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.
To quantify women's satisfaction with delivery care in informal settlements of Nairobi, Kenya, and to determine characteristics of women and delivery care associated with satisfaction.
Household survey data analysis of 1266 women who delivered in health facilities in 2004 or 2005.
Two densely populated informal settlements 7 and 12 km from Nairobi's center, where residents work primarily in the nearby industrial area or in the informal sector.
Satisfaction was assessed by whether women would recommend the delivery care facility and deliver there again.
Over half (56%) of women would both recommend and deliver again in the same facility. In multivariate analysis, women's satisfaction with delivery care was associated with greater provider empathy (OR = 3.68, 95% CI 2.27, 5.97). Women's satisfaction with delivery care was also associated with the pregnancy having been wanted (OR = 2.75, 95% CI 1.82, 4.14) or mistimed vs. unwanted. Women delivering at private facilities in the settlement near the industrial area were more satisfied than women delivering at private facilities in the more distant and marginalized settlement (OR = 2.12, 95% CI 1.45, 3.09). The association of women's satisfaction and provider empathy was stronger among women who experienced complications compared to those who did not.
Health providers should be sensitized to the finding that unintended pregnancy is associated with lower satisfaction with delivery care. Maternal health programmes should focus on increasing provider empathy, especially for women who experience complications, in both private and government health facilities.
To compare the quality of family planning services delivered at public and private facilities in Kenya.
Data from the 2004 Kenya Service Provision Assessment were analysed. The Kenya Service Provision Assessment is a representative sample of health facilities in the public and private sectors, and comprises data obtained from a facility inventory, service provider interviews, observations of client–provider interactions and exit interviews. Quality-of-care indicators are compared between the public and private sectors along three dimensions: structure, process and outcome.
Private facilities were superior to public sector facilities in terms of physical infrastructure and the availability of services. Public sector facilities were more likely to have management systems in place. There was no difference between public and private providers in the technical quality of care provided. Private providers were better at managing interpersonal aspects of care. The higher level of client satisfaction at private facilities could not be explained by differences between public and private facilities in structural and process aspects of care.
Formal private sector facilities providing family planning services exhibit greater readiness to provide services and greater attention to client needs than public sector facilities in Kenya. Consistent with this, client satisfaction is much higher at private facilities. Technical quality of care provided is similar in public and private facilities.
To assess the validity and reliability of the Hebrew and Arabic translations of the complete and shortened versions of the Care Transition Measure (CTM)—a measure of patients' experience of the transition between hospital and community care.
Translation of questionnaire's items, evaluation of reliability, construct validity, factor structure and convergent validity.
An oncology center at a tertiary care facility that serves the entire population of the north part of Israel.
Patients receiving care at the clinics of an oncology treatment center.
Psychometric properties of both the 15-item (complete) and 3-item (shortened) versions of the CTM in Hebrew and Arabic. Reliability established using internal consistency with Cronbach's-. Exploratory factor analysis conducted using Varimax rotation. Convergent validity determined with Pearson correlation and ANOVA tests.
Three hundred and eighteen Hebrew- and Arabic-speaking oncology patients completed the questionnaire. Cronbach's- for the questionnaire was 0.94 and 0.90 for the Hebrew and the Arabic versions, respectively. Factor analysis resulted in three factors in each of the translated versions with a cumulative variance of 73.41% and 69.2% in the Hebrew and Arabic versions, respectively. Tests of the convergent validity showed that the measure is correlated with health status and that the shortened and complete versions' ratings are consistent across different patient groups.
The translated Hebrew and Arabic versions of the questionnaire are reliable and valid instruments to assess patients' transitions across settings in diverse populations.
To develop a tool for assessing the performance of primary care services in South Korea from the patient's perspective and to test the validity of the tool under the conceptual framework of the recently developed definition of primary care in Korea.
Item development for questionnaire and a cross-sectional survey for tool validation at 16 primary care clinics. All family physicians included in this study were required to have practiced at their current clinic for at least 2 years.
A nine expert panel was assembled for tool development and patients (or guardians) who had visited their primary care clinic on six or more occasions over a period of more than 6 months participated in the survey.
Scores corresponding to each domain of primary care.
A total of 722 effective data sets were used for the analysis. Five items were eliminated from the preliminary 30-item tool after expert discussions at two seminars. Another four items were eliminated by principle component analysis. For each of the four domains (comprehensiveness, coordination function, personalized care, and family/community orientation), tests of scaling assumptions were well satisfied by all Likert-scaled measures. On the other hand, ‘first contact’ turned out to be a composite domain with five independent single-item scales.
The Korean primary care assessment tool (version 1) consists of four multi-item scales and one composite scale. Widespread application of this tool will provide an empirical basis for the measurement, monitoring and continuous improvement of primary care in South Korea.
US critical access hospitals play an integral role in rural healthcare. Accreditation may be helpful in assuring that these hospitals provide high-quality care.
To determine whether quality measures used in the US Centers for Medicare and Medicaid Services Hospital Compare database differed for critical access hospitals based on Joint Commission on Accreditation of Healthcare Organizations accreditation status.
Cross-sectional with t-test statistics computed on weighted data to ascertain statistically significant differences (P ≤ 0.01).
Differences between accredited and non-accredited rural critical access hospitals on quality care indicators related to acute myocardial infarction, heart failure, pneumonia and surgical infection.
US critical access hospitals.
The differences between accredited and non-accredited rural critical access hospitals for 4 out of 16 hospital quality indicators were statistically significant (P ≤ 0.01) and favored accredited hospitals. Also, accredited hospitals were more likely to rank in the top half of hospitals for 6 of the 16 quality measures.
The results indicate that in the setting of critical access hospitals, external accreditation appears to result in modestly better performance.
To review the literature concerning strategies for implementing quality indicators in hospital care, and their effectiveness in improving the quality of care.
A systematic literature study was carried out using MEDLINE and the Cochrane Library (January 1994 to January 2008).
Hospital-based trials studying the effects of using quality indicators as a tool to improve quality of care.
Two reviewers independently assessed studies for inclusion, and extracted information from the studies included regarding the health care setting, type of implementation strategy and their effectiveness as a tool to improve quality of hospital care.
A total of 21 studies were included. The most frequently used implementation strategies were audit and feedback. The majority of these studies focused on care processes rather than patient outcomes. Six studies evaluated the effects of the implementation of quality indicators on patient outcomes. In four studies, quality indicator implementation was found to be ineffective, in one partially effective and in one it was found to be effective. Twenty studies focused on care processes, and most reported significant improvement with respect to part of the measured process indicators. The implementation of quality indicators in hospitals is most effective if feedback reports are given in combination with an educational implementation strategy and/or the development of a quality improvement plan.
Effective strategies to implement quality indicators in daily practice in order to improve hospital care do exist, but there is considerable variation in the methods used and the level of change achieved. Feedback reports combined with another implementation strategy seem to be most effective.
Barriers to guideline-based diabetes care include poor patient activation, haphazard clinic appointments, poorly organized medical records and a lack of automated physician decision support. We developed a patient recall intervention to mitigate these barriers and improve diabetes care coordination. We evaluated this intervention in terms of operational feasibility, provider and patient acceptance and effects on process of care measures.
On the basis of the American Diabetes Association criteria, we identified patients with diabetes in a large internal medicine practice who were due for provider visits; hemoglobin A1c, lipid, microalbumin and serum creatinine laboratories; and retinal examinations. An outreach coordinator contacted patients to summarize this information and schedule recommended services. We assessed patient responsiveness to outreach and used medical chart review to compare diabetes care rendered before and after the intervention. Providers gave feedback about their satisfaction with the program.
Over 3 months, 709 patients were overdue for diabetes-related services. Of 415 overdue for provider visits, a total of 125 (30.1%) completed such visits arranged by an outreach coordinator and, of these, 101 (80.8%) completed laboratories at least a day ahead of time. An additional 52 out of 415 patients (12.5%) bypassed the outreach coordinator to self-schedule diabetes visits within a 6-week period after the outreach letter was mailed. Among overdue patients, completion of recommended services and intensity of diabetes care were significantly greater through the outreach program compared with traditional care. Provider attitudes were favorable.
An outreach intervention was associated with improved timeliness and intensity of diabetes care in an outpatient setting. The success of this pilot program in terms of process measures warrants additional evaluation focused on clinical outcomes.
To review integrated care interventions and their effects on the quality of care for patients with cancer.
Search in Medline and Cochrane Library databases from January 1996 to October 2006.
Randomized controlled trials and controlled before–after studies in which the intervention focused on at least one of the three principles of integrated care: patient-centredness, organization of care and multidisciplinary care.
Of the 1397 references, 33 studies were included and analysed. No study focused on all three principles of integrated care: 16 studies focused on patient-centredness (48%), 14 on the organization of care (42%), 1 on multidisciplinary care and 2 on both patient-centredness and organization of care. There was a large variation in interventions reported and in outcomes used for evaluation. Effective interventions to improve patient-centredness are the ‘provision of an audiotape of the consultation to the patient’, ‘provision of information to patients’ and ‘use of a decision aid’. Effective interventions to improve the organization of care can be ‘follow-up’ and ‘case management’, especially by nurses and ‘one-stop clinics’.
To improve integrated care for patients with cancer, a multicomponent intervention programme is required focusing on patients, professionals and the organization of care. The promising interventions found in this review should be part of this programme. This programme should be evaluated using rigorous methods and unequivocal outcome measures linked to the intervention.
The results of many quality improvement (QI) projects are gaining wide-spread attention. Policy-makers, hospital leaders and clinicians make important decisions based on the assumption that QI project results are accurate. However, compared with clinical research, QI projects are typically conducted with substantially fewer resources, potentially impacting data quality. Our objective was to provide a primer on basic data quality control methods appropriate for QI efforts.
Data quality control methods should be applied throughout all phases of a QI project. In the design phase, project aims should guide data collection decisions, emphasizing quality (rather than quantity) of data and considering resource limitations. In the data collection phase, standardized data collection forms, comprehensive staff training and a well-designed database can help maximize the quality of the data. Clearly defined data elements, quality assurance reviews of both collection and entry and system-based controls reduce the likelihood of error. In the data management phase, missing data should be quickly identified and corrected with system-based controls to minimize the missing data. Finally, in the data analysis phase, appropriate statistical methods and sensitivity analysis aid in managing and understanding the effects of missing data and outliers, in addressing potential confounders and in conveying the precision of results.
Data quality control is essential to ensure the integrity of results from QI projects. Feasible methods are available and important to help ensure that stakeholder's decisions are based on accurate data.
Interpretation and comparison of patient safety information have been compromised by the lack of a common understanding of the concepts involved. The World Alliance set out to develop an International Classification for Patient Safety (ICPS) to address this, and to test the relevance and acceptability of the draft ICPS and progressively refine it prior to field testing.
Two-stage Delphi survey. Quantitative and qualitative analyses informed the review of the ICPS.
International web-based survey of expert opinion.
Experts in the fields of patient safety, health policy, reporting systems, safety and quality control, classification theory and development, health informatics, consumer advocacy, law and medicine; 253 responded to the first round survey, 30% of whom responded to the second round.
In the first round, 14% felt that the conceptual framework was missing at least one class, although it was apparent that most respondents were actually referring to concepts they felt should be included within the classes rather than the classes themselves. There was a need for clarification of several components of the classification, particularly its purpose, structure and depth. After revision and feedback, round 2 results were more positive, but further significant changes were made to the conceptual framework and to the major classes in response to concerns about terminology and relationships between classes.
The Delphi approach proved invaluable, as both a consensus-building exercise and consultation process, in engaging stakeholders to support completion of the final draft version of the ICPS. Further refinement will occur.
Understanding the patient safety literature has been compromised by the inconsistent use of language.
To identify key concepts of relevance to the International Patient Safety Classification (ICPS) proposed by the World Alliance For Patient Safety of the World Health Organization (WHO), and agree on definitions and preferred terms.
Six principles were agreed upon—that the concepts and terms should: be applicable across the full spectrum of healthcare; be consistent with concepts from other WHO Classifications; have meanings as close as possible to those in colloquial use; convey the appropriate meanings with respect to patient safety; be brief and clear, without unnecessary or redundant qualifiers; be fit-for-purpose for the ICPS.
Definitions and preferred terms were agreed for 48 concepts of relevance to the ICPS; these were described and the relationships between them and the ICPS were outlined.
The consistent use of key concepts, definitions and preferred terms should pave the way for better understanding, for comparisons between facilities and jurisdictions, and for trends to be tracked over time. Changes and improvements, translation into other languages and alignment with other sets of patient safety definitions will be necessary. This work represents the start of an ongoing process of progressively improving a common international understanding of terms and concepts relevant to patient safety.
Depressive disorders are of great medical and political significance. Although evidence-based guidelines have been published and educational initiatives have been launched to implement them, they are rarely actually used. The aim of the study was to implement clinical practice guidelines for outpatient care of depression using a practice-oriented and interdisciplinary approach.
Controlled clinical trial with a naturalistic design (data collection within routine practice) designed as a prospective pre-post study.
Outpatient care.
29 general practitioners (intervention: 18; control: 11) and 15 psychiatrists (intervention: 11; control: 4). Overall, the treatment of 698 patients (two samples: pre: 361; post: 337) was documented.
Multifaceted intervention combining benchmarking, continuous medical education and interdisciplinary quality circles for the diagnosis and treatment of depressive disorders.
Mixed-effects regression models for cluster-adjusted analysis of patients' symptom reduction.
Although physicians in the intervention group improved their clinical effectiveness (proportion of patients with response/remission) to a greater extent than physicians in the control group (intervention: 48.6% to 66.9%; control: 54.9% to 61.5%), cluster-adjusted analysis failed to prove a statistically significant effect of the intervention on the treatment outcome.
Although no statistically significant improvements were found regarding the outcomes, the action programme provides important work, materials and results for an integrated treatment model for depression.
Writing actionable best-evidence guidelines that prioritize key recommendations while indicating the levels of adoption needed for population health benefits to be accomplished.
Developing implementation plans for the priority guideline recommendations. These should systematically consider skills training and accreditation; social influences including opinion leaders and patient influences; environmental factors; monitoring and feedback; and incentives for clinical change.
Pilot testing the effectiveness of proposed approaches in producing the desired clinical changes. If implementation requires system changes and evaluation at an organizational level, the use of alternative research designs to the randomized controlled trial could be considered. The purpose evaluation would be to enable refinement of the implementation plans before widespread dissemination.
To apply the Hazard Analysis and Critical Control Points method to the preparation of anti-cancer drugs. To identify critical control points in our cancer chemotherapy process and to propose control measures and corrective actions to manage these processes.
The Hazard Analysis and Critical Control Points application began in January 2004 in our centralized chemotherapy compounding unit. From October 2004 to August 2005, monitoring of the process nonconformities was performed to assess the method.
According to the Hazard Analysis and Critical Control Points method, a multidisciplinary team was formed to describe and assess the cancer chemotherapy process. This team listed all of the critical points and calculated their risk indexes according to their frequency of occurrence, their severity and their detectability. The team defined monitoring, control measures and corrective actions for each identified risk. Finally, over a 10-month period, pharmacists reported each non-conformity of the process in a follow-up document.
Our team described 11 steps in the cancer chemotherapy process. The team identified 39 critical control points, including 11 of higher importance with a high-risk index. Over 10 months, 16 647 preparations were performed; 1225 nonconformities were reported during this same period.
The Hazard Analysis and Critical Control Points method is relevant when it is used to target a specific process such as the preparation of anti-cancer drugs. This method helped us to focus on the production steps, which can have a critical influence on product quality, and led us to improve our process.
The aim of this study was to adapt and validate an instrument for assessing quality of care from the patients' perspective in the context of Chilean primary care.
The ‘Health Centre Assessment Questionnaire’ is made up of six multiple-item scales and two single-item scales addressing eight key areas of primary care activity. A further two single-item scales ask about the overall satisfaction and the way in which the centre deals with patients' health issues. The adaptation process was developed according to methods described in the specialized literature. The instrument was initially pre-tested in a sample of 100 primary care patients. The validation was carried out in 10 urban public primary healthcare centres where 2896 patients were invited to complete the questionnaire. The validity and reliability of the instrument was assessed using standard psychometric techniques.
Ninety nine per cent (2870) of those approached completed the questionnaire. It was acceptable to most of the patients as reflected by the high response rate, and a full range of possible scores in most of the scales. Reliability was good as reflected by high internal consistency and homogeneity. Validity was supported by the confirmation of scaling assumptions, the moderate correlations between multiple-item scales, and by the confirmation of our ‘a priori’ hypothesis.
The questionnaire could be a useful instrument for assessing a number of important dimensions in Chilean primary care. It is acceptable, reliable and valid. Further work is required to evaluate its validity against external criteria and its test–retest reliability.
In this study, we evaluated patient care communication in the integrated care setting of children with cerebral palsy in three Dutch regions in order to identify relevant communication gaps experienced by both parents and involved professionals.
A three-step mixed method approach was used starting with a questionnaire to identify communication links in which parents experienced gaps. In subsequent in-depth interviews with parents and focus group meetings with professionals underlying factors were evaluated.
In total, 197 parents completed the questionnaire (response 67%); 6% scored negative on parent–professional communication, whereas 17% scored negative on inter-professional communication, especially between the rehabilitation physician and primary care physiotherapy (16%) and (special) education/day care (15%). In-depth interviews among a subset of 20 parents revealed various sources of dissatisfaction such as lack of cooperation and patient centeredness, inappropriate amount of information exchange and professional use of parents as messenger of information. Focus group meetings revealed that professionals recognized these gaps. They attributed them to capacity problems, lack of interdisciplinary guidelines and clear definition of roles, but also a certain hesitance for contact due to unfamiliarity with involved professionals in the care network.
Parents particularly identified gaps in inter-professional communication between (rehabilitation) hospitals and primary care settings. Involved professionals recognized these gaps and primarily attributed them to organizational factors. Improvement initiatives should focus on these factors as well as facilitation of low-threshold contact across the patient's care network.
The objective of this study is to identify the elements and clusters of a quality management model for integrated care.
In order to develop the model a combination of three methods were applied. A literature study was conducted to identify elements of integrated care. In a Delphi study experts commented and prioritized 175 elements in three rounds. During a half-a-day session with the expert panel, Concept Mapping was used to cluster the elements, position them on a map and analyse their content. Multi-dimensional statistical analyses were applied to design the model.
Thirty-one experts, with an average of 8.9 years of experience working in research, managing improvement projects or running integrated care programmes.
The literature study resulted in 101 elements of integrated care. Based on criteria for inclusion and exclusion, 89 unique elements were determined after the three Delphi rounds. By using Concept Mapping the 89 elements were grouped into nine clusters. The clusters were labelled as: ‘Quality care’, ‘Performance management’, ‘Interprofessional teamwork’, ‘Delivery system’, ‘Roles and tasks’, ‘Patient-centeredness’, ‘Commitment’, ‘Transparent entrepreneurship’ and ‘Result-focused learning’.
The identified elements and clusters provide a basis for a comprehensive quality management model for integrated care. This model differs from other quality management models with respect to its general approach to multiple patient categories, its broad definition of integrated care and its specification into nine different clusters. The model furthermore accentuates conditions for effective collaboration such as commitment, clear roles and tasks and entrepreneurship. The model could serve evaluation and improvement purposes in integrated care practice. To improve external validity, replication of the study in other countries is recommended.