Clinical governance: its origins and its foundations

This article from the NHS Clinical Governance Support Team (NCGST) outlines the development of quality concerns since the NHS was founded in 1948. It traces the development of clinical governance as a means of achieving continuous quality improvement and describes what the implementation of clinical governance means for patients and professionals. It analyses features of the cultural shift necessary to underpin quality improvement initiatives and describes with practical examples the constituents of the culture necessary for successful clinical governance. Future articles in this series will address other issues around clinical governance and will explain the model being followed by delegates to the NCGST's Clinical Governance Development Programme as they implement clinical governance "on the ground".     

Research and continuous improvement: the merging of two entities?

Hospital administrators are under pressure to provide a quality product at reasonable prices. As a result, all aspects of hospital structure and culture are under review, which places continuous improvement (CI) programs addressing quality and satisfaction in a more prominent role. Although the theory, data collection methods, and analysis techniques of continuous improvement have grown considerably since the days of quality assurance, clinical problems in healthcare organizations are also increasingly complex and difficult to solve. From this perspective, research has a great deal to offer our current continuous improvement efforts. This paper proposes that CI and research are similar problem-solving approaches, based on philosophies that provide direction for theorizing, collecting and analyzing data, and identifying solutions. A clinical problem elaborates on the similarities of each approach. Finally, common misconceptions are discussed.     

临床输血管理质量指标体系的建立与应用

遵循科学性、系统性、可操作性原则,采用文献回顾、专家咨询和实地研究等方法,建立临床输血管理质量指标体系,建立指标监测组织,加强数据管理,开展持续改进,实现了临床输血全过程质量监管与评价,促进了临床输血质量和管理水平持续改进,达到了提高输血质量、保障患者安全的目的。     

The quality improvement-research divide and the need for external oversight

Historically, quality assurance studies have received scant ethical attention.The advent of information systems capable of supporting research-grade continuous quality improvement projects demands that we clearly define how these projects differ from research and when they require external review. The ethical obligation for the performance of quality assurance projects, with its emphasis on identifiable immediate action for a served population, is a critical distinction.The obligation to perform continuous quality improvement is a deliverable of the social contract entered into implicitly by patients and health care providers and systems. In this article, the authors review the ethical framework that requires these studies, evaluate the differences between quality assurance studies and classic research, and propose criteria for requiring external review.     

Meal rounds: an essential aspect of quality nutrition services in long-term care

INTRODUCTION AND RATIONALE: Weight change and, specifically, weight loss are common in residents of long-term care facilities (LTCFs). The occurrence of weight change results from multifactorial processes, some of which can be considered nutrition risk factors. Meal rounds can be a continuous quality improvement activity to readily identify nutrition risk factors that can influence weight change. METHODS: This brief report will describe the activity of meal rounds and how they can be used to improve nutrition services. Baseline data from a previously published study on 37 residents will provide proportions of nutrition risk factors identified during meal rounds that can influence weight change. OUTCOMES: Feeding and eating difficulties are prevalent in residents with dementia (eg, agitation 29.7%, resisting assistance 21.6%). Early identification of these difficulties using meal rounds may be a means of preventing weight change and promoting quality nutrition care in LTCFs. The proposed intervention of meal rounds conducted as described can improve the quality of nutrition services in LTCFs.     

Clinical evaluation units: a research agenda

A new model for evaluating quality rests on the tripod of outcomes research, practice pattern analysis, and the tenets of continuous quality improvement. The hospital-based locus for this tripod could be clinical evaluation units. This article describes the conceptual framework, study design, and research challenges associated with an ongoing project whose purpose is to assess the current status of these clinical evaluation units in academic medical centers nationwide.     

基于大数据和标杆分析法的市级医院病种质量评价指标构建及应用

目的 推动公立医院从粗放型管理转变为强调医疗质量和运营效率的精细化管理,引领公立医院高质量发展。方法 以循证医学理念为核心,以病种精细化管理为抓手,以医疗大数据为基础,通过文献研究、专家咨询、层次分析、模型构建、标杆分析等方法对医疗质量管理的指标体系、评价方式、运行机制进行研究。结果 构建了一种基于“病种-专科-医院”的区域分层医疗质量评价方法,开发了一套基于实时数据的标杆分析法,用于区域医疗质量的评价和持续改进,并通过信息化平台向全市市级医院展示。结论 依托上海申康医院发展中心医联工程临床大数据平台,开展从病种、专科到医院的上海市级医院医疗质量评价及促进的实证研究,为公立医院高质量发展提供了新思路。     

The empowering potential of quality improvement data.

Data are being used to redefine, transform, and empower the roles of providers, payers, and patients. The empowering potential of data on these three groups, and their changing roles are reviewed. The use of data to transform care and increase equality is not new, yet the comprehensive application of principles of continuous quality improvement to the delivery processes is just beginning. The approach to the quality improvement processes employed by peer review organizations includes idea capture, development of intuitively appealing quality indicators, formulating the intervention, formalizing the research architecture, and quantifying the impact of the interventions. The multifaceted interventions for improvement are discussed. The future of medicine includes a greater use of data and the quantitative sciences to inspire improvement across the health care delivery continuum.     

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.     

Assessing the impact of continuous quality improvement/total quality management: concept versus implementation.

OBJECTIVE: This study examines the relationships among organizational culture, quality improvement processes and selected outcomes for a sample of up to 61 U. S. hospitals. DATA SOURCES AND STUDY SETTING: Primary data were collected from 61 U. S. hospitals (located primarily in the midwest and the west) on measures related to continuous quality improvement/total quality management (CQI/TQM), organizational culture, implementation approaches, and degree of quality improvement implementation based on the Baldrige Award criteria. These data were combined with independently collected data on perceived impact and objective measures of clinical efficiency (i.e., charges and length of stay) for six clinical conditions. STUDY DESIGN: The study involved cross-sectional examination of the named relationships. DATA COLLECTION/EXTRACTION METHODS: Reliable and valid scales for the organizational culture and quality improvement implementation measures were developed based on responses from over 7,000 individuals across the 61 hospitals with an overall completion rate of 72 percent. Independent data on perceived impact were collected from a national survey and independent data on clinical efficiency from a companion study of managed care. PRINCIPAL FINDINGS: A participative, flexible, risk-taking organizational culture was significantly related to quality improvement implementation. Quality improvement implementation, in turn, was positively associated with greater perceived patient outcomes and human resource development. Larger-size hospitals experienced lower clinical efficiency with regard to higher charges and higher length of stay, due in part to having more bureaucratic and hierarchical cultures that serve as a barrier to quality improvement implementation. CONCLUSIONS: What really matters is whether or not a hospital has a culture that supports quality improvement work and an approach that encourages flexible implementation. Larger-size hospitals face more difficult challenges in this regard.     

Using scientific evidence to improve information practice

The recent policy statement of the Medical Library Association (MLA) takes the position that scientific evidence is the basis for improving the quality of library and information sciences now and in the future. Research activity is seen as the foundation of an evolving knowledge base for the profession--a knowledge base that will set health sciences librarians apart from others in an increasingly competitive world of information service providers. The statement represents the culmination of many years of activity by association members, during which the role of research in health information practice has been debated. Over a similar time period, the quality movement, with its increasing demand for the collection and use of data, has been growing. Developments such as total quality management (TQM) and continuous quality improvement (CQI) reinforce the centrality of research with its increasing demand for the collection and use of data, has been growing. Developments such as total quality management (TQM) and continuous quality improvement (CQI) reinforce the centrality of research and its relationship to efficient and effective information practice as envisioned in the MLA policy statement.     

CQI progress reports: the dashboard approach provides a better way to keep board informed about quality

Once continuous quality improvement is under way, nearly all healthcare organizations send progress reports to the board. Typically, however, the board gets a potpourri of data--from written and oral reports of quality improvement projects to clinical outcome measurements, and customer satisfaction data. That's why top executives are trying to determine more precisely what information trustees and other leaders really need. One solution is a "dashboard" of critical indicators based on the organization's strategic plan.     

The role of organizational infrastructure in implementation of hospitals' quality improvement

Quality improvement (QI) is an organized approach to planning and implementing continuous improvement in performance. Although QI holds promise for improving quality of care and patient safety, hospitals that adopt QI often struggle with its implementation. This article examines the role of organizational infrastructure in implementation of quality improvement practices and structures in hospitals. The authors focus specifically on four elements of hospital support and infrastructure for QI-integrated data systems, financial support for QI, clinical integration, and information system capability. These macrolevel factors provide consistent, ongoing support for the QI efforts of clinical teams engaging in direct patient care, thus promoting institutionalization of QI. Results from the multivariate analysis of 1997 survey data on 2350 hospitals provide strong support for the hypotheses. Results signal that organizations intent upon improving quality must attend to the context in which QI efforts are practiced, and that such efforts are unlikely to be effective unless appropriate support systems are in place to ensure full implementation.     

追踪方法学在医院评价及质量持续改进中的应用

描述了追踪方法学的基本理论和基本方法,结合具体案例,运用个案追踪和系统追踪的方法,阐释在医疗机构内就优先关注流程、优先关注内容、临床服务团队、评审流程、追踪路径等重要内容,应用追踪方法学开展评审或评价工作,以促进医疗服务质量的持续改进。     

Use of variance from clinical paths: coming of age

The introduction of critical paths, generically referred to as clinical paths, into the planning, delivery, documentation, and evaluation of patient care provided a tangible method for clinical experts to identify elements they collaboratively perceived to represent a stable, predictable, patient-care episode. Variance is the difference between the planned, stable process for a homogeneous group of patients and the actual, individual, unique care delivery experience. Building the formal use of both task (intervention) and outcome variance into a clinical path approach is fundamental to the individualization of care given concurrently and the creation of an aggregate database for retrospective evaluation, continuous quality improvement, and research. As clinical paths have become more accepted and sophisticated over the last decade, the use of variance also has evolved, albeit one step behind. Variance from length of stay and task (intervention)/resource still predominates clinical path application and literature. Real progress in healthcare practice will not be made until variances from measurable intermediate goals and patient responses and outcomes are combined with other data and transformed into knowledge. The use of variance, from past to future stages, provides a mirror of the transformation of healthcare delivery in the United States and other countries.     

Quality improvement in the healthcare industry: some evidence from Singapore

Presents an exploratory field research on all hospitals in Singapore, highlighting the different routes hospitals have adopted in pursuing their corporate quality journey for the new millennium. In general, both continuous improvement and innovation-based approaches have generated cost and time savings and helped to streamline work processes. However, the initial survey results show that innovation-based programs require a longer time frame for implementation, are more prone to resistance to change and suffer from program failure. Also, large hospitals and public hospitals are more inclined to implement innovation based approaches while medium-sized hospitals tend to use continuous improvement as a medium for quality improvement.     

医疗质量管理发展现状及展望

当前医疗质量管理的发展现状包括医疗质量实时控制、持续质量改进、IS09000质量体系认证、循证医学、临床路径等。未来医疗质量管理发屉应以超严质量要求为目标，数字化管理为基础，持续质量改进和质量管理创新为手段，科学管理和“化管理”的有机结合为根本。立足发展现状，展望医疗质量管理的未来，21世纪将是“质量的世纪”。无论对于工业产品抑或医疗产品，其超严质量要求就是“零缺陷”；其管理方式就是“零缺陷管理”。同时，将人的质量作为质量管理的核心也是一种新的管理思路，它要求医院管理更多地去关注和研究医疗行为和就医行为。     

Creation of hospital peer groups

Hospital characteristics vary greatly across a geographic area such as a state. Hospital peer groups internally exhibit similar characteristics and can be used as a basis for the analysis of data, the dissemination of information, and the adoption of continuous quality improvement project results. This paper reflects the efforts made toward the identification of hospital peer groups within the state of Michigan. Hospital characteristics data for fiscal year 1992 were obtained from the American Hospital Association's Annual Survey of Hospitals and the Health Care Financing Administration's MEDPRO database. Thirteen peer group clusters have been identified, reviewed, and commented on by the state's hospital association and have met general approval by hospital administrators across the state. The established peer groups are being used to identify the differences in patterns of care among hospitals in the state. The peer groups also are being used for the feedback of comparable data and the identification of hospitals for participation in continuous quality improvement projects. The next research objective is to experiment with other clustering techniques and other inpatient populations. The consistency of the peer groupings across all clustering techniques and across both Medicare and total inpatient populations will be studied.     

角膜塑形镜验配管理中实施质量持续改进的临床价值

目的探讨质量持续改进在角膜塑形镜验配管理中的应用效果。方法2017年3月—2019年6月,将90例眼科患者作为该次研究的目标,按照随机数字表法将其分为对照组45例(常规管理措施);观察组45例(质量持续改进管理),对比两组满意度以及管理质量。结果对比两组质量持续改进管理的满意度差异有统计学意义(P<0.05)。对比两组不良事件发生率差异有统计学意义(P<0.05)。结论通过在角膜塑形镜验配中实施质量持续改进管理,能够显著提高满意度,减少不良事件情况的发生。