Over the last two decades, we have seen the successive rise and fall of a number of concepts, ideas or methods in healthcare quality improvement (QI). Paradoxically, the content of many of these QI methodologies is very similar, though their presentation often seeks to differentiate or distinguish them.
This paper sets out to explore the processes by which new QI methodologies are developed and disseminated and the impact this has on the effectiveness of QI programmes in healthcare organizations. It draws on both a bibliometric analysis of the QI literature over the period from 1988 to 2007 and a review of the literature on the effectiveness of QI programmes and their evaluation.
The repeated presentation of an essentially similar set of QI ideas and methods under different names and terminologies is a process of ‘pseudoinnovation’, which may be driven by both the incentives for QI methodology developers and the demands and expectations of those responsible for QI in healthcare organizations. We argue that this process has important disbenefits because QI programmes need sustained and long-term investment and support in order to bring about significant improvements. The repeated redesign of QI programmes may have damaged or limited their effectiveness in many healthcare organizations.
A more sceptical and scientifically rigorous approach to the development, evaluation and dissemination of QI methodologies is needed, in which a combination of theoretical, empirical and experiential evidence is used to guide and plan their uptake. Our expectations of the evidence base for QI methodologies should be on a par with our expectations in relation to other forms of healthcare interventions.
In The Danish Cholecystectomy Database (DCD), quality indicators are derived from clinical data in combination with administrative data from the National Patient Registry. The indicators ‘Length of postoperative stay ≤1 day and no readmission’, ‘Length of stay (LOS) >3 days and/or readmission’, ‘Additional procedures within 30 days’, ‘Reconstructive bile duct surgery’, ‘Other surgery of the bile duct’ and ‘Death within 30 days’ are all derived from administrative data. This study investigates the validity of the administrative data and evaluates the association between these indicators and postoperative complications.
Data from 1360 medical records of patients undergoing cholecystectomy were compared with the relevant administrative data from the National Patient Registry. The medical records served as the ‘gold standard’. The association between the individual indicators and the occurrence of a postoperative complication was assessed.
Validation of administrative data against the gold standard was done by the calculation of per cent agreement (including kappa-values) sensitivity/specificity and predictive values. The association between indicators and complications was analysed with crude event rates and odds ratios.
The validity of the administrative data was excellent (97.1–100% agreement, = 0.73–1.00). All of the indicators except ‘Other bile duct surgery’ were significantly associated with postoperative complications. A subdivision of some indicators strengthened the associations.
The DCD is a valid method for monitoring the quality of cholecystectomy in Denmark.
Initiatives to improve patient safety have high priority among health professionals and politicians in most developed countries. Currently, however, assessment of patient safety problems relies mainly on case-based methodologies. The evidence for their efficiency and reproducibility, proving that safety of care has improved with their usage, is questionable. The exact incidence and prevalence of patient safety quality problems are unknown. Therefore, there is a need for firm, evidence-based methods to survey and develop patient safety and derived activities.
The objective of this paper is to describe a method to select patient safety indicators and present the indicators derived through this process.
The patient safety indicators were derived and recommended for use in a formalized consensus process based on literature review, targeted information gathering, expert consultation and rating procedures.
A total of 42 indicators, of which 28 originated from existing international indicator programmes, were selected. The processes and outcome indicators that were recommended for institutional-level use in Europe were 24, covering safety of care aspects such as culture, infections, surgical complications, medication errors, obstetrics, falls and specific diagnostic areas.
The patient safety indicators recommended present a set of possible measures of patient safety. One of the future perspectives of implementing patient safety indicators for systematic monitoring is that it will be possible to continuously estimate the prevalence and incidence of patient safety quality problems. The lesson learnt from quality improvement is that it will pay off in terms of improving patient safety.
Assess impact of nationwide home health quality improvement campaign to reduce acute care hospitalization of home health recipients.
Observational pre–post comparison of self-selected participating and non-participating agencies' quality performance; survey to determine uptake of program materials.
US home health care agencies.
A total of 147 agencies with 147 non-participating agencies matched on patient length of service, pre-intervention hospitalization rate and pre-intervention rate of change in hospitalization rate.
Public events; provision of educational packages and technical assistance; quality measure feedback.
Post-intervention difference in risk-adjusted acute care hospitalization rate between participants and non-participants; difference in self-reported campaign material use between agencies whose hospitalization rate declined 2% or more and those whose rates increased by 2% or more.
Hospitalization rate had a negative trend beginning before the campaign. In the matched pairs studied, it did not differ significantly between participants and non-participants, or from pre- to post-intervention period (28% in every case). Agencies that improved were more likely to report activities consistent with the campaign and using campaign interventions than those not improving (P < 0.001), regardless of participation status.
Merely agreeing to participate in the campaign did not improve performance, but effective participation through adoption of campaign methods did.
To determine the effect of accreditation of non-governmental organizations' health units on patient satisfaction and provider satisfaction and the output of accreditation on compliance to some accreditation standards.
Sixty non-governmental health units were selected as follows: 30 units already submitted for accreditation in three governorates and 30 pair-matched units not programmed for accreditation. Matching was done according to the socioeconomic standard and administration type, and from the same governorate. Satisfaction was measured by an interview questionnaire using the Likert scale. Assessment of compliance to some accreditation standards was done using a checklist.
Mean patient satisfaction scores were significantly higher among the accredited non-governmental health units regarding: cleanliness, waiting area, waiting time, unit staff and overall satisfaction. No significant differences were noticed in provider satisfaction except for the overall satisfaction score. Most of the checked standards had compliance above 90% in the accredited units and were significantly higher than in the non-accredited units.
Accreditation of the non-governmental health units has a positive effect regarding patient satisfaction and the continuation of performance according to the accreditation standards compared with non-accredited health units. This short-term effect was shown within the first year from accreditation. Future research is needed to assess long duration effects of applying accreditation in non-governmental health units.
The objective of our study was to develop a theory-based and empirically tested instrument for measuring patient-reported ‘psychosocial care by physicians’. We propose a model integrating patients' perceptions with respect to: (i) devotion by physicians, (ii) support by physicians, (iii) information by physicians and (iv) shared decision-making (SDM).
Data were gathered during 2001 within a cross-sectional, retrospective mail survey.
A total of 4192 inpatients of six German hospitals.
Specific scales of the Cologne Patient Questionnaire were used. A two-step structural equation model procedure was applied. In the first structural equation model, all items were modeled as indicators of the intended underlying latent construct, ‘psychosocial care by physicians’. In the second structural equation model, criterion-related validity of the intended construct was tested with respect to patients' ‘satisfaction’, ‘trust in physicians’ and the ‘image of the hospital’.
The results confirmed that the aspects of psychosocial care provided by physicians measured by the scale items are indeed indicators of the same construct. Furthermore, indicator reliabilities and selectivities revealed that the content of all 13 items was highly representative of the underlying construct. The second structural equation model showed that ‘psychosocial care by physicians’ is related to ‘patients’ satisfaction', ‘trust in physicians’ and ‘hospital-image’ in a significant and relevant manner.
On the basis of our instrument's reported psychometric characteristics and of the initial validity indicators, it may be regarded as an adequate measure for further use in outcome and intervention research, and as a quality indicator for the physician-patient relationship.
To develop and validate a list of objective criteria to assess the appropriateness of hospital days for patients admitted to rehabilitation centres and sub-acute care units.
Sixteen appropriateness criteria were defined by a multidisciplinary panel of 33 experts using a formalized consensus method. A single ticked criterion classifies the hospital day as appropriate. Reliability was studied by measuring concordance between two independent and simultaneous ratings using the instrument. External validity was tested by comparing conclusions derived from the instrument with the individual judgements of one, two or three experts on the same random sample of hospital days.
The assessment on these criteria was performed on a randomized sample of 406 hospital days from 17 French wards.
Inter-rater reliability and external validity were evaluated using the statistic and prevalence-adjusted and bias-adjusted kappa (PABAK).
The inter-rater reliability test showed a -value of 0.71 [95% confidence interval (95% CI) 0.63–0.78] and a PABAK of 0.77 (95% CI 0.70–0.83). There was a good agreement between the conclusions reached using the instrument and the individual judgements of experts with a coefficient of 0.42 (95% CI 0.35–0.50) and a PABAK of 0.60 (95% CI 0.52–0.67).
The instrument is reliable and valid for assessing appropriateness of hospital days in rehabilitation centres and sub-acute care units. The next step in this study is the development of a tool for the analysis of causes of inappropriateness.
To identify whether attributes of perceived clinic quality and patient education are associated with patient satisfaction and recommendation of a primary care provider.
Data used in this study were obtained through a national telephone survey by random sampling.
Clinics throughout Taiwan.
A total of 1910 patients.
Overall patient satisfaction and recommendation were measured by single item questions. Attributes of clinic quality were measured using 11 items: doctor's technical skill (four items), doctor's interpersonal skill (three items), staff care and access (four items). Patient education was measured on the basis of education provided on disease prevention and control during the visit.
With regard to clinic quality, doctor's technical skill was most related to overall satisfaction and recommendation, followed by doctor's interpersonal skill. Staff care and access were associated with overall satisfaction but were not associated with recommendation. Patient education was related to both overall satisfaction and recommendation.
Doctor's technical skill is the most critical attribute of primary care quality for both overall satisfaction and recommendation, followed by doctor's interpersonal skill. Staff care and access are associated with improved overall satisfaction but not related to increasing the likelihood of recommending a clinic to relatives and friends. Doctor's technical and interpersonal skills rather than staff care and access can be the essence of quality competition in the primary care market. Providing patient education during the visit on how to prevent or control diseases may also relate to improved patient satisfaction and recommendation.
The role of process modelling has been widely recognized for effective quality improvement. However, application in health care is somewhat limited since the health care community lacks knowledge about a broad range of methods and their applicability to health care. Therefore, the objectives of this paper are to present a summary description of a limited number of distinct modelling methods and evaluate how health care workers perceive them.
Various process modelling methods from several different disciplines were reviewed and characterized. Case studies in three different health care scenarios were carried out to model those processes and evaluate how health care workers perceive the usability and utility of the process models.
Eight distinct modelling methods were identified and characterized by what the modelling elements in each explicitly represents. Flowcharts, which had been most extensively used by the participants, were most favoured in terms of their usability and utility. However, some alternative methods, although having been used by a much smaller number of participants, were considered to be helpful, specifically in understanding certain aspects of complex processes, e.g. communication diagrams for understanding interactions, swim lane activity diagrams for roles and responsibilities and state transition diagrams for a patient-centred perspective.
We believe that it is important to make the various process modelling methods more easily accessible to health care by providing clear guidelines or computer-based tool support for health care-specific process modelling. These supports can assist health care workers to apply initially unfamiliar, but eventually more effective modelling methods.