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Management complexity and the high prevalence of diabetes have prompted efforts to improve patient care efficiency. One method of system redesign based on the chronic care model is the Shared Medical Appointment (SMA) in which groups of patients (8–20) are seen by an inter‐professional team in a 1–2 hour appointment. In a primary care clinic at a tertiary care academic medical centre, SMAs targeted patients at particularly high cardiovascular risk: A1c >9%, systolic blood pressure (SBP) >160mmHg and/or LDL‐c >130mg/dl. Levels of A1c, LDL‐c and SBP all fell significantly post‐intervention and the reductions in A1c and SBP were significantly greater among SMA participants compared with control patients. The improvements from this system redesign were observed without incremental increase in personnel costs.
See pp 322 and 349
Although a potentially attractive strategy for reducing medical error is to target patients at high risk of adverse outcomes, it does not necessarily follow that analysing data exclusively obtained from this group provides the most to learn about improving systems of care. Stratification of 21537 patients with a principal discharge diagnosis of acute myocardial infarction according to risk of death based on age and coexisting conditions demonstrated little variation for high‐risk patients across 17 hospitals. In contrast, low‐risk patients demonstrated the greatest variation in mortality across hospitals, suggesting that outcomes for this patient group are more sensitive to the prevalence of medical error. Factors such as advanced age and significant co‐morbidity may overwhelm variation in quality of care in determining outcomes in such patients. This study suggests that analysis of quality indicators for low‐risk patients might afford a better chance of identifying best‐performing hospitals and learning from their structures and processes to effect system‐wide change that will benefit all patients.
See p 324
A French national survey of adverse events (AEs) was conducted by interviewing ward staff. This reflects a shift in methodology from previous surveys where record review was used. Incidence of AEs was 6.6 per 1000 days of hospitalisation (CI 95% 5.7–7.5), of which 35% were considered preventable. Invasive procedures were the source of half the AEs, and 20% of these were preventable. Psychological and pain‐related AEs were the types of AEs that were considered the most preventable. This experience demonstrates that this methodology is feasible and well accepted by healthcare professionals. This approach to AE detection in this context may have advantages over retrospective record review, including (1) more effective detection, (2) more reliable assessment, (3) more accurate estimation of incidence, (4) better appreciation of clinical context and chain of errors leading to an AE, (5) smaller sample size needed to show variations and (6) enhanced educational opportunities.
See p 369
Statistical process control (SPC) with its core tool, the control chart, is a quality improvement technique with considerable potential to facilitate effective change management. A systematic review of 57 empirical studies revealed that SPC has been applied in a wide range of settings and specialties, and directly by patients, using 97 different variables. This review found that SPC helped different actors manage change and improve healthcare processes. It also enabled patients with chronic conditions, such as asthma or diabetes, to manage their own health, and thus had therapeutic qualities. However, its power hinges on appropriate and expert application. Applied proficiently, it is a versatile tool that can enable diverse stakeholders to manage change in healthcare and improve patients' health.health.
See p 387