How can we improve the quality of health care in Japan? Learning from JCQHC hospital accreditation

The World Health Report 2000 placed Japan first for overall health system attainment: a surprising development considering that, aside from discussing excessive expenditure, health care professionals and the Health Ministry have paid little attention recently to the quality of health care. Japan's free access policy and the universal health care system have actually fostered a very relaxed attitude toward evaluation. Concerned about the possible risks to patient safety, physicians established a volunteer association to promote quality health care issues. Then in 1995, the Japan Council for Quality Health Care (JCQHC) was founded to implement the third party accreditation of hospitals. Concurrent with the formation of the JCQHC, the sharply rising costs of malpractice litigation motivated the authorities and medical facilities to work toward protecting patient safety at different levels. Despite the WHO's positive review, critics maintain that significant inequities still exist in Japanese health care. Examples include, financial inequities between private and public hospitals, and the number and quality of hospitals and physicians between rural and urban areas. To protect patient safety and improve the quality of care, every effort must be made to eliminate inequities in the health care system. JCQHC accreditation is an important tool for furthering these efforts.     

Development and testing of emergency department patient transfer communication measures

Purpose: Communication problems are a major contributing factor to adverse events in hospitals. 1 The contextual environment in small rural hospitals increases the importance of emergency department (ED) patient transfer communication quality. This study addresses the communication problems through the development and testing of ED quality measurement of interfacility patient transfer communication. Methods: Input from existing measures, measurement and health care delivery experts, as well as hospital frontline staff was used to design and modify ED quality measures. Three field tests were conducted to determine the feasibility of data collection and the effectiveness of different training methods and types of partnerships. Measures were evaluated based on their prevalence, ease of data collection, and usefulness for internal and external improvement. Findings: It is feasible to collect ED quality measure data. Different data sources, data collection, and data entry methods, training and partners can be used to examine hospital ED quality. There is significant room for improvement in the communication of patient information between health care facilities. Conclusion: Current health care reform efforts highlight the importance of clear communication between organizations held accountable for patient safety and outcomes. The patient transfer communication measures have been tested in a wide range of rural settings and have been vetted nationally. They have been endorsed by the National Quality Forum, are included in the National Quality Measurement Clearinghouse supported by the Agency for Health Care Research and Quality (AHRQ), and are under consideration by the Centers for Medicare and Medicaid Services for future payment determinations beginning in calendar year 2013.     

Creating a framework for getting quality into the public health system

The US health care system has undertaken concerted efforts to improve the quality of care that Americans receive, using well-documented strategies and new incentives found in the Affordable Care Act of 2010. Applying quality concepts to public health has lagged these efforts, however. This article describes two reports from the Department of Health and Human Services: Consensus Statement on Quality in the Public Health System and Priority Areas for Improvement of Quality in Public Health. These reports define what is meant by public health quality, establish quality aims, and highlight priority areas needing improvement. We describe how these developments relate to the Affordable Care Act and serve as a call to action for ensuring a better future for population health. We present real-world examples of how a framework of quality concepts can be applied in the National Vaccine Safety Program and in a state office of minority health.     

From To Err Is Human to Improving Diagnosis in Health Care: The risk management perspective

The publication of To Err Is Human in 2000, followed by Crossing the Quality Chasm in 2001, marked a watershed in patient safety. The Institute of Medicine (IOM) reports intensified the focus on patient safety and demanded a redesign of the healthcare system to improve quality and safety. Since publication of these reports, the focus has been on improving processes—those methods of healthcare delivery prone to failure and errors. Recently, there has been a concerted and sustained drive to add cognitive (diagnostic) errors to the focus. The recent publication of the IOM's Improving Diagnosis in Health Care has expanded the focus on patient safety and quality improvement. A new focus on diagnostic errors augments rather than replaces the previous focus. In this article, the authors offer a brief review of To Err Is Human and Crossing the Quality Chasm to lay a historical foundation. They then discuss a transition into the focus on diagnostic errors and summarize the latest recommendations from Improving Diagnosis in Health Care. This collated synthesis of 3 powerful IOM reports should guide risk managers and other healthcare personnel as they strive to improve every aspect of healthcare delivery.     

Using patient reports to improve medical care: a preliminary report from 10 hospitals

This article describes the early activities of the Picker/Commonwealth Program for Patient-Centered Care and reports results from a study of 10 hospitals trying to develop better ways of providing patient-centered care. Reported problems were relatively infrequent, but several problems occurred as often as in an earlier national study of acute care hospitals. Academic medical centers and other teaching hospitals tended to have more problems than nonteaching hospitals, but there was great variability within hospital types. The article discusses ways patient reports can be used to improve the quality of hospital care.     

Opportunities for improving the care of patients with community-acquired pneumonia

In Missouri, community-acquired pneumonia is the second leading cause of hospital admission in the Medicare population. Analysis of 1993 discharges revealed that more than 18,000 Medicare patients were admitted to acute care hospitals with a principal diagnosis of pneumonia. Statewide, the case fatality rate for these admissions was 9.6%, with an average length of stay of 8.2 days. Under the auspices of Medicare's Health Care Quality Improvement Program, the Missouri Patient Care Review Foundation (MPCRF) collaborated with five hospitals in the state on a project to enhance the outcomes and quality of care for patients admitted with community-acquired pneumonia. Narrowing the focus to bacterial community-acquired pneumonia, the five hospitals agreed to collect data, for a specified period, on each Medicare patient admitted with this diagnosis. The hospitals were encouraged to implement recommended critical pathways and guidelines for the initial management and treatment of community-acquired pneumonia. MPCRF assumed responsibility for data management activities for the project as well as production of feedback reports that were shared routinely with the hospitals. Although evaluation of the project continues, preliminary analysis of claims data for admissions occurring after process changes were implemented indicates that there has been improvement in the two outcome measures, patient mortality and length of stay. These results suggest that monitoring of key process indicators, coupled with ongoing analysis and feedback, has potential for facilitating positive change in the quality of care for patients with community acquired pneumonia.     

The revolution in hospital management

Five healthcare systems that have either won the Malcolm Baldrige National Quality Award in Health Care or been documented in extensive case studies share a common model of management: they all emphasize a broadly accepted mission; measured performance; continuous quality improvement; and responsiveness to the needs of patients, physicians, employees, and community stakeholders. This approach produces results that are substantially and uniformly better than average, across a wide variety of acute care settings. As customers, courts, and accrediting and payment agencies recognize this management approach, we argue that it will become the standard for all hospitals to achieve. This article examines documented cases of excellent hospitals, using the reports of three winners of the Baldrige National Quality Award in Health Care and published studies of other institutions with exceptional records.     

Evaluating trauma care capabilities in Mexico with the World Health Organization's Guidelines for Essential Trauma Care publication.

OBJECTIVE: To identify affordable, sustainable methods to strengthen trauma care capabilities in Mexico, using the standards in the Guidelines for Essential Trauma Care, a publication that was developed by the World Health Organization and the International Society of Surgery to provide recommendations on elements of trauma care that should be in place in the various levels of health facilities in all countries. METHODS: The Guidelines publication was used as a basis for needs assessments conducted in 2003 and 2004 in three Mexican states. The states were selected to represent the range of geographic and economic conditions in the country: Oaxaca (south, lower economic status), Puebla (center, middle economic status), and Nuevo León (north, higher economic status). The sixteen facilities that were assessed included rural clinics, small hospitals, and large hospitals. Site visits incorporated direct inspection of physical resources as well as interviews with key administrative and clinical staff. RESULTS: Human and physical resources for trauma care were adequate in the hospitals, especially the larger ones. The survey did identify some deficiencies, such as shortages of stiff suction tips, pulse oximetry equipment, and some trauma-related medications. All of the clinics had difficulties with basic supplies for resuscitation, even though some received substantial numbers of trauma patients. In all levels of facilities there was room for improvement in administrative functions to assure quality trauma care, including trauma registries, trauma-related quality improvement programs, and uniform in-service training. CONCLUSIONS: This study identified several low-cost ways to strengthen trauma care in Mexico. The study also highlighted the usefulness of the recommended norms in the Guidelines for Essential Trauma Care publication in providing a standardized template by which to assess trauma care capabilities in nations worldwide.     

Patient-physician relationships and racial disparities in the quality of health care

OBJECTIVES: This study explored whether racial differences in patient-physician relationships contribute to disparities in the quality of health care. METHODS: We analyzed data from The Commonwealth Fund's 2001 Health Care Quality Survey to determine whether racial differences in patients' satisfaction with health care and use of basic health services were explained by differences in quality of patient-physician interactions, physicians' cultural sensitivity, or patient-physician racial concordance. RESULTS: Both satisfaction with and use of health services were lower for Hispanics and Asians than for Blacks and Whites. Racial differences in the quality of patient-physician interactions helped explain the observed disparities in satisfaction, but not in the use of health services. CONCLUSIONS: Barriers in the patient-physician relationship contribute to racial disparities in the experience of health care.     

The American Hospital Quest for Quality Prize

Improving the quality and safety of health care requires dedicated leadership and the involvement of everyone who affects care within an organization, from trustees and administrators to physicians, nurses and frontline staff. To honor organizations that have made exceptional improvements in quality and patient safety, the American Hospital Association, along with McKesson Corp. and McKesson Foundation, established The American Hospital Quest for Quality Prize: honoring leadership and innovation in patient care quality, safety and commitment. The award recognizes hospitals and health systems that have created measurable and sustainable quality and patient safety programs. Among other things, the organization must have a blame-free work environment and systems in place to help identify actual and potential adverse events and solutions to improve them. As the winner of the inaugural Quest for Quality Prize, Missouri Baptist Medical Center, Town and Country, Mo., received $75,000 to further its safety and quality efforts. Two finalists--Children's Hospitals and Clinics, Minneapolis/St. Paul, Minn., and Fairview Hospital, Great Barrington, Mass.--each received a $12,500 award. A Citation of Merit was presented to Brigham and Women's Hospital, Boston.     

Crossing the quality chasm: building a safe nutrition system

Recent reports to Congress and the public from the Institute of Medicine underscore concern about the quality of healthcare in America. The nutrition community has focused most of its attention on the report titled The Role of Nutrition in Maintaining Health in the Nation's Elderly, which evaluated nutrition services coverage for the Medicare population. Of equal importance was the recent publication of two reports from the Committee on Quality of Health Care in America: To Err is Human--Building a Safer Health System and Crossing the Quality Chasm--A New Health System for the 21st Century. IV nutrition support was a breakthrough in medical care that has become a standard tool in treating patients who cannot eat for prolonged periods of time. It is also a medical treatment that can result in harm to patients. As problems with patient safety associated with the use of IV nutrition were documented, safer methods to deliver this life-saving form of treatment were developed and evaluated. Although an interdisciplinary team approach has been shown to be the safest way to administer IV nutrition, this system is costly and not universally used. Alternatives to the interdisciplinary team approach should be evaluated to assure that patients receive optimum nutrition care. The tools that can be used to improve patient safety include self-assessment of practitioners who routinely use nutrition support in their practice, curricular-based continuing education programs, board certification in nutrition support practice, and the use of clinical guidelines to assist in making clinical decisions. By developing and promoting these tools, A.S.P.E.N. is committed to building a safe nutrition system so every patient receives optimal nutrition care.     

A comparison of quality of care indicators in urban acute care hospitals and rural critical access hospitals in the United States.

OBJECTIVE: Two recent Institute of Medicine reports highlight that the quality of healthcare in the US is less than what should be expected from the world's most extensive and expensive healthcare system. This may be especially true for critical access hospitals since these smaller rural-based hospitals often have fewer resources and less funding than larger urban hospitals. The purpose of this paper was to compare quality of hospital care provided in urban acute care hospitals to that provided in rural critical access hospitals. DESIGN: Cross-sectional study analyzing secondary Hospital Compare data. T-test statistics were computed on weighted data to ascertain if differences were statistically significant (P=0.01). SETTING: Centers for Medicare and Medicaid Services hospitals. PARTICIPANTS: US Acute Care and Critical Access hospitals. MAIN OUTCOME MEASURES: Differences between urban acute care hospitals and rural critical access hospitals on quality care indicators related to acute myocardial infarction, heart failure and pneumonia. RESULTS: For 8 of the 12 hospital quality indicators the differences between urban acute care and rural critical access hospitals were statistically significant (P=0.01). In seven instances these differences favored urban hospitals. One indicator related to pneumonia favored rural hospitals CONCLUSIONS: Although this study focused on only three disease states, these are among the most common clinical conditions encountered in inpatient settings. The findings suggested that there may be differences in quality in rural critical access hospitals and urban acute care hospitals and support the need for future studies addressing disparities between urban acute care and rural critical access hospitals.     

The National Consensus Project for Quality Palliative Care Clinical Practice Guidelines Domain 8: Ethical and Legal Aspects of Care

In 2001, leaders with palliative care convened to discuss the standardization of palliative care and formed the National Consensus Project for Quality Palliative Care. In 2004, the National Consensus Project for Quality Palliative Care produced the first edition of Clinical Guidelines for Quality Palliative Care. The Guidelines were developed by leaders in the field who examined other national and international standards with the intent to promote consistent, accessible, comprehensive, optimal palliative care through the health care spectrum. Within the guidelines there are eight domains to the provision of palliative care. This article focuses on the last, but very significant Domain 8—Ethical and Legal Aspects of Care.     

Why should health services be primary care-led?

A primary care-led health service is the latest fashion in health policy, yet there is no consensus on what this means. One manifestation of this policy is the attempt to shift the balance of resources from secondary to primary care, with the goal of improving the cost-effectiveness of health care. This has been taken furthest in the UK, where GP fundholders have been given resources to purchase a significant proportion of their patients' health care. The scheme provides incentives to shift the location of care out of hospitals, but there is very little evidence that this will result in better quality patient care at lower cost.     

The Representation of Health Professionals on Governing Boards of Health Care Organizations in New York City

The Representation of Health Professionals on Governing Boards of Health Care Organizations in New York City. The heightened importance of processes and outcomes of care—including their impact on health care organizations’ (HCOs) financial health—translate into greater accountability for clinical performance on the part of HCO leaders, including their boards, during an era of health care reform. Quality and safety of care are now fiduciary responsibilities of HCO board members. The participation of health professionals on HCO governing bodies may be an asset to HCO governing boards because of their deep knowledge of clinical problems, best practices, quality indicators, and other issues related to the safety and quality of care. And yet, the sparse data that exist indicate that physicians comprise more than 20 % of the governing board members of hospitals while less than 5 % are nurses and no data exist on other health professionals. The purpose of this two-phased study is to examine health professionals’ representations on HCOs—specifically hospitals, home care agencies, nursing homes, and federally qualified health centers—in New York City. Through a survey of these organizations, phase 1 of the study found that 93 % of hospitals had physicians on their governing boards, compared with 26 % with nurses, 7 % with dentists, and 4 % with social workers or psychologists. The overrepresentation of physicians declined with the other HCOs. Only 38 % of home care agencies had physicians on their governing boards, 29 % had nurses, and 24 % had social workers. Phase 2 focused on the barriers to the appointment of health professionals to governing boards of HCOs and the strategies to address these barriers. Sixteen health care leaders in the region were interviewed in this qualitative study. Barriers included invisibility of health professionals other than physicians; concerns about “special interests”; lack of financial resources for donations to the organization; and lack of knowledge and skills with regard to board governance, especially financial matters. Strategies included developing an infrastructure for preparing and getting appointed various health professionals, mentoring, and developing a personal plan of action for appointments.     

Review: feedback about practice patterns for measurable improvements in quality of care--a challenge for PROs under the Health Care Quality Improvement Program

The Health Care Quality Improvement Program (HCQIP), administered by the Health Care Financing Administration and implemented through Utilization and Quality Control Peer Review Organizations (PROs), is a new approach to monitoring the health care received by Medicare beneficiaries. The HCQIP shifts the focus of the PRO program from regulatory quality management to quality improvement principles. Through a series of cooperative projects, each focusing on a specific medical condition or procedure, PROs will conduct pattern analysis and share information about these analyses with health care organizations for the purpose of stimulating internal quality improvement efforts. As a fundamental shift in the way PROs have conducted quality-related activities, the HCQIP presents PROs with numerous challenges. This paper provides insight into one of their most significant challenges, the development of a model for constructive, nonevaluative feedback. Successful HCQIP feedback efforts may serve as models for quality management programs that will accompany national health care reform.     

Relationship between management philosophy and clinical outcomes

BACKGROUND: Medical research continues to focus overwhelmingly on biomedical interventions, such as drugs, devices, and procedures. The dysfunctional health care cultures and systems need more attention for quality of care to improve further. PURPOSE: The existing health services management research has not used a systematic theoretical framework to predict the effects of organizational variables on clinical outcomes. This study tests the theoretical model proposed by N. Khatri, A. Baveja, S. Boren, and A. Mammo (2006). METHODOLOGY: This study surveyed employees from hospitals in Missouri. The sample consisted of 77 respondents from 16 hospitals. FINDINGS: The control-based management approach (Management Control and Silos) was found to be positively associated with Culture of Blame and negatively with Learning From Mistakes. In contrast, the commitment-based approach (Fair Management Practices and Employee Participation) was negatively associated with Culture of Blame and positively with Learning From Mistakes, Camaraderie, and Motivation. Mediating variables of Learning From Mistakes and Camaraderie showed a significant negative relationship with Medical Errors. Learning From Mistakes, Camaraderie, and Motivation all showed a significant positive relationship with Quality of Patient Care. The mediating variables had much stronger relationships with Medical Errors and Quality of Patient Care than did the independent variables, lending support to the proposed mediation. IMPLICATIONS FOR PRACTICE: Health care organizations can improve the quality of care and reduce medical errors significantly by enhancing learning from mistakes and boosting camaraderie and morale of their employees. They can do so by breaking down silos in their structures, implementing just and fair management practices, and involving employees in decision making.     

New initiatives to improve medication safety in hospitals

Medication errors constitute a significant public health problem and are recognised as such nowadays among healthcare professionals, societies, authorities and international organizations. This has led to seeking and implementing effective practices focused on improving medication use safety. This article briefly describes some of the most recent initiatives promoted to prevent medication errors in the hospital setting. These safety improvement initiatives are based upon progressively developing an institutional culture of safety and on establishing practices designed to reduce errors or detect them in time, thus avoiding adverse effects to patients. Among these recent initiatives are the safety practices approved by the National Quality Forum, and the National Patient Safety Goals that the Joint Commission on Healthcare Accreditation has required since 2003. Also mentioned are several strategies that have been offered to facilitate the application of these practices, among which are the Pathways to Medication Safely, the development of collaborative projects among hospitals and organizations of experts, and the inclusion of a medication safety specialist in hospitals as a support figure overseeing the application of safety measures. Finally, the challenges inherent in putting these preventive measures into real patient's care are discussed. The barriers confronting this step must obviously be faced if improvements in patient safety are truly to be achieved.     

美国医院质量评价体系及评价方法

介绍美国目前采用的四个医院质量评价体系,即美国年度最佳医院评价体系、美国百佳医院评价体系、国际医疗质量评价体系和医疗机构评审联合委员会评价体系。其中最佳医院评价体系是由基础建设指标、过程指标、结果指标三部分组成,先按专科领域进行排名,然后采用加权指数法计算医院质量指数,再根据医院专科排名和数量产生最佳医院。百佳医院评价体系是在同规模医院范围内,根据医院质量与安全指标评出百佳医院,评价指标包括风险调整死亡率指数、并发症指数、病情严重度调整平均住院日等8项。国际医疗质量和医疗机构评审联合委员会评价体系也在多个国家应用,用于评定临床医疗效率,在医疗质量临测和促进方面,享有较高的信誉。     

Systematic analysis and controlling of health care organisations lead to numerical health care improvements.

The EFQM model for organisational excellence is used in the health care sector as a tool to diagnose and assess the starting position for the effective QM programme. Feedback reports cover the fields of acute medical care, rehabilitation and ambulant care and contain strengths areas for improvement. Building on the EFQM feedback reports, the Modular Concept for Quality in Health Care ("Heidelberg Model") improves QM both holistically and specifically by implementing so-called "Modules for Excellence". The implementation process follows principles of project management covering medical, nursing and managing issues and the performance is periodically evaluated against targets. QM projects that are designed in the dichotomic way follow three goals. Organisational diagnosis and therapy lead to numerical health care improvements in "Prevention of nosocomial infections" and "Optimising out-patient treatment". Different assessment approaches lead to a diagnosing feedback report for QM in health care. The Modular Concept for Quality in Health Care ("Heidelberg Model") clusters, priorities, implements and evaluates the organisation's key areas for improvement.