The Quality of Care
01 Jan 2010-pp 165-186
TL;DR: The quality of care in the homes together with policy and practice regarding the registration and inspection of homes was one of Townsend's key concerns as discussed by the authors, and the quality of inspection was also mixed.
Abstract: Thus far, we have considered some of the features of continuity and change in the surviving homes and in the everyday lives of those living and working in them. A question that is frequently asked, however, is whether the homes today are better than they were in the past. In this chapter, therefore, we present our findings about the quality of care in the surviving homes then and now. The quality of care in the homes together with policy and practice regarding the registration and inspection of homes was one of Townsend’s key concerns. In the late 1950s, homes owned by the local authority were not subject to registration and inspection procedures. Voluntary and private homes, however, were required to be registered with, and inspected by, the local authority. However, Townsend found that for a variety of reasons some of the voluntary and private homes he visited were exempt; others had not been inspected for at least a year and some for more than five years. The quality of inspection was also mixed. Given some of the conditions found by Townsend, this situation was of considerable concern to him.
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TL;DR: An extended model of the SEIPS, SEIPS 2.0 is a new human factors/ergonomics framework for studying and improving health and healthcare that describes how sociotechnical systems shape health-related work done by professionals and non-professionals, independently and collaboratively.
Abstract: Healthcare practitioners, patient safety leaders, educators and researchers increasingly recognise the value of human factors/ergonomics and make use of the discipline's person-centred models of sociotechnical systems. This paper first reviews one of the most widely used healthcare human factors systems models, the Systems Engineering Initiative for Patient Safety (SEIPS) model, and then introduces an extended model, 'SEIPS 2.0'. SEIPS 2.0 incorporates three novel concepts into the original model: configuration, engagement and adaptation. The concept of configuration highlights the dynamic, hierarchical and interactive properties of sociotechnical systems, making it possible to depict how health-related performance is shaped at 'a moment in time'. Engagement conveys that various individuals and teams can perform health-related activities separately and collaboratively. Engaged individuals often include patients, family caregivers and other non-professionals. Adaptation is introduced as a feedback mechanism that explains how dynamic systems evolve in planned and unplanned ways. Key implications and future directions for human factors research in healthcare are discussed.
773 citations
TL;DR: Poor quality of care (QoC) in many facilities becomes a paramount roadblock in the quest to end preventable mortality and morbidity.
698 citations
TL;DR: The history and development of the NSQIP, from its inception in the Veterans Administration Health System to its implementation within the private sector sponsored by the ACS, documents the growth of a program that has substantially improved the quality of surgical care and has had a considerable influence on the culture of quality improvement in the profession.
479 citations
International Agency for Research on Cancer1, University of Oxford2, National Health Service3, Imperial College London4, University of Surrey5, Royal Surrey County Hospital6, Erasmus University Rotterdam7, Leeds Teaching Hospitals NHS Trust8, University of Dundee9, Stavanger University Hospital10, University of Zagreb11, Mario Negri Institute for Pharmacological Research12, Karolinska Institutet13, German Cancer Research Center14, University of Oslo15, Queen Mary University of London16, Peking Union Medical College17, American Cancer Society18, University of Amsterdam19, FH Joanneum20, University of Burgundy21, University of Ljubljana22, University of Vermont23, National Cancer Research Institute24, University of Caen Lower Normandy25, Catholic University of Korea26, St George's Hospital27, University of Latvia28, Oregon Health & Science University29, University of Copenhagen30, GlaxoSmithKline31, Centers for Disease Control and Prevention32, University of North Carolina at Chapel Hill33, Ruhr University Bochum34, Institute of Oncology Ljubljana35, Cancer Care Ontario36, University of Toronto37, University of Coimbra38, University of Chicago39, University Hospitals Coventry and Warwickshire NHS Trust40, Charles University in Prague41, Katholieke Universiteit Leuven42, University of Miami43, Niigata University44, Memorial Sloan Kettering Cancer Center45, Flinders University46
TL;DR: An overview of the principles, recommendations and standards in the guidelines for quality assurance in CRC screening and diagnosis are presented in journal format in an open-access Supplement of Endoscopy.
Abstract: Population-based screening for early detection and treatment of colorectal cancer (CRC) and precursor lesions, using evidence-based methods, can be effective in populations with a significant burden of the disease provided the services are of high quality. Multidisciplinary, evidence-based guidelines for quality assurance in CRC screening and diagnosis have been developed by experts in a project co-financed by the European Union. The 450-page guidelines were published in book format by the European Commission in 2010. They include 10 chapters and over 250 recommendations, individually graded according to the strength of the recommendation and the supporting evidence. Adoption of the recommendations can improve and maintain the quality and effectiveness of an entire screening process, including identification and invitation of the target population, diagnosis and management of the disease and appropriate surveillance in people with detected lesions. To make the principles, recommendations and standards in the guidelines known to a wider professional and scientific community and to facilitate their use in the scientific literature, the original content is presented in journal format in an open-access Supplement of Endoscopy. The editors have prepared the present overview to inform readers of the comprehensive scope and content of the guidelines.
440 citations
TL;DR: Improvements in nursing home quality have likely occurred, but improvements are still needed, according to Donabedian's structure, process, and outcome (SPO) model.
Abstract: In the past, nursing home care and long-term care were synonymous. If elders needed long-term care, it would invariably be provided in a nursing home. In recent years, the long-term care sector has changed considerably and is arguably evolving into a “system” in which care can be provided in settings that are more appropriate for consumers’ needs. This includes care by home health providers, adult day care, residential care, and assisted living (to name just four). However, nursing homes are still an essential component of the current long-term care system. In the United States, approximately 1.6 million elderly and disabled persons receive care in 1 of the 17,000 nursing homes (National Nursing Home Survey, 2004). Enduring issues surrounding nursing homes have been quality related. The often-poor quality of nursing homes has been a consistent issue of concern for consumers, government, and researchers.
In this commentary, we first provide a brief review of the history of nursing home quality. This centers on how nursing home quality has been measured and provides some context and insight into currently used quality indicators in the nursing home industry. In doing so, we note that the concepts of what is measured, who does the measuring, and why measures are used are intertwined. We secondly provide our opinion on the relative merits of indicators of quality. Notable current quality indicators are presented. We then speculate on steps that need to be taken in the future to address and potentially improve the quality of care provided by nursing homes. These steps include policy changes and future research that is needed.
Numerous definitions of quality exist. A current well-cited example comes from the Institute of Medicine (IOM) (1996): “The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (p. 5). Operationalizing “quality” from definitions such as these proffered by the IOM can be problematic as the definitions are extremely general and subjective and as such resulting measures tend to be unable to fully realize the quality concept (Castle, Zinn, Brannon, & Mor, 1996).
Because of this inability to adequately realize “quality” in nursing homes, quality indicators are prevalent rather than quality measures. This helps denote a less precise association between the “indicator” and actual quality (i.e., they are surrogate measures). This has also fostered the creation of many quality indicators. For example, in choosing the quality indicators to be reported in Nursing Home Compare (www.medicare.gov/NHCompare; discussed subsequently), 181 indicators were considered. With many quality indicators available, some organization is useful. In this regard, in conceptualizing and organizing quality indicators, the approach of Donabedian (1985) is valuable.
Donabedian proposed that quality could be measured in terms of structures (S), processes (P), and outcomes (O). Structural measures are the organizational characteristics associated with the provision of care. Process measures are characteristics of things done to and for the resident. Outcome measures are the desired states one would (or would not) like to achieve for the resident. Donabedian's SPO approach is somewhat pervasive in the quality literature. For example, in MEDLINE (2005–2010), 57% (N = 3,950) of nursing home studies either directly or indirectly applied this approach of conceptualizing quality indicators. This approach of conceptualizing quality indicators as SPO measures is also used in this commentary.
The SPO approach also has theoretical underpinnings in that good structure should facilitate good process and good process should facilitate good outcomes. However, we note that the theoretical SPO underpinnings were not developed specifically for nursing homes and some have questioned its suitability for this setting (Glass, 1991). Moreover, SPO linkages are not always validated in the nursing home literature (Gustafson, Sainfort, Van Konigsveld, & Zimmerman, 1990). Some scholars have also further substantially developed components of this approach by including factors such as culture (S) and work groups (P) (Scott Poole & Van De Ven, 2004), whereas others in long-term care have modified the SPO theory, for example by combining it with contingency theory (Zinn & Mor, 1998).
305 citations
References
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TL;DR: A differential diagnosis for why physicians do not follow practice guidelines is offered, as well as a rational approach toward improving guideline adherence and a framework for future research are offered.
Abstract: ContextDespite wide promulgation, clinical practice guidelines have had limited
effect on changing physician behavior. Little is known about the process and
factors involved in changing physician practices in response to guidelines.ObjectiveTo review barriers to physician adherence to clinical practice guidelines.Data SourcesWe searched the MEDLINE, Educational Resources Information Center (ERIC),
and HealthSTAR databases (January 1966 to January 1998); bibliographies; textbooks
on health behavior or public health; and references supplied by experts to
find English-language article titles that describe barriers to guideline adherence.Study SelectionOf 5658 articles initially identified, we selected 76 published studies
describing at least 1 barrier to adherence to clinical practice guidelines,
practice parameters, clinical policies, or national consensus statements.
One investigator screened titles to identify candidate articles, then 2 investigators
independently reviewed the texts to exclude articles that did not match the
criteria. Differences were resolved by consensus with a third investigator.Data ExtractionTwo investigators organized barriers to adherence into a framework according
to their effect on physician knowledge, attitudes, or behavior. This organization
was validated by 3 additional investigators.Data SynthesisThe 76 articles included 120 different surveys investigating 293 potential
barriers to physician guideline adherence, including awareness (n = 46), familiarity
(n = 31), agreement (n = 33), self-efficacy (n = 19), outcome expectancy (n
= 8), ability to overcome the inertia of previous practice (n = 14), and absence
of external barriers to perform recommendations (n = 34). The majority of
surveys (70 [58%] of 120) examined only 1 type of barrier.ConclusionsStudies on improving physician guideline adherence may not be generalizable,
since barriers in one setting may not be present in another. Our review offers
a differential diagnosis for why physicians do not follow practice guidelines,
as well as a rational approach toward improving guideline adherence and a
framework for future research.
6,378 citations
Journal Article•
TL;DR: An overview of present knowledge about initiatives to changing medical practice is provided, showing that none of the approaches for transferring evidence to practice is superior to all changes in all situations.
3,895 citations
01 Jan 2003
TL;DR: This guideline is more than 5 years old and has not yet been updated to Ensure that it reflects current knowledge and practice, and can no longer be assumed to be current.
Abstract: Each recommendation is identified as falling into one of three categories of endorsement, indicated by a bracketed Roman numeral following the statement. The three categories represent varying levels of clinical confidence regarding the recommendation: [I] Recommended with substantial clinical confidence. [II] Recommended with moderate clinical confidence. [III] May be recommended on the basis of individual circumstances.
657 citations
TL;DR: The VA Bipolar Guidelines are designed for easy clinical reference in decision making with individual patients, as well as for use as a scholarly reference tool and have utility in training activities and quality improvement programs.
Abstract: Background: For the last several years, the Department of Veterans Affairs (VA) has been involved in the development of practice guidelines for major medical, surgical, and mental disorders. This article describes the development and content of the VA-Clinical Practice Guidelines for Bipolar Disorder, which are available in their entirety on the Journal Web site (http://www. psychiatrist.com). Method: A multidisciplinary work group composed of content experts in the field of bipolar disorder and practitioners in general clinical practice was convened by the VA's Office of Performance and Quality and the Mental Health Strategic Health Group. The work group was instructed in algorithm development and methods of evidence evaluation. Draft guidelines were developed over the course of 6 months of meetings and conference calls, and that draft was then sent to nationally prominent content experts for final critique. Results: The Bipolar Guidelines are part of the family of the VA Clinical Guidelines for Management of Persons with Psychosis and consist of explicit algorithms supplemented by annotations that explain the specific decision points and their basis in the scientific literature. The guidelines are organized into 5 modules: a Core Module for diagnosis and assignment to mood state plus 4 treatment modules (Manic/Hypomanic/Mixed Episode, Bipolar Depressive Episode, Rapid Cycling, and Bipolar Disorder With Psychotic Features). The modules specify particular diagnostic and treatment tasks at each step including both somatotherapeutic and psychotherapeutic interventions. Conclusion: The VA Bipolar Guidelines are designed for easy clinical reference in decision making with individual patients, as well as for use as a scholarly reference tool. They also have utility in training activities and quality improvement programs.
242 citations
TL;DR: Examination of medication prescribing patterns for bipolar I disorder in hospital settings and comparing them to recently published expert consensus guidelines suggest that a substantial proportion of patients with bipolar I Disorder are discharged from hospitals on medications not generally recommended by current practice guidelines.
Abstract: Objective The purposes of this paper were to examine the medication prescribing patterns for bipolar I disorder in hospital settings and to compare them to recently published expert consensus guidelines for medication treatment of bipolar disorder. Methods Data were obtained from the 1996-2000 CQI+SM Outcomes Measurement System, on patients age 18 or older admitted to psychiatric inpatient units from over 100 medical-surgical hospitals. A total of 1864 patients with a primary discharge diagnosis of bipolar I or II disorder were identified from a large cohort of hospitalized patients. Patient characteristics were assessed at hospital admission and medication usage, at discharge. The medication analysis focused on the 1471 individuals with bipolar I mania or bipolar I depression (with or without psychotic features), representing 54% and 25% of admitted bipolar patients, respectively. Results At admission, the typical bipolar patient (mean age 57) had experienced a relatively severe and chronic course of illness. The array of psychotropic agents used was broad, with no single prescribing pattern predominant. Only one in three bipolar I (manic or depressed) patients with psychotic features was discharged on medications recommended by expert guidelines as preferred or alternate recommended treatment. Absent psychotic features, this dropped to one in six patients. Surprising was the relatively high use of antidepressants for patients with mania, particularly those without psychotic symptoms. Conclusions Results suggest that a substantial proportion of patients with bipolar I disorder are discharged from hospitals on medications not generally recommended by current practice guidelines.
73 citations