divided into two main schemes: teaching hospital accreditation and hospital accreditation. Health Care (ISQua) indicated the importance of these systems and the interest of international societies in elaborating The former programme was conducted by the Ministry of Education and the DOH; the latter was operated separately and developing a set of international accreditation standards for health care [8,13,18]. by the DOH [1]. Accredited hospitals in Taiwan were classified into four However, issues, policies, controversies, and challenges regarding international accreditation standards have been categories: medical centre hospitals, regional hospitals, district teaching hospitals and district non-teaching hospitals [25,26]. discussed and debated for many years [1,5,14,18–23]. After the ISQua meeting in Venice, Italy in 1994, the Society On 16 March 1999, the DOH, the Hospital Association, the Private Hospitals & Clinics Association, and the Physicians organized its own accreditation section and agenda, and in 1998 the Agenda for Leadership in Programs for Healthcare Union funded the Taiwan Joint Commission on Hospital Accreditation and Quality Assurance (TJCHA, the foundaAccreditation was formalized in Budapest, Hungary [8]. Recently, the international health care community has tried to tion). The Commission took over the accreditation programme for district hospitals and in 1999 was appointed by develop new methods and techniques to review and learn from different health services accreditation external peer the DOH as the sole or primary accreditation body for these hospitals. However, the DOH still conducted the accreditation review systems such as the European External Peer Review Techniques (ExPeRT) Project and the Joint Commission programme for medical centre hospitals and regional hospitals. In 1998, there were 719 hospitals in Taiwan. Of this International Accreditation task force project. In the Asia-Pacific region, the Australian Council on total, 567 hospitals were accredited including 14 medical centre hospitals, 45 regional hospitals and 508 district and Hospital Standards was the first to launch a hospital accreditation programme in 1974 [6,24]. In the past two decades, speciality hospitals. hospital accreditation programmes or systems have been established in several countries or areas such as: Taiwan (1978), Korea (1981), Mainland China (1989), New Zealand Governance and policies (1990), Japan (1995), The Philippines (1999), Malaysia (1999) [16,25,26]. Many additional countries or areas have shown According to the MCA, the DOH was allowed to assign great interest in the development of a hospital accreditation responsibility to some medical societies and hospital assystem, for example Hong Kong, Indonesia and Singapore. sociations for some parts of the accreditation programme such as accreditation of intensive care units and psychiatric services. Although some parts of the accreditation programme were handed over to the TJCHA, the DOH still plays a role Hospital accreditation in Taiwan as an accreditation body in areas such as formulation of accreditation policies, developing standards, and appointing For the purpose of assigning teaching hospitals as the setting for medical students’ teaching practice Taiwan, the Republic accreditation surveyors for on-site visits.
TL;DR: Data-based feedback as a management tool has been associated with improved organizational functioning in Greek hospitals, however, systematic use of this intervention within Greek hospitals has been limited.
Abstract: Objective. The development and application of a questionnaire that eventually could be used as a management tool and a means of promoting the quality of care provided in ‘P. & A. Kyriakou’ Children’s Hospital. Design. Parents’ survey, during treatment of their children. Setting. ‘P. & A. Kyriakou’ Children’s Hospital, Athens, Greece. Participants. Sample of 240 parents. Main outcome measure. Parent satisfaction. Results. The most important finding of the study, although normative statements cannot be made, appears to be signalling of low satisfaction with care. The general mean observed (45 on a scale of 100) is not close to the mean (76) derived from a systematic review of 221 satisfaction studies. Moreover, satisfaction appears to be very low (14/100) for the procedures of the hospital, low for the outpatient dimension (42/100) and rather satisfactory for the inpatient dimension (61/100). Conclusion. Data-based feedback as a management tool has been associated with improved organizational functioning. However, systematic use of this intervention within Greek hospitals has been limited. Therefore, the next phase of the project will be used as feedback to the Governing Board and the personnel of the hospital. Finally, a study will be planned to investigate the effects of implementing changes based on parents’ ratings of staff performance.