Integrating clinical and support process design for effective health services

With increased capitation and managed care competition, health care systems must demonstrate effective health services with predictable costs, timing, transitions, and health outcomes. By involving patients, payers, and multiple providers, a health care system can design integrated clinical and support processes across the continuum for defined populations. The goals are lower costs, increased payer and patient satisfaction, and improved health status. This article shares examples and experiences from four health care systems that teamed with Premier, Inc., to design an integrated services sequence for defined populations.     

Towards case-based performance measures: uncovering deficiencies in applied medical care

Measures are designed to evaluate the processes and outcomes of care associated with the delivery of clinical (and non‐clinical) services. They allow for intra‐ and interorganizational comparison to be used continuously to improve patient health outcomes. The use of performance measures always means to abstract the complex reality (medical scenarios and procedures) in order to provide an understandable and comparable output. Measures can focus on global performance. The more detailed data are available the more specific judgements with respect to the appropriateness of clinical decision‐making and implementation of evidence are feasible. Externally reported measures are intended both to inform and lead to action. By providing this information, deficiencies in patient care and unnecessary variations in the care process can be uncovered. Such variations have contributed to disparities in morbidity and mortality. The developments in information technology, especially world‐wide interconnectivity, standards for electronic data exchange and facilities to store and manage large amounts of data, offer the opportunity to analyse health‐relevant information in order to make the delivery of healthcare services more transparent for consumers and providers. Global performance measures, such as the overall life expectancy (mortality) in a country, can give a rough orientation of how well health systems perform but they do not offer general solutions nor spe‐cific insights into care processes that have to be improved. In contrast to population‐based measures, case‐based performance measures use a defined group of patients depending on specific patient characteristics and features of disease. By means of these measures we are able to compare the number of patients that receive a necessary medical procedure against those patients who do not. The use of case‐based measures is a bottom‐up approach to improve the overall performance in the long run. They are not only a tool for global orientation but can offer a straightforward link to the areas of deficient care and the underlying procedures. Performance measures are relevant to providers as well as consumers, from their own individual perspective. Cased‐based measures focus on the management of individual patient. This approach to performance measurement can inform physicians in a meaningful and constructive way by monitoring their individual performance and by pointing out possible areas of improvement.     

Outcome effectiveness of community health workers: an integrative literature review

Community health workers (CHWs) are promoted as a mechanism to increase community involvement in health promotion efforts, despite little consensus about the role and its effectiveness. This article reviews the databased literature on CHW effectiveness, which indicates preliminary support for CHWs in increasing access to care, particularly in underserved populations. There are a smaller number of studies documenting outcomes in the areas of increased health knowledge, improved health status outcomes, and behavioral changes, with inconclusive results. Although CHWs show some promise as an intervention, the role can be doomed by overly high expectations, lack of a clear focus, and lack of documentation. Further research is required with an emphasis on stronger study design, documentation of CHW activities, and carefully defined target populations.     

Laboratory clinical effectiveness: pathologists improving clinical outcomes

This article calls on pathologists to take a larger role in improving the performance of the American health care system. To improve outcomes for populations and individuals require that pathologists increase their activities outside of the traditional laboratory in interdisciplinary collaborations, outcomes research, health care systems development, and clinical care.     

Development of a risk-adjusted urinary incontinence outcome measure of quality for nursing homes

BACKGROUND: Quality of nursing home care is of ongoing concern. The availability of uniform, patient-level information-the Minimum Data Set (MDS)-offers the opportunity to assess quality based on risk-adjusted health outcomes. OBJECTIVE: To develop a risk-adjusted measure of quality based on urinary incontinence (UI) outcomes for nursing homes, derived from the MDS. RESEARCH DESIGN: A retrospective statistical analysis of individual resident level data. SUBJECTS: MDS+ data for 46,453 residents of 671 nursing homes in New York State during the 1995 to 1997 period. MEASURES: Improvement in UI status was defined based on the resident's UI status at 3 months post admission relative to status at admission. Individual risk factors were also defined at admission. Facility level quality indicators were developed. RESULTS: Facility level indicators show substantial variation. An average facility, providing average quality care to a population of average risk, would experience improvement in UI outcomes for 11 of its 25 admissions in a year. The difference between the best and the worst facilities (two standard deviations above and below the average) is eight new residents with improvement in UI outcomes out of 25 annual admissions. CONCLUSIONS: This study demonstrates the feasibility of measuring quality of UI care based on nationally available MDS data. The measures presented can be used to support internal quality improvement efforts. Before such measures can be used externally, either in the survey process or in quality report cards, they should be further validated.     

Assessing the outcomes of total knee replacement

Abstract: The past few years have seen a growth of interest in outcome measurement in a variety of settings including audit, health care management and commissioning – besides the traditional applications in research work. This paper reports on a study of the outcomes of total knee replacement in an acute hospital where the outcomes were studied as part of an audit process. The outcome measures used included clinical and symptomatic measures as well as generic health status scales. The initial study in one hospital was expanded to include a number of others in the same region and a comparative database of outcomes developed. Examples of the results are shown. The technical measures using knee scores and general health status measure show significant improvement from pre-operatively to 3 months later. This improvement was maintained up to the 1-year follow-up on both measures. Although the information systems for collecting and measuring outcomes has been successful, the ability of such measures to lead to behavioural change has been limited. The problems in using outcome measures are discussed in particular in the context of an audit within hospitals, and for purchasing agencies.     

Client relevant care and quality of life: the trial of a Client Generated Index (CGI) tool for community nursing

Community nursing organisations worldwide seek optimal ways to ensure adequate measurement of health outcomes for the client following nursing care, and to facilitate a consumer focus. This article presents a trial of the Client Generated Index (CGI) tool that subjectively assesses and measures the quality of life outcomes pertaining to a client's health status, whilst also facilitating individualised care. Sixty district nursing clients participated in the trial, which ascertained that the CGI tool effectively directs the client to list, grade and prioritise personally relevant quality of life issues. Consequently, this tool is being incorporated into client admission and discharge assessment within the organisation.     

Performance: a multi-disciplinary and conceptual model

We contend that the scientific study of performance requires a model or paradigm. We propose a performance model with an underlying mathematical basis that is well defined, has explicit assumptions and has the potential to be both heuristic and scientifically testable. The model is based on an integration of concepts from health sciences and psychology that have been adapted to performance measurement in health care. The proposed performance model consists of a combination of four primary elements: quality of care, cost of care, access to care and satisfaction. Satisfaction is defined as a function of perceived and expected outcomes of care and perceived and expected input. This performance model can serve as both a tool for understanding and as a vehicle for comparing performance within and between health care organizations. We believe that this model can be used to develop a performance profile report and the future report card.     

Patient‐reported Outcome Measures in Emergency Care Research: A Primer for Researchers,Peer Reviewers,and Readers

Patient‐reported outcomes (PROs) are of increasing importance in clinical research because they capture patients’ experience with well‐being, illness, and their interactions with health care. Because PROs tend to focus on specific symptoms (e.g., pain, anxiety) or general assessments of patient functioning and quality of life that offer unique advantages compared to traditional clinical outcomes (e.g., mortality, emergency department revisits), emergency care researchers may benefit from incorporation of PRO measures into their research design as a primary or secondary outcome. Patients may also benefit from the ability of PROs to inform clinical practice and facilitate patient decision making, as PROs are obtained directly from the lived experience of other patients with similar conditions or health status. This review article introduces and defines key terminology relating to PROs, discusses reasons for utilizing PROs in clinical research, outlines basic psychometric and practical assessments that can be used to select a specific PRO measure, and highlights examples of commonly utilized PRO measures in emergency care research.     

The relationship between family physician density and health related outcomes: the Canadian evidence

This paper analyzes if and to what extent the density of family physicians influences health related outcomes in Canada. The density of family physicians in a given region is assumed to serve as proxy for the access to and availability of desirable primary care services. We use self-reported general and mental health status as our overall health outcome measures. We also use several quality of care indicators reflecting whether or not an individual received influenza immunization, mammography, pap smear, and colorectal cancer screening if at high-risk. The empirical results of this study suggest that an additional family physician per 10,000 population has a statistically significant impact in the order of 2% to 4% on self-reported general health status, as well as, other quality of care outcomes. We also find important socioeconomic and demographic factors, such as income, education and immigrant status, influencing health related outcomes considered in this study. Understanding the influence of physician density and socioeconomic factors on health related outcomes are important considerations for health policy and planning.     

The assessment and documentation of language and communication needs in healthcare systems: current practices and future directions for coordinating safe, patient-centered care

Several issues surface when one considers the task of unpacking health disparities and examining features of health care systems that influence patient access, utilization, and outcomes. Although progress has been made in the collection of language data across healthcare systems, little attention has been devoted to examining how a patient's English proficiency and the need for interpretation services are being determined, and how this information is communicated to providers. A lack of a standardized approach to these system-based processes exposes potential limitations in the ability of systems and providers to effectively coordinate care that meets patients' needs and minimizes disparate outcomes. Attention must be given to standardizing these processes to ensure safe, patient-centered care and enable meaningful analyses of access, utilization, and outcomes across linguistically diverse populations. Nurses play a key role in developing and evaluating information systems with which accurate and reliable data can be collected, documented, retrieved, and utilized.     

The application of a vulnerable populations conceptual model to rural health

BACKGROUND: This article describes the application of the vulnerable populations conceptual model to rural health. Vulnerable populations are social groups who have an increased susceptibility to adverse health outcomes. Evidence of this differential in vulnerability or increased risk includes premature mortality, comparative morbidity, decreased functional status, and diminished quality of life. ORGANIZING FRAMEWORK: The vulnerable populations conceptual model postulates that there are interrelationships among resource availability, relative risk, and health status. Resource availability speaks to socioeconomic and environmental resources that are operationalized in this model as income, jobs, education, housing, availability of health care, quality of health care, and patterns of family and community life. Relative risk addresses the likelihood of exposure to risk factors and is reflected in lifestyle behaviors and choices and exposure to stressful events. Health status is operationalized as morbidity and mortality. FINDINGS: This review of the literature supports the utility of the vulnerable populations conceptual model in working with rural populations. IMPLICATIONS: This model has potential utility to inform nursing research, practice, and policy about the opportunities and resources needed to achieve and maintain health in rural communities.     

Psychiatric-mental health nursing: career characteristics, professional activities, and client attributes of members of the American Nurses Association Council of Psychiatric Nurses.

As the twenty-first century approaches, psychiatric nursing is reviewing its past and speculating about its future. This article reports on the current status of 525 psychiatric-mental health nurses. The nurses responded to a questionnaire designed to elicit information on career characteristics, professional activities, and client attributes. The nurses work primarily in acute care institutions or hospitals. The typical client is white, middle class, and adult. The focus of care in mental health is moving to the community. If psychiatric nurses want a viable role in the mental health system of the future, they must begin to develop a system of care for at-risk populations in the community now.     

Indigenous community participation: how does it relate to student centered learning and embrace primary health care philosophies?

The health and well-being of Indigenous Australians has been identified as a critical problem with high levels of chronic illness, morbidity and mortality compared to other Australian population groups. However, as health professionals we continue to discuss and theorise components of Indigenous health addressing issues in a piecemeal way. The concept of primary health care has been shown to have an independent effect on improving the health status of populations and having the ability to reduce health inequalities. Countries with well developed primary care systems have healthier populations and reduced health care costs (Macinko et al., 2003, p. 407). Primary health care combined with a community holistic approach and the defined use of student centered learning in Indigenous education has the potential to provide optimal health care and thus be an effective way to improve Indigenous Community health (McMurray, 2003, p. 296).     

Report of the health care delivery work group: behavioral research related to the establishment of a chronic disease model for diabetes care

As one of four work groups for the November 1999 conference on Behavioral Science Research in Diabetes, sponsored by the National Institute on Diabetes and Digestive and Kidney Diseases, the health care delivery work group evaluated the status of research on quality of care, patient-provider interactions, and health care systems' innovations related to improved diabetes outcomes. In addition, we made recommendations for future research. In this article, which was developed and modified at the November conference by experts in health care delivery, diabetes and behavioral science, we summarize the literature on patient-provider interactions, diabetes care and self-management support among underserved and minority populations, and implementation of chronic care management systems for diabetes. We conclude that, although the quality of care provided to the vast majority of diabetic patients is problematic, this is principally not the fault of either individual patients or health care professionals. Rather, it is a systems issue emanating from the acute illness model of care, which still predominates. Examples of proactive population-based chronic care management programs incorporating behavioral principles are discussed. The article concludes by identifying barriers to the establishment of a chronic care model (e.g., lack of supportive policies, understanding of population-based management, and information systems) and priorities for future research in this area needed to overcome these barriers.     

Pre‐hospital and retrieval medicine: Clinical governance and workforce models

Pre‐hospital and retrieval medicine (PHARM) has developed significantly in the past decade. This perspective article proposes that PHARM should develop with a clear focus on contemporary health governance principles, and that its workforce and models of care adopt modern interdisciplinary approaches. Many of the older systems of managing clinical standards, and outdated cultural approaches to professional ‘turf’, workforce and scope of practice have little place in high‐performance organisations. This paper calls us to attention with a recommendation that best and safest systems of care, structured to optimise patient outcomes and system performance should be our goal.     

Medical errors: an introduction to concepts

The prevalence of medical errors in health care systems has generated immense interest in recent years. The research on adverse events in hospitalized populations has consistently revealed high rates of adverse events. Some of these adverse events result from medical errors and a majority of these errors may be preventable. These errors can occur anywhere and at anytime in health care processes. The consequences of these errors may vary from little or no harm to being ultimately fatal to the patients. It is important to recognize that a degree of error is inevitable in any human task and human fallibility in health care should be accepted. The underlying precursors for many of these human errors may primarily be attributed to latent systemic factors inherent in today's increasingly complex health care system. The focus of adverse event analyses on individual shortcomings without appropriate attention to system issues leads to ineffective solutions. The cognitive influence on medical decision-making and error generation is also significant and should not be discounted.     

Feria de Salud: implementation and evaluation of a communitywide health fair

Evaluating the effectiveness of community interventions is a major responsibility for community health nurses (CHNs). Without evidence of the effectiveness of interventions, their impact on the health status of populations or communities cannot be determined. This article presents the planning, implementation, and evaluation processes of a communitywide health fair. This fair was held in a suburban community of approximately 12,000 individuals, located 20 kilometers outside of Mexico City. The health fair was one component of a collaborative project aimed at addressing the overall health needs of the community. Emphasis is on the development and utilization of measurable objectives in evaluating both processes and outcomes of the health fair. Green and Kreuter's (1991) PRECEDE-PROCEED program planning model provided direction for program planning and evaluation. The findings of process, impact, and outcome evaluation are described, providing both qualitative and quantitative measures of program effectiveness. These findings provide direction for program replication and modification. Recommendations address the utility of theory-based assessment, program planning, and evaluation, the importance of formative evaluation, and the need for cultural sensitivity in community health program planning.