In low-income countries, medical record management is often lacking. We sought to evaluate the impact of an inexpensive business process re-engineering project on the accessibility and completeness of patient information and on physician satisfaction.
Pre–post intervention study during 2006–07, using time-motion studies, medical record audits and physician surveys.
A rural hospital in Ethiopia.
Medical record personnel, hospital administrators, clinical staff.
We implemented a hospital-wide patient registration and medical records re-engineering process, which included a simple, custom-made computer database to manage patient information, standardized medical records forms and processes and enhanced human resource management efforts.
We measured medical records accessibility and completeness, and physician satisfaction.
Medical record accessibility and completeness and physician satisfaction improved significantly (P < 0.05) based on pre- and post-intervention comparisons. The success rate of retrieving the proper medical record number for returning patients improved from 14 to 87% (P < 0.01); time to locate medical records decreased from 31.2 sec per record to 15.7 sec per record (P < 0.01); the percentage of complete medical records increased from 6.5 to 45.7% (P < 0.01). Physician satisfaction with the medical records system was significantly higher after the intervention (P = 0.02).
Our findings indicate that a well-organized medical record management system can be effective in improving patient information accessibility and completeness in hospitals in low-income countries despite the lack of resources. Longer follow-up is required to assess the sustainability of the hospital improvements accomplished.
To estimate the incidence, nature and consequences of adverse events and preventable adverse events in Swedish hospitals.
A three-stage structured retrospective medical record review based on the use of 18 screening criteria.
Twenty-eight Swedish hospitals.
A representative sample (n = 1967) of the 1.2 million Swedish hospital admissions between October 2003 and September 2004.
Proportion of admissions with adverse events, the proportion of preventable adverse events and the types and consequences of adverse events.
In total, 12.3% (n = 241) of the 1967 admissions had adverse events (95% CI, 10.8–13.7), of which 70% (n = 169) were preventable. Fifty-five percent of the preventable events led to impairment or disability, which was resolved during the admission or within 1 month from discharge, another 33% were resolved within 1 year, 9% of the preventable events led to permanent disability and 3% of the adverse events contributed to patient death. Preventable adverse events led to a mean increased length of stay of 6 days. Ten of the 18 screening criteria were sufficient to detect 90% of the preventable adverse events. When extrapolated to the 1.2 million annual admissions, the results correspond to 105 000 preventable adverse events (95% CI, 90 000–120 000) and 630 000 days of hospitalization (95% CI, 430 000–830 000).
This study confirms that preventable adverse events were common, and that they caused extensive human suffering and consumed a significant amount of the available hospital resources.
To evaluate the incidence of adverse events in Brazilian hospitals.
Retrospective cohort study based on patient record review.
Three teaching hospitals in the State of Rio de Janeiro, Brazil.
Random sample (1103) of 27 350 adult patients admitted in 2003. Patients under 18 years old, psychiatric patients and patients whose length of stay was less than 24 hr were excluded, and obstetric cases were included.
Incidence of patients with adverse events; proportion of preventable adverse events; number of adverse events per 100 patients and incidence density of adverse events per 100 patient-days.
The incidence of patients with adverse events was 7.6% (84 of 1103 patients). The overall proportion of preventable adverse events was 66.7% (56 of 84 patients). The incidence density was 0.8 adverse events per 100 patient-days (103 of 13 563 patient-days). The patient's ward was the most frequent location of adverse events (48.5%). In regard to classification, surgical adverse events were the most frequent ones (35.2%).
The incidence of patients with adverse events at the three hospitals was similar to that in international studies. However, the proportion of preventable adverse events was much higher in the Brazilian hospitals.
To develop a generic French self-administered instrument for measuring hospitalized patients' satisfaction based on the patient's point of view: the questionnaire for satisfaction of hospitalized (QSH) patients.
The development was supervised by a steering committee and undertaken through three standard steps. Item generation was derived from 95 face-to-face interviews, performed in hospitalized patients and in patients scheduled to be admitted. The item reduction led to a 69-item questionnaire. The validation process was based on validity, reliability and some aspects of external validity.
Medical, surgical and obstetrical departments (n = 187) of public hospitals (n = 11) from different French regions (n = 3).
Eligible patients were adult subjects hospitalized for at least 24 h.
QSH, sociodemographic data, hospitalization department, visual analogue scales of satisfaction.
The final version of QSH contained 45 items describing 9 dimensions, leading to 2 composite scores (staff and structure index). The factor structure accounted for 71% of the total variance. Internal consistency was satisfactory (item-internal consistency over 0.40; Cronbach's alpha coefficients ranged from 0.76 to 0.96). The scalability was satisfactory with inlier-sensitive fit (INFIT) statistics inside an acceptable range. Scores of dimensions were strongly positively correlated with visual analogue scale scores (all P < 0.001). External validity showed statistical associations between QSH scores and age or department. Participation rate was 91%.
The availability of a reliable and valid French questionnaire concerning hospitalized patients' satisfaction, exclusively generated from patients' interviews, enables patient feedback to be incorporated in a continuous quality health-care improvement strategy.
Strategy development and implementation in acute care settings is often restricted by competing challenges, the pace of policy reform and the existence of parallel hierarchies.
To describe a generic approach to strategy development, illustrate the use of the Balanced Scorecard as a tool to facilitate strategy implementation and demonstrate how to break down strategic goals into measurable elements.
Multi-method approach using three different conceptual models: Health Promoting Hospitals Standards and Strategies, the European Foundation for Quality Management (EFQM) Model and the Balanced Scorecard. A bundle of qualitative and quantitative methods were used including in-depth interviews, standardized organization-wide surveys on organizational values, staff satisfaction and patient experience.
Three acute care hospitals in four different locations belonging to a German holding group.
Chief executive officer, senior medical officers, working group leaders and hospital staff.
Development and implementation of the Balanced Scorecard.
Twenty strategic objectives with corresponding Balanced Scorecard measures.
A stepped approach from strategy development to implementation is presented to identify key themes for strategy development, drafting a strategy map and developing strategic objectives and measures.
The Balanced Scorecard, in combination with the EFQM model, is a useful tool to guide strategy development and implementation in health care organizations. As for other quality improvement and management tools not specifically developed for health care organizations, some adaptations are required to improve acceptability among professionals. The step-wise approach of strategy development and implementation presented here may support similar processes in comparable organizations.
Root cause analysis is a method to examine causes of unintended events. PRISMA (Prevention and Recovery Information System for Monitoring and Analysis) is a root cause analysis tool. With PRISMA, events are described in causal trees and root causes are subsequently classified with the Eindhoven Classification Model (ECM). It is important that root cause analysis tools are reliable, because they form the basis for patient safety interventions.
Determining the inter-rater reliability of descriptions, number and classifications of root causes.
Totally, 300 unintended event reports were sampled from a database of 2028 events in 30 hospital units. The reports were previously analysed using PRISMA by experienced analysts and were re-analysed to compare descriptions and number of root causes (n = 150) and to determine the inter-rater reliability of classifications (n = 150).
Percentage agreement and Cohen's kappa ().
Agreement between descriptions of root causes was satisfactory: 54% agreement, 17% partial agreement and 29% no agreement. Inter-rater reliability of number of root causes was moderate ( = 0.46). Inter-rater reliability of classifying root causes with the ECM was substantial from highest category level ( = 0.71) to lowest subcategory level ( = 0.63). Most discrepancies occurred in classifying external causes.
Results indicate that causal tree analysis with PRISMA is reliable. Analysts formulated similar root causes and agreed considerably on classifications, but showed variation in number of root causes. More training on disclosure of all relevant root causes is recommended as well as adjustment of the model by combining all external causes into one category.
To investigate the effectiveness of a quality improvement educational program in rural hospitals.
Hospital-randomized controlled trial.
A total of 47 rural and small community hospitals in Texas that had previously received a web-based benchmarking and case-review tool.
The 47 hospitals were randomized either to receive formal quality improvement educational program or to a control group. The educational program consisted of two 2-day didactic sessions on continuous quality improvement techniques, followed by the design, implementation and reporting of a local quality improvement project, with monthly coaching conference calls and annual follow-up conclaves.
Performance on core measures for community-acquired pneumonia and congestive heart failure were compared between study groups to evaluate the impact of the educational program.
No significant differences were observed between the study groups on any measures. Of the 23 hospitals in the intervention group, only 16 completed the didactic program and 6 the full training program. Similar results were obtained when these groups were compared with the control group.
While the observed results suggest no incremental benefit of the quality improvement educational program following implementation of a web-based benchmarking and case-review tool in rural hospitals, given the small number of hospitals that completed the program, it is not conclusive that such programs are ineffective. Further research incorporating supporting infrastructure, such as physician champions, financial incentives and greater involvement of senior leadership, is needed to assess the value of quality improvement educational programs in rural hospitals.
To explore the potential for international comparison of patient safety as part of the Health Care Quality Indicators project of the Organization for Economic Co-operation and Development (OECD) by evaluating patient safety indicators originally published by the US Agency for Healthcare Research and Quality (AHRQ).
A retrospective cross-sectional study.
Acute care hospitals in the USA, UK, Sweden, Spain, Germany, Canada and Australia in 2004 and 2005/2006.
Routine hospitalization-related administrative data from seven countries were analyzed. Using algorithms adapted to the diagnosis and procedure coding systems in place in each country, authorities in each of the participating countries reported summaries of the distribution of hospital-level and overall (national) rates for each AHRQ Patient Safety Indicator to the OECD project secretariat.
Each country's vector of national indicator rates and the vector of American patient safety indicators rates published by AHRQ (and re-estimated as part of this study) were highly correlated (0.821–0.966). However, there was substantial systematic variation in rates across countries.
This pilot study reveals that AHRQ Patient Safety Indicators can be applied to international hospital data. However, the analyses suggest that certain indicators (e.g. ‘birth trauma’, ‘complications of anesthesia’) may be too unreliable for international comparisons. Data quality varies across countries; undercoding may be a systematic problem in some countries. Efforts at international harmonization of hospital discharge data sets as well as improved accuracy of documentation should facilitate future comparative analyses of routine databases.
The aim of this exploratory study was to investigate to what extent primary care professionals are able to change their systems for delivering care to chronic obstructive pulmonary disease (COPD) patients and what professional and organizational factors are associated with the degree of process implementation.
Quasi-experimental design with 1 year follow-up after intervention.
Three regional COPD management programmes in the Netherlands, in which general practices cooperated with regional hospitals.
All participating primary care professionals (n = 52).
COPD management programme.
Professional commitment, organizational context and degree of process implementation.
Professionals significantly changed their systems for delivering care to COPD patients, namely self-management support, decision support, delivery system design and clinical information systems. Associations were found between organizational factors, professional commitment and changes in processes of care. Group culture and professional commitment appeared to be, to a moderate degree, predictors of process implementation.
COPD management was effective; all processes improved significantly. Moreover, theoretically expected associations between organizational context and professional factors with the implementation of COPD management were indeed confirmed to some extent. Group culture and professional commitment are important facilitators.