Quality improvement of medical diagnostic laboratories

Service quality in medical laboratories is influenced by a number of variables. Medical laboratories have long recognized the need for total quality management that incorporates the continuous improvement of all stages, such as the pre-analytical, analytical and post-analytical phases, of the diagnostic process, in addition to the traditional internal and external quality control of analytical procedures. Based on national and international experience, continuous improvement of quality and its external assessment are of high priority in order to guarantee a reliable, effective and cost-effective diagnostic service. Certification of health care services, according to ISO 9001 standards in Hungarian hospitals, is not sufficient to prove professional competence of medical laboratories, which called for a system of laboratory accreditation. Accreditation is an external professional audit by which an independent accreditation body gives formal recognition that the medical laboratory is competent to provide high quality services that are compliant with rigorous professional standards of best practice. The primary aim of accreditation is the improvement of the quality of diagnostic services by voluntary participation, professional peer review, continuous training and education and compliance with professional standards. In vitro medical laboratories have pioneered quality control and quality assurance in health care. Based on these strengths and traditions, the introduction of the accreditation program of medical laboratories in Hungary is one of the key professional and ethical responsibilities of diagnostic professions, in order to improve the quality, efficiency and effectiveness of laboratory services during the course of Hungary's accession to the European Union.     

Evaluation of quality improvement programmes

In response to increasing concerns about quality, many countries are carrying out large scale programmes which include national quality strategies, hospital programmes, and quality accreditation, assessment and review processes. Increasing amounts of resources are being devoted to these interventions, but do they ensure or improve quality of care? There is little research evidence as to their effectiveness or the conditions for maximum effectiveness. Reasons for the lack of evaluation research include the methodological challenges of measuring outcomes and attributing causality to these complex, changing, long term social interventions to organisations or health systems, which themselves are complex and changing. However, methods are available which can be used to evaluate these programmes and which can provide decision makers with research based guidance on how to plan and implement them. This paper describes the research challenges, the methods which can be used, and gives examples and guidance for future research. It emphasises the important contribution which such research can make to improving the effectiveness of these programmes and to developing the science of quality improvement.     

Paradoxes of French accreditation

The accreditation system introduced into the French healthcare system in 1996 has five particular characteristics: (1) it is mandatory for all healthcare establishments; (2) it is performed by an independent government agency; (3) surveyors have to report all instances of non-compliance with safety regulations; (4) the accreditation report is delivered to regional administrative authorities and a summary is made available to the public; and (5) regional administrative authorities can use the information contained in the accreditation report to revise hospital budgets. These give rise to a number of paradoxes: (1) the fact that accreditation is mandatory lends itself to ambiguity and likens the process to an inspection; (2) the fact that decision makers can use the information contained in the accreditation report for resource allocation can incite establishments to adopt strategic behaviours aimed merely at complying with the accreditation manual; and (3) there is a tendency for establishments to reduce quality processes to nothing more than the completion of accreditation and to focus efforts on standardizing practices and resolving safety issues to the detriment of organizational development. All accreditation systems must be aware of these paradoxes and decide on the level of government involvement and the relationship between accreditation and resource allocation. With time, accreditation in France could benefit from both a professionally driven system and from the increased amount of freedom to focus on quality improvement which is necessary for organizational development.     

Professional accreditation of occupational therapy educational programs: A bright or embattled future?

As Australia introduces a new system of individual accreditation through the program for individual accreditation of occupational therapists, there is a need to also consider the place and scope of specialised educational program accreditation in the maintenance of professional standards. The present article reviews issues relating to educational program accreditation including: the need for accreditation and its tradition in occupational therapy; types of accreditation and stakeholders involved; accreditation processes; and evidence of effectiveness. It suggests that professional association demands of programs and the accreditation processes used for audit and inspection must be relevant and reasonable in order to be considered credible and necessary by all stakeholders. Standards and professional accreditation processes that do not demonstrate that they are relevant and reasonable will face an embattled future. Those that do provide mechanisms for true quality improvement through relevant, well-conceived processes should have a bright future in a world seeking benchmarks for quality in professional preparation programs.     

Systematic reviews of the effectiveness of quality improvement strategies and programmes

Systematic reviews provide the best evidence on the effectiveness of healthcare interventions including quality improvement strategies. The methods of systematic review of individual patient randomised trials of healthcare interventions are well developed. We discuss methodological and practice issues that need to be considered when undertaking systematic reviews of quality improvement strategies including developing a review protocol, identifying and screening evidence sources, quality assessment and data abstraction, analytical methods, reporting systematic reviews, and appraising systematic reviews. This paper builds on our experiences within the Cochrane Effective Practice and Organisation of Care (EPOC) review group.     

Accreditation: a cultural control strategy

PURPOSE: The purpose of this paper is to describe and understand the effects of the accreditation process on organizational control and quality management practices in two Quebec primary-care health organizations. DESIGN/METHODOLOGY/APPROACH: A multiple-case longitudinal study was conducted taking a mixed qualitative/quantitative approach. An analytical model was developed of the effects of the accreditation process on the type of organizational control exercised and the quality management practices implemented. The data were collected through group interviews, semi-directed interviews of key informers, non-participant observations, a review of the literature, and structured questionnaires distributed to all the employees working in both institutions. FINDINGS: The accreditation process has fostered the implementation of consultation mechanisms in self-assessment teams. Improving assessments of client satisfaction was identified as a prime objective but, in terms of the values promoted in organizations, accreditation has little effect on the perceptions of employees not directly involved in the process. As long as not all staff members have integrated the basis for accreditation and its outcomes, the accreditation process appears to remain an external, bureaucratic control instrument. ORIGINALITY/VALUE: This study provides a theoretical model for understanding organizational changes brought about by accreditation of primary services. Through self-assessment of professional values and standards, accreditation may foster better quality management practices.     

Organisational change theory and the use of indicators in general practice

General practices are making greater use of indicators to help shape and develop organisational arrangements supporting the delivery of health care. Debate continues concerning what exactly such indicators should measure and how they should be used to achieve improvement. Organisational theories can provide an analytical backdrop to inform the design of indicators, critique their construction, and evaluate their use. Systems theory, organisational development, social worlds theory, and complexity theory each has a practical contribution to make to our understanding of how indicators work in prompting quality improvements and why they sometimes don't. This paper argues that systems theory exerts the most influence over the use of indicators. It concludes that a strategic framework for quality improvement should take account of all four theories, recognising the multiple realities that any one approach will fail to reflect.     

Occupational exposure limits for chemicals

 Occupational exposure limits (OELs) are tools to help employers protect the health of those who may be exposed to chemicals in their workplace. Under the United Kingdom Control of Substances Hazardous to Health (COSHH) Regulations they define adequate control by inhalation.
 OELs are set by the Health and Safety Commission (HSC) on advice from its Advisory Committee on Toxic Substances (ACTS) and after public consultation. Thus they are consensus limits which have the support of both sides of industry.
 COSHH uses two types of occupational exposure limit—the occupational exposure standard (OES) and the maximum exposure limit (MEL).
 OESs are set for substances for which it is possible to identify a concentration at which there is no significant risk to health. Employers are required to meet the limit, there is no requirement to go below it, and it can be exceeded provided steps are taken to meet it as soon as reasonably practicable.
 MELs are set for substances which have serious health implications and for which an OES cannot be set. Most of the substances with MELs are either carcinogens or causes of occupational asthma. Employers must not exceed an MEL and must reduce exposure as far below it as is reasonably practicable.
 MELs are set at concentrations achievable by good occupational hygiene practice such that risks to workers are judged to be reduced to a tolerable level. The HSC consider that this approach is preferable to the use of mathematical models to generate risk estimates, which inevitably gives a spurious appearance of accuracy.
 The MEL/OES system is poorly understand by many employers who use chemicals, is not comprehensive as some substances meet neither the OES nor MEL criteria, and does not mesh well with indicative occupational exposure limit values which will increasingly be set under the European Union Chemical Agents Directive.
 COSHH essentials: easy steps to control chemicals provides the practical help that firms need to control chemicals. It takes users straight from hazard and exposure considerations to benchmark standards of good practice.
 The problems with the current system have prompted ACTS to set up a subgroup to review the OEL framework.

     

Mentoring and Facilitating Professional Engagement as Quality Enhancement Strategies: An Overview and Evaluation of the Family Child Care Partnerships Program

Background

The importance of professional development training for individuals tasked with providing quality early child care is widely accepted. However, research assessing the impact of specific, long-term professional development programs on changes in caregiver behavior is largely absent, as is research about the processes and mechanisms of such training efforts that produce changes in child care practices.

Objective

We specify the underlying activities and processes of a mentor–delivered quality enhancement and professional development program, Family Child Care Partnerships (FCCP), and present the results of two studies using implementation data to examine program effectiveness as measured by mentors’ observational assessments of the global quality of caregiving practices and providers’ self-reported professional engagement.

Methods

Study 1 consisted of 365 family child care providers who were invited to participate in FCCP. Study 2 was a subsample of Study 1 and consisted of 109 providers. We used latent difference score modeling to examine changes in global child care quality from program entry to program departure and bivariate associations among changes in quality and professional engagement.

Results

Significant increases were found between pre- and post-enrollment assessments of caregiving quality and professional engagement. Increases in professional engagement were associated with increases in quality.

Conclusions

Findings are discussed in the context of the limited information available to guide quality improvement and professional development in family child care and in light of recommendations that the early childhood care and education field develop methods of training that embed knowledge and skills development in practice.     

A case of the birth and death of a high reliability healthcare organisation

High reliability organisations (HROs) are those in which errors rarely occur. To accomplish this they conduct relatively error free operations over long periods of time and make consistently good decisions resulting in high quality and reliability. Some organisational processes that characterise HROs are process auditing, implementing appropriate reward systems, avoiding quality degradation, appropriately perceiving that risk exists and developing strategies to deal with it, and command and control. Command and control processes include migrating decision making, redundancy in people or hardware, developing situational awareness, formal rules and procedures, and training. These processes must be tailored to the specific organisation implementing them. These processes were applied to a paediatric intensive care unit (PICU) where care was derived from problem solving methodology rather than protocol. After a leadership change, the unit returned to the hierarchical medical model of care. Important outcome variables such as infant mortality, patient return to the PICU after discharge, days on the PICU, air transports, degraded. Implications for clinical practice include providing caregivers with sufficient flexibility to meet changing situations, encouraging teamwork, and avoiding shaming, naming, and blaming.     

Evaluation of lifestyle interventions to treat elevated cardiometabolic risk in primary care (E-LITE): a randomized controlled trial

Background

Physicians in small to moderate primary care practices in the United States (U.S.) (<25 physicians) face unique challenges in implementing quality improvement (QI) initiatives, including limited resources, small staffs, and inadequate information technology systems 23,36. This qualitative study sought to identify and understand the characteristics and organizational cultures of physicians working in smaller practices who are actively engaged in measurement and quality improvement initiatives.

Methods

We undertook a qualitative study, based on semi-structured, open-ended interviews conducted with practices (N = 39) that used performance data to drive quality improvement activities.

Results

Physicians indicated that benefits to performing measurement and QI included greater practice efficiency, patient and staff retention, and higher staff and clinician satisfaction with practice. Internal facilitators included the designation of a practice champion, cooperation of other physicians and staff, and the involvement of practice leaders. Time constraints, cost of activities, problems with information management and or technology, lack of motivated staff, and a lack of financial incentives were commonly reported as barriers.

Conclusion

These findings shed light on how physicians engage in quality improvement activities, and may help raise awareness of and aid in the implementation of future initiatives in small practices more generally.     

Practice Facilitation to Improve Diabetes Care in Primary Care: A Report From the EPIC Randomized Clinical Trial

PURPOSE

We investigated 3 approaches for implementing the Chronic Care Model to improve diabetes care: (1) practice facilitation over 6 months using a reflective adaptive process (RAP) approach; (2) practice facilitation for up to 18 months using a continuous quality improvement (CQI) approach; and (3) providing self-directed (SD) practices with model information and resources, without facilitation.

METHODS

We conducted a cluster-randomized trial, called Enhancing Practice, Improving Care (EPIC), that compared these approaches among 40 small to midsized primary care practices. At baseline and 9 months and 18 months after enrollment, we assessed practice diabetes quality measures from chart audits and Practice Culture Assessment scores from clinician and staff surveys.

RESULTS

Although measures of the quality of diabetes care improved in all 3 groups (all P <.05), improvement was greater in CQI practices compared with both SD practices (P <.0001) and RAP practices (P <.0001); additionally, improvement was greater in SD practices compared with RAP practices (P <.05). In RAP practices, Change Culture scores showed a trend toward improvement at 9 months (P = .07) but decreased below baseline at 18 months (P <.05), while Work Culture scores decreased from 9 to 18 months (P <.05). Both scores were stable over time in SD and CQI practices.

CONCLUSIONS

Traditional CQI interventions are effective at improving measures of the quality of diabetes care, but may not improve practice change and work culture. Short-term practice facilitation based on RAP principles produced less improvement in quality measures than CQI or SD interventions and also did not produce sustained improvements in practice culture.     

Designing a quality improvement intervention: a systematic approach

Most quality improvement or change management interventions are currently designed intuitively and their results are often disappointing. While improving the effectiveness of interventions requires systematic development, no specific methodology for composing intervention strategies and programmes is available. This paper describes the methodology of systematically designing quality of care improvement interventions, including problem analysis, intervention design and pretests. Several theories on quality improvement and change management are integrated and valuable materials from health promotion are added. One method of health promotion—intervention mapping—is introduced and applied. It describes the translation of knowledge about barriers to and facilitators of change into a concrete intervention programme. Systematic development of interventions, although time consuming, appears to be worthwhile. Decisions that have to be made during the design process of a quality improvement intervention are visualised, allowing them to serve as a starting point for a systematic evaluation of the intervention.     

Accreditation: what can we learn from the Anglophone model?

There is growing interest in the development and application of standards for the health care to both promote quality assurance but also to improve the processes by which health services are held accountable to the public. This paper maps the development of organisational accreditation systems in the USA, Canada, Australia and the United Kingdom. In the USA, accreditation, which began as a means of ensuring the correct environment for clinical practice has developed into a form of public regulation. In the United Kingdom, many different approaches to the setting of standards and their assessment has created a variety of accreditation systems. The case studies demonstrate that as the concept of accreditation diffuses into the health care systems of different countries, it is being adapted to meet the wider policy needs of different national circumstances.     

Undergraduate medical education accreditation as a driver of lifelong learning

We describe the accreditation of medical education programs that lead to the Doctor of Medicine degree in the United States and Canada. We identify select accreditation standards that relate directly to the preparation of medical school graduates, as required for the supervised practice of medicine in residency training and for developing the skills of self-directed, independent learning. With standards that promote flexibility and encourage innovation, the Liaison Committee on Medical Education utilizes a continuous improvement model for the accreditation of undergraduate medical education with standards that promote flexibility and encourage innovation. The standards focus on curricula to meet learning objectives that address the current context of medical care. In undergraduate and graduate medical education, the relevance of the hospital as the predominant learning environment is challenged; in continuing medical education, traditional lectures are called into question for failing to change physician behavior and improve health care outcomes. To improve medical education from undergraduate through continuing medical education, all the relevant accrediting agencies must collaborate for success.     

Public Health Department Accreditation Implementation: Transforming Public Health Department Performance

In response to a call for improved quality and consistency in public health departments, the Public Health Accreditation Board (PHAB) is leading a voluntary public health accreditation initiative in the United States.The public health department accreditation system will implement a comprehensive set of standards that set uniform performance expectations for health departments to provide the services necessary to keep communities healthy. Continuous quality improvement is a major component of PHAB accreditation, demonstrating a commitment to empower and encourage public health departments to continuously improve their performance.The accreditation process was tested in 30 health departments around the country in 2009 and 2010, and was launched on a national level in September 2011 at the National Press Club in Washington, DC.ACCREDITATION IS A WELL-established process for improving performance within organizations1 and takes place when a formal authority concludes that an organization meets predetermined standards.2 In the health care field, the Joint Commission and National Committee for Quality Assurance are long-standing, respected accreditation authorities recognized for establishing standards and advancing quality through accreditation of health care organizations.3,4 Initiatives undertaken in 4 states—North Carolina, Michigan, Missouri, and Illinois—have demonstrated the relevance and usefulness of similar accreditation systems in public health. 5–8 Important lessons have been learned from these programs about the need for and development of a national public health accreditation system. Nonetheless, despite state examples and the critical role of public health in the health of the nation, no national accreditation organization has been established to ensure public health department standards of performance, until now.Public health department accreditation has become one of the most important initiatives in public health today, representing the culmination of many years of collaboration and research. Leading this initiative is the Public Health Accreditation Board (PHAB), a nonprofit organization dedicated to advancing the continuous quality improvement of state, local, tribal, and territorial health departments through accreditation.9 The goal of the PHAB, set by the Robert Wood Johnson Foundation and the Center for Disease Control and Prevention, is to ensure that 60% of the US population is served by an accredited health department by 2015.10,11 Achievement of this goal is expected to promote and protect the health of the public by advancing the performance of state, tribal, territorial, and local public health departments.9,12We have provided an overview of the voluntary national accreditation program led by the PHAB, the current status of accreditation, and a roadmap for next steps that will be undertaken in the transformation of public health quality in the United States.     

Natural History of Practice Transformation: Development and Initial Testing of an Outcomes-Based Model

PURPOSE

Practice transformation is the cornerstone of the future of family medicine and health care reform, but little is known about how the process occurs. We sought to develop and test a model of the natural history of practice transformation.

METHODS

We developed an outcomes-based model of how a practice moves through practice transformation in 2 phases: (1) initial model created through meetings with collaborative experts and practice facilitators, and (2) clinical and practice systems change reports examined from the first group of participating North Carolina Improving Performance In Practice practices to test and further refine the model.

RESULTS

The resultant model described motivators and supports to transformation. Three emerging practice patterns were identified with the model: transformed practices experiencing robust improvement, activated practices with moderate change, and engaged practices with minimal change in measured quality over a 2-year period. Transformed practices showed broad-based improvement; some reached a threshold and others continued to improve. These practices had highly engaged leadership and used data to drive decisions. Activated practices had a slower improvement trajectory, usually encountering a barrier that took time to overcome (eg, extracting population data, spreading practice changes). Engaged practices did not improve or were unable to sustain change; despite good intentions, multiple competing distractions interfered with practice transformation.

CONCLUSIONS

Practice transformation is a continuous and long-term process. Internal and external practice motivations and specific practice supports provided by a community-based quality improvement program appear to have an impact on engagement, rate of quality improvement, and long-term sustainability. Early successes play a key role as practices learn how to change their performance.     

Navigating practice and academic change in collaborative partnership with a community advisory board

University-based allied health programs must prepare entry-level professionals for a continually-evolving practice landscape. Health care education must demonstrate relevance to community needs in an environment of diminishing resources and increased scrutiny from governmental and accreditation bodies. Diverse perspectives, insights, and strategic counsel are needed to meet these challenges. Strategies associated with the development and functions of corporate and non-profit boards were used to tailor a community advisory board for a dietetics program at a public university. Over a 4-year period, this new board established an annual scholarship conference, funded an endowed scholarship, organized a student mentorship program, and secured new program equipment. The board played a pivotal role in development of and securing administrative approval for the establishment of a Nutrition Center for research, innovative practice, and service learning. In a recent accreditation site visit report, the role of the advisory board was cited as helping to meet education standards. An active advisory board can support strategic program innovation, resource development and help prepare health professionals for 21st century practice. The change-oriented, creative approach described can serve as a model for professional education programs seeking to engage the community in the success of their students.     

The globalization of accreditation in the professions

The direct relationship between educational quality and a successful economy, the proliferation of regional and global trade agreements which encourage professional mobility, and the growing international recognition of academic degrees are contributing factors to the globalization of quality assurance in higher education, including accreditation. On every continent, attention is being paid to developing professional educational standards within an international context, assuring that ?world class? professionals are produced for international as well as national practice.