In countries where the National Health Service provides universal health coverage, socioeconomic position should not influence the quality of health care. We examined whether socioeconomic position plays a role in short-term mortality and waiting time for surgery after hip fracture.
Retrospective cohort study.
From the Hospital Information System database, we selected all patients, aged at least 65 years and admitted to acute care hospitals in Rome for a hip fracture between 1 January 2006 and 30 November 2007. The socioeconomic position of each individual was obtained using a city-specific index of socioeconomic variables based on the individual's census tract of residence.
Three different outcomes were defined: waiting times for surgery, mortality within 30 days and intervention within 48 h of hospital arrival for hip fracture. We used a logistic regression to estimate 30-day mortality and a Cox proportional hazard model to calculate hazard ratios of intervention within 48 h. Median waiting times were estimated by adjusted Kaplan–Meyer curves. Analyses were adjusted for age, gender and coexisting medical conditions.
Low socioeconomic level was significantly associated with higher risk of mortality [adjusted relative risk (RR) = 1.51; P < 0.05] and lower risk of early intervention (adjusted RR = 0.32; P < 0.001). Socioeconomic level had also an effect on waiting times within 30 days.
Individuals living in disadvantaged census tracts had poorer prognoses and were less likely than more affluent people to be treated according to clinical guidelines despite universal healthcare coverage.
Although specialized centers are generally accepted for treatment of relatively uncommon diseases, such as cystic fibrosis, statements regarding the amount of expertise or minimum number of patients treated are increasingly included in guidelines for the treatment of other chronic diseases such as rheumatoid arthritis and diabetes mellitus.
Medline and Embase from 1987 through March 2008 were searched.
Studies reporting the effect of treatment in a specialized or high-volume center or by subspecialists on a clinically relevant outcome.
Two reviewers extracted the data independently and assessed the methodological quality.
We included 22 articles. Two randomized-controlled trials and a quasi-experimental study compared the effect of outpatient team care with traditional outpatient care for patients with rheumatoid arthritis. These studies showed no difference or were inconsistent. Studies on the outcomes of care for diabetic patients (5 prospective or historical cohort studies and 10 retrospective cohort studies) were generally of poor quality. Studies comparing the subspecialist care with the care provided by general internists or primary care providers produced inconsistent results. Similar inconsistency and poor quality were found for three observational studies on cystic fibrosis.
The available literature suggests that among patients with rheumatoid arthritis, diabetes mellitus or cystic fibrosis, outcomes are not superior in specialized centers or with subspecialists compared with other forms of chronic illness care.
To assess the effectiveness of acute medical units (AMUs) in hospitals.
(i) Controlled and observational studies in peer-reviewed journals retrieved from PubMed, EPOC, CINAHL and ERIC databases published between January 1990 and July 2008; and (ii) reports from non-peer-reviewed websites combined with Google search.
Articles reporting effects of the introduction of an AMU on mortality, length of stay, discharge disposition, readmissions, resource use and patient and/or staff satisfaction.
Data on unit operations and outcome measures were extracted by a single author and confirmed by a second author, with disagreement settled by consensus.
Nine peer-reviewed reports of before–after analyses of seven units introduced into the UK and Ireland were analysed. Two studies, one prospective, reported significant reductions in in-patient mortality between 0.6 and 5.6% points following commencement of AMU. Four studies reported significant reductions in the length of stay between 1.5 and 2.5 days. Waiting times for patient transfer from emergency departments to medical beds decreased by 30% in one study. In three studies, the proportion of medical patients discharged directly home from the AMU increased by 8–25% points. Three studies noted no increase in 30-day readmission rates following unit commencement. Two studies described significant improvements in patient and staff satisfaction with care. Eight non-peer-reviewed reports relating to 48 units confirmed reductions in the length of stay.
Limited observational data suggest AMUs reduce in-patient mortality, length of stay and emergency department access block without increasing readmission rates, and improve patient and staff satisfaction.
To determine the impact and preventability of adverse events (AEs) associated with health care in Spanish hospitals.
Retrospective cohort study.
Twenty-four Spanish hospitals.
Patients of any age with a clinical record indicating an inpatient stay of >24 h and a discharge between 4 and 10 June 2005 (n = 5908).
None.
Percentage of AEs considered preventable.
We were able to identify 525 patients suffering AEs associated directly with medical care, who accumulated 655 AEs with 43% of these AEs considered preventable. Overall, 45% (295 AEs) were considered minor, 39% (255 AEs) moderate and 16% (105 AEs) severe. There were no significant differences in AE severity by hospital size, but AEs associated with surgical services were more likely to be severe than those associated with medical services. Some 31.4% of AEs resulted in a longer stay and 23.4% led to hospital admission. AEs associated with medical care caused 6.1 additional days per patient. Of the patients, 66.3% required additional procedures and 69.9% required additional treatments. Incidence of death in patients with AEs was 4.4% (CI 95%: 2.8–6.5). Age over 65 was associated with a higher incidence of preventable AEs. The highest percentages of preventable AEs were related to diagnosis (84.2%), to nosocomial infections (56.6%) and to care (56%).
In Spanish hospitals, AEs associated with health care cause distress, disability, death, lengthen hospital stay and cause increased consumption of health-care resources. A relatively high percentage of AEs in Spain may be preventable with improvements in medical care.
To develop international guidance for improving the quality of mental health care in low- and middle-income countries.
A panel developed recommendations based on a comprehensive literature review, consultation with over 100 experts from 46 countries and an analysis of international best practices.
A 5-pronged approach to improving the quality of mental health care is recommended. Quality improvement requires the alignment of policy and legislation with the attainment of good quality mental health outcomes. Key partners must be brought into the quality improvement process. Funding can be an important tool for promoting good quality but needs to be correctly aligned to meet policy objectives and to promote evidence-based interventions. Accreditation procedures and quality standards need to be carefully developed and resources allocated for their implementation. Finally, quality improvement must be brought into routine service management and delivery.
Through a systematic approach to quality improvement, it is possible to ensure that the best possible interventions are provided within the constraints of each country and that the rights and well-being of people with mental disorders is optimally promoted. Quality improvement is not a luxury but an integral part of ensuring that the best possible services are provided to all who need them.
The objective of this study was to elicit hospital staff's knowledge, attitudes, and current practices regarding hospital standards and to assess the level of motivation for staff and hospitals to meet new standards.
This was a qualitative study using in-depth interviews and focus group discussions with staff in four hospitals. There was no intervention.
Four rural public and private not-for-profit hospitals in central Uganda.
Medical superintendents and other staff of four hospitals in Uganda who were familiar with the use of standards and had participated in a previous Uganda national accreditation program (Yellow Star).
All staff expressed strong support for the development and implementation of hospital standards, but also said they would need more recognition and ongoing motivation. They cited the need for technical assistance, funding, and training as the main obstacles. Key areas requiring standards were: infection control, cleanliness and hygiene, infrastructure and medical records.
There was strong support for the development and implementation of hospital standards. The main perceived obstacles to the implementation of hospital standards are resource limitations and technical capability. There is a need to develop and implement preliminary standards for hospitals in Uganda.
To explore how hospital management could gain a better picture of risks to support them in setting priorities for patient safety.
This study deals with the combined application of prospective and retrospective methods for risk analysis on two units of a Dutch general hospital. In the prospective analyses, employees identified and assessed possible risks in selected processes. In the retrospective analyses, incidents were reported by employees and subsequently investigated. The methods were integrated by using information from retrospective incident reports for prospective risk identification and assessment, and by matching their categorization schemes. Two evaluation forms provided insight into the perceived usefulness of the methods and their integration.
For both units, the prospective and retrospective analyses resulted in divergent overviews of risks in terms of nature and magnitude, which suggests that one or both methods were subject to biases. Findings from the evaluation forms showed that both methods were perceived as useful and that triangulation provided additional insight into risks. Due to the convergent evidence, triangulation of prospective and retrospective methods can provide hospital management and frontline staff with a more complete and less biased picture of risks. An integrative approach might be advantageous in terms of efficiency of analysis, setting priorities for patient safety and improving the methods themselves.
The purpose of this study was to determine the optimum content of a 1-day classroom-based crew resource management (CRM) course for health-care personnel working in ad hoc teams in complex, time-critical hospital departments such as surgery, intensive care or emergency.
A two-round modified Delphi panel. Participants selected teamwork competency components suitable for inclusion in 1 day of training from a list developed via literature review.
Fifteen experts in health care, CRM and training.
Knowledge, skill and attitude competency components for a 1-day CRM course.
Of the 110 knowledge, skill and attitude CRM competency components, 40 components were selected by greater than 70% of respondents, whereas the remaining 62 components were selected by fewer than 55% of respondents. These 40 competency components ranged across five competency domains: communication, task management, situational awareness, decision-making and leadership, and provided a consensus on the most critical areas for inclusion in training for health-care personnel.
This new competency model is now available for use. Although the sample size was limited, a high degree of consensus was reached after only two rounds. A modified Delphi technique within the context of competencies first refined from the literature was a useful and cost-effective method for determining the content of a 1-day CRM training course for health-care workers.
The aim of this study was to develop a grading scale for predicting the 30-day mortality of spontaneous intracerebral hemorrhage (ICH) using initial evaluation data.
Univariate and multivariate logistic regression models were used to identify independent risk factors and to construct a grading scale for predicting the outcome of ICH.
The Taichung Veterans General Hospital in Taichung, Taiwan.
Two hundred and ninety-three patients were diagnosed with spontaneous ICH between 1 January 2006 and 31 December 2007.
Development of the simplified ICH score (sICH score) for predicting the 30-day mortality of ICH.
The discrimination of the prediction model was determined by measuring the accuracy, sensitivity, specificity and the area under the receiver operating characteristic curves (AUC).
The accuracy of the sICH score was 80.5%, the sensitivity was 82.5% and the specificity was 80.2%. The AUCs are as follows: sICH score, 0.89 (0.84–0.94); ICH score, 0.74 (0.65–0.83) and ICH-GS, 0.74 (0.65–0.83).
The sICH score showed best discrimination among tested models. Also, it was easier for physicians without special training in neurology or radiology to use this scale. With statistical power and ease of use, the sICH score is a very suitable model for risk stratification of spontaneous ICH.
Differences in access to elective surgery may contribute to socioeconomic differences in health. We studied the associations between pre-operative health status (as an indicator of clinical need) and deprivation.
Cross-sectional study with risk-adjusted comparison of preoperative patient-reported health status and deprivation scores.
Thirteen NHS hospitals, two independent sector treatment centres and one private hospital in England and Wales.
A total of 1160 NHS-funded patients undergoing hip replacement, knee replacement or varicose vein surgery.
None.
General health status (EQ-5D), disease-specific health status (Oxford hip score, Oxford knee score and Aberdeen varicose vein symptom severity score) and area deprivation score.
Patients from more deprived areas reported worse EQ-5D scores. Differences in crude mean disease-specific health status scores between the least and most deprived fifths were small: hip score 3.5; knee score 6.8; varicose vein score 4.8. When risk adjusted the strength of the association fell by about half for hip (0.176–0.083) and knee (0.214–0.117) and one-third for varicose vein surgery (0.215–0.140), although the coefficients remained statistically significant (P ≤ 0.01).
Deprivation was associated with worse pre-operative general health status. However, given that the variation in pre-operative disease-specific health status by deprivation score was of small clinical significance and the limited power of the risk adjustment model, there is little evidence of socioeconomic inequity in access to three common elective surgical procedures.
To examine: (1) the reliability of the severity rating scale used by the National Reporting and Learning System (NRLS) in England and Wales for medication errors; and (2) the likelihood of reporting medication errors among healthcare professionals.
A 900-bed acute university teaching hospital in the North West of England.
Forty healthcare professionals (10 doctors, 10 nurses, 10 pharmacists and 10 pharmacy technicians).
Participants were asked to complete a self-administered questionnaire containing nine medication error scenarios on two separate occasions. They were asked to rate the severity of each incident using the NRLS severity rating scale and also the likelihood of reporting the incident via the hospital incident reporting system. The main outcome measures included comparisons of severity ratings and likelihood of reporting by the four health professional groups. Test–retest reliability of the severity ratings was also examined within and between professional groups.
Pharmacists and nurses were significantly more likely to report the errors if they had witnessed them (mean scores 36.3 and 36.2, respectively, compared with 27.9 for doctors, P < 0.001). Nurses and pharmacy technicians assigned higher severity ratings for medication errors (mean scores 23.6 and 25, respectively) than pharmacists or doctors (both 19.4). Both within and between healthcare professional groups, there was wide variation in the assignment of medication error severity ratings.
There are marked differences in the severity ratings for medication errors graded against the NRLS severity criteria between different health professional groups and at different time points rated by the same individuals.
To assess whether comparison of quality of hip fracture care among three teams located in different hospitals is associated with improvement in process and outcomes.
A baseline assessment was performed using quality indicators selected by professionals. Results were discussed among the three teams followed by a post-comparison assessment of the same indicators.
Three hospitals in North Western France.
Professionals caring for patients operated on for a low-impact hip fracture.
Review and discussion of comparative performance results by three teams followed by implementation of quality improvement as deemed necessary by each team.
Fifteen quality indicators of health care during orthopedic and rehabilitation stay, mobility, dependence and place of residence before hip fracture and 3 months after discharge, 3 month post-surgery mortality and readmission rates.
Major differences were observed among hospitals throughout the care process during baseline period. Comparison of performance and discussion among the three teams were followed by corrective action in 11 areas. After comparison, a significant improvement was observed in 10 areas, seven of which corresponded to quality improvement areas chosen for improvement action by professionals. A significant decrease in readmission rate (6.7% vs. 15.7%, P < 0.001) was observed but there was no change in mortality, functional outcome or length of stay.
Comparison of performance among voluntary teams, on fields selected by health-care professionals, was associated with improvement in the care process and with improvement of some related outcomes.
Many changes have been initiated in the Dutch hospital sector to optimize health-care delivery: national agenda-setting, increased competition and transparency, a new system of hospital reimbursement based on diagnosis-treatment combinations, intensified monitoring of quality and a multi-layered organizational development programme based on quality improvement collaboratives. The objective is to answer the question as to whether these changes were accompanied by a further development of hospital quality management systems and to what extent did the development within the multi-layered programme hospitals differ from that in other hospitals.
Longitudinal data were collected in 1995, 2000, 2005 and 2007 using a validated questionnaire. Descriptive analyses and multi-level modelling were applied to test whether: (1) quality management system development stages in hospitals differ over time, (2) development stages and trends differ between hospitals participating or not participating in the multi-layered programme and (3) hospital size has an effect on development stage.
Dutch hospital sector between 1995 and 2007.
Hospital organizations.
Changes through time.
Quality management system development stage.
Since 1995, hospital quality management systems have reached higher development levels. Programme participants have developed their quality management system more rapidly than have non-participants. However, this effect is confounded by hospital size.
Study results suggest that the combination of policy measures at macro level was accompanied by an increase in hospital size and the further development of quality management systems. Hospitals are entering the stage of systematic quality improvement.
Incidents and quality problems are a prime cause why health care leaders are calling to redesign health care delivery. One of the concepts used is lean thinking. Yet, lean often leads to resistance. Also, there is a lack of high quality evidence supporting lean premises. In this paper, we present an overview of lean thinking and its application to health care.
Lean thinking evolved from a tool designed to improve operational shop-floor performance at an automotive manufacturer to a management approach with both operational and sociotechnical aspects. Sociotechnical dynamics have until recently not received much attention. At the same time a balanced approach might lead to a situation where operational and sociotechnial improvements are mutually reinforcing. Application to health care has been limited and focussed mainly on operational aspects using original lean tools. A more integrative approach would be to pay more attention to sociotechnical dynamics of lean implementation efforts. Also, the need to use the original lean tools may be limited, because health care may have different instruments and tools already in use that are in line with lean thinking principles.
We believe lean thinking has the potential to improve health care delivery. At the same time, there are methodological and practical considerations that need to be taken into account. Otherwise, lean implementation will be superficial and fail, adding to existing resistance and making it more difficult to improve health care in the long term.
To evaluate the patient safety culture in primary healthcare units.
A cross-sectional study, utilizing the Turkish version of the Hospital Survey on Patient Safety Culture developed by the Agency for Healthcare Research and Quality and a demographic questionnaire.
Twelve primary healthcare centers in the center of the city of Konya, Turkey.
One hundred and eighty healthcare staff, including general practitioners (GPs), nurses, midwives and health officers.
None.
The patient safety culture score including subscores on 12 dimensions and 42 items; patient safety grade and number of events reported.
Fifty-four (30%) of the participants were GPs, 48 (27%) were nurses, 51 (28%) were midwives and 27 (15%) were health officers. The mean overall score for positive perception of patient safety culture in primary healthcare units was 46 ± 20 (43–49 CI). No differences were found by staff members' profession. Among the dimensions of patient safety, those with the highest percentage of positive ratings were teamwork within units (76%) and overall perceptions of safety (59%), whereas those with the lowest percentage of positive ratings were the frequency of event reporting (12%) and non-punitive response to error (18%). Reporting of errors was infrequent with 87% of GPs, 92% of nurses and 91% of other health staff indicating that they did not report or provide feedback about errors.
Improving patient safety culture should be a priority among health center administrators. Healthcare staff should be encouraged to report errors without fear of punitive action.
To assess the quality of clinical care provided to patients with HIV in Felege Hiwot Referral Hospital.
Normative evaluation based on Donabedian's structure–process–outcome model of health care quality. Cross-sectional study design was employed to gather data in September 2007.
Felege Hiwot Referral Hospital is a government hospital in North West Ethiopia. The hospital is providing clinical care for patients infected with HIV free of patient charge since 2005.
The evaluation used 10 process and 5 outcome indicators of quality measured by reviewing 351 randomly selected patient records and interview with 368 patients. Resource inventory was conducted to assess the availability of trained staff, laboratory facilities and drugs required for provision of HIV care.
All resources recommended by the national antiretroviral therapy (ART) Implementation Guideline including trained staff, laboratory facilities and drugs were continuously available, except for a shortage of cotrimoxazole. Despite this, important components of care and treatment recommended by national treatment guidelines were not delivered for significant portion of patients. The study showed that only 45.9% of patients eligible for cotrimoxazole prophylactic therapy (CPT) and 76.8% of patients eligible for ART were actually taking CPT and ART, respectively. Compliance with national guidelines to monitor patients was also found to be a major problem.
Availability of resources alone does not ensure the quality of HIV care and treatment. The study results indicate a need for regular monitoring and improvement of processes and outcomes of care in the Ethiopian Health System.
As part of a trial aiming to improve care for patients with chronic (systolic) heart failure, a standardized, multifaceted case management approach was evaluated in German general practices. It consisted of regular telephone monitoring, home visits, health counselling, diagnostic screening and booklets for patients. Practice-based doctors' assistants (equivalent to a nursing role) adopted these new tasks and reported regularly to the employing general practitioner (GP).
To explore GPs' perceptions of case management, subsequent changes in relationships within the practice team and the potential future role.
Twenty-four GPs participated in five moderated, semi-structured, audio-taped focus groups. Full transcription and thematic content analysis was undertaken.
GPs rated all elements and instruments of case management conducted by doctors' assistants feasible, except for the geriatric assessment as patients had not been at risk. GPs perceived difficulties in their own role in delivering health behaviour counselling. Relationships between doctors' assistants and patients and between GPs and patients or doctors' assistants remained stable or improved. All GPs perceived a variety of role changes in doctors' assistants including more in-depth medical knowledge and higher responsibilities yielding more recognition by patients and GPs. Some GPs suggested transferring the case management programme to other chronic conditions and that it should form part of a further education curriculum for doctors' assistants.
This primary care-based case management model characterized by the orchestrated delegation of tasks to doctors' assistants offers a promising strategy of enhanced chronic illness care, but it needs further adaptation and evaluation.
Several studies raise questions about whether clinical practice guidelines actually guide practice. We evaluated patterns of use of breast-conserving surgery (BCS) over time to examine the effect of guideline publication.
Retrospective analysis of time-series data on breast cancer treatment. Multiple logistic regression analysis was performed, adjusting for covariates including the patient's age, comorbidity status and admission year, to assess whether the use of BCS was higher after publication of treatment guidelines.
Five teaching hospitals participating in the Quality Improvement/Indicator Project (QIP) in Japan.
Female breast cancer patients who received surgical treatment at five teaching hospitals from January 1996 through December 2007 (n = 2199).
Rates of use of BCS.
The proportion of BCS use increased from 26.4% before guideline publication to 59.9% after guideline publication in Japan. After controlling for other characteristics, the use of BCS has increased significantly over time, especially since 2001. Women aged 70 years and older (P=0.004) and those with any comorbidity (P < 0.001) were significantly less likely to receive BCS.
This study demonstrated that the adjusted proportion of BCS has increased dramatically since 2001, 2 years after guideline publication in Japan and this is consistent with a relationship between guideline publication and a change in this clinical practice.
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.
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.
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.
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.
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.
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.
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 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.
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.
Determine the degree of congruence between several measures of adverse events.
Cross-sectional study to assess frequency and type of adverse events identified using a variety of methods.
Mayo Clinic Rochester hospitals.
All inpatients discharged in 2005 (n = 60 599).
Adverse events were identified through multiple methods: (i) Agency for Healthcare Research and Quality-defined patient safety indicators (PSIs) using ICD-9 diagnosis codes from administrative discharge abstracts, (ii) provider-reported events, and (iii) Institute for Healthcare Improvement Global Trigger Tool with physician confirmation. PSIs were adjusted to exclude patient conditions present at admission.
Agreement of identification between methods.
About 4% (2401) of hospital discharges had an adverse event identified by at least one method. Around 38% (922) of identified events were provider-reported events. Nearly 43% of provider-reported adverse events were skin integrity events, 23% medication events, 21% falls, 1.8% equipment events and 37% miscellaneous events. Patients with adverse events identified by one method were not usually identified using another method. Only 97 (6.2%) of hospitalizations with a PSI also had a provider-reported event and only 10.5% of provider-reported events had a PSI.
Different detection methods identified different adverse events. Findings are consistent with studies that recommend combining approaches to measure patient safety for internal quality improvement. Potential reported adverse event inconsistencies, low association with documented harm and reporting differences across organizations, however, raise concerns about using these patient safety measures for public reporting and organizational performance comparison.