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1.  [No title available] 
PMCID: PMC2653167
2.  A proposal: publication guidelines for healthcare improvement education reports 
Quality & Safety in Health Care  2007;16(6):402-403.
The value of education reports lies in improving patient care outcomes
PMCID: PMC2653168  PMID: 18055881
3.  Quality Lines 
PMCID: PMC2653169
4.  [No title available] 
PMCID: PMC2653170
5.  Extracting information from hospital records: what patients think about consent 
Quality & Safety in Health Care  2007;16(6):404-408.
Background and objective
There is increasing regulation and concern about the use of material from patients' records. Studies on patients' views have focused on primary care and on use of material for research. This study investigated patients' preferences about whether and how doctors should seek permission for use of specified items of anonymised information from their hospital records for clinical audit, teaching, national data collection and research.
A specially designed questionnaire sent to recently discharged patients under the care of medical and surgical specialists.
166/316 (53%) patients completed the questionnaires. The percentage of respondents who “definitely wanted” or “preferred” to be asked for permission for use of anonymised information was highest for medical history (21%) and reasons for treatment (20%). The purpose for which information was requested (eg, research, audit) made little difference to the overall percentages (range 10–12%). 21 (13%) patients “definitely wanted” to be asked for permission for use of some item or proposed use of information—most had no preference or preferred not to be asked. The most popular method for asking permission was signing a form while in hospital, rather than by specific requests later.
Most hospital patients have no preference or prefer not to be asked permission for doctors to use information from their records. About 1 in 8 patients would like to be asked for permission, some even for clinical audit of outcomes—although a minority, this could compromise thorough clinical audit. Systems for obtaining permission when patients are admitted to hospital need to be considered. Resolution of uncertainties surrounding legislation on the use of information would be helpful to clinicians.
PMCID: PMC2653171  PMID: 18055882
6.  [No title available] 
PMCID: PMC2653172
7.  Barriers and facilitators to the implementation of the collaborative method: reflections from a single site 
Quality & Safety in Health Care  2007;16(6):409-414.
A collaborative is an effective method of implementing evidence‐based practice across multiple sites through the sharing of experience and knowledge of others in a similar setting, over a short period of time. Collaborative methods were first used in the USA but have been adopted internationally.
This paper sought to document the facilitators and barriers to the implementation of the collaborative method, based on a single site's experience of participating in a multisite, state‐wide heart failure collaborative.
Qualitative data was collected using three complementary methods: participant observation, reflective journalling and key informant interviews. Quantitative monitoring of team performance occurred monthly according to prespecified performance indicators.
Barriers and facilitators that were identified by this study included: organisational factors, team composition, dynamics and networking, changing doctor behaviour, clinical leadership and communication.
The findings from this study underscore the importance of leadership, communication and team cohesion for the successful implementation of the collaborative method at individual sites. In addition, the importance of a preparatory stage that deals with known barriers and facilitators to the collaborative method before the commencement of the official study period was highlighted. The potential for the collaborative approach to improve clinical outcomes warrants further systematic evaluation of process issues and consideration of the barriers and facilitators to implementation in various settings.
PMCID: PMC2653173  PMID: 18055883
8.  Evaluating the clinical appropriateness of nurses' prescribing practice: method development and findings from an expert panel analysis 
Quality & Safety in Health Care  2007;16(6):415-421.
The number of nurses independently prescribing medicines in England is rising steadily. There had been no attempt systematically to evaluate the clinical appropriateness of nurses' prescribing decisions.
(i) To establish a method of assessing the clinical appropriateness of nurses' prescribing decisions; (ii) to evaluate the prescribing decisions of a sample of nurses, using this method.
A modified version of the Medication Appropriateness Index (MAI) was developed, piloted and subsequently used by seven medical prescribing experts to rate transcripts of 12 nurse prescriber consultations selected from a larger database of 118 audio‐recorded consultations collected as part of a national evaluation. Experts were also able to give written qualitative comments on each of the MAI dimensions applied to each of the consultations.
Experts' ratings were analysed using descriptive statistics. Qualitative comments were subjected to a process of content analysis to identify themes within and across both MAI items and consultations.
Experts' application of the modified MAI to transcripts of nurse prescriber consultations demonstrated validity and feasibility as a method of assessing the clinical appropriateness of nurses' prescribing decisions. In the majority of assessments made by the expert panel, nurses' prescribing decisions were rated as clinically appropriate on all nine items in the MAI.
A valid and feasible method of assessing the clinical appropriateness of nurses' prescribing practice has been developed using a modified MAI and transcripts of audio‐recorded consultations sent to a panel of prescribing experts. Prescribing nurses in this study were generally considered to be making clinically appropriate prescribing decisions. This approach to measuring prescribing appropriateness could be used as part of quality assurance in routine practice, as a method of identifying continuing professional development needs, or in future research as the expansion of non‐medical prescribing continues.
PMCID: PMC2653174  PMID: 18055884
nurse prescribing; quality measurement; prescribing appropriateness
9.  Educational quality improvement report: outcomes from a revised morbidity and mortality format that emphasised patient safety 
Quality & Safety in Health Care  2007;16(6):422-427.
Although morbidity and mortality conferences (MMCs) are meant to promote quality care through careful analysis of adverse events, focus on individual actions or the fear of incrimination may interfere with identification of system issues contributing to the adverse outcomes.
Participant attitudes before and after the intervention towards patient safety and conference redesign were assessed using an attitudinal survey. A list of contributing factors, recommended solutions and targeted system improvements was maintained with ongoing progress recorded.
Department of Internal Medicine training programme at University of Missouri–Columbia.
Residents and fellows from the above residency programme.
Educational objectives
(1) Distinguish between culture of blame/shame and patient safety culture, (2) identify gaps in quality contributing to adverse outcomes (3) identify strategies to close gaps and (4) participate in root cause analysis, demonstrating an ability to review an adverse event and recommend an action plan.
Strategies for change
An interdisciplinary team modified the internal medicine MMC to emphasise a better understanding of patient safety principles and system‐based practice interventions. For each adverse event analysed, root causes were identified, followed by discussion of system interventions that might prevent future such events.
Key measures for improvement
(1) Attitudes of residents and fellows regarding patient safety, as measured on a 20‐item, five‐point ordinal scale survey, (2) system improvements generated from the patient safety MMC (PSMMC) and (3) attendance at PSMMC.
Effects of change
Clinical outcomes: 121 system improvement recommendations were made and 39 were pursued on the basis of likelihood of achieving high impact changes. 23 improvements were implemented, 11 were partially implemented or in progress, and 5 were abandoned due to impracticality or redundancy. Educational outcomes: 58 residents and fellows completed surveys before and after modification of conference format. 6/20 survey items showed substantial change with four of these changes occurring in the desired direction. Eleven of the remaining 14 responses changed in the desired direction. Average MMC attendance increased from 41±8 to 50±10 participants (p<0.03).
Lessons learnt
The new PSMMC initiated multiple improvements in the quality of patient care without sacrificing attendance or attitudes of the residents or fellows. The new PSMMC promotes opportunities for participants to improve quality of patient care in a safe and nurturing environment.
PMCID: PMC2653175  PMID: 18055885
10.  [No title available] 
PMCID: PMC2653176
11.  Extent, nature and consequences of adverse events: results of a retrospective casenote review in a large NHS hospital 
Quality & Safety in Health Care  2007;16(6):434-439.
To estimate the extent, nature and consequences of adverse events in a large National Health Service (NHS) hospital, and to evaluate the reliability of a two‐stage casenote review method in identifying adverse events.
A two‐stage structured retrospective patient casenote review.
A large NHS hospital in England.
A random sample of 1006 hospital admissions between January and May 2004: surgery (n = 311), general medicine (n = 251), elderly (n = 184), orthopaedics (n = 131), urology (n = 61) and three other specialties (n = 68).
Main outcome measures
Proportion of admissions with adverse events, the proportion of preventable adverse events, and the types and consequences of adverse events.
8.7% (n = 87) of the 1006 admissions had at least one adverse event (95% CI 7.0% to 10.4%), of which 31% (n = 27) were preventable. 15% of adverse events led to impairment or disability which lasted more than 6 months and another 10% contributed to patient death. Adverse events led to a mean increased length of stay of 8 days (95% CI 6.5 to 9). The sensitivity of the screening criteria in identifying adverse events was 92% (95% CI 87% to 96%) and the specificity was 62% (95% CI 53% to 71%). Inter‐rater reliability for determination of adverse events was good (κ = 0.64), but for the assessment of preventability it was only moderate (κ = 0.44).
This study confirms that adverse events are common, serious and potentially preventable source of harm to patients in NHS hospitals. The accuracy and reliability of a structured two‐stage casenote review in identifying adverse events in the UK was confirmed.
PMCID: PMC2653177  PMID: 18055887
12.  [No title available] 
PMCID: PMC2653178
13.  European Surveillance of Antimicrobial Consumption (ESAC): quality indicators for outpatient antibiotic use in Europe 
Quality & Safety in Health Care  2007;16(6):440-445.
Background and objective
Indicators to measure the quality of healthcare are increasingly used by healthcare professionals and policy makers. In the context of increasing antimicrobial resistance, this study aimed to develop valid drug‐specific quality indicators for outpatient antibiotic use in Europe, derived from European Surveillance of Antimicrobial Consumption (ESAC) data.
27 experts (15 countries), in a European Science Foundation workshop, built on the expertise within the European Drug Utilisation Research Group, the General Practice Respiratory Infections Network, the ESCMID Study Group on Primary Care Topics, the Belgian Antibiotic Policy Coordination Committee, the World Health Organization, ESAC, and other experts. A set of proposed indicators was developed using 1997–2003 ESAC data. Participants scored the relevance of each indicator to reducing antimicrobial resistance, patient health benefit, cost effectiveness and public health policy makers (scale: 1 (completely disagree) to 9 (completely agree)). The scores were processed according to the UCLA‐RAND appropriateness method. Indicators were judged relevant if the median score was not in the 1–6 interval and if there was consensus (number of scores within the 1–3 interval was fewer than one third of the panel). From the relevant indicators providing overlapping information, the one with the highest scores was selected for the final set of quality indicators—values were updated with 2004 ESAC data.
22 participants (12 countries) completed scoring of a set of 22 proposed indicators. Nine were rated as relevant antibiotic prescribing indicators on all four dimensions; five were rated as relevant if only relevance to reducing antimicrobial resistance and public health policy makers was taken into account. A final set of 12 indicators was selected.
12 of the proposed ESAC‐based quality indicators for outpatient antibiotic use in Europe have face validity and are potentially applicable. These indicators could be used to better describe antibiotic use in ambulatory care and assess the quality of national antibiotic prescribing patterns in Europe.
PMCID: PMC2653179  PMID: 18055888
14.  Differences in the quality of primary medical care services by remoteness from urban settlements 
Quality & Safety in Health Care  2007;16(6):446-449.
To examine if the quality of primary medical care varies with remoteness from urban settlements.
Cross‐sectional analysis of publicly available data of 18 process and intermediate outcome measures for people with coronary heart disease (CHD), diabetes and stroke.
Setting and participants
Populations registered with 912 general practices in Scotland grouped into three categories by level of remoteness from urban settlements: not remote, remote and very remote.
Main outcome measures
Mean percentages achieving quality indicators and interquartile range scores.
Remote and very remote practices were more likely to have characteristics associated with low Quality and Outcomes Framework (QOF) total points score (smaller, higher capitation income, dispensing practice, and had lower statin prescribing despite higher prevalence of cardiovascular disease and diabetes). However, in contrast with previous research, there was little evidence that quality of care was lower in more remote areas for the 18 process and intermediate outcome measures examined. The exception was significantly lower cholesterol measurement and control in people with CHD, diabetes and stroke attending very remote practices (p<0.01) and β‐blocker prescription in CHD (p = 0.01).
Under QOF, there are few differences in the quality of care delivered to patients in practices with different degrees of remoteness. The differences in achievement for cholesterol were consistent with lower rates of statin prescribing relative to disease burden in very remote practices. No differences were found for complex process measures such as retinopathy screening, implying that differences under QOF are more likely to be due to slower adoption of evidence‐based practice than access problems. Examining this will require analysis of individual patient data.
PMCID: PMC2653180  PMID: 18055889
15.  [No title available] 
PMCID: PMC2653181
16.  Comparison of patients' assessments of the quality of stroke care with audit findings 
Quality & Safety in Health Care  2007;16(6):450-455.
To determine the extent of correlation between stroke patients' experiences of hospital care with the quality of services assessed in a national audit.
Patients' assessments of their care derived from survey data were linked to data obtained in the National Sentinel Stroke Audit 2004 for 670 patients in 51 English NHS trusts. A measure of patients' experience of hospital stroke care was derived by summing responses to 31 survey items and grouping these into three broad concept domains: quality of care; information; and relationships with staff. Audit data were extracted from hospital admissions data and management information to assess the organisation of services, and obtained retrospectively from patient records to evaluate the delivery of care. Patient survey responses were compared with audit measures of organisation of care and compliance with clinical process standards.
Patient experience scores were positively correlated with clinicians' assessment of the organisational quality of stroke care, but were largely unrelated to clinical process standards. Responses to individual questions regarding communication about diagnosis revealed a discrepancy between clinicians' and patients' reports.
Better organised stroke care is associated with more positive patient experiences. Examining areas of disparity between patients' and clinicians' reports is important for understanding the complex nature of healthcare and for identifying areas for quality improvement. Future evaluations of the quality of stroke services should include a validated patient experience survey in addition to audit of clinical records.
PMCID: PMC2653182  PMID: 18055890
17.  [No title available] 
PMCID: PMC2653183
18.  Impact of short evidence summaries in discharge letters on adherence of practitioners to discharge medication. A cluster‐randomised controlled trial 
Quality & Safety in Health Care  2007;16(6):456-461.
International concern about quality of medical care has led to intensive study of interventions to ensure care is consistent with best evidence. Simple, inexpensive, feasible and effective interventions remain limited.
We examined the impact of one‐sentence evidence summaries appended to consultants' letters to primary care practitioners on adherence of the practitioners to recommendations made by the consultants regarding medication for patients with chronic medical problems.
Cluster‐randomised trial.
Secondary/primary care interface (urban district hospital/referral practices).
178 practices received one or more discharge letters with evidence summaries. The 66 practices in the intervention group provided feedback on 172 letters, and the 56 practices in the control group provided feedback on 96 letters.
Appending an evidence summary to discharge letters resulted in a decrease in non‐adherence to discharge medication from 29.6% to 18.5% (difference adjusted for underlying medical condition 12.5%; p = 0.039). Among the five possible reasons for discontinuing discharge medication, the evidence summaries seemed to have the largest impact on budget‐related reasons for discontinuation (2.6% in the intervention versus 10.7% in the control group (p = 0.052)). Most clinicians (72%) were enthusiastic about continuing receiving evidence summaries with discharge letters in routine care.
The one‐sentence evidence summary is a simple, inexpensive, well‐accepted intervention that may improve primary care practitioners' adherence to evidence‐based consultant recommendations.
PMCID: PMC2653184  PMID: 18055891
19.  Exploring users' experiences of accessing out‐of‐hours primary medical care services 
Quality & Safety in Health Care  2007;16(6):469-477.
Since 2000, out‐of‐hours primary medical care services in the UK have undergone major changes in the organisation and delivery of services in response to recommendations by the Carson Review and more recently, through the new General Medical Services Contract (GMS2). People calling their general practice in the evening or at weekends are redirected to the out‐of‐hours service which may offer telephone advice, a home visit or a visit to a treatment centre. Little is known about users' experiences under the new arrangements.
To explore users' experiences of out‐of‐hours primary medical care.
Design of study
A qualitative study employing focus groups and telephone interviews.
Three out‐of‐hours primary medical care service providers in England.
Focus groups and telephone interviews were conducted with 27 recent users of out‐of‐hours services.
Key areas of concern included the urgency with which cases are handled, and delays when waiting for a call back or home visit. Users felt that providers were reluctant to do home visits. The service was regarded as under‐resourced and frequently misused. Many expressed anxiety about calling, feeling unsure about how appropriate their call was and many were uncertain about how the service operated.
Service users need clear information on how current out‐of‐hours services operate and how it should be used. Problems with triaging need to be addressed, users should be kept informed of any delays, and care needs to be taken to ensure that the new arrangements do not alienate older people or individuals with complex health needs.
PMCID: PMC2653185  PMID: 18055893
20.  Making the right decision: Benjamin Franklin's son dies of smallpox in 1736 
Quality & Safety in Health Care  2007;16(6):478-480.
PMCID: PMC2653186  PMID: 18055894
21.  Surgical adverse outcomes and patients' evaluation of quality of care: inherent risk or reduced quality of care? 
Quality & Safety in Health Care  2007;16(6):428-433.
Previous research has shown that sicker patients are less satisfied with their healthcare, but specific effects of adverse health outcomes have not been investigated. The present study aimed to assess whether patients who experience adverse outcomes, in hospital or after discharge, differ in their evaluation of quality of care compared with patients without adverse outcomes.
Inhospital adverse outcomes were prospectively recorded by surgeons and surgical residents as part of routine care. Four weeks after discharge, patients were interviewed by telephone about the occurrence of post‐discharge adverse outcomes, and their overall evaluation of quality of hospital care and specific suggestions for improvements in the healthcare provided.
Of 2145 surgical patients admitted to the Leiden University Medical Center in 2003, 1876 (88%) agreed to be interviewed. Overall evaluation was less favourable by patients who experienced post‐discharge adverse outcomes only (average 19% lower). These patients were also more often dissatisfied (OR 2.02, 95% CI 1.24 to 3.31) than patients without adverse outcomes, and they more often suggested that improvements were needed in medical care (OR 2.07, 1.45 to 2.95) and that patients were discharged too early (OR 3.26, 1.72 to 6.20). The effect of inhospital adverse outcomes alone was not statistically significant. Patients with both inhospital and post‐discharge adverse outcomes also found the quality of care to be lower (on average 33% lower) than patients without adverse outcomes.
Post‐discharge adverse outcomes negatively influence patients' overall evaluation of quality of care and are perceived as being discharged too early, suggesting that patients need better information at discharge.
PMCID: PMC2653187  PMID: 18055886
22.  Capturing users' experience of UK out‐of‐hours primary medical care: piloting and psychometric properties of the Out‐of‐hours Patient Questionnaire 
Quality & Safety in Health Care  2007;16(6):462-468.
Background and objective
Provision of out‐of‐hours care in the UK National Health Service (NHS) has changed in recent years with new models of provision and the introduction of national quality requirements. Existing survey instruments tend to focus on users' satisfaction with service provision; most were developed without undertaking supporting qualitative fieldwork. In this study, a survey instrument was developed taking account of these changes in service provision and undertaking supporting qualitative fieldwork. This paper reports on the development and psychometric properties of the new survey instrument, the Out‐of‐hours Patient Questionnaire (OPQ), which aims to capture information on the entirety of users' experiences of out‐of‐hours care, from the decision to make contact through to completion of their care management.
An iterative approach was undertaken to develop the new instrument which was then tested in users of out‐of‐hours services in three geographically distributed UK settings. For the purposes of this study, “service users” were defined as “individuals about whom contact was made with an out‐of‐hours primary care medical service”, whether that contact was made by the user themselves, or via a third party. Analysis was undertaken of the acceptability, reliability and validity of the survey instrument.
The OPQ tested is a 56‐item questionnaire, which was distributed to 1250 service users. Respondents were similar in respect of gender, but were older and more affluent (using a proxy measure) than non‐respondents. Item completion rates were acceptable. Respondents sometimes completed sections of the questionnaire which did not equate to their principal mode of management as recorded in the record of the contact. Preliminary evidence suggests the OPQ is a valid and reliable instrument which contains within it two discrete scales—a consultation satisfaction scale (nine items) and an “entry‐access” scale (four items). Further work is required to determine the generalisability of findings obtained following use of the OPQ, especially to non‐white user populations.
The OPQ is an acceptable instrument for capturing information on users' experiences of out‐of‐hours care. Preliminary evidence suggests it is both valid and reliable in use. Further work will report on its utility in informing out‐of‐hours service planning and configuration and standard‐setting in relation to UK national quality requirements.
PMCID: PMC2653188  PMID: 18055892
23.  [No title available] 
PMCID: PMC2464958
24.  Using computer simulation to reduce access time for outpatient departments 
Quality & Safety in Health Care  2007;16(5):382-386.
To develop general applicable models for analysing the capacity needed in appointment‐based hospital facilities.
A fairly simple analytical queuing model was used to obtain rapid global insight into the capacity needed to meet the norm of seeing 95% of all new patients within 2 weeks. For more detailed analysis, a simulation model was developed that could handle daily variations in demand and capacity schedules. The capacity needed to eliminate backlogs and the capacity needed to keep access time within 2 weeks was calculated. Both models were applied to two outpatient departments (neurology and gynaecology) at the Academic Medical Center in Amsterdam, the Netherlands. Model results for neurology were implemented.
For neurology, to eliminate the 6‐week backlog, 26 extra consultations per week were needed over 2 months. A permanent increase of 2‐weekly consultations was required to keep access time within 2 weeks. Evaluation after implementation showed the improvements the model had predicted. The gynaecology department had sufficient capacity. With the simulation, it was calculated that the same service level could be achieved with 14% less capacity. Thus the models supported decisions made for departments with shortages of capacity as well as those for departments with adequate capacity.
The analytical model provided quick insight into the extra capacity needed for the neurology department. The added value of the simulation model was the possibility of taking into account variations in demand for different weekdays and a realistic schedule for doctors' consultations. General applicability of the models was shown by applying both models to the gynaecology department.
PMCID: PMC2464959  PMID: 17913781
25.  Shared medical appointments based on the chronic care model: a quality improvement project to address the challenges of patients with diabetes with high cardiovascular risk 
Quality & Safety in Health Care  2007;16(5):349-353.
The epidemic proportions and management complexity of diabetes have prompted efforts to improve clinic throughput and efficiency. One method of system redesign based on the chronic care model is the Shared Medical Appointment (SMA) in which groups of patients (8–20) are seen by a multi‐disciplinary team in a 1–2 h appointment. Evaluation of the impact of SMAs on quality of care has been limited. The purpose of this quality improvement project was to improve intermediate outcome measures for diabetes (A1c, SBP, LDL‐cholesterol) focusing on those patients at highest cardiovascular risk.
Primary care clinic at a tertiary care academic medical center.
Patients with diabetes with one or more of the following: A1c >9%, SBP blood pressure >160 mm Hg and LDL‐c >130 mg/dl were targeted for potential participation; other patients were referred by their primary care providers. Patients participated in at least one SMA from 4/05 to 9/05.
Study design
Quasi‐experimental with concurrent, but non‐randomised controls (patients who participated in SMAs from 5/06 through 8/06; a retrospective period of observation prior to their SMA participation was used).
SMA system redesign
Analytical methods
Paired and independent t tests, χ2 tests and Fisher Exact tests.
Each group had up to 8 patients. Patients participated in 1–7 visits. At the initial visit, 83.3% had A1c levels >9%, 30.6% had LDL‐cholesterol levels >130 mg/dl, and 34.1% had SBP ⩾160 mm Hg. Levels of A1c, LDL‐c and SBP all fell significantly postintervention with a mean (95% CI) decrease of A1c 1.4 (0.8, 2.1) (p<0.001), LDL‐c 14.8 (2.3, 27.4) (p = 0.022) and SBP 16.0 (9.7, 22.3) (p<0.001). There were no significant differences at baseline between control and intervention groups in terms of age, baseline intermediate outcomes, or medication use. The reductions in A1c in % and SBP were greater in the intervention group relative to the control group: 1.44 vs –0.30 (p = 0.002) for A1c and 14.83 vs 2.54 mm Hg (p = 0.04) for SBP. LDL‐c reduction was also greater in the intervention group, 16.0 vs 5.37 mg/dl, but the difference was not statistically significant (p = 0.29).
We were able to initiate a programme of group visits in which participants achieved benefits in terms of cardiovascular risk reduction. Some barriers needed to be addressed, and the operations of SMAs evolved over time. Shared medical appointments for diabetes constitute a practical system redesign that may help to improve quality of care.
PMCID: PMC2464960  PMID: 17913775

Results 1-25 (899)