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1.  Advancing Performance Measurement in Oncology: Quality Oncology Practice Initiative Participation and Quality Outcomes 
Journal of Oncology Practice  2011;7(3 Suppl):31s-35s.
American Society of Clinical Oncology Quality Oncology Practice Initiative has grown to include 973 practices as of 2010. Practices demonstrated rates of end-of-life care and other measures of quality.
The American health care system, including the cancer care system, is under pressure to improve patient outcomes and lower the cost of care. Government payers have articulated an interest in partnering with the private sector to create learning communities to measure quality and improve the value of health care. In 2006, the American Society for Clinical Oncology (ASCO) unveiled the Quality Oncology Practice Initiative (QOPI), which has become a key component of the measurement system to promote quality cancer care. QOPI is a physician-led, voluntary, practice-based, quality-improvement program, using performance measurement and benchmarking among oncology practices across the United States. Since its inception, ASCO's QOPI has grown steadily to include 973 practices as of November 2010. One key area that QOPI has addressed is end-of-life care. During the most recent data collection cycle in the Fall of 2010, those practices completing multiple data collection cycles had better performance on care of pain compared with sites participating for the first time (62.61% v 46.89%). Similarly, repeat QOPI participants demonstrated meaningfully better performance than their peers in the rate of documenting discussions of hospice and palliative care (62.42% v 54.65%) and higher rates of hospice enrollment. QOPI demonstrates how a strong performance measurement program can lead to improved quality and value of care for patients.
PMCID: PMC3092462  PMID: 21886517
2.  Timely access and quality of care in colorectal cancer: a population-based cohort study using administrative data 
BMC Research Notes  2013;6:355.
While efforts to improve cancer outcomes have typically focused on improving quality of care, recently, a growing emphasis has been placed on timely access to quality cancer care. This retrospective cohort study examines, at a population level, the relationship between quality and timeliness of colorectal cancer (CRC) care in a single Canadian province (Nova Scotia). Through the provincial cancer registry, we identified all residents diagnosed with invasive CRC between 2001 and 2005 that underwent a non-emergent resection. Using anonymized administrative databases that are individually linked at the patient level, we obtained clinicodemographic, diagnostic, and treatment event data. Selected charts were reviewed to ensure completeness of chemotherapy data.
Performance on six quality indicators and the percentage of patients achieving wait-time benchmarks for diagnosis, surgery, and adjuvant therapy were calculated. The relationship between quality indicators and wait-time benchmarks was examined using logistic regression.
Where an association was identified, patients who received ‘higher quality care’ had longer wait times. Individuals who received a complete preoperative colonoscopy were less likely to meet benchmarks for time from presentation to diagnosis and from diagnosis to surgery. Those who received an appropriate radiation oncology consultation were less likely to meet benchmarks for time from diagnosis to surgery and from surgery to adjuvant therapy.
As governments and other organizations move forward with strategies to reduce wait times, they must also focus on how to define and monitor quality care, and consider the relationship between these two dimensions of health care. Similarly, when developing quality improvement initiatives, the impact on resource utilization and potential to create longer waits for care must be considered.
PMCID: PMC3847107  PMID: 24010527
Colorectal neoplasms; Quality indicators; Healthcare quality; Access; Evaluation
3.  Prospects for comparing European hospitals in terms of quality and safety: lessons from a comparative study in five countries 
Being able to compare hospitals in terms of quality and safety between countries is important for a number of reasons. For example, the 2011 European Union directive on patients' rights to cross-border health care places a requirement on all member states to provide patients with comparable information on health-care quality, so that they can make an informed choice. Here, we report on the feasibility of using common process and outcome indicators to compare hospitals for quality and safety in five countries (England, Portugal, The Netherlands, Sweden and Norway).
Main Challenges Identified
The cross-country comparison identified the following seven challenges with respect to comparing the quality of hospitals across Europe: different indicators are collected in each country; different definitions of the same indicators are used; different mandatory versus voluntary data collection requirements are in place; different types of organizations oversee data collection; different levels of aggregation of data exist (country, region and hospital); different levels of public access to data exist; and finally, hospital accreditation and licensing systems differ in each country.
Our findings indicate that if patients and policymakers are to compare the quality and safety of hospitals across Europe, then further work is urgently needed to agree the way forward. Until then, patients will not be able to make informed choices about where they receive their health care in different countries, and some governments will remain in the dark about the quality and safety of care available to their citizens as compared to that available in neighbouring countries.
PMCID: PMC3557961  PMID: 23292003
measurement of quality; external quality assessment; health-care system
4.  Addressing diabetes racial and ethnic disparities: lessons learned from quality improvement collaboratives 
A review of national data confirms that while the quality of healthcare in the USA is slowly improving, disparities in diabetes prevalence, processes of care and outcomes for racial/ethnic minorities are not. Many quality measures can be addressed through system level interventions, referred to as quality improvement (QI), and QI collaboratives have been found to effectively improve processes of care for chronic conditions, including diabetes. However, the impact of QI collaboratives on the reduction of health disparities has been mixed. Lessons learned from previous QI collaboratives including the complexity of impacting clinical outcomes, the need for expert support for skills outside of QI methodology, limiting impact of poor data, and the need to develop disparities quality measures, can be used to inform future QI collaborative approaches to reduce diabetes racial/ethnic minority health disparities.
PMCID: PMC3339626  PMID: 22563350
5.  Quality improvement in pediatric inflammatory bowel disease: Moving forward to improve outcomes 
In recent years, pediatric health care has embraced the concept of quality improvement to improve patient outcomes. As quality improvement efforts are implemented, network collaboration (where multiple centers and practices implement standardized programs) is a popular option. In a collaborative network, improvement in the conduct of structural, process and outcome quality measures can lead to improvements in overall health, and benchmarks can be used to assess and compare progress. In this review article, we provided an overview of the quality improvement movement and the role of quality indicators in this movement. We reviewed current quality improvement efforts in pediatric inflammatory bowel disease (IBD), as well as other pediatric chronic illnesses. We discussed the need to standardize the development of quality indicators used in quality improvement networks to assess medical care, and the validation techniques which can be used to ensure that process indicators result in improved outcomes of clinical significance. We aimed to assess current quality improvement efforts in pediatric IBD and other diseases, such as childhood asthma, childhood arthritis, and neonatal health. By doing so, we hope to learn from their successes and failures and to move the field forward for future improvements in the care provided to children with IBD.
PMCID: PMC3801307  PMID: 24151355
Inflammatory bowel disease; Colitis; Ulcerative; Crohn’s disease; Child; Adolescent; Quality of health care; Review
6.  Outcome as a Measure of Quality of Care in Oncology 
Measurement of outcomes is increasingly employed as an indicator of the quality of clinical care. The most commonly measured outcome in many clinical studies, especially in oncology, still remains the overall survival rate. Sultan Qaboos University Hospital (SQUH), Oman, is striving for excellence through quality management. In seeking continual improvement, quality measurement exercises have been initiated throughout the Hospital. We present the overall survival rate of four of the ten most common cancers diagnosed in Oman.
The cancers included non-Hodgkin’s lymphoma (NHL), Hodgkin’s lymphoma (HL), breast cancer, and stomach cancer. The studies were all retrospective and had been conducted previously. For present purposes, only the overall survival was compared with studies both from the region, and with bench-mark studies.
For NHL, with a median follow-up of 8 months, the 2-year overall survival rate was 64%; 90% for low risk, 55% for intermediate risk, and 15% for high risk groups. For HL, the 5-year overall survival rate was 64%; 76% for low risk and 42% for high risk. For breast cancer, the 5-year survival rate was 67%; percentages were 88%, 75% and 59% for Groups I, II, and III respectively. For gastric cancer, the 5-year survival rate was 16.5 %; 24% for the non-metastatic group.
The outcome of patients with early stages and fewer adverse prognostic factors is comparable to what has been reported in the international literature; however, the outcome is inferior for patients presenting with advanced stage disease and several adverse prognostic factors.
PMCID: PMC3087735  PMID: 21654954
Oncology; Outcome assessment; Quality indicators; Lymphoma; Hodgkin’s; Lymphoma; Non-Hodgkin; Cancer, breast; Cancer, gastric; Oman
7.  Quality indicators of clinical cancer care (QC3) in colorectal cancer 
BMJ Open  2013;3(7):e002818.
Assessing the quality of cancer care (QoCC) has become increasingly important to providers, regulators and purchasers of care worldwide. The aim of this study was to develop evidence-based quality indicators (QIs) for colorectal cancer (CRC) to be applied in a population-based setting.
A comprehensive evidence-based literature search was performed to identify the initial list of QIs, which were then selected and developed using a two-step-modified Delphi process involving two multidisciplinary expert panels with expertise in CRC care, quality of care and epidemiology.
The QIs of the clinical cancer care (QC3) population-based project, which involves all the public and private hospitals and clinics present on the territory of Canton Ticino (South Switzerland).
Ticino Cancer Registry, The Colorectal Cancer Working Group (CRC-WG) and the external academic Advisory Board (AB).
Main outcome measures
Set of QIs which encompass the whole diagnostic-treatment process of CRC.
Of the 149 QIs that emerged from 181 sources of literature, 104 were selected during the in-person meeting of CRC-WG. During the Delphi process, CRC-WG shortened the list to 89 QI. AB finally validated 27 QIs according to the phase of care: diagnosis (N=6), pathology (N=3), treatment (N=16) and outcome (N=2).
Using the validated Delphi methodology, including a literature review of the evidence and integration of expert opinions from local clinicians and international experts, we were able to develop a list of QIs to assess QoCC for CRC. This will hopefully guarantee feasibility of data retrieval, as well as acceptance and translation of QIs into the daily clinical practice to improve QoCC. Moreover, evidence-based selected QIs allow one to assess immediate changes and improvements in the diagnostic-therapeutic process that could be translated into a short-term benefit for patients with a possible gain both in overall and disease-free survival.
PMCID: PMC3717445  PMID: 23869102
QUALITATIVE RESEARCH; Quality in health care < HEALTH SERVICES ADMINISTRATION & MANAGEMENT; Gastrointestinal tumours < ONCOLOGY; Gastrointestinal tumours < GASTROENTEROLOGY
8.  Informatics Resources to Support Health Care Quality Improvement in the Veterans Health Administration 
Information systems are increasingly important for measuring and improving health care quality. A number of integrated health care delivery systems use advanced information systems and integrated decision support to carry out quality assurance activities, but none as large as the Veterans Health Administration (VHA). The VHA's Quality Enhancement Research Initiative (QUERI) is a large-scale, multidisciplinary quality improvement initiative designed to ensure excellence in all areas where VHA provides health care services, including inpatient, outpatient, and long-term care settings. In this paper, we describe the role of information systems in the VHA QUERI process, highlight the major information systems critical to this quality improvement process, and discuss issues associated with the use of these systems.
PMCID: PMC516240  PMID: 15187063
9.  Quality or financing: what drives design of the health care system? 
Quality & safety in health care  2003;12(2):136-142.

 The scope and scale of problems in the quality of health service provision have been increasingly recognised in recent years. Policy and planning for financing are usually concerned with how funding is made available and allocated, rather than with what is being achieved, including the quality of health services delivered. A fundamental challenge is how to improve the delivery of health services to achieve improved patient outcomes and to optimize financial outcomes. To accomplish this it is essential that the debates on quality of care and financing are aligned. Approaches to improving the quality of care are drawn from Australia, the US, and the UK. Financing arrangments for care at a national level have a bearing on how payment incentives can be used to promote or impede quality. The level of overall expenditure is obviously important, as are the mechanisms for payment. Long term programs to build knowledge, standardise processes, provide credible performance data and foster accountability are required to ensure that further investments lead to improvement in care.
PMCID: PMC1743679  PMID: 12679511
10.  Principles and Recommendations for the Provision of Healthcare in Canada to Adolescent and Young Adult–Aged Cancer Patients and Survivors 
Adolescents and young adults (AYA) with cancer and survivors of cancer in childhood, adolescence, and young adulthood are a constituency facing disparities of care affecting quality of life and other outcomes in many parts of the world. In Canada, this situation occurs in a nation with population-based cancer control programs and a government-funded healthcare system. The Canadian Task Force on Adolescents and Young Adults with Cancer was established in 2008 with a mission to ensure that AYA-aged Canadians with cancer and AYA survivors of cancer have prompt, equitable access to the best care, and to establish and support research to identify how their health outcomes and quality of life can be optimized. Following a survey of existing services, and in consultation with survivors, healthcare professionals, and policy makers, the Task Force identified principles of care, priority issues for research and the establishment of outcome metrics, and strategies for implementing change that are designed to improve the outcomes and quality of life of this specific cohort of patients and survivors with unique developmental needs. The six broad recommendations highlight the need for age-appropriate psychosocial, survivorship, palliative, and medical care as well as research to redress inequities in the care provided to this group relative to both younger and older cancer patients. Improved care for this group will enable individuals to reach their full potential as productive, functioning members of society, and will provide economic and other societal benefits.
PMCID: PMC3621594  PMID: 23610731
11.  Integrating palliative care with intensive care for critically ill patients with lung cancer 
With newer information indicating more favorable outcomes of intensive care therapy for lung cancer patients, intensivists increasingly are willing to initiate an aggressive trial of this therapy. Concerns remain, however, that the experience of the intensive care unit for patients with lung cancer and their families often may be distressing. Regardless of prognosis, all patients with critical illness should receive high-quality palliative care, including symptom control, communication about appropriate care goals, and support for both patient and family throughout the illness trajectory. In this article, we suggest strategies for integrating palliative care with intensive care for critically ill lung cancer patients. We address assessment and management of symptoms, knowledge and skill needed for effective communication, and interdisciplinary collaboration for patient and family support. We review the role of expert consultants in providing palliative care in the intensive care unit, while highlighting the responsibility of all critical care clinicians to address basic palliative care needs of patients and their families.
PMCID: PMC3306209  PMID: 22339793
12.  Conformance With Supportive Care Quality Measures Is Associated With Better Quality of Life in Patients With Cancer Receiving Palliative Care 
Journal of Oncology Practice  2013;9(3):e73-e76.
The authors used a quality data assessment tool to examine the relationship between conformance with palliative care quality measures and patient outcomes.
As palliative care further integrates into cancer care, descriptions of how supportive care quality measures improve patient outcomes are necessary to establish best practices.
We assessed the relationship between conformance to 18 palliative care quality measures and quality of life from data obtained using our novel point-of-care, electronic quality monitoring system, the Quality Data Collection Tool for Palliative Care (QDACT-PC). All patients with cancer from January 2008 through March 2011 seen in the Carolinas Palliative Care Consortium were evaluated for demographic, disease, prognostic, performance status, and measure conformance variables. Using univariate and multivariate regression, we examined the relationship between these variable and high quality of life at the initial specialty palliative care consultation.
Our cohort included 459 patients, the majority of whom were over age 65 years (66%) and white (84%). Lung (29.1%) and GI (24.7%) cancers were most common. In univariate analyses, conformance to assessment of comprehensive symptoms, fatigue and constipation assessment, timely management of pain and constipation, and timely emotional well-being assessment were associated with highest levels of quality of life (all Ps < .05). In a multivariate model (C-stat = 0.66), performance status (odds ratio [OR], 5.21; P = .003), estimated life expectancy (OR, 22.6; P = .003), conformance to the measure related to emotional well-being assessment (OR, 1.60; P = .026), and comprehensive screening of symptoms (OR, 1.74, P = .008) remained significant.
Oncology care pathways that routinely incorporate supportive care principles, such as comprehensive symptom and emotional well-being assessments, may improve patient outcomes.
PMCID: PMC3651574  PMID: 23942504
13.  Quality Indicators in Pediatric Orthopaedic Surgery: A Systematic Review 
The ability to measure health system quality has become a priority for governments, the private sector, and the public. Quality indicators (QIs) refer to clear, measurable items related to outcomes. The use of QIs can initiate local quality improvement and track changes in quality over time as interventions are implemented.
We identified existing evidence-based indicators of quality pediatric orthopaedic care and evaluated published QIs that may be applicable to pediatric orthopaedic care.
Search Strategy
Using five standard search engines we searched the literature using terms such as “quality indicators,” “orthopaedic surgery,” and “pediatric.” Study selection was performed in a stepwise manner, first by title, then abstract, and then full-text review. Of the 604 citations identified, 13 articles were selected for inclusion. Eight papers included only pediatric patients.
The most commonly reported indicator was mortality followed by postoperative complications. Reoperation and readmission rates were also reported along with patient-centered QIs, although with less frequency.
Although mortality and postoperative complications were the most frequently reported QIs, concern for their applicability was raised because of their relative infrequency in pediatrics. Patient-centered QIs appear to be the most useful tools reported, although their use is somewhat limited in the published literature. Although there are benefits and drawbacks to all reported QIs, patient-centered and surgeon-defined outcomes along with cost-effectiveness have important roles in evaluating the quality of pediatric orthopaedic care.
PMCID: PMC3293946  PMID: 21912995
14.  Is quality of colorectal cancer care good enough? Core measures development and its application for comparing hospitals in Taiwan 
Although performance measurement for assessing care quality is an emerging area, a system for measuring the quality of cancer care at the hospital level has not been well developed. The purpose of this study was to develop organization-based core measures for colorectal cancer patient care and apply these measures to compare hospital performance.
The development of core measures for colorectal cancer has undergone three stages including a modified Delphi method. The study sample originated from 2004 data in the Taiwan Cancer Database, a national cancer data registry. Eighteen hospitals and 5585 newly diagnosed colorectal cancer patients were enrolled in this study. We used indicator-based and case-based approaches to examine adherences simultaneously.
The final core measure set included seventeen indicators (1 pre-treatment, 11 treatment-related and 5 monitoring-related). There were data available for ten indicators. Indicator-based adherence possesses more meaningful application than case-based adherence for hospital comparisons. Mean adherence was 85.8% (79.8% to 91%) for indicator-based and 82.8% (77.6% to 88.9%) for case-based approaches. Hospitals performed well (>90%) for five out of eleven indicators. Still, the performance across hospitals varied for many indicators. The best and poorest system performance was reflected in indicators T5-negative surgical margin (99.3%, 97.2% - 100.0%) and T7-lymph nodes harvest more than twelve(62.7%, 27.6% - 92.2%), both of which related to surgical specimens.
In this nationwide study, quality of colorectal cancer care still shows room for improvement. These preliminary results indicate that core measures for cancer can be developed systematically and applied for internal quality improvement.
PMCID: PMC2835701  PMID: 20105287
15.  Performance measures of surgeon-performed colonoscopy in a Veterans Affairs medical center 
Surgical Endoscopy  2009;23(10):2364-2368.
Quality indicators are increasingly emphasized in the performance of colonoscopy. This study aimed to determine the standard of care rendered by surgeon-endoscopists in a Veterans Affairs (VA) medical center by evaluating the indications for colonoscopy and outcome performance measures according to established quality indicators for colonoscopy.
A prospective standardized computer endoscopic reporting database (ProVation MD) was retrospectively reviewed. All colonoscopies performed by attending surgeons at the San Diego VA medical center between 1 January 2004 and 31 July 2007 were included in the study. Patients with charts that had incomplete reporting were excluded. The quality indicators used included the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) criteria for colorectal cancer screening, the American Cancer Society (ACS) guidelines for postcancer resection surveillance, and the American Society of Gastrointestinal Endoscopists (ASGE) quality indicators for colonoscopy.
The data for 558 patients (96% men) were analyzed. The average patient age was 63 years (range, 25–93 years). Almost all the colonoscopies (99%) were performed in accordance with established criteria. The most common indications for colonoscopy were screening (n = 143, 26%), non-acute gastrointestinal bleeding (n = 127, 23%), polyp surveillance (n = 100, 18%), postcancer resection surveillance (n = 91, 17%), abdominal pain (n = 19, 4%), and anemia (n = 14, 3%). Postcancer resection surveillance colonoscopies were performed according to recommended criteria in 98% of the cases. The cecal intubation rate was 97%, and the overall adenoma detection rate was 26%. Two patients (<1%) experienced complications requiring intervention.
The study data indicate that surgeon-performed colonoscopies meet standard quality criteria for indications and performance measures. The authors therefore conclude that surgeon-endoscopists demonstrate proficiency in the standard of care for colonoscopy examinations.
PMCID: PMC2760710  PMID: 19266235
Adenoma detection rate; Colonoscopy; Performance measures; Quality; Surgeon-endoscopist
16.  Utilizing NCCN Practice Guidelines to Measure the Quality of Colorectal Cancer Care in the Veterans Health Administration 
Clinical practice guidelines can be used to help develop measures of quality of cancer care. This paper describes the use of a Cancer Care Quality Measurement System (CCQMS) for monitoring these measures for colorectal cancer in the Veterans Health Administration.
The CCQMS assessed practice guideline concordance primarily based on colon (14 indicators) and rectal (11 indicators) cancer care guidelines of the National Comprehensive Cancer Network (NCCN). Indicators were developed with input from VHA stakeholders with the goal of examining the continuum of diagnosis, neoadjuvant therapy, surgery, adjuvant therapy, and survivorship surveillance and/or end-of-life care. In addition, 9 measures of timeliness of cancer care were developed. The measures/indicators formed the basis of a computerized data abstraction tool that produced reports on quality of care in real-time as data were entered.
The tool was developed for a 28-facility learning collaborative, the Colorectal Cancer Care Collaborative (C4), aimed at improving CRC care quality. Data on 1,373 incident stage I-IV CRC cases were entered over approximately 18 months. Data were used to target and monitor quality improvement activities. The primary opportunity for improvement involved surveillance colonoscopy and services in patients after curative intent treatment.
NCCN guidelines were successfully used to develop a measurement system for VHA research-operations quality improvement partnership.
PMCID: PMC3712652  PMID: 23584346
Colorectal Cancer; United States Department of Veterans Affairs; Practice Guidelines; Quality of Care
17.  Developing a Community Action Plan to Eliminate Cancer Disparities: Lessons Learned 
African Americans bear an unequal burden of breast, cervical, and colorectal cancer. The Deep South Network for Cancer Control (DSN) is a community–academic partnership operating in Alabama and Mississippi that was funded by the National Cancer Institute (NCI) to address cancer disparities using community-based participatory research approaches.
In addition to reporting on the plans of this work in progress, we describe the participatory process that local residents and the DSN used to identify needs and priorities, and elaborate on lessons learned from applying a participatory approach to the development of a community action plan.
We conducted 24 community discussion groups involving health care professionals, government officials, faith-based leaders, and other stakeholders to identify cancer health disparity needs, community resources/assets, and county priorities to eliminate cancer health disparities. To develop a community action plan, four working groups explored the themes that emerged from the discussion groups, taking into consideration evidence-based strategies and promising community practices.
The DSN formulated a community action plan focusing on (1) increasing physical activity by implementing a campaign for individual-level focused activity; (2) increasing the consumption of fruits and vegetables by implementing NCI’s Body and Soul Program in local churches; (3) increasing cancer screening by raising awareness through individual, system, and provider agents of change; and (4) training community partners to become effective advocates.
A community–academic partnership must involve trust, respect, and an appreciation of partners’ strengths and differences. The DSN applied these guiding principles and learned pivotal lessons.
PMCID: PMC3600640  PMID: 21623018
18.  Physician Job Satisfaction and Quality of Care Among Hospital Employed Physicians in Japan 
Physician job satisfaction is reportedly associated with interpersonal quality of care, such as patient satisfaction, but its association with technical quality of care, as determined by whether patients are offered recommended services, is unknown.
We explored whether the job satisfaction of hospital-employed physicians in Japan is associated with the technical quality of care, with an emphasis on process qualities as measured by quality indicators.
Cross-sectional study linking data from physician surveys with data abstracted from outpatient charts.
A total of 53 physicians working at 13 hospitals in Japan participated. Medical records covering 568 patients were reviewed.
Disease-specific indicators related to the care of patients with hypertension, type 2 diabetes, and asthma, as well as disease-independent measures of the process of care were abstracted. We analyzed the association between the quality of care score for individual physicians, which is defined as the percentage of quality indicators satisfied among the total for which their patients were eligible, and physician job satisfaction, which was measured by a validated scale.
No statistically significant association between physician job satisfaction and quality of care was observed. A 1-standard deviation (SD) increment in the physician job satisfaction scale was associated with an increase of only 0.3% for overall quality (P = 0.85), −3.0% for hypertension (P = 0.22), 2.5% for type 2 diabetes (P = 0.44), 8.0% for asthma (P = 0.21), and −0.4% for cross-cutting care (P = 0.76).
Contrary to the positive association reported between physician job satisfaction and high quality of interpersonal care, no association was seen between physician job satisfaction and the technical quality of care.
PMCID: PMC2642562  PMID: 19130149
physician job satisfaction; technical quality of care; process qualities; quality indicators
19.  Improving comfort and communication in the ICU: a practical new tool for palliative care performance measurement and feedback 
Quality & Safety in Health Care  2006;15(4):264-271.
To develop a practical set of measures for routine monitoring, performance feedback, and improvement in the quality of palliative care in the intensive care unit (ICU).
Use of an interdisciplinary iterative process to create a prototype “bundle” of indicators within previously established domains of ICU palliative care quality; operationalization of indicators as specified measures; and pilot implementation to evaluate feasibility and baseline ICU performance.
The national Transformation of the Intensive Care Unit program developed in the United States by VHA Inc.
Critically ill patients in ICUs for 1, >3, and >5 days.
Measurements and main results
Palliative care processes including identification of patient preferences and decision making surrogates, communication between clinicians and patients/families, social and spiritual support, and pain assessment and management, as documented in medical records. Application is triggered by specified lengths of ICU stay. Pilot testing in 19 ICUs (review of >100 patients' records) documented feasibility, while revealing opportunities for quality improvement in clinician‐patient/family communication and other key components of ICU palliative care.
The new bundle of measures is a prototype for routine measurement of the quality of palliative care in the ICU. Further investigation is needed to confirm associations between measured processes and outcomes of importance to patients and families, as well as other aspects of validity.
PMCID: PMC2564022  PMID: 16885251
intensive care; critical care; palliative care; quality indicators; communication; pain measurement
20.  Incorporating Person Centred Care Principles into an Ongoing Comprehensive Cancer Management Program: An Experiential Account 
Indian Journal of Palliative Care  2011;17(Suppl):S61-S67.
Recent research indicates a definite positive impact on treatment outcomes when an integrative approach that focuses on symptom control and quality of life is provided along with the standard therapeutic regimens. However implementation or practice of this approach is not seen widely due to the culture of medical training and practice. This article presents the initial development of a program for incorporating integrative care principles into an ongoing comprehensive cancer care program at a tertiary centre. The key purpose of the program being to develop, facilitate, and establish comprehensive and holistic processes including palliative care principles, that would positively enhance the quantity and quality of life of the person with disease, as well as create an environment that reflects and sustains this approach. The vision, objectives, goals, strategies, activities and results within the 7 months of implementation are documented. The new learnings gained during the process have also been noted in the hope that the model described may be used to conceptualize similar care giving facilities in other centres.
PMCID: PMC3140097  PMID: 21811374
Integrative oncology; Multi-disciplinary team; Palliative; Quality of life
21.  The families evaluation on management, care and disclosure for terminal stage cancer patients 
Quality of life is an important concept which is subjective and personal; what is an acceptable quality of life to one may be 'worse than death' to another. The objective of this study was to develop and validate a questionnaire to assess relatives' perceptions and attitudes towards their terminal stage cancer patients' management (information disclosure, treatment choice, hospitalization and support-communication and care) including aspects regarding end-of-life and quality-of-life decisions.
The final study consisted of 146 relatives of advanced terminal stage cancer patients receiving palliation, attending a Pain Relief and Palliative Care Unit. The questionnaire incorporated 6 multi-item and 7 single-item scales, and was developed following a systematic review of measures appropriate for use in palliative care settings.
Following analysis of the 25-item scale, the questionnaire has been validated as a shortened 21-item scale consisting of 5 multi-item and 5 single-item scales. Factor analysis was based upon information disclosure, hospitalization, and support-communication demonstrating Cronbach's alpha coefficients of 0.66, 0.5 and 0.70 respectively. Average item totals and inter-item scale correlations were between 0.62–0.70, with convergent validity correlations between 0.60–0.86. The questionnaire was well accepted by all subjects with an 8–10 minute completion time.
The shortened 21-item self-assessment questionnaire may provide acceptable and valid assessment of caregiver(s)/Greek cancer patients' relatives perceptions on palliative care.
PMCID: PMC102762  PMID: 11945181
22.  Quality of care associated with number of cases seen and self-reports of clinical competence for Japanese physicians-in-training in internal medicine 
The extent of clinical exposure needed to ensure quality care has not been well determined during internal medicine training. We aimed to determine the association between clinical exposure (number of cases seen), self- reports of clinical competence, and type of institution (predictor variables) and quality of care (outcome variable) as measured by clinical vignettes.
Cross-sectional study using univariate and multivariate linear analyses in 11 teaching hospitals in Japan. Participants were physicians-in-training in internal medicine departments. Main outcome measure was standardized t-scores (quality of care) derived from responses to five clinical vignettes.
Of the 375 eligible participants, 263 (70.1%) completed the vignettes. Most were in their first (57.8%) and second year (28.5%) of training; on average, the participants were 1.8 years (range = 1–8) after graduation. Two thirds of the participants (68.8%) worked in university-affiliated teaching hospitals. The median number of cases seen was 210 (range = 10–11400). Greater exposure to cases (p = 0.0005), higher self-reports of clinical competence (p = 0.0095), and type of institution (p < 0.0001) were significantly associated with higher quality of care, using a multivariate linear model and adjusting for the remaining factors. Quality of care rapidly increased for the first 100 to 200 cases seen and tapered thereafter.
The amount of clinical exposure and levels of self-reports of clinical competence, not years after graduation, were positively associated with quality of care, adjusting for the remaining factors. The learning curve tapered after about 200 cases.
PMCID: PMC1513227  PMID: 16768807
23.  Determining Community Provider Practices in Hospices: The Challenges of Documentation 
Documentation is a key factor in supporting consistency and quality of patient care in the hospice setting, however variation among program provider practices, including documentation, were observed during the initial data collection phase of our National Cancer Institute (NCI) funded study, Cancer Pain in Elders: Promoting Evidence-Based Practices (EBPs) in Hospices. The study is a randomized trial to test a multifaceted intervention to promote adoption and maintenance of EBPs for cancer pain management involving 16 Midwestern hospices of varied size and structure. In the face of such variance, and especially in the absence of uniformly adopted outcome measures and documentation standards, quality improvement initiatives in this important and growing healthcare sector will be difficult to manage. This paper provides background on the importance of documentation, quality measures, outcomes of care, and regulatory imperatives in the hospice setting with specific observations from our research study and suggestions for changes in documentation practices.
From our observations, we posit the necessity of pertinent outcome measures supported by standardized documentation processes in hospice. Uniformity in key practice indicators and patient outcome measures in documentation systems would advance the movement to improve quality and consistency of care in hospices. Standardization of documentation systems and language would also facilitate the conduct of research in the hospice setting, a population for which advancing knowledge is essential to assure quality care at the end of life.
PMCID: PMC2858422  PMID: 20419047
Hospice; Documentation; Cancer Pain Management; End-of-Life; Evidence-Based Practices; Quality; Older Adult
24.  The Quality of Care Provided to Patients with Chronic Non-Communicable Diseases: A Retrospective Multi-Setup Study in Jimma Zone, Southwest Ethiopia 
Chronic Non-Communicable Diseases are among the major causes of morbidity and mortality worldwide. However, access to and quality of health care for patients is very low in developing countries including Ethiopia. Hospitals and Health Centers are the main sources of health care for such patients in Ethiopia. In this study we assessed the quality of care patients with Chronic Non-Communicable Diseases received in hospital and health center setups.
A retrospective multi-setup study was conducted in Jimma University Specialized Hospital and four Health Centers in Jimma Zone from February to March 2010. A total of 52 process indicators of quality covering three disease conditions: Diabetes, Hypertension and Epilepsy were measured by reviewing randomly selected medical records. Quality of care was measured as a proportion of recommended components of care actually provided to patients. And also outcome and structural measures were assessed to supplement process measures of quality.
Six hundred seventy four medical records were reviewed. Recommended care components were actually provided to patients in 35.1% (95% CI:34.1%, 36.0%), 38.5% (95% CI:37.5%, 39.5%) and 60.1% (95% CI:59.3%, 61.0%) of times on which patients were eligible, among patients with Diabetes, Hypertension and Epilepsy, respectively. After case mix adjustment, it was found that 45.9% (95% CI:45.4%, 46.5%) of recommended components of care was actually provided to patients. This was 45.1% (95% CI:44.4%, 45.8%) in the hospital and 30.5% (95% CI:29.7%, 31.3%) in the health centers. Among patients for whom outcome data was available, optimal level of disease control was achieved only for 47 (30.5%), 40 (38.5%) and 193 (52.9%) of patients with Diabetes, Hypertension and Epilepsy, respectively.
The quality of care provided to patients with Chronic Non-Communicable Diseases is very low in both settings though it is relatively better in Jimma University Specialized Hospital. Therefore, a continuous process of quality improvement is recommended in both settings.
PMCID: PMC3275857  PMID: 22434991
Health care; Health care quality; Quality indicators; Guideline Adherence; Chronic diseases; Diabetes; Hypertension; Epilepsy
25.  Measuring Quality of Care in the Treatment of Colorectal Cancer: The Moffitt Quality Practice Initiative 
Journal of Oncology Practice  2007;3(2):60-65.
The Moffitt Quality Practice Initiative (MQPI) is a practice-based system of quality self-assessment, the ultimate goal of which is to improve the quality of cancer care at a statewide level. The initial phase of this project focused on developing procedures, determining feasibility, and evaluating utility for assessing quality of care for colorectal cancer within an existing affiliate network.
Patients and Methods
Representatives from four oncology groups selected quality measures consistent with evidence-, consensus-, and safety-based guidelines that could be abstracted from medical records. Trained abstractors then reviewed records of all eligible colorectal patients seen by each practice in 2004. Frequencies of responses for each indicator were tabulated for overall and practice-specific level of adherence and were compared among practices.
Adherence was uniformly high for several indicators, including confirmatory pathology report, staging information, and chemotherapy discussion or recommendation. Lower adherence was evident across practices for performance of carcinoembryonic tests and complete colonoscopic evaluations. Significant variation among practices was evident only for consent for chemotherapy.
The initial phase of MQPI demonstrated the feasibility and utility of assessing quality indicators for colorectal cancer among members of an existing affiliate network. Findings identified areas where adherence to care was uniformly high, but also identified areas where both overall and practice-specific adherence were less than optimal. These efforts lay the groundwork for expanding MQPI in several directions that have in common the potential to improve the quality of cancer care on a statewide basis.
PMCID: PMC2793747  PMID: 20859375

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