Showing papers in "International Journal for Quality in Health Care in 2007"

Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups

Abstract: Background. Qualitative research explores complex phenomena encountered by clinicians, health care providers, policy makers and consumers. Although partial checklists are available, no consolidated reporting framework exists for any type of qualitative design. Objective. To develop a checklist for explicit and comprehensive reporting of qualitative studies (indepth interviews and focus groups). Methods. We performed a comprehensive search in Cochrane and Campbell Protocols, Medline, CINAHL, systematic reviews of qualitative studies, author or reviewer guidelines of major medical journals and reference lists of relevant publications for existing checklists used to assess qualitative studies. Seventy-six items from 22 checklists were compiled into a comprehensive list. All items were grouped into three domains: (i) research team and reflexivity, (ii) study design and (iii) data analysis and reporting. Duplicate items and those that were ambiguous, too broadly defined and impractical to assess were removed. Results. Items most frequently included in the checklists related to sampling method, setting for data collection, method of data collection, respondent validation of findings, method of recording data, description of the derivation of themes and inclusion of supporting quotations. We grouped all items into three domains: (i) research team and reflexivity, (ii) study design and (iii) data analysis and reporting. Conclusions. The criteria included in COREQ, a 32-item checklist, can help researchers to report important aspects of the research team, study methods, context of the study, findings, analysis and interpretations.

Language proficiency and adverse events in US hospitals: a pilot study

Abstract: Objective. To examine differences in the characteristics of adverse events between English speaking patients and patients with limited English proficiency in US hospitals. Setting. Six Joint Commission accredited hospitals in the USA. Method. Adverse event data on English speaking patients and patients with limited English proficiency were collected from six hospitals over 7 months in 2005 and classified using the National Quality Forum endorsed Patient Safety Event Taxonomy. Results. About 49.1% of limited English proficient patient adverse events involved some physical harm whereas only 29.5% of adverse events for patients who speak English resulted in physical harm. Of those adverse events resulting in physical harm, 46.8% of the limited English proficient patient adverse events had a level of harm ranging from moderate temporary harm to death, compared with 24.4% of English speaking patient adverse events. The adverse events that occurred to limited English proficient patients were also more likely to be the result of communication errors (52.4%) than adverse events for English speaking patients (35.9%). Conclusions. Language barriers appear to increase the risks to patient safety. It is important for patients with language barriers to have ready access to competent language services. Providers need to collect reliable language data at the patient point of entry and document the language services provided during the patient – provider encounter.

Development of medical checklists for improved quality of patient care

Abstract: Background. Checklists are used in both medical and non-medical industries as cognitive aids to guide users through accurate task completion. Their development requires a systematic and comprehensive approach, particularly when implemented in high intensity fields such as medicine. Objective. A narrative review of the literature was conducted to outline the methodology to designing and implementing clear and effective medical checklists. Methods. We systematically searched for relevant English-language medical and non-medical literature both to describe where checklists have been demonstrated to improve delivery of care and also, how to develop valid checklists. Results. The MEDLINE search yielded 8303 citations of which 1042 abstracts were reviewed. On the basis of criteria for inclusion and subsequent full-manuscript review, 178 sources, including 17 non-medical publications, were included in the narrative review. This information was further supplemented by expert opinion in the area of checklist development and implementation. A small number of strategies for designing effective checklists were referenced in the literature, including utilization of pre-published guidelines, formation of expert panels and repeat pilot-testing of preliminary checklists. Conclusion. Despite currently available evidence, a highly effective, standardized methodology for the development and design of medical-specific checklists has not previously been developed and validated, which has likely contributed to their inconsistent use in several key fields of medicine, despite evidence of their fundamental role in error management.

Understanding what works--and why--in quality improvement: the need for theory-driven evaluation.

Abstract: Clinicians who are asked to participate in quality improvement programmes in healthcare organizations are often heard to ask for the evidence that they ‘work’. By that, they often mean they want randomized controlled trials, which show that accreditation, or credentialing, or criterion-based audit, or adverse event monitoring, or continuous quality improvement programmes, or whatever approach is being used cause meaningful and worthwhile improvements in the quality of care [1]. When they learn that there are relatively few experimental studies of quality improvement interventions [2], and those which do exist often show weak or moderate effects at best, this state of affairs is sometimes used to argue that it is not worthwhile investing time and effort in quality improvement. After all, the argument goes, we should not embark on using a new clinical intervention such as a drug or a surgical procedure without solid experimental evidence of its effectiveness, so why should we have a lower threshold for the adoption of organizational interventions like quality improvement programmes? Surely, they too should be proven to ‘work’ before they are adopted or implemented widely? This point of view needs to be challenged. It is founded on a fundamental misunderstanding of the place of experimental methods in investigating and understanding complex social interventions, which is commonplace particularly among clinicians and biomedical researchers and which can seriously hamper those both researching …

Testing the technology acceptance model for evaluating healthcare professionals' intention to use an adverse event reporting system.

Abstract: Background. Many healthcare organizations have implemented adverse event reporting systems in the hope of learning from experience to prevent adverse events and medical errors. However, a number of these applications have failed or not been implemented as predicted. Objective. This study presents an extended technology acceptance model that integrates variables connoting trust and management support into the model to investigate what determines acceptance of adverse event reporting systems by healthcare professionals. Method. The proposed model was empirically tested using data collected from a survey in the hospital environment. A confirmatory factor analysis was performed to examine the reliability and validity of the measurement model, and a structural equation modeling technique was used to evaluate the causal model. Results. The results indicated that perceived usefulness, perceived ease of use, subjective norm, and trust had a significant effect on a professional’s intention to use an adverse event reporting system. Among them, subjective norm had the most contribution (total effect). Perceived ease of use and subjective norm also had a direct effect on perceived usefulness and trust, respectively. Management support had a direct effect on perceived usefulness, perceived ease of use, and subjective norm. Conclusion. The proposed model provides a means to understand what factors determine the behavioral intention of healthcare professionals to use an adverse event reporting system and how this may affect future use. In addition, understanding the factors contributing to behavioral intent may potentially be used in advance of system development to predict reporting systems acceptance.

The impact of hospital accreditation on quality of care: perception of Lebanese nurses

Abstract: Background In developing countries, accreditation is increasingly being used as a tool for government regulation to guarantee quality of care. Although Lebanon is the first country in the East Mediterranean Region to develop and implement accreditation standards, little is known yet on its impact on quality of care. Objective To assess the perceived impact of accreditation on quality of care through the lens of health care professionals, specifically nurses. This paper also investigates the perceived contributing factors that can explain change in quality of care. Methods A cross-sectional survey design where all hospitals that successfully passed both national accreditation surveys (I and II) were included. A total of 1048 registered nurses from 59 hospitals were sampled. The survey tool, assessing quality of care and contributing factors, includes nine scales and subscales rated on five-point Likert scale. Results The high score for the variable ‘Quality Results’ indicates that nurses perceived an improvement in quality during and after the accreditation process. Predictors of better Quality Results were Leadership, Commitment and Support, Use of Data, Quality Management, Staff Involvement and hospital size. The variable Quality Management, as measured by the scale Quality Management, had the greatest impact in medium-sized hospitals while the subscale measuring Staff Involvement had the greatest impact in small-sized hospitals. Conclusion According to Lebanese nurses, hospital accreditation is a good tool for improving quality of care. In order to ensure that accreditation brings effective quality improvement practices, there is a need to assess quality based on patient outcome indicators.

Improving quality through effective implementation of information technology in healthcare.

Abstract: Objectives. To describe an implementation of one information technology system (electronic medical record, EMR) in one hospital, the perceived impact, the factors thought to help and hinder implementation and the success of the system and compare this with theories of effective IT implementation. To draw on previous research, empirical data from this study is used to develop IT implementation theory. Design. Qualitative case study, replicating the methods and questions of a previously published USA EMR implementation study using semi-structured interviews and documentation. Setting. Large Swedish teaching hospital shortly after a merger of two hospital sites. Participants. Thirty senior clinicians, managers, project team members, doctors and nurses. Results. The Swedish implementation was achieved within a year and for under half the budget, with a generally popular EMR which was thought to save time and improve the quality of patient care. Evidence from this study and findings from the more problematic USA implementation case suggests that key factors for cost effective implementation and operation were features of the system itself, the implementation process and the conditions under which the implementation was carried out. Conclusion. There is empirical support for the IT implementation theory developed in this study, which provides a sound basis for future research and successful implementation. Successful implementation of an EMR is likely with an intuitive system, requiring little training, already well developed for clinical work but allowing flexibility for development, where clinicians are involved in selection and in modification for their department needs and where a realistic timetable is made using an assessment of the change-capability of the organization. Once a system decision is made, the implementation should be driven by top and departmental leaders assisted by competent project teams involving information technology specialists and users. Corrections for unforeseen eventualities will be needed, especially with less developed systems, requiring regular reviews of progress and modifications to systems and timetables to respond to user needs.

Does delay in surgery after hip fracture lead to worse outcomes? A multicenter survey

Abstract: Objective. To estimate the impact of delays in surgery for hip fracture on short- and long-term outcomes. Design. Analysis of inpatient hospital data integrated with national health plan data and Central Bureau Statistics. Setting. Seven major tertiary hospitals. Patients. All consecutive elderly patients admitted with hip fracture during the years 2001 –2005. Main outcome measures. Time from the hospitalization to operation; one-year mortality. Main results. Study population comprise 4633 patients, older than 65 years. The conservative approach was chosen in 818 patients (17.7%), while 1350 patients (29.1%) waited .2 days from admission to the surgery. There was a substantial variation in median pre-operative stay among the hospitals (range 0 – 4 days). Patients who had surgery within 2 days had lower mortality (in-hospital, 1-month and 1-year) compared to those who waited for surgery .4 days (2.9%, 4.0%, 17.4% vs. 4.6%, 6.1%, 26.2%, respectively). A Cox proportional regression model of 1-year mortality in operated patients adjusted for background morbidity (Charlson index) showed that the length of operation delay has a gradual effect on increasing mortality (,2 days—reference group, 2– 4 days—OR ¼ 1.20, 5 days or longer, OR ¼ 1.50). The 818 (17.7%) non-operated patients suffered the highest 1-year mortality, 36.2%. Conclusions. Delays in surgery for hip fracture are associated with significant increase in short-term and 1-year mortality. Variation among the hospitals was substantial and calls for prompt quality improvement actions.

Promoting quality: the health-care organization from a management perspective.

Abstract: Background Although agreement about the need for quality improvement in health care is almost universal, the means of achieving effective improvement in overall care is not well understood. Avedis Donabedian developed the structure–process–outcome framework in which to think about quality-improvement efforts. Issue There is now a robust evidence-base in the quality-improvement literature on process and outcomes, but structure has received considerably less attention. The health-care field would benefit from expanding the current interpretation of structure to include broader perspectives on organizational attributes as primary determinants of process change and quality improvement. Solutions We highlight and discuss the following key elements of organizational attributes from a management perspective: (i) executive management, including senior leadership and board responsibilities (ii) culture, (iii) organizational design, (iv) incentive structures and (v) information management and technology. We discuss the relevant contributions from the business and medical literature for each element, and provide this framework as a roadmap for future research in an effort to develop the optimal definition of ‘structure’ for transforming quality-improvement initiatives.

Performance improvement based on integrated quality management models: what evidence do we have? A systematic literature review.

Abstract: Purpose. Health care organizations have to improve their performance for multiple stakeholders and organize integrated care. To facilitate this, various integrated quality management models can be used. This article reviews the literature on the Malcolm Baldrige Quality Award (MBQA) criteria, the European Foundation Quality Management (EFQM) Excellence model (Excellence award models) and the Chronic Care Model. The focus is on the empirical evidence for improved performance by the implementation of interventions based on these models.

Differentials in the quality of antenatal care in India

Abstract: Objective To investigate the socio-economic differentials in the quality (clinical and interpersonal) of antenatal care and also the correlation between differentials in the quality and utilization of antenatal care. Design The study uses cross-sectional, nationally representative data from National Family Health Survey (1998–99). Setting Four south Indian states (Andhra Pradesh, Karnataka, Kerala and Tamil Nadu) and four north Indian states (Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh). Main outcomes measured More than four antenatal care visits for utilization, and index of clinical, information and interpersonal quality of care. Results Lower than desired quality of antenatal care was observed in both north and south Indian states, though the quality was significantly better in south India compared with north India, especially among the disadvantaged women. Significant socio-economic differentials in the quality of care were evident in both north and south India, but were more glaring in north India. A significantly positive relationship was observed between the quality and utilization of antenatal care in the rural areas from village-level multivariate analysis. Discussion Poor quality of antenatal care is likely to reduce its utilization. Policy and program interventions to improve the quality of care of antenatal care, especially for the poor and other disadvantaged population groups, more so in north India, are essential to improve maternal health outcomes. The India's National Rural Health Mission (NRHM), launched in 2005, should lay greater emphasis on improving the quality of antenatal care, among other things, to increase utilization of antenatal care and achieve better maternal health outcomes.

The influence of socioeconomic status on utilization and outcomes of elective total hip replacement: a multicity population-based longitudinal study

Abstract: Objective. In countries with universal health coverage, socioeconomic status is not expected to influence access to effective treatment and its prognosis. We tested whether socioeconomic status affects the rates of elective total hip replacement and whether it plays a role in early and late outcomes. Design. Multicity population-based longitudinal study. Settings and participants. From Hospital Registries of four Italian cities (Rome, Milan, Turin, and Bologna), we identified 6140 residents aged 65+ years undergoing elective total hip replacement in 1997–2000. Main outcome measures. An area-based (census block) income index was used for each individual. Poisson regression yielded rate ratios (RR) of population occurrence by income level. Logistic regression estimated odds ratios (OR) of selected outcomes within 90 days. Cox proportional hazard models evaluated effects of income on rates of revision of total hip replacement and mortality up to 31 December 2004. Analyses were adjusted for age, gender, city of residence, and coexisting medical conditions. Results. Low-income people were less likely than high-income counterparts to undergo total hip replacement [RR = 0.87, 95% confidence interval (CI) 0.81–0.95]; the effect was stronger among those aged 75+ years (RR = 0.76, 95% CI = 0.66–0.86). Low income was associated with higher risk of acute adverse medical events (P trend = 0.05) and of general infections and decubitus ulcer (P trend = 0.02) within 90 days. The effects were even higher among those aged 75+ years. No effects were found either for orthopaedic complications within 90 days or for revision and mortality. Conclusions. Total hip replacement is underutilized among elderly deprived individuals. Disadvantaged patients seem more vulnerable to acute adverse medical events after surgery. The evidence of unmet need and poor prognosis of low social class people has important implications for health care policy.

Socioeconomic disadvantage and primary non-adherence with medication in Sweden.

Abstract: Objective Lack of adherence with pharmacological therapy is a public health concern that compels tremendous costs for the health care system and the community. To analyse the association between socioeconomic disadvantage and primary non-adherence with medication, and to explore possible mediating effects of trust in health care and lifestyle profile. Design Cross-sectional population-based study based on data from the Swedish national public health surveys 2004–2005. Participants The study comprised 13603 men and 18292 women aged 21–84 years who had any contact with a physician at a hospital or primary care centre. Measures Primary non-adherence with medication based on whether respondents reported that they refrained from purchasing at the pharmacy prescribed medication. Socioeconomic Disadvantage Index was based on four different indicators of economic deprivation. Results Socioeconomic disadvantage was associated with primary non-adherence with medication independent of long-term illness, risky lifestyle, low education, living alone and low trust for health care. This association increased with older age, particularly among women. Among individuals aged 21–34 years, severe compared with no socioeconomic disadvantage, was associated with two-fold increased odds for non-adherence with medication. The corresponding odds among individuals aged 65–84 years were three-fold increase among elderly men (OR = 3.3, 95% CI: 1.4–7.8) and six-fold increase among elderly women (OR = 6.2, 95% CI: 2.5–15.3). Yet every seventh elderly woman aged 65–84 years suffered from long-term illness. Conclusions Results indicate that health policies for ‘care on equal terms’ in Sweden have been less successful in relation to equitable access to prescribed medication, especially among the elderly.

An observational study of medication administration errors in old-age psychiatric inpatients

Abstract: Background. Relatively little is known about medication administration errors in mental health settings. Objective. To investigate the frequency and nature of medication administration errors in old-age psychiatry. To assess the acceptability of the observational technique to nurse participants. Method. Cross-sectional study technique using (i) direct observation, (ii) medication chart review and (iii) incident reports. Setting. Two elderly long-stay wards in an independent UK psychiatric hospital. Participants. Nine nurses administering medication at routine medication rounds. Main outcome measures. Frequency, type and severity of directly observed medication administration errors compared with errors detected by retrospective chart review and incident reports. Results. Using direct observation 369 errors in 1423 opportunities for errors (25.9%) were detected vs. chart review detected 148 errors and incident reports none. Most errors were of doubtful or minor severity. The pharmacist intervened on four occasions to prevent an error causing patient harm. The commonest errors observed were unauthorized tablet crushing or capsule opening (111/369, 30.1%), omission without a valid reason (100/369, 27.1%) and failure to record administration (87/369, 23.6%). Among the nurses observed, the error rate varied widely from no errors to one error in every two doses administered. Of the seven nurses who completed the post-observation questionnaire, all said they would be willing to be observed again. Conclusion. Medication administration errors are common and mostly minor. Direct observation is a useful, sensitive method for detecting medication administration errors in psychiatry and detects many more errors than chart review or incident reports. The technique appeared to be acceptable to most of the nursing staff that were observed.

Safety in home care: a broadened perspective of patient safety.

Abstract: Background. Home care is the most rapidly growing segment of the Canadian healthcare system. Overwhelmingly, research on patient safety has been conducted within institutional settings, resulting in a significant knowledge gap about safety in homecare. Given the dramatic increase in the amount, acuity and complexity of health care being provided in the home and community, it is essential to develop our understanding of safety in this sector. Objective. The objective of this paper is to describe the landscape of safety in home care in Canada. Method. This pan-Canadian initiative included three phases: a literature review, 20 key informant interviews and an invitational roundtable. Data were synthesized using a content analysis approach. Results. Patient safety is a failure of systems rather than of humans; there are many change processes required to create safe environments; organizational culture and workplace factors are critical. Patients have a key role to play in their care and thus must be part of the patient safety discourse. Themes central to safety in home care are: the inextricably linked relationships and communication among clients/families and caregivers/providers; unregulated and uncontrolled settings, autonomy and isolation; the multidimensionality of safety ( physical, emotional, social, functional); a diminishing focus on prevention, health promotion and chronic care; challenges of human resources and maintenance of competence.

Team climate for innovation: what difference does it make in general practice?

Abstract: Objective. Teamwork in primary healthcare is associated with patient care processes and staff outcomes. The ability of teams to be innovative is a hypothesized mechanism. We examined the characteristics of general practices with good team climate for innovation, and assessed the impact of climate on chronically ill patients’ assessment of their care and on the job satisfaction of the staff. Design. Large cross-sectional study. Setting. Australian general practices. Participants. A total of 654 general practitioners and staff and 7505 chronically ill patients from 93 general practices in 6 Australian states and territories. Measures. The Team Climate Inventory and the Overall Job Satisfaction Scale, customized for use with general practices, were administered to general practitioners and practice staff, and the General Practice Assessment Survey was administered to patients. Practice characteristics were collected by survey from the principal doctor or practice manager. Results. Mean scores of team climate in Australian general practices were similar to those reported in the UK, except that in our study there was no association between the number of doctors in a practice and their team climate. Better team climate was found in practices with fewer non-clinical staff. Team climate predicted the job satisfaction of the general practitioners and staff, irrespective of the number of practice staff. Better team climate was associated with greater satisfaction by patients with their care. Conclusions. Team climate is important for patient and staff satisfaction. In large general practices, separate sub-cultures may exist between administrative and clinical staff, which has implications for designing effective team interventions.

A comparison of quality of care indicators in urban acute care hospitals and rural critical access hospitals in the United States.

Abstract: Objective Two recent Institute of Medicine reports highlight that the quality of healthcare in the US is less than what should be expected from the world's most extensive and expensive healthcare system. This may be especially true for critical access hospitals since these smaller rural-based hospitals often have fewer resources and less funding than larger urban hospitals. The purpose of this paper was to compare quality of hospital care provided in urban acute care hospitals to that provided in rural critical access hospitals. Design Cross-sectional study analyzing secondary Hospital Compare data. T-test statistics were computed on weighted data to ascertain if differences were statistically significant ( P = 0.01). Setting Centers for Medicare and Medicaid Services hospitals. Participants US Acute Care and Critical Access hospitals. Main outcome measures Differences between urban acute care hospitals and rural critical access hospitals on quality care indicators related to acute myocardial infarction, heart failure and pneumonia. Results For 8 of the 12 hospital quality indicators the differences between urban acute care and rural critical access hospitals were statistically significant ( P = 0.01). In seven instances these differences favored urban hospitals. One indicator related to pneumonia favored rural hospitals Conclusions Although this study focused on only three disease states, these are among the most common clinical conditions encountered in inpatient settings. The findings suggested that there may be differences in quality in rural critical access hospitals and urban acute care hospitals and support the need for future studies addressing disparities between urban acute care and rural critical access hospitals.

Quality of informed consent for invasive procedures.

Abstract: Objective. To assess quality of informed consent among patients undergoing procedures and patient’s preferences about decision-making. Design. Cross-sectional survey of hospitalized patients about informed consent before surgery or other procedures. Preference for decision-making was elicited in hospitalized and ambulatory patients. Setting. Large academic general hospital and 10 general clinics, over the years 2002 – 04. Intervention. Data of initial survey were presented at staff meetings, recommending asking patients to restate what was explained to them. Main outcome measures. Rate of patient’s recall for explanations on risks and alternative options; rate of patients preferring shared, autonomous and paternalistic modes of decision-making; degree of satisfaction from the decision-making. Results. Half of the patients did not recall receiving explanations about risks and two-third did not remember discussion of alternative options. The intervention failed, ,10% of patients being asked to re-state what was explained to them. Expectations about decision varied: � 60% favored shared decision, nearly 20% preferred autonomous decision and the remainder wanted physicians to make decisions. Satisfaction was rated as good or very good by 80% of patients. Conclusions. Most patients do not remember receiving explanations about risks or alternatives for procedures, and physicians resist attempts to improve informed consent. Tools should be developed to measure the quality of consent. Since patients significantly differ in their preferred mode of decision-making, the informed consent should be patient-specific.

A comparison of electronic records to paper records in mental health centers

Abstract: Objective. Medication documentation is a critical aspect of quality patient care. The current study examined whether electronic medical records provide medication documentation that is more complete and faster to retrieve than traditional paper records. Method. This study involves a comparison of archived paper medical records to recent electronic medical records through chart review. A convenient sample of three large community mental health centers in Indiana was used. Medical charts for 180 patients with schizophrenia were rated on a checklist composed of 16 items that was adapted from a national project. Documentation that existed before implementation of the electronic medical record system was compared with that after implementation at each of the three centers. The main outcome measures were completeness and retrieval time of medication documentation. Results. Electronic medical records provided medication documentation that was more complete and faster to retrieve than paper records across all centers and within each center. On average, electronic medical records were 40% more complete and 20% faster to retrieve. Conclusion. Electronic records have potential to improve medication management for patients in mental health centers over traditional records. However, medication documentation for patients diagnosed with schizophrenia was found to be deficient in many areas, regardless of documentation format.

Expectations and received knowledge by surgical patients

Abstract: Objective. Here, the aim is to compare surgical patients’ knowledge expectations at admission with the knowledge they received during their hospital stay. Design. The study used a descriptive and comparative design. Setting. The study was conducted on surgical wards at one randomly selected university hospital in Finland. Participants. The sample (n ¼ 237) consisted of surgical patients (traumatological, gastroenterological, urological and heart and thorax surgery) admitted to hospital during a 2-month period in 2003. Methods. The data were collected by two specially developed, parallel questionnaires: Hospital Patients’ Knowledge Expectations and Hospital Patients’ Received Knowledge. These 40-item instruments used a four-tier response scale and made a distinction between the bio-physiological, functional, experiential, ethical, social and financial dimensions of knowledge. The data were analysed statistically. Results. Surgical patients received less knowledge than they felt they expected on the bio-physiological, functional, experiential, ethical, social and financial dimensions. Their knowledge expectations and the knowledge they received were related to age, gender and level of basic education. Conclusions. The results highlighted the need for improved patient education. Surgical patients expect to receive more knowledge than they actually receive on all dimensions. The most problematic areas in the education of surgical patients are the experiential, ethical, social and financial dimensions of knowledge. In particular, younger patients, female patients and patients with a higher level of education require more attention.

Monitoring patients using control charts: a systematic review

Abstract: Objectives To systematically review the uses control charts to monitor clinical variables in individual patients. Data sources Systematic searches of MEDLINE, CINAHL, Embase and five other databases yielded 74 studies, of which seven met our inclusion criteria of using control charts to monitor clinical variables for disease at an individual patient level. Review methods Included articles were reviewed independently by two reviewers. Data were extracted on study design, clinical condition or disease being monitored, clinical variable or marker, measurement method, outcome measure and any changes in clinical indicator identified in the articles. Results Control charts were applied to four conditions—hypertension, asthma, renal function post-transplant and diabetes. Studies fell into two categories. Three studies sought to determine the ‘performance’ of control charts in comparison with existing ‘gold standard methods’ in terms of sensitivity and specificity based on moderate sample sizes ( n = 35–45). This category of studies found control charts to be simple, low-cost, effective tools with good sensitivity and specificity characteristics and concluded in favour of control charts. The other four studies were individual patient case-studies in which the use of control charts to monitor clinical variables was associated with a positive impact on patient and carer experience albeit anecdotally and with varying degrees of attention. Conclusions Control charts appear to have a promising but largely under-researched role in monitoring clinical variables in individual patients. Furthermore, rigorous evaluation of control charts is required.

Dispensing errors in community pharmacy: perceived influence of sociotechnical factors

Abstract: Objective This study examined the impact of pharmacists' perceptions of errors in dispensing, errors in communication, delays in prescription processing, efficiency and physical mobility in the pharmacy by practice setting and sociotechnical factors (i.e. pharmacy design, drive through pick-up window services and automated dispensing systems). Setting Community pharmacy practice in the USA. Design A two-page survey was mailed to a geographically stratified random sample of 1047 community pharmacies. One-way analysis of variance was used to determine the impact of attitudinal items with respect to pharmacy practice setting (e.g. mass merchant, supermarket, chain and independent) and sociotechnical factors. Pharmacy characteristics, pharmacist experience and total dispensing errors were also addressed. Results The response rate was 45.0% ( n = 429). Pharmacists perceived that pharmacy design significantly ( P < 0.05) contributed to dispensing errors, errors in communication, problems with efficiency and those similar problems were observed for all items relating to drive through window pick-up services. Automated dispensing systems were perceived as less likely ( P < 0.05) to contribute to dispensing errors, errors in communication, efficiency problems and extra physical movement. Perceived dispensing error rate was 0.057%, and the number of dispensing errors was positively and significantly ( P < 0.001) correlated with prescription volume. Cognitive errors accounted for ∼80% of the dispensing errors. Conclusions Perceptions of dispensing errors by pharmacists are influenced by design, drive through pick-up window services, and automated dispensing systems. However, more effort is needed to determine how cognitive processes relate to sociotechnical variables in pharmacy practice and other environments.

Impact of pharmacy validation in a computerized physician order entry context.

Abstract: Background Computerised physician order entry offers a potential means of reducing prescribing errors, and can also increase the feasibility of pharmacy validation as a secondary filter for eliminating errors. The impacts of these two benefits have never been evaluated in combination. Objective To describe (i) the pharmacists’ interventions during validation of drug prescriptions on a computerized physician order entry system, (ii) the impact of these interventions on the prescribing process and (iii) the extent to which computerized physician order entry was responsible for the identified errors. Method Prospective collection of all medication order lines during five days in a tertiary care university hospital using computerized physician order entry for drug prescription. All orders were reviewed by a pharmacist. We described the frequency of pharmacy alerts and their short-term impact on the correction of potential prescribing errors (modification of the prescription). An independent committee reviewed their type and link with the computerized physician order entry system. Results About 399 (11%) prescription order lines, corresponding to 222 (52%) patients, required a pharmacy alert during the study period. Among the 81 pharmacy alerts targeted to the prescriber, 21 [26% (IC95% = 17–37%)] resulted in a modification of the prescription. Among the 95 potential prescribing error, the independent review committee judged 16 (17%) as potentially life-threatening and attributed 47 (49%) to the use of computerized physician order entry system (unit error, no use of typical order prespecified, prescription inconsistency or other). Conclusion Pharmacy validation produced only a moderate short-term impact on the reduction of potential prescribing errors. However, pharmacy validation may also provide ongoing benefits by identifying necessary improvements in the computerized physician order entry system. Those improvements would allow pharmacists to concentrate on the most relevant interventions.

Content of antenatal care services in secondary health care facilities in Nigeria: implication for quality of maternal health care.

Abstract: Objective. To assess the contents of antenatal care and to relate the findings to the adequacy of maternal health care. Design. Cross-sectional study. Setting. Public secondary health-care facilities. Participants. Pregnant women. Interventions. Three hundred and ninety consecutive pregnant women attending 12 selected secondary health facilities were recruited proportionate to the client load recorded for each facility during the year preceding the study. Interviews were conducted using the antenatal care exit interview form of the Safe Motherhood Needs Assessment package. Main Outcome Measures. Antenatal care services provided to pregnant women in current pregnancy. Results. Blood pressure measurement, abdominal palpation and detection of foetal heart rate were provided to all participants. Three hundred and eighty-six (99%) were reached with at least one educational message. One hundred and sixty-seven (42.8%) had haemoglobin or packed cell volume estimated, whereas 168 (43.1%) had urine checked for protein, at least once during antenatal visits. Routine iron and folate supplements, and malaria prophylaxis were, respectively, given to 142 (36.4%) and 25 (6.4%). Conclusions. The antenatal care service as provided had reasonable capacity for intervention against pre-eclampsia and some foetal problems, and could contribute to delivery in a health facility and by a health worker. Capacity to address the possible effects of severe anaemia and malaria in pregnancy was lacking. Equipping health-care facilities with capacity to detect anaemia and proteinuria as well as ensuring that iron and folate supplements, and malaria prophylaxis are given to all pregnant women would help to meet national guidelines and improve quality of service.

Effects of socioeconomic status on patients' outcome after total knee arthroplasty

Abstract: Objective To identify whether patients in lower socioeconomic groups had worse pain and functional levels prior to total knee arthroplasty and then establish whether these patients had poorer post-operative outcomes following total knee arthroplasty. Method Data was obtained from a prospective observational study of 974 patients undergoing primary total knee arthroplasty for osteoarthritis. The study was undertaken in 13 centers in 4 countries. Pre-operative data was collected and patients were followed for 2 years post-operatively. Pre-operative details of the patients' demographics; socioeconomic status (SES) (education and income); height; weight and co-morbid conditions were obtained. The WOMAC scores were obtained preoperatively and during follow-up. Results Using multivariate linear regression analysis, patients with a lower income had a significantly worse pre-operative WOMAC Pain ( P = 0.021) and function score ( P = 0.039) than those with higher incomes. However, income did not have a significant impact on outcome at final follow-up after adjusting for other significant covariates. Level of education did not correlate with pre-operative scores or with outcome at any time during follow-up. Conclusion Across all four countries, patients with lower incomes appeared to have a greater need for total knee arthroplasty. However, level of income and educational status did not appear to affect the final outcome following total knee arthroplasty. Patients with lower incomes appeared able to compensate for their worse pre-operative score and obtain similar outcomes post-operatively. These findings are in contrast to studies on other medical conditions and surgical interventions, in which a lower SES has been found to have a negative impact on patient outcomes.

Patient, carer and staff experience of a hospital-based stroke service.

Abstract: Objective Here, the aim is to study the experiences of patients, carers and staff throughout a hospital stroke care pathway. Design Focus groups of patients, carers and staff followed a semi-structured format to elucidate experiences. The groups were recorded, transcribed and subjected to thematic analysis. Analyses were verified by researchers and participants. Results Patients and carers produced four overlapping themes: ‘information’, ‘staff attitudes’, ‘availability of care/treatment’ and ‘considering the whole person in context’. The carers' group produced two additional themes: ‘accommodation of patients’ individual needs' and ‘burden of care’. Their experiences were complex and multi-faceted; positive views of the whole service co-existed with negative views of some aspects. The staff groups produced six themes: ‘specialist service’, ‘split service’, ‘availability of care’, ‘consistency of care’, ‘staff morale’ and ‘wish for change’. Positive views of the specialist service were tempered by problems with physical and professional separation, staff shortages and ‘hierarchical practice’ that reduced collective decision-making. Conclusion Some of the patients' and carers' perspectives have not been previously reported in the stroke literature, including a desire for individualized treatment, the consideration of wider, non-physical needs and the carers' sense of burden. In addition, the study revealed how staff, carers and patients viewed each other and the service and demonstrated the concordance of their perceptions. However, staff showed little insight into the users' need for information and negative experiences of care. In contrast with previous research, lack of emotional care, poor continuity of care and lack of staff knowledge and skills were not identified as problems.

Development and implementation of a nationwide health care quality indicator system in Taiwan

Abstract: Quality issues. Quality is an increasingly important issue to the health care sector. The Taiwanese government also recognizes the need to implement a nationwide health care quality indicator system to strengthen quality surveillance. Choice of solution. In 1999, the Department of Health funded a 2-year project led by the Taiwan Healthcare Executive College to develop a comprehensive performance assessment system, subsequently named as Taiwan Healthcare Indicator Series (THIS). The series includes four categories of indicators, namely outpatient, in-patient, emergency care, and intensive care, and has 139 items in total. Implementation. The system was officially launched in 2001. Participation is voluntary. The Taiwan Healthcare Executive College processes the data and provides feedback to the participating hospitals. The information is for the participating hospitals’ own use and is not released to the public. Evaluation. Participating hospitals have increased from 45 in 2001 to 227 in 2006 and now constitute ∼50% of the total hospital population in Taiwan. The reporting rate averaged 77.7% in 2004. The first five most reported indicators are the percentage of first-visit outpatients to outpatient clinics, the average length of in-patient stay, the nosocomial infection rate, the occupancy rate, and the crude mortality rate. Lessons learned. How the data are interpreted and how data interpretation can lead to quality improvement are the principal concerns of participating hospitals. In light of the success of the indicator series, the Bureau of National Health Insurance (BNHI) of Taiwan has proposed participation in the series as being one of the criteria to be reimbursed for quality.

Using control charts to monitor quality of hospital care with administrative data

Abstract: Objective. Nearly all hospital-specific comparative analyses, based on administrative data, are presented using cross-sectional displays. In this paper, we compare cross-sectional analyses with sequential monitoring using control charts. Design. Analysis of administrative data to compare cross-sectional funnel plots with one type of control chart: the riskadjusted, expected-minus-observed plot. Setting. Eighteen tertiary and base hospitals in Queensland, Australia, for the two financial years 2003 – 04 and 2004 – 05. Participants. Patients admitted with acute myocardial infarction. Main outcome measure. Risk-adjusted, 30-day, in-hospital, mortality rates. Results. There were no outliers on the cross-sectional funnel plots for either of the 2 years using three-sigma limits and three low-outliers and one high-outlier using two-sigma limits. One reasonable interpretation of these plots is that most of the variations are due to statistical noise and there is little to be learnt by seeking to understand the reasons for variation across hospitals. In contrast, for the control charts, 28% of hospitals signalled for a relative increase of 75% above that for all hospitals combined. Conclusion. If the aim of clinical indicators based on administrative data is to provide a starting point for learning, then control charting provides potentially more useful information than the more commonly used cross-sectional analyses. Control charts provide an understandable and up-to-date overview that allows early detection of runs of good or bad outcomes that can help hospitals identify areas for more in-depth self-monitoring and learning.

Questionnaire to assess patient satisfaction with pharmaceutical care in Spanish language.

Abstract: Objective To develop and validate a questionnaire, in Spanish, for assessing patient satisfaction with pharmaceutical care received in community pharmacies. Design Selection and translation of questionnaire's items; definition of response scale and demographic questions. Evaluation of face and content validity, feasibility, factor structure, reliability and construct validity. Setting Forty-one community pharmacies of the province of Santa Fe. Argentina. Participants Questionnaire administered to patients receiving pharmaceutical care or traditional pharmacy services. Main outcome measure Pilot test to assess feasibility. Factor analysis used principal components and varimax rotation. Reliability established using internal consistency with Cronbach's alpha. Construct validity determined with extreme group method. Results A self-administered questionnaire with 27 items, 5-point Likert response scale and demographic questions was designed considering multidimensional structure of patient satisfaction. Questionnaire evaluates cumulative experience of patients with comprehensive pharmaceutical care practice in community pharmacies. Two hundred and seventy-four complete questionnaires were obtained. Factor analysis resulted in three factors: Managing therapy, Interpersonal relationship and General satisfaction, with a cumulative variance of 62.51%. Cronbach's alpha for the whole questionnaire was 0.96, and 0.95, 0.88 and 0.76 for the three factors, respectively. Mann–Whitney test for construct validity did not showed significant differences between pharmacies that provide pharmaceutical care and those that do not, however, 23 items showed significant differences between the two groups of pharmacies. Conclusion The questionnaire developed can be a reliable and valid instrument to assess patient satisfaction with pharmaceutical care in community pharmacies in Spanish. Further research is needed to deepen the validation process.

Does setting adolescent-friendly standards improve the quality of care in clinics? Evidence from South Africa

Abstract: Objective. To determine whether setting and implementing adolescent-friendly standards improves the quality of adolescent services in clinics. Design. The evaluation used a quasi-experimental case – control design. Setting/participants. Eleven public health clinics involved in the adolescent-friendly program [The National Adolescent Friendly Clinic Initiative (NAFCI)] and 11 control clinics. Intervention. This included implementation of a set of 10 adolescent-friendly standards and 41 corresponding criteria. Main outcome measures. Percentage scores were achieved for each standard and criterion. Clinics were awarded a Gold Star if they achieved an overall clinic score (average standard score) of � 90%, a Silver Star for a score between 60 and 89% and a Bronze Star for a score between 30 and 59%. Results. The NAFCI clinics performed better than the control clinics on most criteria. The combined average overall clinic score of all the NAFCI clinics (79.9%) was significantly higher (P ¼ 0.005) than the overall score for the control group clinics (60.9%). Results showed that the longer NAFCI was implemented at a clinic, the higher the score and the more likely that clinic would be accredited as an ‘adolescent friendly’ clinic. NAFCI clinics performed significantly better than the control clinics on criteria specific to the provision of adolescent-friendly services including knowledge of adolescent rights and nonjudgmental attitudes of staff. Conclusion. Setting and implementing standards and criteria improves the quality of adolescent services in clinics. The standards and criteria should be set on the basis of the characteristics of adolescent-friendly services and quality of care indicators. Best results are achieved when a facilitator trained in quality improvement methodologies supports clinics.