From a process of care to a measure: the development and testing of a quality indicator.

This paper outlines the steps in developing and implementing process measures of quality. Developing a process measure includes defining the purpose of and audiences for the measures, choosing the clinical area to evaluate, organizing the assessment team, choosing the component of the process to measure, writing the indicator specifications, performing preliminary tests of feasibility, reliability and validity, and determining scoring and analytical specifications. Given the growing evidence in the literature regarding the impact of care, and an evolving understanding of how to develop and implement process of care measures as outlined here, the future should bring the development and implementation of quality indicators that are rigorously developed and that will provide insights into opportunities to improve the quality of care.     

The advantages and disadvantages of process-based measures of health care quality.

As consumers, payers, and regulatory agencies require evidence regarding health care qualities the demand for process of care measures will grow. Although outcome measures of quality represent the desired end results of health care, validated process of care measures provide an important additional element to quality improvement efforts, as they illuminate exactly which provider actions could be changed to improve patient outcomes. In this essay, we discuss the advantages and disadvantages of process measures of quality, and outline some practical strategies and issues in implementing them.     

The effects of quality improvement for depression in primary care at nine years: results from a randomized, controlled group-level trial

Objective

To examine 9-year outcomes of implementation of short-term quality improvement (QI) programs for depression in primary care.

Data Sources

Depressed primary care patients from six U.S. health care organizations.

Study Design

Group-level, randomized controlled trial.

Data Collection

Patients were randomly assigned to short-term QI programs supporting education and resources for medication management (QI-Meds) or access to evidence-based psychotherapy (QI-Therapy); and usual care (UC). Of 1,088 eligible patients, 805 (74 percent) completed 9-year follow-up; results were extrapolated to 1,269 initially enrolled and living. Outcomes were psychological well-being (Mental Health Inventory, five-item version [MHI5]), unmet need, services use, and intermediate outcomes.

Principal Findings

At 9 years, there were no overall intervention status effects on MHI5 or unmet need (largest F (2,41)=2.34, p=.11), but relative to UC, QI-Meds worsened MHI5, reduced effectiveness of coping and among whites lowered tangible social support (smallest t(42)=2.02, p=.05). The interventions reduced outpatient visits and increased perceived barriers to care among whites, but reduced attitudinal barriers due to racial discrimination and other factors among minorities (smallest F (2,41)=3.89, p=.03).

Conclusions

Main intervention effects were over but the results suggest some unintended negative consequences at 9 years particularly for the medication-resource intervention and shifts to greater perceived barriers among whites yet reduced attitudinal barriers among minorities.     

Perception and use of the results of patient satisfaction surveys by care providers in a French teaching hospital.

OBJECTIVE: . The aim of this study was to assess clinical staff's opinions on the results of in-patient satisfaction surveys and their use within the quality improvement process. SETTING: The institution is a 2200-bed teaching hospital of tertiary health care employing 8000 professionals. Patient satisfaction surveys are carried out each year using a validated questionnaire mailed to a random sample of patients. The specific results of each department are sent to the medical and paramedical managers. METHODS: We conducted a questionnaire survey on 500 care providers randomly selected in every medical and surgical department. RESULTS: A total of 261 questionnaires were returned and analysed. Overall, 94% of responders had a favourable opinion of the patient satisfaction surveys. They considered that the patient was able to judge hospital service quality, especially in its relational, organizational, and environmental dimensions. The specific results for the department were less well known than the overall hospital results (60 versus 76%). These results were formally discussed in the department according to 40% of responders; 40% declared that these data resulted in improvement actions and considered that they led to modifications in their behaviour with patients. CONCLUSIONS: Despite a declared interest in satisfaction surveys, the results remain underused by hospital staff and insufficiently discussed within teams.     

Continuous quality improvement in primary health care: A five year project

Background: The aim of the study was to determine the feasibilityof a programme of continuous quality improvement (CQI) in threeprimary care teams (PCTs) and to test the effectiveness of correspondenceanalysis (CA) in identifying factors contributing to qualityperformance. Methods: A CQI task force was responsible for coordinatingall aspects of the programme. Six domains of performance weredefined, each having one or more indicators. The statisticalanalysis included comparison of proportions and, in addition,CA was used to further identify which factors were contributingto a performance below the standard. Results: In the domainof infant care, two of the three PCTs reached the 100% goalon immunisation coverage. The third PCT did not attain the standard(85%). However, through CA it was possible to identify the subpopulationat risk. The proportion of pregnant women accessing pre-natalcare during the first trimester increased from the initial 20to 66% (p<0.001). Physicians' compllance with pre-natal careprotocol increased from 70 to 93% (p<0.05). Performance relatedto recording of home health care visits in medical historiesdid not improve at all, nor did the providers reach the standardfor continuing education. The medical records Information improvedfor alcohol and tobacco consumption, allergies (p<0.05),and blood pressure (p<0.05). The patients' satisfaction wasgreater with doctors than nurses. Conclusions: This experienceindicates the feasibllity and benefits of a comprehensive CQIprogramme at the primary care level. CA is considered a usefulstatistical method for locating factors contributing to qualityperformance.     

A proposed adaptation of the EFQM fundamental concepts of excellence to health care based on the PATH framework.

OBJECTIVE: The use of the European Foundation for Quality Management (EFQM) Model in health care has found that this model is useful in promoting quality improvement, but its use in health care organizations is challenging because being a generic model, it does not cover the clinical aspects or the specifics of this field. For that reason, this article aims to bring the EFQM fundamental concepts of excellence closer to health care, using a specific model as a reference to this field: the Performance Assessment Tool for quality improvement in Hospitals (PATH) conceptual framework, developed by the WHO Regional Office for Europe. METHOD: A content analysis was performed to independently identify the contents that defined the elements of both frameworks. Then, using defined criteria, two independent researchers compared the contents of the elements of both frameworks. The elements from both frameworks that were equivalent were aggregated. Several experts discussed the aspects with discrepancies between the two comparisons. Finally, the EFQM framework is adapted to health care by adding to those aggregated elements the aspects that were exclusive from one of the models. RESULTS: The EFQM framework has many correspondences to a health care-specific framework. The EFQM-health care-adapted framework has eight quality dimensions, two of them (customer focus and safety) being overlapped with the other six (staff, results orientation, responsive governance, leadership and constancy of purpose, clinical effectiveness, and partnership development). This model also has two methodological dimensions (management by processes and facts and continuous learning; improvement and innovation). CONCLUSION: This adapted model seems useful for health care organizations, but it needs to be further used to corroborate this preliminary finding.     

医疗质量持续改进的探讨

针对全球面临"患者安全"问题的挑战,明确"患者安全"是医疗质量的首要问题和最基本的要求。结合当前医疗质量存在的问题,提出医院实现质量持续改进的意见与建议。     

Implementing culture change in health care: theory and practice.

OBJECTIVES: To review some of the key debates relating to the nature of organizational culture and culture change care organizations and systems. METHODS: A literature review was conducted that covered both theoretical contributions and published studies of the processes and outcomes of culture change programmes across a range of health and non-health care settings. RESULTS: There is little consensus among scholars over the precise meaning of organizational culture. Competing claims exist concerning whether organizational cultures are capable of being shaped by external manipulation to beneficial effect. A range of culture change models has been developed. A number of underlying factors that commonly attenuate culture change programmes can be identified. Key factors that appear to impede culture change across a range of sectors include: inadequate or inappropriate leadership; constraints imposed by external stakeholders and professional allegiances; perceived lack of ownership; and subcultural diversity within health care organizations and systems. CONCLUSIONS: Managing organizational culture is increasingly viewed as an essential part of health system reform. To transform the culture of a whole health system such as the UK National Health Service would be a complex, multi-level, and uncertain process, comprising a range of interlocking strategies and supporting tactics unfolding over a period of years.     

Improving the quality of preventive cardiovascular care provided by primary care physicians: insights from a US Quality Improvement Organization.

BACKGROUND: During 2000-03, Qualidigm, a US Quality Improvement Organization, conducted a project to improve the care received by elderly Medicare patients with coronary artery disease or cardiovascular risk factors. METHODS: We recruited primary care physicians in private practice in the state of Connecticut. Then, we identified approximately 30-50 patients per physician from the periods 1 January 2000 to 31 December 2000 and 1 November 2001 to 31 October 2002. We abstracted medical records to assess processes and outcomes of care, and we provided the physicians with performance data and a variety of practice-enhancing materials. The physicians utilized those materials that they perceived to be most helpful. RESULTS: We identified and recruited 974 primary care physicians to participate. Of these, 103 (10.6%) committed to participate, and 85 of the 103 completed the project. Among the intervention tools, physicians and their office personnel utilized personal digital assistants (PDAs) (36.5%) and patient education materials (34.1%) most commonly. Overall, quality of care improved for most physicians (mean quality score 62.0 to 67.8%, P < 0.001). However, not all improved, and most improvements were modest [mean absolute improvement in quality score 5.8%, standard deviation (SD) 6.8%]. CONCLUSIONS: Quality Improvement Organizations and others interested in improving outpatient quality of care face significant challenges in recruiting self-employed primary care physicians to quality improvement projects and in bringing about transformational change. Future primary care quality improvement projects should include careful assessments of practice-specific barriers, interventions that are linked to these barriers, and support of the practices on implementation.     

Validating risk-adjusted surgical outcomes: chart review of process of care.

OBJECTIVE: The primary purpose of this study was to validate risk-adjusted surgical outcomes as indicators of the quality of surgical care at US Department of Veterans Affairs (VA) hospitals. The secondary purpose was to validate the risk-adjustment models for screening cases for quality review. DESIGN: We compared quality of care, determined by structured implicit chart review, for patients from hospitals with higher and lower than expected operative mortality and morbidity (hospital-level tests) and between patients with high and low predicted risk of mortality and morbidity who died or developed complications (patient-level tests). SUBJECTS: 739 general, peripheral vascular and orthopedic surgery cases sampled from the 44 VA hospitals participating in the National VA Surgical Risk Study. MAIN OUTCOME MEASURES: A global rating of quality of care based on chart review. RESULTS: Ratings of overall quality of care did not differ significantly between patients from hospitals with higher and lower than expected mortality and morbidity. On some of the secondary measures, patient care was rated higher for hospitals with lower than expected operative mortality. At the patient level of analysis, those who died or developed complications and had a high predicted risk of mortality or morbidity were rated higher on quality of care than those with a low predicted risk of adverse outcome. CONCLUSIONS: The absence of a relationship between most of our measures of process of care and risk-adjusted outcomes may be due to an insensitivity of chart reviews to hospital-level differences in quality of care. Site visits to National VA Surgical Risk Study hospitals with high and low risk-adjusted mortality and morbidity have detected differences on a number of dimensions of quality. The patient-level findings suggest that the risk-adjustment models are useful for screening adverse outcome cases for quality of care review.     

Quality of primary health care in Saudi Arabia: a comprehensive review.

OBJECTIVES: Little is known about the quality of primary care in Saudi Arabia, despite the central role of primary care centers in Saudi health strategy. This study presents an overview of quality of primary care in Saudi Arabia, and identifies factors impeding the achievement of quality, with the aim of determining how the quality of Saudi primary care could be improved. METHOD: Using a systematic search strategy, data were extracted from the published literature on quality of care in Saudi primary care services, and on barriers to achieving high-quality care. RESULTS: Of the 128 studies initially identified, 31 met the inclusion criteria for the review. Studies identified were diverse in methodology and focus. Components of quality were reviewed in terms of access and effectiveness of both clinical and interpersonal care. Good access and effective care were reported for certain services including: immunization, maternal health care, and control of epidemic diseases. Poor access and effectiveness were reported for chronic disease management programs, prescribing patterns, health education, referral patterns, and some aspects of interpersonal care including those caused by language barriers. Several factors were identified as determining whether high-quality care was delivered. These included management and organizational factors, implementation of evidence-based practice, professional development, use of referrals to secondary care, and organizational culture. CONCLUSION: There is substantial variation in the quality of Saudi primary care services. In order to improve quality, there is a need to improve the management and organization of primary care services. Professional development strategies are also needed to improve the knowledge and skills of staff.     

Quality circles in ambulatory care: state of development and future perspective in Germany.

OBJECTIVE: To survey the quantitative development of quality circles (peer review groups; QC) and their moderators in ambulatory care in Germany, to describe approaches to documentation and evaluation, to establish what types of facilities and support is available and to assess opinions on the future importance of QC. DESIGN: Cross-sectional survey using a standardized questionnaire and supplementary telephone interviews. SETTING: All 23 German regional Associations of Statutory Health Insurance Physicians (ASHIP) were surveyed. RESULTS: The total number of QC in ambulatory care in Germany increased rapidly from 16 in 1993 to 1633 in June 1996, with about 17% (range 1.0-52.1%) of all practicing physicians (112 158) currently involved. Throughout Germany, 2403 moderators were trained in 168 training courses by the qualifying date. Follow-up meetings were held or being planned in 20 ASHIP, with approximately 39% (23-95%) of the moderators participating. Systematic documentation of QC work was undertaken or planned in all 23 ASHIIP, and 10 ASHIP carried out comparative evaluation, with at least five others planning to start it. The ASHIP promoted the work of QC by providing organizational (22) or financial (20) support, materials (20) or mediation of resource persons (16). Eleven ASHIP received grants from drug companies. ASHIP rated the future importance of QC as increasing (18) or stable (four), but in no case as decreasing. CONCLUSIONS AND RECOMMENDATIONS: The quantitative growth of QC in Germany is encouraging, but the extent of support and evaluation appears insufficient. Increased methodological support and facilitation, follow-up meetings on a more regular basis, improved documentation and evaluation of individual QC, and problem oriented evaluation of their impact on health care are essential for further successful development. Principles, problems and solutions discussed may be relevant for similar QI activities in other countries.     

Identifying opportunities to improve the management of care: a population-based diagnostic methodology

The growth of managed care and specifically capitation will dramatically change the basis of competition for health care providers. In order for medical groups to succeed in this new environment they must be able to accept the accountability for both managing the care of populations and managing the delivery of individual encounters of care. Being held accountable for the management of populations will require at-risk medical groups to focus on developing three entirely new strategic capabilities: the assessment of health risk, the management of access, and the management of care. This article describes the analytic approach of Deloitte & Touche Consulting Group's population-based diagnostic methodology, which will enable an at-risk organization to identify opportunities for improving the management of care for specific populations and diseases. The hypotheses driving the need for these organizations to establish population-based care management capabilities stem from the plethora of empirical evidence indicating significant variation in costs, utilization, and outcomes in the practice of medicine. Applying a systematic, planned approach to caring for patients who have common, predictable health care needs will result in better outcomes and lower costs for all.     

Policymaker use of quality of care information.

OBJECTIVE: This study describes public policymakers' experiences with the feasibility of using information from quality of care assessment activities. The objective is to improve the ability to match quality evaluation tools with policymakers' information needs. DESIGN: US state administrative policymakers were interviewed about use of quality of care information and knowledge, attitudes, and experiences with information from specific types of measures. PARTICIPANTS: A purposive sample of 82 key informants from Medicaid program administrations in 48 states. MAIN MEASURE: Users of information from each of eight targeted types of quality of care measurement methods were compared with non-users based upon their levels of knowledge, perceived characteristics of quality of care information, and perceived characteristics of the policy situation. RESULTS: Participants indicated that some types of quality measurement methods have been useful, whereas others have not. Extent of quality assessment information use, and the measurement methods utilized, varied widely. Two factors were associated with the use of information from particular quality assessment methods: information needs of the policymakers and their perceptions of the characteristics, including strengths and weaknesses, of particular measurement methods. CONCLUSIONS: These policymakers had positive attitudes about quality assessment, were knowledgeable about types of methods, and had a variety of potential uses for quality-related information. Yet, perceptions and experiences with different types of measurement methods varied. We describe a set of quality assessment methods with complementary characteristics that could provide a relatively inclusive picture of quality of care and better address policymaker information needs.     

Evaluating implementation of quality management systems in a teaching hospital's clinical departments.

OBJECTIVES: This study evaluated a strategy for implementing continuous quality improvement based on a decentralized quality management system in the clinical departments of a hospital. SETTING: The institution is a 2000-bed teaching hospital of tertiary health care employing 8000 people. METHODS: The quality management intervention was tested in six volunteer departments. This intervention comprised an instructional seminar, methodological assistance, and the dissemination of guidelines. The program was evaluated 1 year after the intervention and included a quality audit, interviews with department staff, and analysis of the written documents produced by the departments. RESULTS: The quality management systems are functioning in all the departments. Quality teams meet regularly and multidisciplinary work groups are in place. The topics most often addressed are patient reception and communication between department staff members. The level of compliance with the guidelines has increased, from 39% before the seminar to 54% 1 year later (P < 0.05). All of the staff members interviewed judged the process useful for them and for the department, while waiting for the concrete results. Among the difficulties the staff members encountered were changing their work habits, lack of time, and the tedious aspect of writing procedures. CONCLUSION: Implementing continuous quality improvement in hospital departments seems to be an interesting alternative to organization-wide implementation strategies. However, these results need to be confirmed by long-term evaluations and by deploying the program i n other departments.     

Patient questionnaires in primary health care. Validation of items used in asthma care.

OBJECTIVE: To evaluate each item in a patient questionnaire for the purpose of investigating whether the validity of each item is acceptable. DESIGN: The questionnaire was completed by the patients at an ordinary follow-up visit for their asthma, and within 1 week a nurse interviewed them by telephone with the aim of analysing the validity of each item through the use of predetermined criteria. SETTINGS: Patients with asthma in primary health care settings in Sweden. STUDY PARTICIPANTS: Fifty-one patients were consecutively included from three different primary health care units. RESULTS: Nine of 13 items had an acceptable validity. The four items that were not found to have acceptable validity were developed further. CONCLUSION: Evaluating each item in a questionnaire by means of interviews with the specific patient population is a useful method of assuring that the intention of the patient questionnaire has been met.     

Development of a Healthcare Quality Improvement Measurement Tool: Results of a Content Validity Study

Current methods of measuring continuous quality improvement (CQI) implementation are too long and not comprehensive. A new survey for CQI implementation was developed and tested for content validity using a panel of 8 experts—7 from the United States and 1 from England. The survey was reduced from 70 items to 22. The resultant survey had a clarity interrater agreement (IR) of .91, a representativeness IR of .93, a clarity content validity index (CVI) of .73, and a representativeness CVI of .91. Content validity served as an excellent data reduction method in building a valid, concise, and comprehensive measure of CQI implementation.     

Issues in the assessment of continuous quality improvement implementation in health care organizations.

OBJECTIVE: This paper has two primary aims. First, it examines the need for improved assessment of continuous quality improvement implementation. Second, it analyzes current worldwide measures and studies of continuous quality improvement implementation. METHOD: A comprehensive literature review was conducted which included all published (English language) studies of organization-wide continuous quality improvement implementation. RESULTS: Analysis of the content and research methods incorporated into current measures of continuous quality improvement implementation used worldwide supports a strong consensus regarding the major criteria that need to be addressed. However, there are still promising areas for future research, namely increased use of criteria other than the Baldrige categories, increased focus upon financial variables, improved measures of implementation stage/phase and the use of different types of respondents from multiple organizational levels. CONCLUSION: Increased understanding of the empirical benefits and costs of continuous quality improvement in health care organizations is heavily contingent upon the continued development and improvement of measures of continuous quality improvement implementation.