Measuring client-perceived quality of maternity services in rural Vietnam.

OBJECTIVE: To examine the feasibility, reliability and validity of a 20-item scale for measuring perceived quality of maternity services provided at commune health centres in rural Vietnam. DESIGN: A survey of 200 women who gave birth in July-August 2000 and 196 pregnant women in 34 communes in Quang Xuong District, Thanh Hoa Province, Vietnam. MAIN OUTCOME MEASURES: Inter-rater reliability, internal consistency and factor structure of the scale were examined. The associations between perceived quality and client characteristics were also investigated. RESULTS: The instrument had relatively good inter-rater reliability and internal consistency. Except for two items: 'good clinical examination' and 'adequacy of health workers for women's health', the scale exhibited good agreement between the two raters, with kappa values ranging from 0.54 to 0.84. The Cronbach's alpha coefficients for the dimensions 'health care delivery', 'health facility', 'interpersonal aspects of care' and 'access to services' were 0.72, 0.64, 0.72 and 0.33, respectively. Respondents were positive on items related to the dimensions 'interpersonal aspects of care' and 'access to services', but negative on the dimensions 'health care delivery' and 'health facility'. The maternity status of clients was found to influence the perceived quality of maternity services. CONCLUSIONS: The feasibility, reliability and validity of the instrument were established in the context of rural Vietnam. Its application in evaluating other health care programmes should be an important follow-up action for the Vietnamese government.     

Youth reproductive health services in Bulawayo,Zimbabwe

This study examines young people's access to reproductive healthcare services via an urban youth advisory centre in Bulawayo, Zimbabwe. The aim is to explain why teenagers do not always use existing health services. Data from exit questionnaires with users and focus groups with non-users are analysed to evaluate service accessibility. Analysis suggests that even where clinics are spatially accessible, barriers to access include temporal factors, lack of factual knowledge and stigmatisation. The paper concludes that spatial accessibility is not the only factor necessary to ensure equal access to health services. Recommendations are made towards tackling young people's unmet needs for reproductive healthcare services.     

基于服务质量差距模型的医院服务营销实践

面向全国的医药卫生体制改革方案虽然还没最后确定,但是市场机制的作用在医疗服务提供中将是不能忽视的重要力量。市场机制的核心就是按着需求来调配资源满足顾客需求。医院的服务营销是医疗服务的内在要求,是医院经营管理的应有之意．是医疗服务质量的基础。结合服务质量差距模型理论进一步阐述了“以病人为中心”的服务理念和“弥合差距”的服务营销实践。     

Treatment outcomes of new adult tuberculosis patients in relation to HIV status in Zimbabwe

Setting:

All public health facilities in Chitungwiza District, Zimbabwe.

Objective:

To determine, in new tuberculosis (TB) patients registered in 2009, 1) the proportion of persons human immunodeficiency virus (HIV) tested, stratified by age, sex and type of TB, and 2) treatment outcomes in relation to type of TB and HIV status.

Design:

Retrospective cohort study.

Results:

Of 1800 TB patients, 1100 (61%) were tested, of whom 877 (80%) were HIV-positive and 75 (9%) were documented as receiving antiretroviral treatment (ART). HIV testing and HIV positivity were similar between patients with different types of TB. Overall, the treatment success rate was 70%, and 17% had transferred out. Being HIV-positive on ART was associated with better treatment success and lower transfer out; age ≥55 years was associated with poor treatment success and higher death rates. Defaulting was more common in those who did not undergo smear testing or in extra-pulmonary TB patients, while deaths were higher in males.

Conclusion:

In a Zimbabwe district, less than two thirds of TB patients were tested. Better treatment success was observed in patients documented as HIV-positive and on ART. Important lessons for improved TB control include increasing HIV testing uptake for better access to ART, more comprehensive recording practices on ART and better reporting on true outcomes of transfer-out patients.     

The challenge of measuring quality of care at health centre level in Africa: the example of Tsholotsho health district in Matabeleland North, Zimbabwe

This study is on the evaluation of quality of health care within first line health services in rural Zimbabwe. It took place between 2001 and 2002, and consisted of a cross-sectional survey designed to compare the quality of health care on offer at a newly created health centre with that provided by the district hospital's outpatient department. The hypothesis to be tested was that the health centre offered better quality of care. A comprehensive quality of care evaluation framework was designed. The concept of patient enablement was incorporated into the study's assessment of health care delivery outcomes. The results did not provide conclusive evidence that the care offered at the health centre was better than the care on offer at the hospital OPD. The reasons for these unexpected findings are discussed in depth. They are related to the limited understanding amongst local health workers of the organisational changes introduced by the District Health Executive (DHE), together with a (European) cultural bias in the quality of care model under test. An important lesson of this study is that the notion of enablement, notwithstanding the need to put into context the tools used to measure it, was considered by the DHE as relevant in the organisation and evaluation of health care.     

The impact of changing the diagnostic algorithm for TB in Manicaland,Zimbabwe

SETTING:Governmental health facilities performing TB diagnostics in Manicaland, Zimbabwe.OBJECTIVE:To investigate the effect of making Xpert® MTB/RIF the primary TB diagnostic for all patients presenting with presumptive TB on 1) the number of samples investigated for TB, 2) the proportion testing TB-positive, and 3) the proportion of unsuccessful results over time.DESIGN:This retrospective study used data from GeneX-pert downloads, laboratory registers and quality assurance reports between 1 January 2017 and 31 December 2018.RESULTS:The total number of Xpert tests performed in Manicaland increased from 3,967 in the first quarter of 2017 to 7,011 in the last quarter of 2018. Mycobacterium tuberculosis DNA was detected in 4.9–8.6% of the samples investigated using Xpert, with a higher yield in 2017 than in 2018. The overall proportion of unsuccessful Xpert assays due to “no results”, errors and invalid results was 6.3%, and highly variable across sites.CONCLUSION:Roll out of more sensitive TB diagnostics does not necessarily result in an increase of microbiologically confirmed TB diagnosis. While the number of samples tested using Xpert increased, the proportion of TB-positive tests decreased. GeneXpert soft- and hardware infrastructure needs to be strengthened to reduce the rate of unsuccessful assays and therefore, costs and staff time.     

Duet® for menstrual protection: a feasibility study in Zimbabwe

BackgroundManaging menses is a challenge for women in developing countries. Duet® is a cervical barrier being developed for contraception and STI prevention. We explored the hypothetical acceptability of using Duet as a menstrual cup, among Zimbabwean women.Study DesignA survey and focus group discussions (FGD) were conducted with 43 women aged 18–45 years to gain information about their menstrual practices and attitudes regarding the use of Duet for menstrual protection.ResultsAll 43 women reported that if Duet were available, they would “definitely” try it, and that it was “very important” that Duet is low cost and easy to clean; 86% reported that using it would make a difference in their lives. FGD findings highlighted unhygienic practices due to the lack of affordable options for menstrual management and a genuine interest in Duet, including its potential use for multiple purposes (contraception, disease prevention and menstrual protection).ConclusionsAccessing affordable and hygienic menstrual protection was a problem for these Zimbabwean women. Duet appeared acceptable and it would be feasible to conduct a user-acceptability study of Duet as a menstrual cup in Zimbabwe.     

Migration as a risk factor for school dropout amongst children made vulnerable by HIV/AIDS: a prospective study in eastern Zimbabwe

Orphans and other children made vulnerable by HIV in sub-Saharan Africa are at increased risk of moving household and of dropping out of school. However, the relationship between child migration and school enrolment has not been established. Multivariable regression models and prospective data from a cohort of children in Manicaland, Zimbabwe, were used to investigate the effect of migration on school enrolment. Children who had moved household were at increased risk of dropping out of school after adjusting for orphan status, relationship to primary caregiver, and household wealth. Interventions are needed to ensure that children who migrate are re-enrolled in school.     

Dissecting hospital quality. Antecedents of clinical and perceived quality in hospitals

Clinical quality (CQ) and patient satisfaction (PS) are key elements on the agenda of European public healthcare systems. This paper seeks to explore the relationship between CQ and PS, at hospital level, as freedom of hospital choice may lead to a trade-off between them. In addition, the paper studies the influence of some factors--location, size, case-mix, length of stay and occupancy rate (OR)--on hospital clinical and perceived quality. Correlation analyses and the linear mixed-effect methodology are used. The study focuses on the Andalusian Health Service, one of the biggest European public health services, and covers the years from 2002 to 2006. The results indicate that CQ and perceived quality are not related. The 'volume-expertise' effect is not confirmed in our study, but we find a 'complexity-expertise' effect, i.e. attending more complex cases may improve CQ. Shorter hospitalizations and higher ORs might negatively affect CQ. Location, size, case-mix and ORs significantly affect PS. Hospitals with better patient assessments might attract patients without providing a better clinical care. Caution should be taken when evaluating hospital performance and implementing reforms to improve hospital efficiency as quality may be harmed.     

Improving the quality of child health services: participatory action by providers.

OBJECTIVE: To test a quality improvement approach called COPE (Client-Oriented, Provider-Efficient services), for use in strengthening health systems and supporting Integrated Management of Child Health (IMCI) efforts. DESIGN: Pre- and post-intervention observations of client/provider interactions, facility audits, staff and client surveys, and focus groups to evaluate differences between eight COPE intervention and eight matched non-intervention facilities after a 15-month intervention in 2001. SETTING: Primary care clinics in Guinea and Kenya. STUDY PARTICIPANTS: Health care providers and child caregivers. INTERVENTIONS: Over 15 months, the intervention supported four COPE exercises at each intervention site, supported supervisor training in quality management, and organized minimal training in topics selected by site staff as areas where training was needed. MAIN OUTCOME MEASURES: Differences in staff's and child caregiver's knowledge, attitudes, and practices; differences in the quality of services provided. RESULTS: On almost every quality indicator (over 65 indicators), whether reported by staff, observed by evaluators, or reported by clients, the intervention sites performed statistically significantly better than control sites. INTERVENTION: sites were cleaner and more pleasant, with more respect and information for clients, and more privacy. Staff had better personal communication skills, better diagnostic skills, and prescribing practices and gave better home care instructions to carers. Clients in intervention sites were more informed and more satisfied, and their children had better immunization coverage than those in control sites. CONCLUSION: COPE is a simple process, yet our study confirms that it can have a very dramatic effect on the quality of services. This study demonstrated how all areas of quality can be addressed by empowering health care providers to take action by using COPE. We suggest that COPE can complement Integrated Management of Childhood Illness (IMCI) training and can help to achieve better health for children.     

某医科大学卫生事业管理专业本科毕业论文质量调查分析

目的：了解卫生事业管理专业本科毕业论文质量,为探讨改善该专业毕业论文质量的对策提供参考。方法：选择某医科大学2007—2009届卫生管理专业本科毕业论文205份,采用自行设计的卫生管理专业本科毕业论文文本要素调查表,从毕业论文文本、评语及评分中提取相关要素,填写调查表。主要从论文内容、论文水平和引用抄袭三个角度描述论文质量。结果：论文篇幅大多集中在6000～15000字;53．2％的论文为理论研究型,30．2％为专题研究型;51．2％的论文缺少综述;32．2％的论文仅有O～5篇参考文献;有英文参考文献的占10．7％;42．4％的毕业论文正文中“弓I用比例在40％～60％”;97．6％论文被认为“研究方法合理”;2．9％论文被评价为“论文结论有特色或创新”;20．0％的论文被评价为“有一定参考借鉴或应用价值”;43．4％的毕业论文得分高于85分。结论：论文篇幅基本达到本科毕业论文要求;调查研究类论文偏少;毕业论文结构不够完整;论文正文中引用比例较高;论文评分较高但论文水平有待进一步提高。建议尽早开设科研设计相关课程,同时要制定相关制度,鼓励承担科研任务的带教老师吸收实习生参与课题调研,并指导他们进行调查研究类论文的写作。在卫生管理教学管理中要进一步强调论文综述的写作;在毕业论文写作过程中要强调教师指导和前期培训;毕业论文评分还应采用模块化、标准化的评分方法,量化评分标准,改变只给总成绩的模糊做法。     

From customer satisfaction survey to corrective actions in laboratory services in a university hospital.

OBJECTIVE: To find out the satisfaction of clinical units with laboratory services in a university hospital, to point out the most important problems and defects in services, to carry out corrective actions, and thereafter to identify the possible changes in satisfaction. SETTING: and STUDY PARTICIPANTS: Senior physicians and nurses-in-charge of the clinical units at Oulu University Hospital, Finland. DESIGN: Customer satisfaction survey using a questionnaire was carried out in 2001, indicating the essential aspects of laboratory services. Customer-specific problems were clarified, corrective actions were performed, and the survey was repeated in 2004. RESULTS: In 2001, the highest dissatisfaction rates were recorded for computerized test requesting and reporting, turnaround times of tests, and the schedule of phlebotomy rounds. The old laboratory information system was not amenable to major improvements, and it was renewed in 2004-05. Several clinical units perceived turnaround times to be long, because the tests were ordered as routine despite emergency needs. Instructions about stat requesting were given to these units. However, no changes were evident in the satisfaction level in the 2004 survey. Following negotiations with the clinics, phlebotomy rounds were re-scheduled. This resulted in a distinct increase in satisfaction in 2004. CONCLUSIONS: Satisfaction survey is a screening tool that identifies topics of dissatisfaction. Without further clarifications, it is not possible to find out the specific problems of customers and to undertake targeted corrective actions. Customer-specific corrections are rarely seen as improvements in overall satisfaction rates.     

The costs of hospital services: a case study of Evangelical Lutheran Church hospitals in Tanzania.

The health care systems of many developing countries are facing a severe crisis. Problems of financing services leads to high patient fees which make institutions of Western health care unaffordable for the majority of the rural poor. The conflict between sustainability and affordability of the official health care system challenges both local decision-makers and health management consultants. Decisions must be made soon so that the existing health care systems can survive. However, these decisions must be based on sound data, especially on the costs of health care services. The existing accounting systems of most hospitals in developing countries do not provide decision-makers with these data. Costs are generally underestimated. The leadership of the 16 hospitals of the Evangelical Lutheran Church in Tanzania is currently analyzing how the existing health care services should be restructured. Therefore, reliable estimates of the costs of hospitals services are required. A survey on 'Costing of health services of the Evang. Luth. Church in Tanzania' was prepared, which summarizes the results of seven months of field investigations in Lutheran hospitals. The major findings are that the costs of providing adequate services are much higher than expected. The most important factors determining these costs are the administrative efficiency of the hospital and the scope of services offered. The paper closes with some recommendations on how to improve the services in order to make them both affordable for the rural poor and financially sustainable for the Church. It is concluded that even the best improvement of technical efficiency will not safeguard the survival of the hospital-based health care services of the Lutheran Church in Tanzania. These findings call for a reallocation of health care resources to lower levels of the health care pyramid.     

Knowledge management infrastructure to support quality improvement: A qualitative study of maternity services in four European hospitals

The influence of multilevel healthcare system interactions on clinical quality improvement (QI) is still largely unexplored. Through the lens of knowledge management (KM) theory, this study explores how hospital managers can enhance the conditions for clinical QI given the specific multilevel and professional interactions in various healthcare systems.The research used an in-depth multilevel analysis in maternity departments in four purposively sampled European hospitals (Portugal, England, Norway and Sweden). The study combines analysis of macro-level policy documents and regulations with semi-structured interviews (96) and non-participant observations (193 hours) of hospital and clinical managers and clinical staff in maternity departments.There are four main conclusions: First, the unique multilevel configuration of national healthcare policy, hospital management and clinical professionals influence the development of clinical QI efforts. Second, these different configurations provide various and often insufficient support and guidance which affect professionals’ action strategies in QI efforts. Third, hospital managers’ opportunities and capabilities for developing a consistent KM infrastructure with reinforcing enabling conditions which merge national policies and guidelines with clinical reality is crucial for clinical QI. Fourth, understanding these interrelationships provides an opportunity for improvement of the KM infrastructure for hospital managers through tailored interventions.     

Setting national priorities for quality assessment of health care services in Korea.

OBJECTIVE: To identify target services and determine national priorities among those services identified for a national quality assessment program of the Health Insurance Review Agency (HIRA) in Korea. DESIGN: Target services were identified from published sources addressing quality problems, various quality-monitoring programs in other countries, suggestions from 26 medical specialty associations in Korea, and frequently reported consumer claims. Three steps were involved in the prioritization decision: (i) development of a set of priority criteria; (ii) expert panel survey to evaluate the extent to which individual services satisfy each of the priority criteria and to calculate mean priority ratings for individual services; and (iii) formation of four levels of priority groups-top, high-middle, middle, and low-according to the allocated priority ratings. RESULTS: Five priority criteria were selected: "burden of the condition", "seriousness of the quality problem", "interest and demand of society", "acceptability", and "the feasibility of quality assessment". Among the 57 services identified as targets for the national quality assessment program, 10 were selected as having a top priority for quality assessment because of their high feasibility rating. These are: cardiac surgery; cataract surgery; tonsillectomy; appendectomy; tooth extraction; usage of albumin/globulin products; treatments for hypertension, pneumonia, and acute upper respiratory infection; and services provided by clinical laboratory centers. CONCLUSION: The priority services identified from the studies will assist the HIRA in selecting target services and implementing the national assessment program.     

Measuring the quality of junior hospital doctors in general medicine

During the course of a larger study aimed at relating staffing levels of junior doctors in general medicine to the safety of the care provided, it became clear that consultant doctors considered the quality of their junior staff as being at least as important as the quantity. This paper describes several attempts to develop a feasible and valid method of measuring the quality of senior house officers (SHOs) and registrars using routinely available data. Having rejected three methods and had difficulties with three other methods, a modified Delphi survey was used to explore the extent to which consultants agreed on the key attributes of a high quality SHO or registrar. Sixty-seven (60%) of all consultants in the South-West Thames and Trent regions responded to two rounds of questionnaires which revealed communication skills as being consistently the most significant factor. This was confirmed in a second, anonymous survey of 198 (78%) SHO and registrar posts in the North-West Thames region. It also became clear that consultants viewed the quality of their own SHOs and registrars as generally high. This being so it is argued that the requirement to adjust for quality, when comparing SHO and registrar levels between hospitals, is of minor importance. These results also suggest that the explicit teaching of communication skills should have a high priority in undergraduate and postgraduate education.