Methods of control for hospital quality assurance systems.

The major failure of hospital quality assurance systems is the failure to influence physicians' therapeutic decision making in a way that will ensure their ordering necessary and only necessary services. The primary reason for this is insufficient recognition of the "intensive" technology used to treat acute patients, a technology characterized by the interdependence of therapeutic services and the patient's response to these services. In such situations, the appropriate method of achieving quality control is to provide performance feedback to the physician on a regular basis. To the extent that there is uncertainty about the impact of therapeutic services on the patient's response, the physician should be allowed discretion over the therapeutic process. In contrast, when process-outcome relations in the therapeutic process are relatively certain, feedback should be reinforced with sanctions.     

Developments in professional quality assurance towards quality improvement: some examples of peer review in the Netherlands and the United Kingdom.

This study will explore new developments in three clinical peer review programmes in the UK and the visitatie programme in The Netherlands and how these programmes can be linked, in the future, with other quality systems. The information about the English peer review programmes was gathered by conducting four structured interviews with the programme coordinators (see Acknowledgements). Information about the Dutch visitatie programme was gathered by the author working with different visitatie programmes at the Dutch National Institute for Quality Improvement. Comparing new developments in the models of the Institute for Standardization of Organizations and the European Foundation for Quality Management, common changes are identified which seem to reflect elements viewed internationally as necessary in quality improvement. This study will examine if and how these elements are or will be included in the clinical peer review programmes in the UK and in visitatie in The Netherlands.     

Economic evaluation of quality assurance programmes

Substantial investments are now being made in quality assurance programmes throughout the developed world. Proposes that economic evaluation is one approach to justifying these in terms of value for money. Three key elements are: comparison with some alternative course of action; measurement of costs; and measurement of consequences. Illustrates the difficulties of addressing these by a case-study--an audit programme aiming to increase the use of intravenous thrombolysis for acute myocardial infarction. Discusses the production of accurate costings; the wide confidence limits associated with regression analysis; and the numerous assumptions required in the modelling of effectiveness. Economic evaluation of quality assurance programmes may be useful in future, if the required data can be collected.     

Trauma emergency unit: long-term evaluation of a quality assurance programme.

OBJECTIVE: Long-term evaluation of a quality assurance programme (after an assessment in 1993). DESIGN: Review of medical records. SETTING: Emergency area of an orthopaedic, trauma, and plastic surgery unit in a French teaching hospital (Besancon). SUBJECTS: 1187 consecutive ambulatory patients' records, from July 1995. MAIN MEASURES: Occurrence of near adverse events (at risk events causing situations which could lead to the occurrence of an adverse event). RESULTS: 71 near adverse events were identified (5.9% of the ambulatory visits). There was a significant decrease in the rate of near adverse events between 1993 (9.9% (2056 ambulatory visits, 204 near adverse events)), and 1995 (5.9% (1187 ambulatory visits, 71 near adverse events)), and significant change in the proportion of each category of adverse event (decrease in departures from prevention protocols). CONCLUSIONS: Despite their limitations, the effectiveness and efficiency of quality assurance programmes seem to be real and valuable. Maintaining quality improvement requires conditions which include some of the basic principles of total quality management (leadership, participatory management, openness, continuous feed back). The organisation of this unit as a specialised trauma centre was also a determining factor in the feasibility of a quality assurance programme (specialisation and small size, high activity volume, management of the complete care process). Quality assurance is an important initial step towards quality improvement, that should precede consideration of a total quality management programme.     

A quality assurance, cost avoidance, evaluation model.

The quality assurance and cost avoidance evaluation model has six processes that help management and staff approach quality and cost through a systematic and objective method. Quality of service and care can be provided that need not bankrupt the health care system or the client. What is needed is the continual review of our client's needs and our practices. We cannot lose sight of the fact that there is always another way to accomplish optimal health care.     

Market and evaluation roles in quality assurance

Competitive markets and formal evaluations offer distinctly different mechanisms for controlling the quality of care based on patients' choices as consumers and applied scientific methods, respectively. As the difficulty of acquiring relevant information and its skewness toward providers becomes greater, the need for evaluations increases. Thus the complexities of medical care tend to limit the range of the market. Markets, however, provide information on value, accommodating differences in patient preferences and cost conditions not readily obtained with formal evaluations. Through incentives, markets integrate the evaluation and control functions and may create greater efficiency and responsiveness. A variety of organizational structures for quality assurance are available, and formal evaluations are often incorporated within a market context. The policy task addressed here is to specify how, as conditions vary, greater reliance should be placed on market competition or on formal evaluations and external regulation.     

医疗质量综合评价的综述

医务质量评价是医疗服务提供者和利用者都关心的问题。文章对我国国内医疗质量综合评价的概念、内容、对象、步骤和方法作了综述，对评价中存在的问题和对策进行了探讨。     

医疗质量综合评价的综述(2)

医务质量评价是医疗服务提供者和利用者都关心的问题。文章对我国医疗质量综合评价的概念、内容、对象、步骤和方法作了综述，对评价中存在的问题进行了探讨。     

Initiation of a quality assurance program for social work practice in a teaching hospital.

This first-stage paper describes the steps taken in implementing a quality assurance program. The rationale for writing social work protocols based on medical diagnosis or tasks rather than on psychosocial diagnosis is explained in detail. Protocols for adult rheumatoid arthritis, pediatric cancer, adult discharge planning, and adult nursing home placement are included to demonstrate the result of the medical diagnosis/task approach.     

医院心电图机的检定管理与质量保障

目的通过对心电图机的检定管理,探讨医疗计量设备的质量保障。方法运用医院管理学、临床医学和社会学相关理论,结合现阶段医疗服务体系改革讨论医疗设备的管理。结果对心电图机实施的强制检定直接提升该仪器质量的合格率,有效地保证了临床的应用需要。结论坚持正确地医疗计量设备管理制度,是医院整体管理的重要组成部分,鉴于计量器具种类繁多和使用分散,只有踏实做好这项工作,才能进一步推动医疗设备的质量保障,发挥其积极作用。     

An evaluation of the quality assurance system for skilled nursing facilities in New York state.

A new quality assurance system for nursing homes was implemented by the New York State Department of Health in 1981 in response to widespread dissatisfaction with the previous survey and Inspection of Care programs. The new program combined the Inspection of Care, which is a patient centered review, and the survey, which is a structurally oriented facility review. In this study, the old and new quality assurance systems are compared with respect to (1) the amount of surveillance staff resources spent on on-site and off-site activities, (2) the types and quantity of deficiency citations issued, and (3) the correction of deficiencies. The results indicate that the new system devotes more resources to on-site activities and identifies more patient care deficiencies, hut also has led to the identification of more repeat deficiencies.