Development of an indicator system for evaluating the quality of health care services

Indicator system development for evaluating the quality of health services. The National Health Insurance Fund of Hungary introduces indicators for evaluating the quality of health services. The new system starts by the end of 2003 on the Internet and it will be updated and improved on a regular base. The quality indicators provide possibility to compare the health services and follow up the changes. The Hungarian indicators came from those indicators, which are described, tested and used in the international literature and practice. The data derive from the routinely collected financial data of the National Health Insurance Fund. The conclusions drawn form the results will be arranged and interpreted according to the types of indicators. Those providers whose have out of the ordinary values should fill in a standardized questionnaire--which was developed with the representatives of the certain profession--for explaining the results and define quality improvement plan. The aim of the programme is to increase transparency of health services, to enhance quality improvement and to support the certification and accreditation programmes.     

Meeting the requirements of importing countries: practice and policy for on-farm approaches to food safety

In light of the increasing consumer demand for safe, high-quality food and recent public health concerns about food-borne illness, governments and agricultural industries are under pressure to provide comprehensive food safety policies and programmes consistent with international best practice. Countries that export food commodities derived from livestock must meet both the requirements of the importing country and domestic standards. It is internationally accepted that end-product quality control, and similar methods aimed at ensuring food safety, cannot adequately ensure the safety of the final product. To achieve an acceptable level of food safety, governments and the agricultural industry must work collaboratively to provide quality assurance systems, based on sound risk management principles, throughout the food supply chain. Quality assurance systems on livestock farms, as in other parts of the food supply chain, should address food safety using hazard analysis critical control point principles. These systems should target areas including biosecurity, disease monitoring and reporting, feedstuff safety, the safe use of agricultural and veterinary chemicals, the control of potential food-borne pathogens and traceability. They should also be supported by accredited training programmes, which award certification on completion, and auditing programmes to ensure that both local and internationally recognised guidelines and standards continue to be met. This paper discusses the development of policies for on-farm food safety measures and their practical implementation in the context of quality assurance programmes, using the Australian beef industry as a case study.     

Quality indicators for health promotion programmes

Methods for systematically following up and auditing health promotion have been in demand for a considerable period of time. Quality assurance as an auditing method has opened up new opportunities in this area. On the basis of Donabedian's 'triad' of structure, process and outcome, the theoretical preconditions for and implementation of a number of successful health promotion programmes/ projects have been analysed with regard to their common characteristics. These characteristics have been generalized and then transformed into indicators of a successful health promotion programme/project. To ensure the practical applicability of the quality indicators, they were operationalized in what we call a 'question pro-forma'. Any negative response to a question on the pro-forma indicates quality defects in a programme, and any positive response the opposite. The 'template' can be employed for both the planning and auditing for quality assurance on health promotion programmes and projects. The question pro-forma has been tested successfully on a number of programmes and projects. The results from one study are shown in the article.     

Evaluation of national malaria control programmes in Africa.

Evaluation is an essential management tool for the improvement of public health programmes or projects. As malaria morbidity and mortality continue to increase in most countries in Africa, international agencies and malaria control programme managers have identified the strengthening of programme evaluation as an important strategy for improving the efficiency and effectiveness of malaria control programmes. Managers can develop an evaluation strategy only after they have defined programme objectives and planned specific programme activities. Indicators should be directly related to programme objectives and should be selected on the basis of the following criteria: their validity; reliability; ability to detect change within a reasonable time period and as a result of successful programme implementation; ability to be interpreted; and usefulness in guiding programme change. Only those indicators that can be measured with available programme resources should be selected. Managers will also need to identify the sources of indicator data and to determine how often each indicator will be measured. Programme managers should develop criteria or indicators for the following: programme policies and plans; the process of programme implementation; the outcomes of malaria control interventions in disease management and prevention; and programme impact in terms of reductions in malaria-related mortality and morbidity. Key issues related to the management of evaluation activities within a national programme include the need to begin with available resources and build incrementally; to explore options for administering evaluation activities; to select, train and supervise staff who carry out evaluation activities; to develop quality control strategies; and to ensure that data are managed and communicated in ways that support effective programme decision-making. For evaluation to lead to improvements in malaria control programmes it must be clearly defined as a part of the programme management process. Programme managers should lead this developmental process, ensuring that evaluation methods produce the information they need to monitor and improve their programmes at reasonable cost.     

Strengthening environmental and educational nutrition programmes in worksite cafeterias and supermarkets in The Netherlands

The purpose of this study was to assess conditions for the adoption and continued implementation of different healthy nutrition programmes in worksite cafeterias and supermarkets, i.e. an educational programme and two environmental programmes (a food labelling programme and a food supply programme). Twenty semi-structured interviews were conducted with representatives of worksite cafeterias and supermarkets. Concepts of theories of diffusion were used as a framework for the study. Questions were formulated about the attributes of the innovation, and organizational and personal characteristics that might influence programme adoption and implementation. Results indicated that educational and environmental programmes in both worksite cafeterias and supermarkets should meet specific requirements regarding programme design, methods and materials in order to be adopted and implemented. Besides, some important implementation strategies of the educational and environmental programmes were identified. It is concluded that it seems feasible to conduct educational and environmental intervention programmes in worksite cafeterias and supermarkets, but that certain conditions for adoption and continued implementation have to be met. Based on the implications of this study, the development of an educational programme, a labelling programme and a food supply programme was completed.     

Dynamic Assessment in Disease Management

The effectiveness of disease management programmes hinges on a combination of factors, all of which are important to consider when selecting a programme for implementation. This article provides a brief overview of disease management programmes commonly found in healthcare organisations, highlighting the issue of programme effectiveness.Seven factors critical to the design and development of an effective disease management programme are outlined to guide practitioners and healthcare managers who are responsible for making decisions about such programmes. These decision factors are: (i) defining and establishing programme goals; (ii) defining a target population; (iii) selecting measures of programme success; (iv) determining data availability and information systems capability; (v) deciding to build or buy all or parts of a programme; (vi) determining and enhancing the level of physician involvement; and (vii) selecting strategies to enhance organisational support. Careful consideration of these factors in the decision stage for a disease management programme will help ensure effective and appropriate programme development and implementation. Healthcare managers applying these considerations will be better able to develop disease management programmes that achieve their objectives and provide a foundation for organisational success.     

An implementation study of two evidence-based exercise and health education programmes for older adults with osteoarthritis of the knee and hip

Implementation studies are recommended to assess the feasibility and effectiveness in real-life of programmes which have been tested in randomized controlled trials (RCTs). We report on an implementation study of two evidence-based exercise and health education programmes for older adults with osteoarthritis (OA) of the knee or hip. Three types of primary health-care providers (n = 18) delivered the OA Knee programme (n = 20) and the OA Hip programme (n = 20), supported by programme manuals and implementation guidelines, in four regions. The outcome measures were pain and mobility. The Knee programme had OA knowledge and self-efficacy as additional outcome measures. Differences in outcome measures and background variables of participants were assessed between the RCTs and the implementation study. Positive effects (P < 0.05) were found for OA knowledge, pain and self-efficacy in the Knee programme (n = 157), and for pain in the Hip programme (n = 132). No effect was found for mobility. Effect sizes of the RCTs and the present study were comparable. Background variables did not explain the variance in the outcome measures. The outcomes of the previous RCTs and the implementation study were comparable, and indicated the ecological validity of the two programmes. The implications for nationwide dissemination and implementation in The Netherlands are discussed.     

Support for health promoting schools: a typology of supporting strategies in Austrian provinces

Schools that want to implement health promotion (HP) are often confronted with obstacles that they cannot overcome by themselves and therefore need support from their environment. However, the issue of which kind of support is needed for HP implementation is complex. A systems approach suggests that the individual logic of each school be considered and that supporting strategies be flexible to specific needs. This article pursues the question which types of support for health promoting schools are offered on a provincial level in Austria. Using a grounded theory approach, 18 in-depth interviews with representatives of provincial organizations and 26 documents relevant for school HP were analysed. As a result, five different strategies of supporting health promoting schools have been identified in Austria: (i) organize exchange among schools, (ii) establish certification and quality control of school health efforts, (iii) offer consultation and information, (iv) carry out a specific HP programme and (v) coordinate HP actors and information. These strategies are usually combined and rarely occur in their pure form. It was also determined that the coordination of the different strategies and human resources for HP are missing for schools in Austria. It is argued that each of these supporting strategies has benefits and limitations for schools and the providers, and that they all have the potential to respond to the school as a complex social system.     

Oral health information systems--towards measuring progress in oral health promotion and disease prevention

This article describes the essential components of oral health information systems for the analysis of trends in oral disease and the evaluation of oral health programmes at the country, regional and global levels. Standard methodology for the collection of epidemiological data on oral health has been designed by WHO and used by countries worldwide for the surveillance of oral disease and health. Global, regional and national oral health databanks have highlighted the changing patterns of oral disease which primarily reflect changing risk profiles and the implementation of oral health programmes oriented towards disease prevention and health promotion. The WHO Oral Health Country/Area Profile Programme (CAPP) provides data on oral health from countries, as well as programme experiences and ideas targeted to oral health professionals, policy-makers, health planners, researchers and the general public. WHO has developed global and regional oral health databanks for surveillance, and international projects have designed oral health indicators for use in oral health information systems for assessing the quality of oral health care and surveillance systems. Modern oral health information systems are being developed within the framework of the WHO STEPwise approach to surveillance of noncommunicable, chronic disease, and data stored in the WHO Global InfoBase may allow advanced health systems research. Sound knowledge about progress made in prevention of oral and chronic disease and in health promotion may assist countries to implement effective public health programmes to the benefit of the poor and disadvantaged population groups worldwide.     

The Parent Programme Implementation Checklist (PPIC): The Development and Testing of an Objective Measure of Skills and Fidelity for the Delivery of Parent Programmes

ABSTRACT

Background: Group-based parent programmes demonstrate positive benefits for adult and child mental health, and child behaviour outcomes. Greater fidelity to the programme delivery model equates to better outcomes for families attending, however, fidelity is typically self-monitored using programme specific checklists. Self-completed measures are open to bias, and it is difficult to know if positive outcomes found from research studies will be maintained when delivered in regular services. Currently, ongoing objective monitoring of quality is not conducted during usual service delivery. This is odd given that quality of other services is assessed objectively, for example by the Office for Standards in Education, Children's Services and Skills (OFSTED). Independent observations of programme delivery are needed to assess fidelity and quality of delivery to ensure positive outcomes, and therefore justify the expense of programme delivery.

Methods: This paper outlines the initial development and reliability of a tool, the Parent Programme Implementation Checklist (PPIC), which was originally developed as a simple, brief and generic observational tool for independent assessment of implementation fidelity of group-based parent programmes. PPIC does not require intensive observer training before application/use. This paper presents initial data obtained during delivery of the Incredible Years BASIC programme across nine localities in England and Wales, United Kingdom (UK).

Results: Reasonable levels of inter-rater reliability were achieved across each of the three subscales (Adherence, Quality and Participant Responsiveness) and the overall total score when applying percentage agreements (>70%) and intra-class correlations (ICC) (ICC range between 0.404 and 0.730). Intra-rater reliability (n?=?6) was acceptable at the subscale level.

Conclusions: We conclude that the PPIC has promise, and with further development could be utilised to assess fidelity of parent group delivery during research trials and standard service delivery. Further development would need to include data from other parent programmes, and testing by non-research staff. The objective assessment of quality of delivery would inform services where improvements could be made.     

Global Health Diplomacy, ‘Smart Power’, and the New World Order

Both the theory and practice of foreign policy and diplomacy, including systems of hard and soft power, are undergoing paradigm shifts, with an increasing number of innovative actors and strategies contributing to international relations outcomes in the ‘New World Order’. Concurrently, global health programmes continue to ascend the political spectrum in scale, scope and influence. This concatenation of circumstances has demanded a re-examination of the existing and potential effectiveness of global health programmes in the ‘smart power’ context, based on adherence to a range of design, implementation and assessment criteria, which may simultaneously optimise their humanitarian, foreign policy and diplomatic effectiveness. A synthesis of contemporary characteristics of ‘global health diplomacy’ and ‘global health as foreign policy’, grouped by common themes and generated in the context of related field experiences, are presented in the form of ‘Top Ten’ criteria lists for optimising both diplomatic and foreign policy effectiveness of global health programmes, and criteria are presented in concert with an examination of implications for programme design and delivery. Key criteria for global health programmes that are sensitised to both diplomatic and foreign policy goals include visibility, sustainability, geostrategic considerations, accountability, effectiveness and alignment with broader policy objectives. Though diplomacy is a component of foreign policy, criteria for ‘diplomatically-sensitised’ versus ‘foreign policy-sensitised’ global health programmes were not always consistent, and were occasionally in conflict, with each other. The desirability of making diplomatic and foreign policy criteria explicit, rather than implicit, in the context of global health programme design, delivery and evaluation are reflected in the identified implications for (1) international security, (2) programme evaluation, (3) funding and resource allocation decisions, (4) approval systems and (5) training. On this basis, global health programmes are shown to provide a valuable, yet underutilised, tool for diplomacy and foreign policy purposes, including their role in the pursuit of benign international influence. A corresponding alignment of resources between ‘hard’ and ‘smart’ power options is encouraged.     

Cost and results of information systems for health and poverty indicators in the United Republic of Tanzania

OBJECTIVE: To examine the costs of complementary information generation activities in a resource-constrained setting and compare the costs and outputs of information subsystems that generate the statistics on poverty, health and survival required for monitoring, evaluation and reporting on health programmes in the United Republic of Tanzania. METHODS: Nine systems used by four government agencies or ministries were assessed. Costs were calculated from budgets and expenditure data made available by information system managers. System coverage, quality assurance and information production were reviewed using questionnaires and interviews. Information production was characterized in terms of 38 key sociodemographic indicators required for national programme monitoring. FINDINGS: In 2002-03 approximately US$ 0.53 was spent per Tanzanian citizen on the nine information subsystems that generated information on 37 of the 38 selected indicators. The census and reporting system for routine health service statistics had the largest participating populations and highest total costs. Nationally representative household surveys and demographic surveillance systems (which are not based on nationally representative samples) produced more than half the indicators and used the most rigorous quality assurance. Five systems produced fewer than 13 indicators and had comparatively high costs per participant. CONCLUSION: Policy-makers and programme planners should be aware of the many trade-offs with respect to system costs, coverage, production, representativeness and quality control when making investment choices for monitoring and evaluation. In future, formal cost-effectiveness studies of complementary information systems would help guide investments in the monitoring, evaluation and planning needed to demonstrate the impact of poverty-reduction and health programmes.     

Does money matter for mental health? Evidence from the Child Support Grants in Johannesburg, South Africa

Globally, the poor are consistently at greater risk of suffering from depression and anxiety. Yet in resource-poor countries, mental health remains a neglected topic. This interdisciplinary study explored the potential for a poverty alleviation programme to contribute to breaking the vicious cycle between poverty and common mental disorders (CMD). Quantitatively, beneficiaries of a cash-transfer programme were found to have a lower risk of CMD. Qualitative interviews indicated that Child Support Grants acted as a psychological safety net, but that negative stereotypes of grant recipients could detract from the positive mental health outcomes of the grants. It was concluded that poverty alleviation programmes such as cash transfers could have both positive and negative impacts on mental health. In order to achieve mental health benefits for programme beneficiaries, aspects of programme design and implementation that promote mental health should be enhanced and aspects detrimental to mental health modified.     

Overview of the clinical application of regenerative medicine products in Japan

OBJECTIVE: To identify barriers to the clinical application of regenerative medicine products (RMPs) in Japan. METHODS: Current Japanese regulatory systems and guidelines were compared with those of the United States (US) and the European Union (EU). A questionnaire was administered to representatives from 23 Japanese companies and 10 research institutes, and an in-person semi-structured interview was conducted with representatives from 10 companies that develop RMP. RESULTS: We found that Japan, the US and the EU have similar pre-clinical safety guideline frameworks relating to RMP. However, differences exist between these countries with respect to their review and approval systems and the implementation of guidelines, and these represent major barriers to the clinical application of RMP in Japan. Most companies studied are facing regulatory hurdles such as stringent review processes and regulatory guidelines that do not provide detailed practical examples of the pre-clinical quality and safety data required. CONCLUSIONS: These results suggest that effective regulatory infrastructure including regulatory systems, guidelines, and communication channels between product developers and regulatory bodies are essential for the prompt clinical application of RMP in Japan.     

Impact of social standing on injury prevention in a World Health Organization Safe Community--intervention outcome by household employment contract

BACKGROUND: Although social inequality in health has been an argument for community-based injury prevention programmes, intervention outcomes with regard to differences in social standing have not been analysed. The objective of this study was to investigate rates of injuries treated in health-care among members of households at different levels of labour market integration before and after the implementation of a WHO Safe Community programme. METHODS: A quasi-experimental design was used with pre- and post-implementation data collection covering the total populations <65 years of age during one year in the programme implementation municipality (population 41 000) and in a control municipality (population 26 000). Changes in injury rates were studied using prospective registration of all acute care episodes with regard to social standing in both areas during the study periods. RESULTS: Male members of households categorized as not vocationally active displayed the highest pre-intervention injury rates. Also after the intervention, males in households classified as not vocationally active displayed notably elevated injury rates in both the control and study areas. Households in the study area in which the significant member was employed showed a post-intervention decrease in injury rate among both men (P < 0.001) and women (P < 0.01). No statistically significant change was observed in households in which the significant member was self-employed or not vocationally active. In the control area, only an aggregate-level decrease (P < 0.05) among members of households in which the significant member was employed was observed. CONCLUSIONS: The study displayed areas for improvement in the civic network-based WHO Safe Community model. Even though members of non-vocationally active households, in particular men, were at higher pre-intervention injury risk, they were not affected by the interventions. This fact has to be addressed when planning future community-based injury prevention programmes.     

Involving decision-makers in the research process: Challenges of implementing the accountability for reasonableness approach to priority setting at the district level in Tanzania

Abstract

Globally, the poor are consistently at greater risk of suffering from depression and anxiety. Yet in resource-poor countries, mental health remains a neglected topic. This interdisciplinary study explored the potential for a poverty alleviation programme to contribute to breaking the vicious cycle between poverty and common mental disorders (CMD). Quantitatively, beneficiaries of a cash-transfer programme were found to have a lower risk of CMD. Qualitative interviews indicated that Child Support Grants acted as a psychological safety net, but that negative stereotypes of grant recipients could detract from the positive mental health outcomes of the grants. It was concluded that poverty alleviation programmes such as cash transfers could have both positive and negative impacts on mental health. In order to achieve mental health benefits for programme beneficiaries, aspects of programme design and implementation that promote mental health should be enhanced and aspects detrimental to mental health modified.     

A critical realist approach to understanding and evaluating heart health programmes

Secondary prevention programmes for Coronary Heart Disease (CHD) aim to reduce cardiovascular risks and promote health in people with heart disease. Though programmes have been associated with health improvements in study populations, access to programmes remains low, and quality and effectiveness is highly variable. Current guidelines propose significant modifications to programmes, but existing research provides little insight into why programme effectiveness varies so much. Drawing on a critical realist approach, this article argues that current research has been based on an impoverished ontology, which has elements of positivism, does not explore the social determinants of health or the effects on outcomes of salient contextual factors, and thereby fails to account for programme variations. Alternative constructivist approaches are also weak and lacking in clinical credibility. An alternative critical realist approach is proposed that draws on the merits of subjectivist and objectivist approaches but also reflects the complex interplay between individual, programme-related, socio-cultural and organizational factors that influence health outcomes in open systems. This approach embraces measurement of objective effectiveness but also examines the mechanisms, organizational and contextual-related factors causing these outcomes. Finally, a practical example of how a critical realist approach can guide research into secondary prevention programmes is provided.     

Quality assurance for screening mammography: an international comparison

STUDY OBJECTIVE: In 1998, the International Breast Cancer Screening Network (IBSN) sponsored an assessment of quality assurance policies and practices to define their scope for population-based screening mammography programmes across IBSN countries. DESIGN: Analysis of data from a survey designed to assess multiple elements of screening programme quality assurance, including organisation of quality assurance activities, mechanisms for site visits and accreditation, requirements for quality control and data systems, and inclusion of treatment, follow up, and programme evaluation in screening mammography quality assurance activities. PARTICIPANTS AND SETTING: IBSN representatives in 23 countries completed a comprehensive questionnaire between May and December 1998. MAIN RESULTS: Completed questionnaires were obtained from all 23 countries. Responses indicated that countries vary in their approaches to implementing quality assurance, although all monitor components of structure, process, and outcome. Nearly all have in place laws, surveillance mechanisms, or standards for quality assurance. In all countries, quality assurance activities extend beyond the screening mammography examination. CONCLUSIONS: The assessment has enhanced understanding of the organisation of screening mammography programmes across countries, as well as the comparability of screening mammography data. All countries have established mechanisms for assuring the quality of screening mammography in population-based programmes, although these mechanisms vary across countries.     

Older people enhancing self-efficacy in fall-risk situations

A falls prevention programme based on Bandura's self-efficacy theory was evaluated using qualitative interviews. This programme aimed to enhance older people's self-efficacy in fall-risk situations. The mastery-building component of the programme was the key factor distinguishing it from other falls prevention programmes. It was also one of the most successful aspects of the programme for increasing self-efficacy in community mobility activities. Seven of the eight participants experienced increased self-efficacy in at least some daily activities, particularly those practised during the programme. Awareness of fall risks and how to minimise these increased. Participants took action to reduce environmental hazards and reported increased activity participation. Occupational therapists recognise the importance of self-efficacy as a useful concept in occupational therapy practice due to its emphasis on self-perception of capabilities within the context of specific activities. However, an understanding of self-efficacy has not yet been integrated into occupational therapy practice. This study found that Bandura's self-efficacy theory was easily translated into practice and was readily applicable to the area of falls prevention among older people. The findings of this study support the inclusion of activity participation and mastery experiences being a primary focus of falls prevention programmes.     

Conductive Education Evaluated: Future Directions

A literature review of the effectiveness of conductive education as practised outside Hungary was undertaken. Of 28 potentially relevant studies, 22 were excluded on the grounds that they did not systematically and/or empirically test theories or hypotheses, or did not evaluate programmes outside Hungary. The six remaining represented modifications of the approach and met the criteria. These six studies were reviewed relating evaluation methods, programme characteristics and programme outcomes. The review revealed a total of 25 outcome categories used by the six studies. 24 percent (six) of the outcome categories significantly supported the elements typically found in a conductive education programme while 20 percent (five) significantly supported the comparison programmes, and 56 percent (14) showed no significant differences between the comparison groups. Inconsistency in programme characteristics and methodological flaws in evaluation designs preclude a definitive answer to the question of efficacy. The need for scientifically controlled studies and developing minimum standards of practice for programmes based on conductive education principles is emphasised.