Despite widespread interest in many jurisdictions in monitoring and improving the quality of stroke care delivery, benchmarks for most stroke performance indicators have not been established. The objective of this study was to develop data-derived benchmarks for acute stroke quality indicators.
Nine key acute stroke quality indicators were selected from the Canadian Stroke Best Practice Performance Measures Manual.
A population-based retrospective sample of patients discharged from 142 hospitals in Ontario, Canada, between 1 April 2008 and 31 March 2009 (N = 3191) was used to calculate hospital rates of performance and benchmarks.
The Achievable Benchmark of Care (ABC™) methodology was used to create benchmarks based on the performance of the upper 15% of patients in the top-performing hospitals.
Main Outcome Measures
Benchmarks were calculated for rates of neuroimaging, carotid imaging, stroke unit admission, dysphasia screening and administration of stroke-related medications.
The following benchmarks were derived: neuroimaging within 24 h, 98%; admission to a stroke unit, 77%; thrombolysis among patients arriving within 2.5 h, 59%; carotid imaging, 93%; dysphagia screening, 88%; antithrombotic therapy, 98%; anticoagulation for atrial fibrillation, 94%; antihypertensive therapy, 92% and lipid-lowering therapy, 77%. ABC™ acute stroke care benchmarks achieve or exceed the consensus-based targets required by Accreditation Canada, with the exception of dysphagia screening.
Benchmarks for nine hospital-based acute stroke care quality indicators have been established. These can be used in the development of standards for quality improvement initiatives.
benchmarking; measurement of quality; quality improvement; quality management
Investigate whether high-quality chronic care delivery improved the experiences of patients.
This study had a longitudinal design.
Setting and Participants
We surveyed professionals and patients in 17 disease management programs targeting patients with cardiovascular diseases, chronic obstructive pulmonary disease, heart failure, stroke, comorbidity and eating disorders.
Main Outcome Measures
Patients completed questionnaires including the Patient Assessment of Chronic Illness Care (PACIC) [T1 (2010), 2637/4576 (58%); T2 (2011), 2314/4330 (53%)]. Professionals' Assessment of Chronic Illness Care (ACIC) scores [T1, 150/274 (55%); T2, 225/325 (68%)] were used as a context variable for care delivery. We used two-tailed, paired t-tests to investigate improvements in chronic illness care quality and patients' experiences with chronic care delivery. We employed multilevel analyses to investigate the predictive role of chronic care delivery quality in improving patients' experiences with care delivery.
Overall, care quality and patients' experiences with chronic illness care delivery significantly improved. PACIC scores improved significantly from 2.89 at T1 to 2.96 at T2 and ACIC-S scores improved significantly from 6.83 at T1 to 7.18 at T2. After adjusting for patients' experiences with care delivery at T1, age, educational level, marital status, gender and mental and physical quality of life, analyses showed that the quality of chronic care delivery at T1 (P < 0.001) and changes in care delivery quality (P < 0.001) predicted patients' experiences with chronic care delivery at T2.
This research showed that care quality and changes therein predict more positive experiences of patients with various chronic conditions over time.
chronic care; disease management; quality; integrated care
To evaluate the relationship between self-reported satisfaction with service quality and overall survival in non-small cell lung cancer (NSCLC).
A prospective cohort study.
Cancer Treatment Centers of America® from July 2007 and December 2010.
Nine hundred and eighty-six returning NSCLC patients.
Overall patient experience ‘considering everything, how satisfied are you with your overall experience’ was measured on a 7-point Likert scale ranging from ‘completely dissatisfied’ to ‘completely satisfied.’.
Main Outcome Measure
Patient survival was the primary end point.
The response rate for this study was 69%. Six hundred patients were newly diagnosed, while 386 were previously treated. Four hundred sixty-nine were males, while 517 were females. 101, 59, 288 and 538 patients had stage I, II, III and IV disease, respectively. Mean age was 58.9 years. Six hundred and thirty (63.9%) patients had expired at the time of this analysis. Seven hundred and sixty-two (77.3%) patients were ‘completely satisfied’. Median overall survival was 12.1 months (95% confidence interval (CI): 10.9–13.2 months). On univariate analysis, ‘completely satisfied’ patients had a significantly lower risk of mortality compared with those not ‘completely satisfied’ [hazard ratio (HR) = 0.70; 95% CI: 0.59–0.84; P < 0.001]. On multivariate analysis controlling for stage at diagnosis, prior treatment history, age and gender, ‘completely satisfied’ patients demonstrated significantly lower mortality (HR = 0.71; 95% CI: 0.60–0.85; P < 0.001) compared with those not ‘completely satisfied’.
Self-reported experience with service quality was an independent predictor of survival in NSCLC patients undergoing oncologic treatment, a novel finding in the literature. Based on these provocative findings, further exploration of this relationship is warranted in well-designed prospective studies.
patient satisfaction; service quality; survival; non-small cell lung cancer
To describe the systematic language translation and cross-cultural evaluation process that assessed the relevance of the Hospital Consumer Assessment of Healthcare Providers and Systems survey in five European countries prior to national data collection efforts.
An approach involving a systematic translation process, expert review by experienced researchers and a review by ‘patient’ experts involving the use of content validity indexing techniques with chance correction.
Five European countries where Dutch, Finnish, French, German, Greek, Italian and Polish are spoken.
‘Patient’ experts who had recently experienced a hospitalization in the participating country.
Content validity indexing with chance correction adjustment providing a quantifiable measure that evaluates the conceptual, contextual, content, semantic and technical equivalence of the instrument in relationship to the patient care experience.
All translations except two received ‘excellent’ ratings and no significant differences existed between scores for languages spoken in more than one country. Patient raters across all countries expressed different concerns about some of the demographic questions and their relevance for evaluating patient satisfaction. Removing demographic questions from the evaluation produced a significant improvement in the scale-level scores (P= .018). The cross-cultural evaluation process suggested that translations and content of the patient satisfaction survey were relevant across countries and languages.
The Hospital Consumer Assessment of Healthcare Providers and Systems survey is relevant to some European hospital systems and has the potential to produce internationally comparable patient satisfaction scores.
patient satisfaction; measurement; instrument validation; cross-cultural research; health services research; HCAHPS
To assess the association between quality of care and health-related quality of life among type 2 diabetes patients.
A cross-sectional study assessing the association between quality of care and quality of life using multiple linear regression analysis.
Family medicine clinics (FMC) (n = 39) of the Mexican Institute of Social Security (IMSS) in Mexico City.
Type 2 diabetes patients (n = 312), older than 19 years.
Main Outcome Measure(s)
Health-related quality of life was measured using the MOS Short-Form-12 (SF-12); quality of healthcare was measured as the percentage of recommended care received under each of four domains: early detection of diabetes complications, non-pharmacological treatment, pharmacological treatment and health outcomes.
The average quality of life score was 41.4 points on the physical component and 47.9 points on the mental component. Assessment of the quality of care revealed deficiencies. The average percentages of recommended care received were 21.9 for health outcomes and 56.6 for early detection of diabetes complications and pharmacological treatment; for every 10 percent additional points on the pharmacological treatment component, quality of life improved by 0.4 points on the physical component (coefficient 0.04, 95% confidence intervals 0.01–0.07).
There was a positive association between the quality of pharmacological care and the physical component of quality of life. The quality of healthcare for type 2 diabetes patients in FMC of the IMSS in Mexico City is not optimal.
quality measurement, quality management; quality indicators; patient outcomes (health status, quality of life, mortality)
To investigate the changes in overdue doses rates over a 4-year period in an National Health Service (NHS) teaching hospital, following the implementation of interventions associated with an electronic prescribing system used within the hospital.
Retrospective time-series analysis of weekly dose administration data.
University teaching hospital using a locally developed electronic prescribing and administration system (Prescribing, Information and Communication System or PICS) with an audit database containing details on every drug prescription and dose administration.
Prescription data extracted from the PICS database.
Four interventions were implemented in the Trust: (i) the ability for doctors to pause medication doses; (ii) clinical dashboards; (iii) visual indicators for overdue doses and (iv) overdue doses Root Cause Analysis (RCA) meetings and a National Patient Safety Agency (NPSA) Rapid Response Alert.
Main outcome measure(s)
The percentage of missed medication doses.
Rates of both missed antibiotic and non-antibiotic doses decreased significantly upon the introduction of clinical dashboards (reductions of 0.60 and 0.41 percentage points, respectively), as well as following the instigation of executive-led overdue doses RCA meetings (reductions of 0.83 and 0.97 percentage points, respectively) and the publication of an associated NPSA Rapid Response Alert. Implementing a visual indicator for overdue doses was not associated with significant decreases in the rates of missed antibiotic or non-antibiotic doses.
Electronic prescribing systems can facilitate data collection relating to missed medication doses. Interventions providing hospital staff with information about overdue doses at a ward level can help promote reductions in overdue doses rates.
medical order entry systems; medication errors; electronic prescribing; decision Support Systems; clinical; medication therapy management
Efficient spreading of evidence-based innovations among complex health systems remains an elusive goal despite extensive study in the social sciences. Biology provides a model of successful spread in viruses, which have evolved to spread with maximum efficiency using minimal resources. Here we explore the molecular mechanisms of human immunodeficiency virus (HIV) spread and identify five steps that are also common to a recent example of spread in complex health systems: reduction in door-to-balloon times for patients with ST-segment elevation myocardial infarction (STEMI). We then describe a new model we have developed, called AIDED, which is based on mixed-methods research but informed by the conceptual framework of HIV spread among cells. The AIDED model contains five components: Assess, Innovate, Develop, Engage and Devolve, and can describe any one of the following: the spread of HIV among cells, the spread of practices to reduce door-to-balloon time for patients with STEMI and the spread of certain family health innovations in low- and middle-income countries. We suggest that by looking to the biological sciences for a model of spread that has been honed by evolution, we may have identified fundamental steps that are necessary and sufficient for efficient, low-cost spread of health innovations among complex health systems.
innovation diffusion; HIV; evidence-based medicine; virus spread
It is believed that in order to reduce the number of adverse events, hospitals have to stimulate a more open culture and reflective attitude towards errors and patient safety. The objective is to examine similarities and differences in hospital patient safety culture in three countries: the Netherlands, the USA and Taiwan.
This is a cross-sectional survey study across three countries. A questionnaire, the Hospital Survey on Patient Safety Culture (Hospital SOPS), was disseminated nationwide in the Netherlands, the USA and Taiwan.
The study was conducted in 45 hospitals in the Netherlands, 622 in the USA and 74 in Taiwan.
A total of 3779 professionals from the participating hospitals in the Netherlands, 196 462 from the USA and 10 146 from Taiwan participated in the study.
Main Outcome Measures
The main outcome measures of the study were 12 dimensions of patient safety culture, e.g. Teamwork, Organizational learning, Communication openness.
Most hospitals in all three countries have high scores on teamwork within units. The area with a high potential for improvement in all three countries is Handoffs and transitions. Differences between countries exist on the following dimensions: Non-punitive response to error, Feedback and communication about error, Communication openness, Management support for patient safety and Organizational learning—continuous improvement. On the whole, US respondents were more positive about the safety culture in their hospitals than Dutch and Taiwanese respondents. Nevertheless, there are even larger differences between hospitals within a country.
Comparison of patient safety culture data has shown similarities and differences within and between countries. All three countries can improve areas of their patient safety culture. Countries can identify and share best practices and learn from each other.
patient safety; hospital care; setting of care; quality culture; quality management; surveys; general methodology
To examine the changes in clients' health-care ratings before and after hospital workers received an HIV prevention intervention in Malawi, which increased the workers' personal and work-related HIV prevention knowledge, attitudes and preventive behaviors.
Pre- and post-intervention client surveys.
A large urban referral hospital in Malawi.
Clients at purposefully selected inpatient and outpatient units on designated days (baseline, n = 310 clients; final, n = 683).
Ten-session peer-group intervention for health workers focused on HIV transmission, personal and work-related prevention, treating clients and families respectfully and incorporating HIV-related teaching.
Main Outcome Measures
Brief face-to-face clients' interview obtaining ratings of confidentiality of HIV, whether HIV-related teaching occurred and ratings of service quality.
Compared with baseline, at the final survey, clients reported higher confidence about confidentiality of clients' HIV status (83 vs. 75%, P < 0.01) and more clients reported that a health worker talked to them about HIV and AIDS (37 versus 28%, P< 0.01). More clients rated overall health services as ‘very good’ (five-item mean rating, 68 versus 59%, P< 0.01) and this was true for both inpatients and outpatients examined separately. However, there was no improvement in ratings of the courtesy of laboratory or pharmacy workers or of the adequacy of treatment instructions in the pharmacy.
HIV prevention training for health workers can have positive effects on clients' ratings of services, including HIV-related confidentiality and teaching, and should be scaled-up throughout Malawi and in other similar countries. Hospitals need to improve laboratory and pharmacy services.
patient satisfaction; HIV; intervention studies; health personnel; Malawi
Quality problem or issue
When the Ministry of Public Health (MoPH) of the Islamic Republic of Afghanistan began reconstructing the health system in 2003, it faced serious challenges. Decades of war had severely damaged the health infrastructure and the country's ability to deliver health services.
A national health resources assessment in 2002 revealed huge structural and resource disparities fundamental to improving health care. For example, only 9% of the population was able to access basic health services, and about 40% of health facilities had no female health providers, severely constraining access of women to health care. Multiple donor programs and the MoPH had some success in improving quality, but questions about sustainability, as well as fragmentation and poor coordination, existed.
Plan of action
In 2009, MoPH resolved to align and accelerate quality improvement efforts as well as build structural and skill capacity.
The MoPH established a new quality unit within the ministry and undertook a year-long consultative process that drew on international evidence and inputs from all levels of the health system to developed a National Strategy for Improving Quality in Health Care consisting of a strategy implementation framework and a five-year operational plan.
Even in resource-restrained countries, under the most adverse circumstances, quality of health care can be improved at the front-lines and a consensual and coherent national quality strategy developed and implemented.
developing countries; Afghanistan; quality of health care; national health programs
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.
measurement of quality; external quality assessment; health-care system
Validation of a Danish patient safety incident classification adapted from the World Health Organizaton's International Classification for Patient Safety (ICPS-WHO).
Thirty-three hospital safety management experts classified 58 safety incident cases selected to represent all types and subtypes of the Danish adaptation of the ICPS (ICPS-DK).
Two measures of inter-rater agreement: kappa and intra-class correlation (ICC).
An average number of incident types used per case per rater was 2.5. The mean ICC was 0.521 (range: 0.199–0.809) and the mean kappa was 0.513 (range: 0.193–0.804). Kappa and ICC showed high correlation (r = 0.99). An inverse correlation was found between the prevalence of type and inter-rater reliability. Results are discussed according to four factors known to determine the inter-rater agreement: skill and motivation of raters; clarity of case descriptions; clarity of the operational definitions of the types and the instructions guiding the coding process; adequacy of the underlying classification scheme.
The incident types of the ICPS-DK are adequate, exhaustive and well suited for classifying and structuring incident reports. With a mean kappa a little above 0.5 the inter-rater agreement of the classification system is considered ‘fair’ to ‘good’. The wide variation in the inter-rater reliability and low reliability and poor discrimination among the highly prevalent incident types suggest that for these types, precisely defined incident sub-types may be preferred. This evaluation of the reliability and usability of WHO's ICPS should be useful for healthcare administrations that consider or are in the process of adapting the ICPS.
adverse events; patient safety; incident reporting and analysis; risk management; taxonomy
To determine the effectiveness of a provider-based education and implementation intervention for improving diabetes control.
Cluster-randomized trial with baseline and follow-up cross sections of diabetes patients in each participating physician's practice.
Eleven US Southeastern states, 2006–08.
Two hundred and five rural primary care physicians.
Multi-component interactive intervention including Web-based continuing medical education, performance feedback and quality improvement tools.
Primary Outcome Measures
‘Acceptable control’ [hemoglobin A1c ≤9%, blood pressure (BP) <140/90 mmHg, low-density lipoprotein cholesterol (LDL) <130 mg/dl] and ‘optimal control’ (A1c <7%, BP <130/80 mmHg, LDL <100 mg/dl).
Of 364 physicians attempting to register, 205 were randomized to the intervention (n= 102) or control arms (n= 103). Baseline and follow-up data were provided by 95 physicians (2127 patients). The proportion of patients with A1c ≤9% was similar at baseline and follow-up in both the control [adjusted odds ratio (AOR): 0.94; 95% confidence interval (CI): 0.61, 1.47] and intervention arms [AOR: 1.16 (95% CI: 0.80, 1.69)]; BP <140/90 mmHg and LDL <130 mg/dl were also similar at both measurement points (P= 0.66, P= 0.46; respectively). We observed no significant effect on diabetes control attributable to the intervention for any of the primary outcome measures. Intervention physicians engaged with the Website over a median of 64.7 weeks [interquartile range (IQR): 45.4–81.8) for a median total of 37 min (IQR: 16–66).
A wide-reach, low-intensity, Web-based interactive multi-component intervention did not improve control of glucose, BP or lipids for patients with diabetes of physicians practicing in the rural Southeastern US.
internet; translational research; diabetes mellitus; rural health services; education; medical; continuing process assessment (Health Care)
The ventilator bundle is being promoted to prevent adverse events in ventilated patients including ventilator-associated pneumonia (VAP). We aimed to: (i) examine adoption of the ventilator bundle elements; (ii) determine effectiveness of individual elements and setting characteristics in reducing VAP; (iii) determine effectiveness of two infection-specific elements on reducing VAP; and, (iv) assess crossover effects of complying with VAP elements on central line-associated bloodstream infections.
Four hundred and fifteen ICUs from 250 US hospitals.
Managers/directors of infection prevention and control departments.
Adoption and compliance with ventilator bundle elements.
Main Outcome Measures
The mean VAP rate was 2.7/1000 ventilator days. Two-thirds (n = 284) reported presence of the full ventilator bundle policy. However, only 66% (n = 188/284) monitored implementation; of those, 39% (n = 73/188) reported high compliance. Only when an intensive care unit (ICU) had a policy, monitored compliance and achieved high compliance were VAP rates lower. Compliance with individual elements or just one of two infection-related element had no impact on VAP (β = −0.79, P= 0.15). There was an association between complying with two infection elements and lower rates (β = −1.81, P< 0.01). There were no crossover effects. Presence of a full-time hospital epidemiologist (HE) was significantly associated with lower VAP rates (β = −3.62, P< 0.01).
The ventilator bundle was frequently present but not well implemented. Individual elements did not appear effective; strict compliance with infection elements was needed. Efforts to prevent VAP may be successful in settings of high levels of compliance with all infection-specific elements and in settings with full-time HEs.
ventilator-associated pneumonia; healthcare-associated infections; infection control; ventilator bundle; intensive care units; quality improvement; guidelines
International guidelines establish evidence-based standards for asthma care; however, recommendations are often not implemented and many patients do not meet control targets.
Regional pilot data demonstrated a knowledge-to-practice gap.
Choice of solutions
We engineered health system change in a multi-step approach described by the Canadian Institutes of Health Research knowledge translation framework.
Knowledge translation occurred at multiple levels: patient, practice and local health system. A regional administrative infrastructure and inter-disciplinary care teams were developed. The key project deliverable was a guideline-based interdisciplinary asthma management program. Six community organizations, 33 primary care physicians and 519 patients participated. The program operating cost was $290/patient.
Six guideline-based care elements were implemented, including spirometry measurement, asthma controller therapy, a written self-management action plan and general asthma education, including the inhaler device technique, role of medications and environmental control strategies in 93, 95, 86, 100, 97 and 87% of patients, respectively. Of the total patients 66% were adults, 61% were female, the mean age was 35.7 (SD = ±24.2) years. At baseline 42% had two or more symptoms beyond acceptable limits vs. 17% (P< 0.001) post-intervention; 71% reported urgent/emergent healthcare visits at baseline (2.94 visits/year) vs. 45% (1.45 visits/year) (P< 0.001); 39% reported absenteeism (5.0 days/year) vs. 19% (3.0 days/year) (P< 0.001). The mean follow-up interval was 22 (SD = ±7) months.
A knowledge-translation framework can guide multi-level organizational change, facilitate asthma guideline implementation, and improve health outcomes in community primary care practices. Program costs are similar to those of diabetes programs. Program savings offset costs in a ratio of 2.1:1
asthma; guideline adherence; implementation; knowledge translation; patient education as topic; primary care
To determine the effect of hospital work environments on hospital outcomes across multiple countries.
Primary survey data using a common instrument were collected from separate cross sections of 98 116 bedside care nurses practising in 1406 hospitals in 9 countries between 1999 and 2009.
Main Outcome Measures
Nurse burnout and job dissatisfaction, patient readiness for hospital discharge and quality of patient care.
High nurse burnout was found in hospitals in all countries except Germany, and ranged from roughly a third of nurses to about 60% of nurses in South Korea and Japan. Job dissatisfaction among nurses was close to 20% in most countries and as high as 60% in Japan. Close to half or more of nurses in every country lacked confidence that patients could care for themselves following discharge. Quality-of-care rated as fair or poor varied from 11% in Canada to 68% in South Korea. Between one-quarter and one-third of hospitals in each country were judged to have poor work environments. Working in a hospital with a better work environment was associated with significantly lower odds of nurse burnout and job dissatisfaction and with better quality-of-care outcomes.
Poor hospital work environments are common and are associated with negative outcomes for nurses and quality of care. Improving work environments holds promise for nurse retention and better quality of patient care.
Hospital work environments; nurse burnout; nurse job satisfaction; and quality of care
To assess the quality of medical treatment by disaggregating quality into components that distinguish between insufficient and unnecessary care.
Randomly selected doctors were asked how they would treat a sick child. Their responses were disaggregated into how much of an evidence-based essential treatment plan was completed and the number of additional non-essential treatments that were given. Key variables included the expected cost, the health consequences of insufficient and unnecessary care and comparisons between public and private physicians. Responses to 160 clinical performance vignettes (CPVs) were analysed.
One hundred and forty-three public and private physicians in the Philippines, collected in November 2003–December 2004 and September 2006–June 2007.
CPVs administered to physicians.
Main outcome measures
Process quality measures (accounting for the possibility of both over-treatment and under-treatment).
Based on CPVs, doctors gave both insufficient and unnecessary treatment to under-five children in 69% of cases. Doctors who provided the least sufficient care were also the most likely to give costly or harmful unnecessary care. Insufficient care typically had potentially worse health consequences for the patient than unnecessary care, though unnecessary care remains a concern because of overuse of antibiotics (47%) and unnecessary hospitalization (34%).
Quality of care is complex, but over- and under-treatment coexist and, in our analysis physicians that were more likely to under-treat a sick child were also those more likely to over-treat.
measurement of quality; quality indicators; appropriateness; under-use and over-use; healthcare system; health policy
While international research on patient satisfaction on healthcare has grown tremendously in the past three decades, little research has been conducted concerning healthcare-related patient satisfaction in China. This study was designed to examine what factors including patients’ characteristics and ease of access to care are associated with level of patient satisfaction and how such satisfaction might differ across rural and urban populations in China. This study also serves as an evaluation of the recent healthcare reforms that have taken place in China, which were expected to equalize satisfaction between rural and urban patients.
A cross-sectional survey to assess satisfaction among patients attending county-level hospitals in China.
Forty county-level hospitals in two provinces of China.
Twenty-five patients from each of the 40 county-level hospitals.
Main outcome measure
Patient satisfaction measured with 15 questions.
Perceived convenience was significantly associated with patient satisfaction among all participants. The new rural cooperative medical insurance scheme (NRCMIS) was associated with higher overall satisfaction among the rural residents. Age and income were significantly related to satisfaction only among rural patients.
Rural residents benefit greatly from the implementation of NRCMIS. Future reform could be more effective by catering the needs of each specific group (e.g. low-income population, rural population, etc.) identified by this study.
China; healthcare; patient satisfaction; rural; urban
To assess health-care worker (HCW) awareness, interest and engagement in quality improvement (QI) in HIV care sites in Tanzania.
Cross-sectional survey distributed in May 2009.
Sixteen urban HIV care sites in Dar es Salaam, Tanzania, 1 year after the introduction of a quality management program.
Two hundred seventy-nine HCWs (direct care, clinical support staff and management).
Main Outcome Measures
HCW perceptions of care delivered, rates of engagement, knowledge and interest in QI. HCW-identified barriers to and facilitators of the delivery of quality HIV care.
Two hundred seventy-nine (73%) of 382 HCWs responded to the survey. Most (86%) felt able to meet clients’ needs. HCW-identified facilitators of quality included: teamwork (88%), staff communication (79%), positive work environment (75%) and trainings (84%). Perceived barriers included: problems in patients’ lives (73%) and too few staff or too high patient volumes (52%). Many HCWs knew about specific QI activities (52%) or had been asked for input on QI (63%), but fewer (40.5%) had participated in activities and only 20.1% were currently QI team members. Managers were more likely to report QI involvement than direct care or clinical support staff (P < 0.01). No difference in QI involvement was seen based on patient load or site type.
HCWs can provide important insights into barriers and facilitators of providing quality care and can be effectively engaged in QI activities. HCW participation in efforts to improve services will ensure that HIV/AIDS quality of care is achieved and maintained as countries strive for universal antiretroviral access.
quality improvement; health-care workers; health-care surveys
To understand the extent to which hospitalized patients participate in their care, and the association of patient participation with quality of care and patient safety.
Random sample telephone survey and medical record review.
US acute care hospitals in 2003.
A total of 2025 recently hospitalized adults.
Main Outcome Measures
Hospitalized patients reported participation in their own care, assessments of overall quality of care and the presence of adverse events (AEs) in telephone interviews. Physician reviewers rated the severity and preventability of AEs identified by interview and chart review among 788 surveyed patients who also consented to medical record review.
Of the 2025 patients surveyed, 99.9% of patients reported positive responses to at least one of seven measures of participation. High participation (use of >4 activities) was strongly associated with patients’ favorable ratings of the hospital quality of care (adjusted OR: 5.46, 95% CI: 4.15–7.19). Among the 788 patients with both patient survey and chart review data, there was an inverse relationship between participation and adverse events. In multivariable logistic regression analyses, patients with high participation were half as likely to have at least one adverse event during the admission (adjusted OR = 0.49, 0.31–0.78).
Most hospitalized patients participated in some aspects of their care. Participation was strongly associated with favorable judgments about hospital quality and reduced the risk of experiencing an adverse event.
medical error; adverse events; patient participation
To determine the quality of outpatient hospital care for children under 5 years in Afghanistan.
Case management observations were conducted on 10–12 children under five selected by systematic random sampling in 31 outpatient hospital clinics across the country, followed by interviews with caretakers and providers.
Main Outcome Measures
Quality of care defined as adherence to the clinical standards described in the Integrated Management of Childhood Illness.
Overall quality of outpatient care for children was suboptimal based on patient examination and caretaker counseling (median score: 27.5 on a 100 point scale). Children receiving care from female providers had better care than those seen by male providers (OR: 6.6, 95% CI: 2.0–21.9, P = 0.002), and doctors provided better quality of care than other providers (OR: 2.7, 95% CI: 1.1–6.4, P = 0.02). The poor were more likely to receive better care in hospitals managed by non-governmental organizations than those managed by other mechanisms (OR: 15.2, 95% CI: 1.2–200.1, P = 0.04).
Efforts to strengthen optimal care provision at peripheral health clinics must be complemented with investments at the referral and tertiary care facilities to ensure care continuity. The findings of improved care by female providers, doctors and NGO's for poor patients, warrant further empirical evidence on care determinants. Optimizing care quality at referral hospitals is one of the prerequisites to ensure service utilization and outcomes for the achievement of the Child health Millennium Development Goals for Afghanistan.
quality of care; hospitals; child health; IMCI; Afghanistan
To determine the patient and hospital characteristics associated with severe manifestations of ‘poor glycemic control’—a ‘no-pay’ hospital-acquired condition defined by the US Medicare program based on hospital claims related to severe complications of diabetes.
A nested case–control study.
California acute care hospitals from 2005 to 2006.
All cases (n= 261) with manifestations of poor glycemic control not present on admission admitted to California acute care hospitals from 2005 to 2006 and 261 controls were matched (1:1) using administrative data for age, sex, major diagnostic category and severity of illness.
Main Outcome Measure(s)
The adjusted odds ratio (OR) for experiencing poor glycemic control.
Deaths (16 vs. 9%, P= 0.01) and total costs ($26 125 vs. $18 233, P= 0.026) were significantly higher among poor glycemic control cases. Risk-adjusted conditional logistic regression revealed that each additional chronic condition increased the odds of poor glycemic control by 12% (OR: 1.12, 95% CI: 1.04–1.22). The interaction of registered nurse staffing and hospital teaching status suggested that in non-teaching hospitals, each additional nursing hour per adjusted patient day significantly reduced the odds of poor glycemic control by 16% (OR: 0.84, 95% CI: 0.73–0.96). Nurse staffing was not significant in teaching hospitals (OR: 0.98, 95% CI: 0.88–1.11).
Severe poor glycemic control complications are relatively rare but meaningful events with disproportionately high costs and mortality. Increasing nurse staffing may be an effective strategy in reducing poor glycemic control complications particularly in non-teaching hospitals.
patient safety; poor glycemic control; hospital-acquired conditions; nurse staffing; case–control
The hospital benchmarking system in Germany was originally introduced to detect unintended consequences of reimbursement based on diagnosis-related groups. The new nationwide SQG programme aims to provide information on quality and outcomes of health care provided in hospital, ambulatory specialist and primary care settings, including the healthcare delivery across different sectors. In 2010 the topics for indicator development were cataract surgery, cervical conization, colectoral cancer and percutaneous coronary interventions or coronary angiography. A systematic stepwise modified RAND/UCLA procedure is applied to develop quality indicators in each of these domains. A general framework for data collection is implemented. Benchmarking results are fed back to providers on a regular basis.
quality measurement; quality indicators; health policy; hospital care; primary care/general practice; general medicine; surgery
Familiarity with guidelines is generally thought to be associated with guideline implementation, adherence and improved quality of care. We sought to determine if self-reported familiarity with acute respiratory infection (ARI) antibiotic treatment guidelines was associated with reduced or more appropriate antibiotic prescribing for ARIs in primary care.
Design, Setting, Participants and Main Outcome Measures
We surveyed primary care clinicians about their familiarity with ARI antibiotic treatment guidelines and linked responses to administrative diagnostic and prescribing data for non-pneumonia ARI visits.
Sixty-five percent of clinicians responded to the survey question about guideline familiarity. There were 208 survey respondents who had ARI patient visits during the study period. Respondents reported being ‘not at all’ (7%), ‘somewhat’ (30%), ‘moderately’ (45%) or ‘extremely’ (18%) familiar with the guidelines. After dichotomizing responses, compared with clinicians who reported being less familiar with the guidelines, clinicians who reported being more familiar with the guidelines had higher rates of antibiotic prescribing for all ARIs combined (46% versus 38%; n = 11 164; P < 0.0001), for antibiotic-appropriate diagnoses (69% versus 59%; n = 3213; P < 0.0001) and for non-antibiotic appropriate diagnoses (38% versus 28%; n = 7951; P < 0.0001). After adjusting for potential confounders, self-reported guideline familiarity was an independent predictor of increased antibiotic prescribing (odds ratio, 1.36; 95% confidence interval, 1.25–1.48).
Self-reported familiarity with an ARI antibiotic treatment guideline was, seemingly paradoxically, associated with increased antibiotic prescribing. Self-reported familiarity with guidelines should not be assumed to be associated with consistent guideline adherence or higher quality of care.
guideline adherence; respiratory tract infections; anti-bacterial agents; physicians’ practice patterns; primary health care
Safety culture may influence patient outcomes, but evidence is limited. We sought to determine if intensive care unit (ICU) safety culture is independently associated with outcomes.
Cohort study combining safety culture survey data with the Project IMPACT Critical Care Medicine (PICCM) clinical database.
Thirty ICUs participating in the PICCM database.
A total of 65 978 patients admitted January 2001–March 2005.
Main outcome measures
Hospital mortality and length of stay (LOS).
From December 2003 to April 2004, we surveyed study ICUs using the Safety Attitudes Questionnaire-ICU version, a validated instrument that assesses safety culture across six factors. We calculated factor mean and percent-positive scores (% respondents with mean score ≥75 on a 0–100 scale) for each ICU, and generated case-mix adjusted, patient-level, ICU-clustered regression analyses to determine the independent association of safety culture and outcome.
We achieved a 47.9% response (2103 of 4373 ICU personnel). Culture scores were mostly low to moderate and varied across ICUs (range: 13–88, percent-positive scores). After adjustment for patient, hospital and ICU characteristics, for every 10% decrease in ICU perceptions of management percent-positive score, the odds ratio for hospital mortality was 1.24 (95% CI: 1.07–1.44; P = 0.005). For every 10% decrease in ICU safety climate percent-positive score, LOS increased 15% (95% CI: 1−30%; P = 0.03). Sensitivity analyses for non-response bias consistently associated safety climate with outcome, but also yielded some counterintuitive results.
In a multicenter study conducted in the USA, perceptions of management and safety climate were moderately associated with outcomes. Future work should further develop methods of assessing safety culture and association with outcomes.
safety culture; patient safety; human resources; patient outcomes; intensive care