Caregiving at the end of life: Perceptions of health care quality and quality of life among patients and caregivers

This study explored the association between perceptions of health care quality and quality of life in patients with advanced metastatic cancer and their informal caregivers (n=39). Patients' and caregivers' perceptions of health care quality, mental health, health-related quality of life, symptoms, and burden were measured. The key findings included the following: 1) patients' mental health and depression scores correlated with those of caregivers, suggesting that the mental health of patients and their caregivers are associated; 2) patients and caregivers shared similar perceptions regarding health care quality; 3) the presence of depression in caregivers correlated with caregivers being less satisfied with the health care being given to their patients (this correlation did not exist for patients, a finding that may be due in part to the protective buffering effect that caregivers provide their patients as illness progresses); and 4) a modified Primary Care Assessment Survey, originally designed for primary care patients, was a useful measure of health care assessment for both patients and caregivers. These data suggest that patients with advanced disease and their caregivers share similar perceptions and evolve as a "unit of care," and caregivers, as unique and important members of the patient's health care team, are also in need of care. When depressed, caregivers may unilaterally lose trust by becoming less satisfied with the quality of health care being provided to their patients.     

Improvement of quality of nursing care: a goal to challenge in the eighties

Some general thoughts on the use of the quality concept as a means to structure critical reflection on patient-client care and health services is discussed. The continuous request for more health care facilities and quality of services occupies not only the minds of the health workers, but also of the consumer who is becoming more aware of his rights and privileges. Health care should not be identified with curative care only. It involves prevention and promotion of people's status of health as well. Nurses have an important contribution to make in the promotion of health. The paper deals also with the evaluation of quality of care. If nurses become involved in the evaluation of nursing care they should have a clear concept of what nursing is. The nursing profession has a responsibility to develop standards and criteria for the evaluation of nurses' contribution in patient care. An example of a well-tested monitoring quality instrument is given. In the last part of the paper some practical suggestions for managers who are responsible for the quality care improvement in their own health care institutions are given.     

Quality and quality improvement in occupational health nursing.

Donabedian first defined quality as the result of assessing the structures, processes, and outcomes of health care. The emphasis on quality assurance is changing to quality improvement. The definition of quality in health care has expanded to include the expectations and opinion of patients, their representative, and society. As the cost of health care continues to rise at twice the rate of inflation, business wants to know how health care dollars are spent. Occupational health nurses, to add value to the businesses in which they work, must be a part of the trend in measuring the quality of the products and services of their health services.     

Reaching common ground: a patient-family-based conceptual framework of quality EOL care

Improvement in the quality of end-of-life (EOL) care is a priority health care issue since serious deficiencies in quality of care have been reported across care settings. Increasing pressure is now focused on Canadian health care organizations to be accountable for the quality of palliative and EOL care delivered. Numerous domains of quality EOL care upon which to create accountability frameworks are now published, with some derived from the patient/family perspective. There is a need to reach common ground on the domains of quality EOL care valued by patients and families in order to develop consistent performance measures and set priorities for health care improvement. This paper describes a meta-synthesis study to develop a common conceptual framework of quality EOL care integrating attributes of quality valued by patients and their families.     

Issues affecting the health of older citizens: meeting the challenge

The health of older Americans will become a critical national policy issue during this century. As the population of older adults increases dramatically, there are few signs that adequate resources are available to meet the challenge of providing health care and good quality of life for older adults and their families. A fundamental change in the values emphasized in the American culture, and in other cultures, will be required to change the present health care system from one which focuses on diagnosis and treatment of disease to a system that attends to the major issues that affect quality of life of older adults and their families. This article discusses four critical areas influencing the quality of life of older Americans: providing resources to individuals to help manage chronic medical conditions, assuring a sufficient number of primary health care providers educated in geriatrics and gerontology, removing financial barriers to accessing health care and medications, and changing the American cultural value system that emphasizes disease treatment over providing emotional, educational, and support resources. To make these profound changes in the formal health care system, health care providers, health care organizations, and policy makers must commit to embracing the importance of quality of life as an integral component of health care for older citizens.     

University of Iowa Hospital and Clinics: outcomes management

Delivery of quality patient care and management of patient outcomes is critical to the success of academic medical centers in the ever-changing health care market. The University of Iowa Hospitals and Clinics (UIHC) promotes quality care through the provision of organizational structures and processes that are described in this article. In addition, quality of care and outcomes management are described by members in various roles within the UIHC health care system. It is the authors' belief that understanding quality from these various perspectives helps UIHC work across departments to achieve excellence in patient care.     

Managing Chronic Disease in Affordable Primary Care

National agencies are calling for quality improvement in primary care health care services and across the United States health care system. Changes would be directed toward improving quality of life for the chronically ill and decreasing their financial burden and that placed on society. Nurse practitioners, based on their expertise and preparation in patient education, are ideal health care providers to establish partnerships with motivated, informed, chronically ill patients and to promote change in health care policy, guidelines, and meeting patient educational needs. Within worksite primary care, nurse practitioners can, through the Chronic Care Model framework, provide chronic disease management and affordable health care access.     

Turning Data Into Information: Opportunities to Advance Rehabilitation Quality,Research, and Policy

Attention to health care quality and safety has increased dramatically. The internal focus of an organization is not without influence from external policy and research findings. Compared with other specialties, efforts to align and advance rehabilitation research, practice, and policy using electronic health record data are in the early stages. This special communication defines quality, applies the dimensions of quality to rehabilitation, and illustrates the feasibility and utility of electronic health record data for research on rehabilitation care quality and outcomes. Using data generated at the point of care provides the greatest opportunity for improving the quality of health care, producing generalizable evidence to inform policy and practice, and ultimately benefiting the health of the populations served.     

Why outcomes measurement must be the basis for the development of clinical guidelines

Three approaches to clinical quality improvement, health care standards, clinical guidelines, and quality improvement research, are differentiated by the quality of the available medical evidence linking health care processes to health care outcomes. The key determinant of Permanente Medical Group physician acceptance and use of a clinical guideline is the belief that solid data links the guideline's advice to improved patient outcomes. Purchasers, government agencies, regulatory organizations, and health plans must understand the difference between health care standards and clinical guidelines. Strict adherence to clinical guidelines should never be the basis for accountability for physicians, medical groups, or organized systems of care.     

Basics of quality improvement in health care

With the rapid expansion of knowledge and technology and a health care system that performs far below acceptable levels for ensuring patient safety and needs, front-line health care professionals must understand the basics of quality improvement methodologies and terminology. The goals of this review are to provide clinicians with sufficient information to understand the fundamentals of quality improvement, provide a starting point for improvement projects, and stimulate further inquiry into the quality improvement methodologies currently being used in health care. Key quality improvement concepts and methodologies, including plan-do-study-act, six-sigma, and lean strategies, are discussed, and the differences between quality improvement and quality-of-care research are explored.     

The critical incident technique and nursing care quality research

The critical incident technique, is a highly flexible qualitative research method used in solving practical problems. Although this research method has been extensively used in the service industry to evaluate consumers' expectations and perceptions, applications to the study of health care quality are just beginning. This article describes critical incident methodology, reviews previous applications of the technique to the study of health care quality and provides illustrations from research. This practical research methodology offers the following important advantages to those interested in designing studies of care quality: identifying patients' experiences in health care settings, exploring dimensions of nurse-patient interactions and identifying patients' responses to illness and health care treatment.     

Quality assurance to quality improvement: the impact of the agenda for changes

Health care professionals are committed to the continual improvement of the quality of patient care. The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) has launched a major research and development project intended to improve its ability to evaluate health care organizations and encourage greater attention to the quality of daily patient care. This chapter describes JCAHO's challenge to evaluate capability and performance of health care organizations and practitioners. The intent of JCAHO's agenda for change is to focus on patient outcomes and quality improvement through a more precise and objective evaluation of both clinical and managerial performance. Through the agenda for change, JCAHO and the health care organization will participate in a continuous-flow monitoring system in which clinical and organizational data are transmitted from the field to JCAHO, analyzed, and fed back to the health care organization.     

Quality health care in an era of limited resources. Challenges and opportunities

Quality health care is a complex phenomenon. The factors contributing to quality in health care are as varied as the strategies needed to achieve this elusive goal. This article examines the impact of medical errors, health finance (insurance), moral hazard, and provider shortages on the quality of health care today in the United States. Emphasis is given to the need to restore public trust and to create a health care system that maximizes scarce physical, fiscal, and human resources.     

Quality management: program design. An interdisciplinary approach

Concepts of quality management related to program design and implementation are relatively new to the health care field. The process used to satisfy the requirements of program evaluation, business planning, and clinical care quality assurance within the framework of quality management is discussed. Using an interdisciplinary approach, the authors trace the development of a specific rehabilitation program. Such programs can allow the health care provider to be more fruitfully involved in a health care service design beneficial to the patients served.     

The truth is in the eye of the beholder? Quality in rehabilitation from the patients' perspective

The definition of "good" quality in health research and quality management in health care and rehabilitation are primarily based on health professionals and their associations. But laypersons, patients, and participants in rehabilitation programmes, too, develop cognitive concepts about what defines good quality in health care. Until now systematic knowledge about the role of the patients' views on quality in rehabilitation is rare. Existing data demonstrate that patients report detailed ideas about indicators and preconditions of good quality of rehabilitative care. Patients' quality concepts differ in some aspect from the quality definitions of health care professionals. There is some evidence that patients' views on quality are a necessary extension and completion of programme evaluation and of quality management. They influence usage and selection of rehabilitation facilities and programme elements and probably patient satisfaction and long-term outcomes as well. Patients' ideas could contribute to gaining a deeper understanding of patients' needs. Here, patients are experts to define challenges for long-term improvements in health and health-related behavior with regard to everyday life and related resources and barriers. Taking patients' views on the quality of rehabilitation into account could help to adapt rehabilitation features, programmes and long-term offers more adequately to patients' needs. More systematic evidence is however needed as a basis for further developments in rehabilitation programmes.     

Report cards: relevance for nursing and patient care safety

The emergence of health care report cards in the North American environment is outlined. While it is evident that substantial activity has emerged, the majority of these initiatives excluded nursing, or use a broad indicator for nursing that may not provide meaningful representations of the quality of nursing care provided in the system and the relevance of this care to patient care safety. Given that nurses are the primary care provider in health care settings, this represents a significant gap in health care report cards. The pioneering work of the American Nurses Association (ANA) Nursing Report Card in the development and validation of report card indicators for nursing is discussed. Challenges related to data availability and data quality are identified. Potential opportunities for linking nursing practice outcomes to patient care quality and patient safety through a report card process are outlined.     

Strategies to advance health care quality

Overcoming the quality crisis in American health care is an enormous challenge. Despite a large cadre of individuals committed to improving quality, progress is stifled by the multiple ways in which issues central to quality care are conceptualized. To realize bona fide improvements in care quality, it is essential to understand the dominant conceptualizations driving quality efforts. Steps must then be taken to revise those conceptualizations that are obstacles to advancing health care quality. In this paper, four strategies are proposed for refocusing quality initiatives: (1) Looking at quality from the clinicians' eyes, (2) moving beyond physician care as a synonym for quality, (3) expanding the triple typology used to classify quality, and (4) enriching the evidence base for quality. The paper concludes with a call to action for nurses to exert stronger leadership to advance quality.     

Internet education of African American consumers on quality of care

This article describes a study using the Internet to teach African American consumers about quality of health care. By reading information on quality of care, consumers can learn ways to assess the care they are receiving, develop strategies needed to participate effectively in communicating with their health care providers, and make informed decisions in their own best interests. We developed an educational intervention using 5 Internet documents on quality of care and evaluated its effectiveness on learning, value of the information, and satisfaction with the instruction between consumers who read the information alone and those who read the information and interacted with a nurse. Participants indicated they learned a great deal from the information at the Web sites and reported that it would be helpful in assessing their own health care. They more frequently described quality care in terms of health outcomes, self care behaviors, and patient education after the Internet instruction, reflecting important concepts contained in the documents.     

Health care value-based purchasing

Two Institute of Medicine studies have focused attention on the glaring deficiencies in health care safety and quality. These studies and others serve as wake-up calls within both the private and government-sponsored United States health care industry. As a result of the "quality chasm" and crippling rise in health care cost, the concept of value-based purchasing (VBP) has gained increasing momentum. The stakeholders affected by the health care value equation include consumers, employers, insurers, and providers. VBP creates quality standards and stakeholder incentives to improve quality of care and become more cost efficient. The greatest challenge is the development of methods and information sources that will allow reliable, accurate, and credible measures of health care quality. VBP presents the ambitious hope of creating transparent measures of quality and cost efficiency that would allow the consumer to make health care purchasing decisions. If this can be achieved, then the competitive forces that increase value in other industries will function in health care.     

Implementing Telemental Health to Improve Access to Mental Health Care in Rural Vermont

Mental health care shortages in the United States are most pronounced in rural areas. This practice-change project aimed to increase access to quality mental health care in rural areas for the treatment of depression and anxiety via telemental health delivery of care. The project yielded improvements across project aims, including an increased percent of enrolled patients from Healthcare Provider Shortage Areas; a decrease in quality measures for depression, anxiety, and disability; and increased patient satisfaction with care. The project can serve as a template for other practices wishing to increase access to mental health care in rural areas.