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
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
In the choice and definition of quality of care indicators, there may be an inherent tension between feasibility, generally enhanced by simplicity, and validity, generally enhanced by accounting for clinical complexity.
To study the process of developing quality indicators using an expert panel and analyze the tension between feasibility and validity.
Design and participants
A multidisciplinary panel of 12 expert physicians was engaged in two rounds of modified Delphi process to refine and choose a smaller subset from 36 indicators; these were developed by a research team studying the quality of care in ambulatory post-myocardial infarction patients with co-morbidities. We studied the correlation between validity/feasibility ranks provided by the expert panel. The correlation between the quality indicators ranks on validity and feasibility scale and variance of experts' responses was also individually studied.
Ten of 36 indicators were ranked in both the highest validity and feasibility groups. The strength of association between validity and feasibility of indicators measured by Kendall tau-b was 0.65. In terms of validity, a strong negative correlation was observed between the ranks of indicators and the variability in expert panel responses (Spearman's rho, r = −0.85). A weak correlation was found between the ranks of feasibility and the variability of expert panel responses (Spearman's rho, r = 0.23).
There was an unexpectedly strong association between the validity and feasibility of quality indicators, with a high level of consensus among experts regarding both feasibility and validity for indicators rated highly on each of these attributes.
clinical guidelines; feasibility; myocardial infarction; quality indicators; quality of health care; validity
Hospital medication safety event detection predominantly emphasizes the identification of preventable adverse drug events (ADEs) through self-reports. These relatively rare events only provide insight into patient harm and self-reports identify only a small portion of ADEs. A broader system-focused approach to medication safety event detection that uses an array of event detection methods is recommended. This approach illuminates medication system deficits and supports improvement strategies that can prevent future patient risk.
To: (i) describe a system-focused approach to hospital medication safety event detection, and (ii) present a case illustration of approach application.
System-Focused Model and Methodology
A three-level medication safety event detection model that ranges from a narrow harm-focused to broader system-focused approach is described. A standardized cross-level methodology to detect medication safety events is presented.
A Level 3 system-focused methodology that incorporated both voluntary and non-voluntary event detection strategies was used in 17 critical care (n = 4), intermediate care (n = 7) and medical-surgical units (n = 6) across two hospitals. A total of 431 events were detected: 78 (18.1%) ADEs and 353 (81.9%) potential ADEs. Of the 353 PADEs, 302 (70.0%) were non-intercepted events. Non-voluntary detection methods yielded the majority of events (367, 85.1%).
The incidence of ADEs was low when compared with non-intercepted PADEs. This was indicative of medication safety system failures that placed patients at risk for potential harm. Non-voluntary detection methods were much more effective at detecting events than traditional self-report methods.
medication safety; health systems
Cardiovascular risk factors increase risk for stroke recurrence. Secondary prevention of stroke may be affected not only by established risk factors, but also socioeconomic status. This study evaluates relationships between socioeconomic status and cardiovascular and behavioral factors.
Public Health and Education Institute, Peking University.
Outpatients (n = 2354) with a past diagnosis of stroke or transient ischemic attack.
The investigation consisted of a questionnaire regarding patients' socioeconomic and living status, and a clinical examination at the research center.
Main outcome measure(s)
Control rates of risk factors for cardiovascular disease.
With regard to hypertension patients, 67.0% were aware of having hypertension, 63.6% were treated and 53.9% had controlled hypertension; for patients with hypercholesterolemia, 46.7% were aware of having hypercholesterolemia, 38.6% were treated and 3.8% had controlled hypercholesterolemia; for patients with diabetes mellitus, 28.0% were aware of having diabetes mellitus, 25.7% were treated and 3.5% had controlled diabetes mellitus. After multivariate analysis, education was the strongest associated factor for controls of hypertension and diabetes mellitus. After adjustment for sex and age, strong and graduated relationships were noted between the level of education and control of risk factors, with the odds ratios increasing at every increment.
Education exerts the most important effect on the control of established cardiovascular risk factors; Successful intervention to reduce these risk factors will have to be addressed, not just with regard to specific risk factors, but also with the societal conditions that lead to the adoption and maintenance of high-risk behaviors.
socioeconomic status; secondary prevention; stroke
This paper reports the measurement of technical efficiency of Tuscan Local Health Authorities and its relationship with quality and appropriateness of care.
First, a bias-corrected measure of technical efficiency was developed using the bootstrap technique applied to data envelopment analysis. Then, correlation analysis was used to investigate the relationships among technical efficiency, quality and appropriateness of care.
Setting and Participants
These analyses have been applied to the Local Health Authorities of Tuscany Region (Italy), which provide not only hospital inpatient services, but also prevention and primary care. All top managers of Tuscan Local Health Authorities were involved in selection of the inputs and outputs for calculating technical efficiency.
Main Outcome Measures
The main measures used in this study are volume, quality and appropriateness indicators monitored by the multidimensional performance evaluation system developed in the Tuscany Region.
On average, Tuscan Local Health Authorities experienced 14(%) of bias-corrected inefficiency in 2007. Correlation analyses showed a significant negative correlation between per capita costs and overall performance. No correlation was found in 2007 between technical efficiency and overall performance or between technical efficiency and per capita costs.
Technical efficiency cannot be considered as an extensive measure of healthcare performance, but evidence shows that Tuscan Local Health Authorities have room for improvement in productivity levels. Indeed, correlation findings suggest that, to pursue financial sustainability, Local Health Authorities mainly have to improve their performance in terms of quality and appropriateness.
appropriateness; bias correction; data envelopment analysis; local health authorities; performance evaluation system
To assess surgical team members’ differences in perception of non-technical skills.
Operating theatres (OTs) at one university hospital, three teaching hospitals and one general hospital in the Netherlands.
Sixty-six surgeons, 97 OT nurses, 18 anaesthetists and 40 nurse anaesthetists.
All surgical team members, of five hospitals, were asked to complete a questionnaire and state their opinion on the current state of communication, teamwork and situation awareness at the OT.
Ratings for ‘communication’ were significantly different, particularly between surgeons and all other team members (P ≤ 0.001). The ratings for ‘teamwork’ differed significantly between all team members (P ≤ 0.005). Within ‘situation awareness’ significant differences were mainly observed for ‘gathering information’ between surgeons and other team members (P < 0.001). Finally, 72–90% of anaesthetists, OT nurses and nurse anaesthetists rated routine team briefings and debriefings as inadequate.
This study shows discrepancies on many aspects in perception between surgeons and other surgical team members concerning communication, teamwork and situation awareness. Future research needs to ascertain whether these discrepancies are linked to greater risk of adverse events or to process as well as systems failures. Establishing this link would support implementation and use of complex team interventions that intervene at multiple levels of the healthcare system.
patient safety; quality of care; teamwork; communication; surgery
To determine the effect of the implementation of a shared care guideline for the lumbosacral radicular syndrome (LRS) on unnecessary early referrals and the duration of the total diagnostic procedure.
Introduction of shared care guideline in November 2005. Pre-test in 2005 (April to October), a first post-test in 2006 (April to October) and a second post-test in 2007 (April to October).
Setting and Intervention
The introduction of a shared care guideline derived from national guidelines for GPs and several medical/paramedical specialists in two Dutch regions. Three hundred and sixty GPs, 550 physiotherapists and two hospitals (9 neurologists and 18 radiologists) were involved. The essential component of the guideline was a trade-off: if the GP complied with the conservative management approach in the first 6 weeks, the hospital guaranteed a priority appointment with the neurologist after 6 weeks, if still required.
Main Outcome Measures
The neurologists in both hospitals registered whether a patient had been unnecessarily referred during the first 6 weeks. The duration of the total diagnostic procedure was defined as the number of days between referral by the GP and the consultation when the neurologist made the final diagnosis.
The percentage of patients being unnecessarily referred within 6 weeks fell significantly from 15% in 2005 to 9% in 2006 and 8% in 2007. The duration of the total diagnostic procedure also fell significantly in both the long and short terms.
The introduction of a shared care guideline for all care providers in a region reduces the number of unnecessary early referrals for patients with LRS.
implementation; guideline adherence; hospitals; primary health care; quality of health care; sciatica
To test to what extent the four-factor structure of the group innovation inventory (GII) is confirmed for improvement teams participating in a quality improvement collaborative.
Quasi-experimental design with baseline and end-measurement after intervention.
This study included quality improvement teams participating in the Care for Better improvement programme for home care, care for the handicapped and the elderly in the Netherlands between 2006 and 2008.
As part of a larger evaluation study, 261 written questionnaires from team members were collected at baseline (pre-project sample) and 129 questionnaires at end-measurement (post-project sample).
Main outcome measure
Group innovation inventory.
Confirmatory factor analyses revealed the expected four-factor structure and good fit indices. The subscales ‘group functioning’ and ‘speed of action’ showed acceptable Cronbach's alphas and high inter-item correlations. The subscales ‘support for risk taking’ and ‘tolerance of mistakes’ showed insufficient reliability and validity.
The group functioning and speed of action subscales of the GII showed acceptable psychometric properties and are applicable to quality improvement teams in health care. In order to understand how social expectations within teams working in health care organizations exert influence over attitudes and behaviours thought to stimulate creativity, further conceptualization of the norms for enhancing creativity within health care is needed.
innovation; quality collaborative; healthcare teams; creativity; implementation
We set out to determine effectiveness of interventions for improving the quality of services provided by specialized drug shops in sub-Saharan Africa.
We searched PubMed, CAB Abstracts, Web of Science, PsycINFO and Eldis databases and websites for organizations such as WHO and Management Sciences for Health. Finally, we searched manually through the references of retrieved articles.
Our search strategy included randomized trials, time-series studies and before and after studies evaluating six interventions; education, peer review, reorganizing administrative structures, incentives, regulation and legislation.
We extracted information on design features, participants, interventions and outcomes assessed studies for methodological quality, and extracted results, all using uniform checklists.
Results of data synthesis
We obtained 10 studies, all implementing educational interventions. Outcome measures were heterogeneous and included knowledge, communication and dispensing practices. Education improved knowledge across studies, but gave mixed results on communication between sellers and clients, dispensing of appropriate treatments and referring of patients to health facilities. Profit incentives appeared to constrain behaviour change in certain instances, although cases of shops adopting practices at the expense of sales revenue were also reported.
Evidence suggests that knowledge and practices of pharmacies and drug shops can be improved across a range of diseases and countries/regions, although variations were reported across studies. Profit incentives appear to bear some influence on the level of success of interventions. More work is required to extend the geographical base of evidence, investigate cost-effectiveness and evaluate sustainability of interventions over periods longer than 1 year.
quality improvement; patient-provider communication/information; developing countries; pharmacy; training/education
The results of many quality improvement (QI) projects are gaining wide-spread attention. Policy-makers, hospital leaders and clinicians make important decisions based on the assumption that QI project results are accurate. However, compared with clinical research, QI projects are typically conducted with substantially fewer resources, potentially impacting data quality. Our objective was to provide a primer on basic data quality control methods appropriate for QI efforts.
Data quality control methods should be applied throughout all phases of a QI project. In the design phase, project aims should guide data collection decisions, emphasizing quality (rather than quantity) of data and considering resource limitations. In the data collection phase, standardized data collection forms, comprehensive staff training and a well-designed database can help maximize the quality of the data. Clearly defined data elements, quality assurance reviews of both collection and entry and system-based controls reduce the likelihood of error. In the data management phase, missing data should be quickly identified and corrected with system-based controls to minimize the missing data. Finally, in the data analysis phase, appropriate statistical methods and sensitivity analysis aid in managing and understanding the effects of missing data and outliers, in addressing potential confounders and in conveying the precision of results.
Data quality control is essential to ensure the integrity of results from QI projects. Feasible methods are available and important to help ensure that stakeholder's decisions are based on accurate data.
data quality; research design; data reporting; quality controls
The vast majority of health system capacity-building efforts have focused on enhancing medical and public health skills; less attention has been directed at developing hospital managers despite their central role in improving the functioning and quality of health-care systems.
Initial assessment and choice of intervention
Initial assessment of hospital management systems demonstrated weak functioning in several management areas. In response, we developed with the Ethiopian Ministry of Health (MoH) a novel Master of Hospital Administration (MHA) program, reflecting a collaborative effort of the MoH, the Clinton HIV/AIDS Initiative, Jimma University and Yale University. The MHA is a 2-year executive style educational program to develop a new cadre of hospital leaders, comprising 5% classroom learning and 85% executive practice.
The MHA has been implemented with 55 hospital leaders in the position of chief executive officer within the MoH, with courses taught in collaboration by faculty of the North and the South universities.
Evaluation and lessons learned
The program has enrolled two cohorts of hospital leaders and is working in more than half of the government hospitals in Ethiopia. Lessons learned include the need to: (i) balance education in applied, technical skills with more abstract thinking and problem solving, (ii) recognize the interplay between management education and policy reform, (iii) remain flexible as policy changes have direct impact on the project, (iv) be realistic about resource constraints in low-income settings, particularly information technology limitations, and (v) manage the transfer of knowledge for longer term sustainability.
Ethiopia; hospital management; Africa