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Preview: International Journal for Quality in Health Care - current issue

International Journal for Quality in Health Care Current Issue





Published: Mon, 18 Sep 2017 00:00:00 GMT

Last Build Date: Tue, 19 Sep 2017 05:51:27 GMT

 






Organizational and managerial factors associated with clinical practice guideline adherence: a simulation-based study in 36 French hospital wards

2017-07-06

Abstract
Objectives
To identify managerial and organizational characteristics of multi-specialty medicine wards and individual characteristics of health professionals that are most strongly associated with clinical practice guidelines (CPG) adherence.
Design
Cross-sectional stratified cluster sample design.
Setting
Data were gathered from 36 randomly selected multi-specialty medicine wards.
Participants
The study population included all health professionals involved in patient care working in the participating wards.
Main outcome measures
The degree of CPG adherence was measured using clinical vignettes on three topics: pain management, managing heart failure and managing diabetes. Responses from each professional to each clinical case were quantified using a 10-point scale. Managerial and organizational characteristics of medical department and individual characteristics of health professionals were obtained using three questionnaires.
Results
The study sample consisted of 859 professionals (362 orderlies, 361 nurses and 136 physicians). Factors independently and positively associated with CPG adherence were (i) individual factors: low age of professionals, expertise in diabetology and activity in cardiology; (ii) organizational and managerial factors: good understanding between physicians and other personnel; and (iii) structural factors: computer-based test results and prescriptions, presence of medical specialists, inter-department mobility of orderlies, medium-length stay (between 7 and 10 days) and large bed capacity.
Conclusions
Good CPG adherence in general medicine needs institutional dynamism, availability of clinical competence and team culture based on cooperation.



Improving inpatient medication adherence using attendant education in a tertiary care hospital in Uganda

2017-06-27

Abstract
Quality problem
Although widely utilized in resource-rich health care systems, the use of quality improvement (QI) techniques is less common in resource-limited environments. Uganda is a resource-limited country in Sub-Saharan Africa that faces many challenges with health care delivery. These challenges include understaffing, inconsistent drug availability and inefficient systems that limit the provision of clinical care.
Initial assessment
Poor adherence to prescribed inpatient medications was identified as a key shortcoming of clinical care on the internal medicine wards of Mulago National Referral Hospital, Kampala, Uganda. Baseline data collection revealed a pre-intervention median inpatient medication adherence rate of 46.5% on the study ward. Deficiencies were also identified in attendant (lay caretaker) education, and prescriber and pharmacy metrics.
Choice of solution
A QI team led by a resident doctor and consisting of a QI nurse, a pharmacist and a ward nurse supervisor used standard QI techniques to address this issue.
Implementation
Plan-Do-Study-Act cycle interventions focused on attendant involvement and education, physician prescription practices and improving pharmacy communication with clinicians and attendants.
Evaluation
Significant improvements were seen with an increase in overall medication adherence from a pre-intervention baseline median of 46.5% to a post-intervention median of 92%. Attendant education proved to be the most effective intervention, though resource and staffing limitations made institutionalization of these changes difficult.
Lessons learned
QI methods may be the way forward for optimizing health care delivery in resource-limited settings like Uganda. Institutionalization of these methods remains a challenge due to shortage of staff and other resource limitations.



Prioritizing quality measure concepts at the interface of behavioral and physical healthcare

2017-06-23

Abstract
Objective
Integrated healthcare models can increase access to care, improve healthcare quality, and reduce cost for individuals with behavioral and general medical healthcare needs, yet there are few instruments for measuring the quality of integrated care. In this study, we identified and prioritized concepts that can represent the quality of integrated behavioral health and general medical care.
Design
We conducted a literature review to identify candidate measure concepts. Experts then participated in a modified Delphi process to prioritize the concepts for development into specific quality measures.
Setting
United States.
Participants
Expert behavioral health and general medical clinicians, decision-makers (policy, regulatory and administrative professionals) and patient advocates.
Main outcome measures
Panelists rated measure concepts on importance, validity and feasibility.
Results
The literature review identified 734 measures of behavioral or general medical care, which were then distilled into 43 measure concepts. Thirty-three measure concepts (including a segmentation strategy) reached a predetermined consensus threshold of importance, while 11 concepts did not. Two measure concepts were ‘ready for further development’ (‘General medical screening and follow-up in behavioral health settings’ and ‘Mental health screening at general medical healthcare settings’). Among the 31 additional measure concepts that were rated as important, 7 were rated as valid (but not feasible), while the remaining 24 concepts were rated as neither valid nor feasible.
Conclusions
This study identified quality measure concepts that capture important aspects of integrated care. Researchers can use the prioritization process described in this study to guide healthcare quality measures development work.



Linking quality indicators to clinical trials: an automated approach

2017-06-23

Abstract
Objective
Quality improvement of health care requires robust measurable indicators to track performance. However identifying which indicators are supported by strong clinical evidence, typically from clinical trials, is often laborious. This study tests a novel method for automatically linking indicators to clinical trial registrations.
Design
A set of 522 quality of care indicators for 22 common conditions drawn from the CareTrack study were automatically mapped to outcome measures reported in 13 971 trials from ClinicalTrials.gov.
Intervention
Text mining methods extracted phrases mentioning indicators and outcome phrases, and these were compared using the Levenshtein edit distance ratio to measure similarity.
Main Outcome Measure
Number of care indicators that mapped to outcome measures in clinical trials.
Results
While only 13% of the 522 CareTrack indicators were thought to have Level I or II evidence behind them, 353 (68%) could be directly linked to randomized controlled trials. Within these 522, 50 of 70 (71%) Level I and II evidence-based indicators, and 268 of 370 (72%) Level V (consensus-based) indicators could be linked to evidence. Of the indicators known to have evidence behind them, only 5.7% (4 of 70) were mentioned in the trial reports but were missed by our method.
Conclusions
We automatically linked indicators to clinical trial registrations with high precision. Whilst the majority of quality indicators studied could be directly linked to research evidence, a small portion could not and these require closer scrutiny. It is feasible to support the process of indicator development using automated methods to identify research evidence.



A World Health Organization field trial assessing a proposed ICD-11 framework for classifying patient safety events

2017-06-17

Abstract
Objective
To assess the utility of the proposed World Health Organization (WHO)'s International Classification of Disease (ICD) framework for classifying patient safety events.
Setting
Independent classification of 45 clinical vignettes using a web-based platform.
Study participants
The WHO's multi-disciplinary Quality and Safety Topic Advisory Group.
Main outcome measure(s)
The framework consists of three concepts: harm, cause and mode. We defined a concept as ‘classifiable’ if more than half of the raters could assign an ICD-11 code for the case. We evaluated reasons why cases were nonclassifiable using a qualitative approach.
Results
Harm was classifiable in 31 of 45 cases (69%). Of these, only 20 could be classified according to cause and mode. Classifiable cases were those in which a clear cause and effect relationship existed (e.g. medication administration error). Nonclassifiable cases were those without clear causal attribution (e.g. pressure ulcer). Of the 14 cases in which harm was not evident (31%), only 5 could be classified according to cause and mode and represented potential adverse events. Overall, nine cases (20%) were nonclassifiable using the three-part patient safety framework and contained significant ambiguity in the relationship between healthcare outcome and putative cause.
Conclusions
The proposed framework enabled classification of the majority of patient safety events. Cases in which potentially harmful events did not cause harm were not classifiable; additional code categories within the ICD-11 are one proposal to address this concern. Cases with ambiguity in cause and effect relationship between healthcare processes and outcomes remain difficult to classify.



A multifaceted quality improvement strategy reduces the risk of catheter-associated urinary tract infection

2017-06-17

Abstract
Objective
Catheter-associated urinary tract infections (CAUTIs) are common and preventable hospital-acquired infections, yet their rate continues to rise nationwide. We describe the implementation of a multifaceted program to reduce catheter use and CAUTI rates while simultaneously addressing barriers to long-term success.
Design/Setting/Participants
Pre–post study of medical inpatient veterans between December 2012 and February 2015.
Intervention
Five component intervention: (i) a bedside catheter reminder; (ii) multidisciplinary educational campaign; (iii) structured catheter order set with clinical decision support; (iv) automated catheter discontinuation orders; and (v) protocol for post-catheter removal care.
Main Outcome Measure(s)
Catheter utilization rates and CAUTI rates on the study ward were followed during the 14-week baseline period, the 27-week transition/intervention period and the 70-week period of full implementation/sustainability. Rates of patient falls per bed days and catheter reinsertions were collected during the same time periods as balancing measures.
Results
Catheter use declined by 35% from the baseline period to the full implementation/sustainability period. This improvement was not realized until deployment of the structured electronic orders with automated catheter discontinuation and protocolized post-catheter care. The average number of days between CAUTIs on the study ward increased from 101 days in the baseline period to over 400 days in the full implementation/sustainability period. There was no significant change in the rates of falls or catheter reinsertions during the study period.
Conclusions
A multicomponent intervention aimed specifically at targeting local barriers was successful in reducing catheter utilization as well as CAUTIs in a veteran population without compensatory increase in patient falls or catheter replacement.



Lessons learned for reducing the negative impact of adverse events on patients, health professionals and healthcare organizations

2017-06-15

ABSTRACT
Purpose
To summarize the knowledge about the aftermath of adverse events (AEs) and develop a recommendation set to reduce their negative impact in patients, health professionals and organizations in contexts where there is no previous experiences and apology laws are not present.
Data sources
Review studies published between 2000 and 2015, institutional websites and experts’ opinions on patient safety.
Study selection
Studies published and websites on open disclosure, and the second and third victims’ phenomenon. Four Focus Groups participating 27 healthcare professionals.
Data extraction
Study characteristic and outcome data were abstracted by two authors and reviewed by the research team.
Results of data synthesis
Fourteen publications and 16 websites were reviewed. The recommendations were structured around eight areas: (i) safety and organizational policies, (ii) patient care, (iii) proactive approach to preventing reoccurrence, (iv) supporting the clinician and healthcare team, (v) activation of resources to provide an appropriate response, (vi) informing patients and/or family members, (vii) incidents’ analysis and (viii) protecting the reputation of health professionals and the organization.
Conclusion
Recommendations preventing aftermath of AEs have been identified. These have been designed for the hospital and the primary care settings; to cope with patient's emotions and for tacking the impact of AE in the second victim's colleagues. Its systematic use should help for the establishment of organizational action plans after an AE.



Adverse events related to hospital care: a retrospective medical records review in a Swiss hospital

2017-06-06

Abstract
Objective
Retrospective records reviews carried out in several countries have shown substantial rates of adverse events (AE) among hospitalized patients, preventable in half the cases. As no such data have been recorded in Switzerland, we estimated the incidence of AE in one acute care hospital as a basis for a safety improvement program.
Design
A two steps retrospective records review (screening criteria and full review of positively screened records).
Setting
A medium size community hospital.
Participants
A stratified sample of 400 surgical and 600 medical hospitalizations whose records fulfilled a set of information quality criteria.
Intervention(s)
Not applicable.
Main outcome measure(s)
Adverse events, preventable adverse events and extent of resulting harm.
Results
The proportion of hospitalizations with at least one AE was 12.3% (95% CI: 10.4–14.1) whereas the overall hospital incidence rate was 14.1% (95% CI: 12.0–16.2). Nearly half of AE were judged preventable, corresponding to one or more preventable AE in 6.4% of hospitalizations (95% CI: 5.0–7.8). Sixty percent of AE resulted in no or minor impairment at discharge whereas 23% resulted in severe disability. AE were twice more frequent in surgical patients, and preventable AE resulted more often in severe impairment than unpreventable AE. No death was attributed to an AE. The proportion of stays with an AE increased with age and length of stay.
Conclusions
The incidence of preventable AE in patients hospitalized in one Swiss hospital is comparable to previously reported rates. Further, patient safety improvement is needed, especially among older patients, and for surgical procedures.



The relationship between shared decision-making and health-related quality of life among patients in Hong Kong SAR, China

2017-06-06

Abstract
Objective
To elucidate the association between health-related quality of life and shared decision-making among patients in Hong Kong after adjustment for potential confounding variables.
Design
A telephone survey was conducted with patients attending all public specialist outpatient clinics in Hong Kong between July and December 2014. The Specialist Outpatient Patient Experience Questionnaire and EQ-5D questionnaire were used to evaluate shared decision-making and quality of life, respectively. We performed a Tobit regression analysis to examine the associations between shared decision-making and quality of life after adjustment for known social, economic and health-related factors.
Setting
Twenty-six of the Hospital Authority's specialist outpatient clinics.
Participants
Patients aged 18 years or older who attended one of the Hospital Authority's specialist outpatient clinics between July and November 2014.
Main Outcome Measure(s)
Shared decision-making and quality of life score.
Results
Overall, 13 966 patients completed the study. The group reporting partial involvement in decision-making had slightly higher EQ-5D scores than the ‘not involved’ group and the ‘fully involved’ group. EQ-5D scores were higher among subjects who were younger, male, and had a higher level of education. Respondents living alone and living in institutions scored lower on the EQ-5D than patients living with families.
Conclusions
Important differences in the relationship between the attitudes towards shared decision-making and quality of life were identified among patients. These associations should be taken into consideration when promoting patient-centred care and improving health professional–patient communication.



The development and testing of the Person-centred Practice Inventory – Staff (PCPI-S)

2017-06-06

ABSTRACT
Objective
The aim of the study was to develop and test an instrument, underpinned by a recognized theoretical framework, that examines how staff perceive person-centred practice, using proven methods of instrument design and psychometric analysis.
Design
The study used a mixed method multiphase research design involving: two Delphi studies to agree definitions and items to measure the constructs aligned to the person-centred practice theoretical framework (Phase 1); and a large-scale quantitative cross-sectional survey (Phase 2).
Setting
Phase 1 was an international study involving representatives from seven countries across Europe and Australia, with Phase 2 conducted in one country across five organizations.
Participants
Two international panels of experts (n = 33) in person-centred practice took part in the Delphi study and a randomly selected sample of registered nurses (n = 703, 23.8%) drawn from across a wide range of clinical settings completed the Person-centred Practice Inventory – Staff (PCPI-S).
Main Outcome Measures
The main outcome is to establish a measure of staff perceptions of person-centred Practice.
Results
Broad consensus on definitions relating to 17 constructs drawn from a person-centred practice framework was achieved after two rounds; likewise with the generation of 108 items to measure the constructs; a final instrument comprising 59 items with proven psychometric properties was achieved.
Conclusions
The PCPI-S is psychometrically acceptable instrument validated by an international expert panel that maps specifically to a theoretical framework for person-centred practice and provides a generic measure of person-centredness.



RECALMIN: The association between management of Spanish National Health Service Internal Medical Units and health outcomes

2017-05-24

Abstract
Objective
To investigate the association between management of Internal Medical Units (IMUs) with outcomes (mortality and length of stay) within the Spanish National Health Service.
Design
Data on management were obtained from a descriptive transversal study performed among IMUs of the acute hospitals. Outcome indicators were taken from an administrative database of all hospital discharges from the IMUs.
Setting
Spanish National Health Service.
Participants
One hundred and twenty-four acute general hospitals with available data of management and outcomes (401 424 discharges).
Main Outcome Measures
IMU risk standardized mortality rates were calculated using a multilevel model adjusted by Charlson Index. Risk standardized myocardial infarction and heart failure mortality rates were calculated using specific multilevel models. Length of stay was adjusted by complexity.
Results
Greater hospital complexity was associated with longer average length of stays (r: 0.42; P < 0.001). Crude in-hospital mortality rates were higher at larger hospitals, but no significant differences were found when mortality was risk adjusted. There was an association between nurse workload with mortality rate for selected conditions (r: 0.25; P = 0.009). Safety committee and multidisciplinary ward rounds were also associated with outcomes.
Conclusions
We have not found any association between complexity and intra-hospital mortality. There is an association between some management indicators with intra-hospital mortality and the length of stay. Better disease-specific outcomes adjustments and a larger number of IMUs in the sample may provide more insights about the association between management of IMUs with healthcare outcomes.



Implementation and evaluation of a prototype consumer reporting system for patient safety events

2017-05-24

Abstract
Objective
No methodologically robust system exists for capturing consumer-generated patient safety reports. To address this challenge, we developed and pilot-tested a prototype consumer reporting system for patient safety, the Health Care Safety Hotline.
Design
Mixed methods evaluation.
Setting
The Hotline was implemented in two US healthcare systems from 1 February 2014 through 30 June 2015.
Participants
Patients, family members and caregivers associated with two US healthcare systems.
Intervention
A consumer-oriented incident reporting system for telephone or web-based administration was developed to elicit medical mistakes and care-related injuries.
Main Outcomes Measures
Key informant interviews, measurement of website traffic and analysis of completed reports.
Results
Key informants indicated that Hotline participation was motivated by senior leaders’ support and alignment with existing quality and safety initiatives. During the measurement period from 1 October 2014 through 30 June 2015, the home page had 1530 visitors with a unique IP address. During its 17 months of operation, the Hotline received 37 completed reports including 20 mistakes without harm and 15 mistakes with injury. The largest category of mistake concerned problems with diagnosis or advice from a health practitioner. Hotline reports prompted quality reviews, an education intervention, and patient follow-ups.
Conclusion
While generating fewer reports than its capacity to manage, the Health Care Safety Hotline demonstrated the feasibility of consumer-oriented patient safety reporting. Further research is needed to understand how to increase consumers’ use of these systems.



Determinants of patient loyalty to healthcare providers: An integrative review

2017-05-24

Abstract
Purpose
Patient loyalty is key to business success for healthcare providers and also for patient health outcomes. This study aims to identify determinants influencing patient loyalty to healthcare providers and propose an integrative conceptual model of the influencing factors.
Data sources
PubMed, CINAHL, OVID, ProQuest and Elsevier Science Direct databases were searched.
Study selection
Publications about determinants of patient loyalty to health providers were screened, and 13 articles were included.
Data extraction
Date of publication, location of the research, sample details, objectives and findings/conclusions were extracted for 13 articles.
Results of data synthesis
Thirteen studies explored eight determinants: satisfaction, quality, value, hospital brand image, trust, commitment, organizational citizenship behavior and customer complaints. The integrated conceptual model comprising all the determinants demonstrated the significant positive direct impact of quality on satisfaction and value, satisfaction on trust and commitment, trust on commitment and loyalty, and brand image on quality and loyalty.
Conclusion
This review identifies and models the determinants of patient loyalty to healthcare providers. Further studies are needed to explore the influence of trust, commitment, and switching barriers on patient loyalty.



Factors associated with compliance to AHA/ACC performance measures in a myocardial infarction system of care in Brazil

2017-05-20

Abstract
Objective
To evaluate compliance with American Heart Association/American College of Cardiology (AHA/ACC) performance measures for adults with acute myocardial infarction (AMI) and to investigate the factors associated with compliance, in an AMI System of Care in Brazil.
Design
Observational longitudinal study.
Setting
A high-complexity University Hospital, part of the AMI System of Care implemented in Belo Horizonte, Brazil, in 2010.
Participants
Of note, 1129 patients with ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) admitted to a single center over 36 months (between 2011 and 2014).
Main Outcome Measures
Compliance with 13 pre-specified AHA/ACC AMI performance measures was evaluated for patients with AMI, observing exclusion criteria and appropriate numerators and denominators. Median compliance was calculated and variables independently associated with compliance rates were evaluated.
Results
Median age was 60 (51/68) years, 67.7% male, 69.8% presented with STEMI and hospital mortality was 8.7%. Median compliance with performance measures was 83% (75/88). Among patients with STEMI, 56% received reperfusion therapy. Overall, 67.3% of patients complied with ≥80% of quality measures. Factors independently associated with better compliance were later date of presentation (semester), likely reflecting ongoing training (OR = 1.19, 95% CI: 1.10–1.28, P < 0.001), male gender (OR = 1.33, 95% CI: 1.00–1.76, P < 0.046), Killip I/II on admission (OR = 1.95, 95% CI: 1.36–2.80, P < 0.001) and diagnosis of NSTEMI (OR = 5.0, 95% CI: 3.51–7.11, P < 0.001).
Conclusion
Compliance with AHA/ACC AMI performance measures remains below target in Brazil, but the time trends observed suggest improvement. Continuing education, reduction of system delays and prioritizing high-risk groups are needed to optimize AMI systems of care and improve patient outcomes.



A diabetes pay-for-performance program and the competing causes of death among cancer survivors with type 2 diabetes in Taiwan

2017-05-20

Abstract
Objective
To examine associations between a diabetes pay-for-performance (P4P) program in Taiwan and all-cause of mortality and competing causes of death in cancer survivors with type 2 diabetes.
Design
A longitudinal observational intervention and comparison group study design.
Setting and participants
Cancer survivors with type 2 diabetes who enrolled in the P4P program compared with survivors who did not participate (non-P4P) under the Taiwan National Health Insurance program.
Intervention(s)
A nationwide diabetes P4P program.
Main outcome measures
The main outcome was a comparison of all-cause, diabetes-related and cancer mortality in P4P and non-P4P patients during a 5-year follow-up period. Total person-years and mortality rates per 1000 person-years for causes of death were calculated. Multivariate Cox proportional hazard models and competing risk regression were used in the analysis.
Results
Overall, our results indicate that P4P cancer survivors had lower risk of all-cause mortality and diabetes-related mortality than non-P4P survivors. Specifically, the hazard ratio (95% confidence interval) was 0.581 (0.447–0.756) for all-cause mortality; SHRs were 0.451 (0.266–0.765) for diabetes-related mortality and 0.791 (0.558–1.121) for cancer mortality.
Conclusions
Our empirical findings provide evidence of potential benefits of diabetes P4P programs in reducing risks of deaths due to diabetes or cardiovascular diseases among cancer survivors, compared with survivors who did not enroll in the P4P program. In consideration of recommended care for long-term survival, the diabetes P4P program can serve as a care model for cancer survivors for reducing mortality due to diabetes or cardiovascular diseases.



Multi-stakeholder perspectives in defining health-services quality in cataract care

2017-05-11

Abstract
Objective
To develop a method to define a multi-stakeholder perspective on health-service quality that enables the expression of differences in systematically identified stakeholders’ perspectives, and to pilot the approach for cataract care.
Design
Mixed-method study between 2014 and 2015.
Setting
Cataract care in the Netherlands.
Participants
Stakeholder representatives.
Intervention(s)
We first identified and classified stakeholders using stakeholder theory. Participants established a multi-stakeholder perspective on quality of cataract care using concept mapping, this yielded a cluster map based on multivariate statistical analyses. Consensus-based quality dimensions were subsequently defined in a plenary stakeholder session.
Main outcome measure(s)
Stakeholders and multi-stakeholder perspective on health-service quality.
Results
Our analysis identified seven definitive stakeholders, as follows: the Dutch Ophthalmology Society, ophthalmologists, general practitioners, optometrists, health insurers, hospitals and private clinics. Patients, as dependent stakeholders, were considered to lack power by other stakeholders; hence, they were not classified as definitive stakeholders. Overall, 18 stakeholders representing ophthalmologists, general practitioners, optometrists, health insurers, hospitals, private clinics, patients, patient federations and the Dutch Healthcare Institute sorted 125 systematically collected indicators into the seven following clusters: patient centeredness and accessibility, interpersonal conduct and expectations, experienced outcome, clinical outcome, process and structure, medical technical acting and safety. Importance scores from stakeholders directly involved in the cataract service delivery process correlated strongly, as did scores from stakeholders not directly involved in this process.
Conclusions
Using a case study on cataract care, the proposed methods enable different views among stakeholders concerning quality dimensions to be systematically revealed, and the stakeholders jointly agreed on these dimensions. The methods helped to unify different quality definitions and facilitated operationalisation of quality measurement in a way that was accepted by relevant stakeholders.



Process value of care safety: women's willingness to pay for perinatal services

2017-05-09

Abstract
Objective
To evaluate the process value of care safety from the patient's view in perinatal services.
Design
Cross-sectional survey.
Settings
Fifty two sites of mandated public neonatal health checkup in 6 urban cities in West Japan.
Participants
Mothers who attended neonatal health checkups for their babies in 2011 (n = 1316, response rate = 27.4%).
Main Outcome Measure
Willingness to pay (WTP) for physician-attended care compared with midwife care as the process-related value of care safety. WTP was estimated using conjoint analysis based on the participants’ choice over possible alternatives that were randomly assigned from among eight scenarios considering attributes such as professional attendance, amenities, painless delivery, caesarean section rate, travel time and price.
Results
The WTP for physician-attended care over midwife care was estimated 1283 USD. Women who had experienced complications in prior deliveries had a 1.5 times larger WTP.
Conclusions
We empirically evaluated the process value for safety practice in perinatal care that was larger than a previously reported accounting-based value. Our results indicate that measurement of process value from the patient's view is informative for the evaluation of safety care, and that it is sensitive to individual risk perception for the care process.



Impact of financial incentives for inter-provider care coordination on health-care resource utilization among elderly acute stroke patients

2017-05-09

Abstract
Objective
To examine the impact of inter-provider care coordination on health-care resource utilization among elderly acute stroke patients.
Design
A retrospective cohort study using health-care insurance claims data.
Setting
Claims data of the Fukuoka Prefecture Wide-Area Association of Latter-Stage Elderly Healthcare.
Participants
About, 6409 patients aged 75 years or older admitted for acute stroke and moved to rehabilitation wards from 1 April 2010 to 30 September 2015.
Main outcome measure
Lengths of stay (LOS) and total charge (TC) were evaluated according to three groups of care pathways (coordinated care, integrated care and other pathways).
Results
Compared with the other care pathway, the coordinated care groups had significantly shorter LOS of 2.0 days in acute ischemic stroke care; they had 2.5 days shorter LOS in hemorrhagic stroke care. However, there were no significant differences in rehabilitation care LOS and TC.
Conclusions
Our findings suggest that a payment system for care coordination is inappropriate since it was not associated with a reduction in overall health-care resource utilization. Further, health-care system reform is necessary to improve care continuity across multiple health-care institutions in Japan.



A quality improvement project using statistical process control methods for type 2 diabetes control in a resource-limited setting

2017-05-09

Abstract
Quality issue
Quality improvement (QI) is a key strategy for improving diabetes care in low- and middle-income countries (LMICs). This study reports on a diabetes QI project in rural Guatemala whose primary aim was to improve glycemic control of a panel of adult diabetes patients.
Initial assessment
Formative research suggested multiple areas for programmatic improvement in ambulatory diabetes care.
Choice of solution
This project utilized the Model for Improvement and Agile Global Health, our organization's complementary healthcare implementation framework.
Implementation
A bundle of improvement activities were implemented at the home, clinic and institutional level.
Evaluation
Control charts of mean hemoglobin A1C (HbA1C) and proportion of patients meeting target HbA1C showed improvement as special cause variation was identified 3 months after the intervention began. Control charts for secondary process measures offered insights into the value of different components of the intervention. Intensity of home-based diabetes education emerged as an important driver of panel glycemic control.
Lessons learned
Diabetes QI work is feasible in resource-limited settings in LMICs and can improve glycemic control. Statistical process control charts are a promising methodology for use with panels or registries of diabetes patients.



Narrative feedback from OR personnel about the safety of their surgical practice before and after a surgical safety checklist intervention

2017-05-02

Abstract
Objective
To examine narrative feedback to understand surgical team perceptions about surgical safety checklists (SSCs) and their impact on the safety of surgical practice.
Design
We reviewed free-text comments from surveys administered before and after SSC implementation between 2011 and 2013. We categorized feedback thematically and as positive, negative or neutral.
Setting
South Carolina hospitals participating in a statewide collaborative on checklist implementation.
Participants
Surgical teams from 11 hospitals offering free-text comments in both pre-and post-implementation surveys.
Intervention
Implementation of the World Health Organization SSC.
Main Outcome Measure
Differences in comments made before and after implementation and by provider role; types of complications averted through checklist use.
Results
Before SSC implementation, the proportion of positive comments among provider roles differed significantly (P = 0.04), with more clinicians offering negative comments (87.9%, (29/33)) compared to other surgical team members (58.3% (7/12) to 60.9% (14/23)), after SSC implementation, these proportions did not significantly differ (clinicians 77.8% (14/18)), other surgical team members (50% (2/4) to 76.9% (20/26)) (P = 0.52). Distribution of negative comments differed significantly before and after implementation (P = 0.01); for example, there were more negative comments made about checklist buy-in after implementation (51.3 % (20/39)) compared to before implementation (24.5% (13/53)). Surgical team members most frequently reported that checklist use averted complications involving antibiotic administration, equipment and side/site of surgery.
Conclusions
Narrative feedback suggested that SSC implementation can facilitate patient safety by averting complications; however, buy-in is a persistent challenge. Presenting information on the impact of the SSC on lives saved, teamwork and complications averted, adapting the SSC to fit the local context, demonstrating leadership support and engaging champions to promote checklist use and address concerns could improve checklist adoption and efficacy.



Predictors of the effectiveness of accreditation on hospital performance: A nationwide stepped-wedge study

2017-05-02

Abstract
Objective
To identify predictors of the effectiveness of hospital accreditation on process performance measures.
Design
A multi-level, longitudinal, stepped-wedge, nationwide study.
Participants
All patients admitted for acute stroke, heart failure, ulcers, diabetes, breast cancer and lung cancer at Danish hospitals.
Intervention
The Danish Healthcare Quality Programme that was designed to create a framework for continuous quality improvement.
Main outcome Measure(s)
Changes in week-by-week trends of hospitals’ process performance measures during the study period of 269 weeks prior to, during and post-accreditations. Process performance measures were based on 43 different processes of care obtained from national clinical quality registries. Analyses were stratified according to condition, type of care (i.e. treatment, diagnostics, secondary prevention and patient monitoring) and hospital characteristics (i.e. university affiliation, location, size, experience with accreditation and accreditation compliance).
Results
A total of 1 624 518 processes of care were included. The impact of accreditation differed across the conditions. During accreditation, heart failure and breast cancer showed less improvement than other disease areas. Across all conditions, diagnostic processes improved less rapidly than other types of processes. However, after stratifying the data by hospital characteristics, process performance measures improved more uniformly. In respect of the measures that had an unsatisfactory level of quality, the processes related to diabetes, diagnostics and patient monitoring all responded to accreditation and showed an increased improvement during the preparatory work.
Conclusion
Hospital characteristics were not found to be predictors for the effects of accreditation, whereas conditions and types of care to some extent predicted the effectiveness.