Total quality training in the hospital setting

Total quality management requires a commitment to continuous quality improvement and a complete transformation of a healthcare organization's operations. An ongoing process, it prescribes training at all levels of an organization's hierarchy as well as the routine evaluation of the training programs' quality.     

Early readmission as an indicator of hospital quality of care

BACKGROUND: The purpose of this study was to assess early readmission as an indicator of quality of care, to estimate the frequency of avoidable emergency readmission in a French hospital, and then to describe the feasibility and contribution of routine use of this indicator. METHODS: A randomly selected sample of 469 readmissions within 30 days after a conventional hospitalization was chosen among the database of 40,242 hospitalizations during the first half of 1997. Two independent practitioners, whose true agreement was measured with a kappa test, studied the features of readmission recorded on the patient files, classing them as "unforeseeable" or "potentially avoidable". Database criteria that could automatically class the readmission in either group were analyzed. RESULTS: There were 119 unforeseeable readmissions (25.4%). The two physicians agreed on the unforeseeable nature of 97 of these readmissions and 50 of them were judged avoidable. None of the database criteria allowed identifying all unforeseeable and avoidable readmissions. Readmission via the emergency unit was a sure indicator of unforeseeable readmission in 66% of the cases and of avoidable readmissions in 60%. The frequency of unforeseen readmissions was estimated at 3.9% of all conventional stays during the first half of 1997. The frequency of avoidable readmissions was 1.5%. CONCLUSIONS: Unforeseen early readmission can be an indicator of quality of the care taking process. It is however impossible to use the current database to classify with certainty readmissions as "unforeseeable" or "avoidable". Emergency unit readmission could offer a possible approach to measuring the frequency of unforeseen readmission. This ratio can provide caretakers with information concerning the quality of care and thus help in making decisions concerning reorganization for improvement.     

AIDS patients' perceptions of nursing care quality

The authors propose a model, adapted from literature on quality in health care and services marketing, that identifies dimensions of quality in nursing care for persons with AIDS. In focus groups, respondents expressed concern about structural factors such as formal hospital practices, and process factors, which include nurses' knowledge of AIDS treatment and issues, their use of universal precautions, discrimination issues, expressions of empathy, and provision of health status information to the patient.     

Palliative care: community nurses' perceptions of quality

OBJECTIVES: To identify community nurses' perceptions of quality care provision for patients requiring palliative care. DESIGN: Semi-structured interviews were conducted with community nurses working within the district nursing service. An adaptation of Flanagan's critical incident technique was employed to elicit factors associated with high or poor quality palliative care. Interviews were tape recorded and transcribed. Data were analysed using thematic content analysis, recurrent themes being agreed by the research team. SETTING: One community healthcare trust. SUBJECTS: 62 members of the district nursing team (grades B-H). RESULTS: Respondents recounted the context in which high quality palliative care could be provided, the actions required, and the indicators that suggested the desired level of care had been achieved. Key factors identified were: the early referral of patients to the district nursing service, family circumstances, the availability of time, the accessibility of services and equipment, and the relationship with other healthcare professionals and informal carers. There was a general view that a positive outcome had been achieved when patients retained control over their circumstances and died a peaceful death, in the place of their choice, supported by their family. CONCLUSIONS: Community nurses were able to articulate clearly the essential components of high quality care. Whilst these factors do not represent a comprehensive list, they are put forward as a useful starting point for standard setting and subsequent audit.     

Perceived quality of hospital care.

Physicians, nurses, and consumers in the New York City area were asked to indicate which of 76 acute-care hospitals they would be willing to be patients in if they became seriously ill. Percentages of favorable judgments ranged from a high of 95% for one university hospital to a low of less than 10% for a community hospital. Over half of all responding physicians, nurses, and consumers indicated that they would not wish to be a patient in the majority of the 76 hospitals sampled. Although a high degree of consistency (r = .93) was observed among all three types of respondents, physicians were on the average significantly more pessimistic (X percentage of favorable judgments = 34) than nurses and consumers. All three groups indicated a statistically significant (p less than .001) preference for larger hospitals as well as institutions that were affiliated with a medical school in some way.     

Inter-regional competition and quality in hospital care

This study analyzes the effect of episode-of-care payment and patient choice on waiting time and the comprehensive quality of hospital care. The study assumes that two hospitals are located in two cities with different population sizes and compete with each other. We find that the comprehensive quality of hospital care as well as waiting time of both hospitals improve with an increase in payment per episode of care. However, we also find that the extent of these improvements differs according to the population size of the cities where the hospitals are located. Under the realistic assumptions that hospitals involve significant labor-intensive work, we find the improvements in comprehensive quality and waiting time in a hospital located in a small city to be greater than those in a hospital located in a large city. The result implies that regional disparity in the quality of hospital care decreases with an increase in payment per episode of care.     

TOPSIS法在医院护理质量评价中的应用研究

目的对医疗护理工作质量做出客观的评价,为医院管理部门制订决策提供科学的依据。方法应用TOPSIS法对笔者所在医院2004-2008年度完成的护理质量指标进行综合评价和分析。结果评价结果与医院5年来护理实际工作情况相符,护理综合质量呈逐年上升趋势,2004年〈2005年〈2006年〈2007年〈2008年。2004年最差,2008年最佳。结论用TOPSIS法评价医院护理质量具有计算简便、结果合理、应用灵活、实用性强的特点。     

Service quality perceptions in primary health care centres in Greece

Context The paper refers to the increased competition between health care providers and the need for patient‐centred services in Greece. Using service quality methodology, this paper investigates service quality perceptions of patients in Greek public primary health centres. Objective To test the internal consistency and applicability of SERVQUAL in primary health care centres in Greece. Strategy SERVQUAL was used to examine whether patients have different expectations from health care providers and whether different groups of patients may consider some dimensions of care more important than others. Results The analysis showed that there were gaps in all dimensions measured by SERVQUAL. The largest gap was detected in empathy. Further analysis showed that there were also differences depending on gender, age and education levels. A separate analysis of expectations and perceptions revealed that this gap was because of differences in patients’ perceptions rather than expectations. Discussion and conclusions This paper raises a number of issues that concern the applicability of SERVQUAL in health care services and could enhance current discussions about SERVQUAL improvement. Quality of health care needs to be redefined by encompassing multiple dimensions. Beyond a simple expectations–perceptions gap, people may hold different understandings of health care that, in turn, influence their perception of the quality of services.     

Discriminating quality of hospital care in the United States.

BACKGROUND AND OBJECTIVE: The Centers for Medicare and Medicaid Services (CMS) report quality of care for patients hospitalized with acute myocardial infarction (AMI), congestive heart failure (CHF), and community-acquired pneumonia (CAP) with the intention of rewarding superior performing hospitals. The aim of the study was to compare identification of superior hospitals for providing financial rewards using 2 different scoring systems: a latent score that weights individual clinical performance measures according to how well each discriminated hospital quality and a raw sum score (the system adopted by CMS). METHODS: This observational cohort study used 2761 acute care hospitals in the United States reporting AMI clinical performance measures, 3271 reporting CHF measures, and 3714 hospitals reporting CAP measures. For each clinical condition, the main outcome measures included the average raw sum score, the latent score estimated from an item response theory (IRT) model, and the percentage of false negative superior designations made on the basis of raw sum scores relative to latent scores. RESULTS: The average raw sum score was highest for AMI (88.8%) and lower for CHF (73.1%) and CAP (76.3%). AMI measures were equally nondiscriminating of hospital quality; hospital discharge instruction was most discriminating of CHF quality; pneumococcal vaccination was most discriminating of CAP quality. False negative rates varied 2-fold: AMI (10%), CHF (16%), and CAP (24%). CONCLUSIONS: Neither the AMI raw sum score nor latent score discriminates hospital quality due to ceiling effects. Current methods for aggregating measures result in different hospital superior designations than those based on the latent score. Organizations that financially reward hospitals on the basis of such scores need to assess predictive validity of scores and determine a minimum level of classification accuracy.     

Patient judgment of the quality of ambulatory care in a Japanese setting

OBJECTIVE: To assess patient satisfaction with a hospital-based ambulatory service in Japan and define the determinants of satisfaction and the patient's intention to return to the service. DESIGN: A questionnaire was developed to measure overall satisfaction, intention to return to the service, patient judgment about the structure/process of the service, patient perception about the global reputation of the service, and other health-related items. The questionnaire was mailed to patients attending the ambulatory service. SETTING AND PATIENTS: All non-psychiatric patients who used the ambulatory service of a 350-bed general hospital in Tokyo in the sampling days were asked to participate. The response rate was 77.2% (1,307 responses). Of these, 1,074 non-proxy and non pediatric responses were used for the main analysis. RESULTS: Based on content analysis and factor analysis, scores for the service components were constructed and found to have high internal consistency and reliability. The results indicated several important points regarding the use of patients' evaluation of ambulatory services as a quality monitoring tool. It was shown that patients' overall satisfaction and intention to return to the same physician were determined primarily by their evaluation of their doctor's conduct and their perceived health outcome. The perceived reputation of the service also was a significant determinant of patient satisfaction and intention to return. Patient satisfaction and intention to return to the hospital were influenced also by non-physician factors such as nurses, clerks, and environmental comforts. Notably, patient intention to return was linked with patient perceived need of care and regularity of care. In multiple-regression results, patient satisfaction with the doctor and with the hospital had different determinants.     

Physician-reviewers' perceptions and judgments about quality of care.

OBJECTIVE: Although Peer Review Organizations (PROs) and researchers rely on physicians to assess quality of care, little is known about what physicians think about when they judge quality. We sought to identify features of individual cases that are associated with physicians' judgments. DESIGN: Using 1994 Medicare data, we selected hospitalizations for 1134 beneficiaries in 42 acute care hospitals in California and Connecticut. The sample was enriched with 17 surgical and six medical complications identified using diagnosis and procedure codes. PRO physicians confirmed quality problems using a structured implicit chart review instrument and provided written open-ended comments about each case. We coded physicians' comments for factors presumed to influence judgments about quality. RESULTS: In crude and adjusted comparisons, reviewers questioned quality more frequently in cases with serious or fatal outcomes, technical mishaps and inadequate documentation. Among surgical (but not medical) patients, they were less likely to record poor quality among patients presenting with an acute illness. CONCLUSION: Factors other than the adequacy of key processes of care are associated with physician-reviewers' judgments about quality.