An audit of blood component therapy in a Canadian general teaching hospital.

As part of a quality assurance program a retrospective audit of transfusion practices for packed red blood cells, fresh frozen plasma and albumin was undertaken with predetermined criteria in a general teaching hospital. Of 520 transfusion episodes with 1218 units of packed red blood cells given to 297 patients 88% were considered appropriate; of 106 episodes with 405 units of fresh frozen plasma given to 83 patients 90% were deemed appropriate; and of 187 episodes with 320 units of albumin given to 99 patients 64% were considered appropriate. The results of this audit, when compared with those of other surveys of blood use in a similar population, suggest that pretransfusion approval of requested components would reduce the number of inappropriate transfusions.     

A computerized MIS to support the administration of quality patient care in HMOs organized as IPAs

All federally qualified HMOs must develop and implement quality assurance programs for monitoring the quality of care, the quality of services, and the costs of inpatient and ambulatory care. Such quality assurance programs are diverse and vary in administrative structure, criteria, review procedures, feedback, and decision making. This paper describes a computerized quality assurance reporting system operating in an HMO organized as an IPA network. The design and use of various MIS reports containing information on inpatient utilization and costs, physician office visits and physician practice patterns, physician productivity, physician referral patterns and costs, and the health problems of members are presented. The importance of these MIS-generated reports on the operations of IPA medical groups and the HMO and how they are used by medical directors, HMO management, and committees charged with quality assurance responsibilities is also included.     

Patient care appraisal as a guide for the design of continuing medical education: 10 years' experience in the Maritime provinces.

Patient care appraisal is a process whereby physicians set down criteria and standards of patient care, prepare a summary of relevant health care activities derived from medical records and other sources of data, analyse the shortcomings discovered and design remedial programs. An attempt was made to introduce such a peer review system to 19 community hospitals in the Maritime provinces as a mechanism to improve the quality of health care. Maximum use was made of all existing quality assurance methods, complemented by innovations compatible with known educational and psychological principles. The staffs of the hospitals were willing to participate but problems were encountered in maintaining their motivation. Much of the success was related to the appropriate use of interested and competent medical record librarians in the retrieval, compilation and display of information. A positive attitude towards peer reviews and peer learning evolved in the participants. It is recommended that practising physicians, health care institutions and university divisions of continuing medical education continue and extend such cooperation and find new ways to apply the peer review mechanisms.     

Role of quality assessment in improving red blood cell transfusion practice

A prospective analysis of perioperative red blood cell transfusion practice in 110 patients undergoing elective primary total hip arthroplasty was conducted as a part of a quality assessment programme at the National Orthopaedic Hospital. In addition to demographic and clinical data, blood loss and perioperative transfusions were also recorded. Blood was collected for evaluation of haematocrit levels at predetermined intervals (preoperative and 6 h, 1, 2, 3, 7 days, postoperatively). Blood transfused with the patient’s haematocrit of more than 30 per cent was considered inappropriate. In addition, a discharge haematocrit exceeding 36 per cent was chosen to identify overtransfusion. Eighty-four per cent were transfused a total of 191 units of homologous blood. Only 4 units were transfused between 3 patients, intraoperatively. All intraoperative transfusions were appropriate. Using the preset criteria (i.e. blood transfused with haematocrit of more than 30 per cent), 36 per cent of total units transfused were inappropriate. Using the criterion of discharge haematocrit of more than 36 per cent, 24 per cent of the patients were overtransfused. As compared to a previous retrospective analysis of blood transfusion in the same patient population which showed that inappropriate transfusion occurred in 45 per cent of the patients, the results from this study suggest a trend towards a more conservative transfusion practice. The improvement in transfusion practice may be due to the ongoing quality assurance programme and the use of transfusion guidelines. Presented at the 1994 annual meeting of the International Anesthesia Research Society, Orlando, Florida, March 1994.     

The 'USHealth Act'. Comprehensive reform for a caring America

USHealth is a program proposed by Congressman Roybal to provide catastrophic and basic health coverage for all Americans, regardless of age, income, or illness. It would be managed by the USHealth Administration, an independent off-budget government agency, and would consolidate Medicare, Medicaid, and private insurance into a single insurance program. Roybal argues the case for his proposal, focusing on cost-containment; the expansion of coverage to include nursing and long-term care; the prioritization of quality assurance; financing along the lines of the current Medicare model; and commitment to "true" criteria: protection of the uninsured, protection of underinsured working families, short-term catastrophic protection for underinsured persons, containment of health care costs, assurance of quality care, and full financing now and in the foreseeable future.     

抓住机遇 深化改革 扎实工作 开创医政工作新局面

对过去三年医政工作在医疗机构改革、医政法制建设、依法行政、医疗质量管理、血液管理等方面取得的进展进行了回顾,提出了新形势下医政工作面临的机遇和挑战,要求继续加强学习、转变观念,加速推进医疗卫生体制改革,依法治医、以德治医,狠抓医疗服务和血液质量管理,进一步加强医政队伍建设。     

Assuring the quality of health care for older persons. An expert panel's priorities

To select topics for quality assurance activities focusing on older patients, we convened a 14-member panel of physicians and experts in quality assurance. In two rounds of ratings, panelists rated 42 medical conditions (eg, pneumonia) in terms of their effects on patient outcomes, the availability of beneficial interventions, and the health benefits from improving current quality. They rated 27 health services (eg, adult day-care) on similar dimensions. The feasibility of doing quality assurance work on each condition and service also was rated. Using the ratings, the conditions selected for quality assurance work were congestive heart failure, hypertension, pneumonia, breast cancer, adverse effects of drugs, incontinence, and depression. Health care services selected were hospital discharge planning, acute inpatient care for the frail elderly, long-term-care facilities (intermediate-care facilities and skilled nursing facilities), home health care services, and case management.     

Patient Blood Management: Single Center Evidence and Practice at Fuwai Hospital

Blood loss and blood transfusion requirement are important quality control indicators of cardiovascular surgery and cardiovascular anesthesia. Patient blood management (PBM) is an evidence-based, multidisciplinary approach to optimizing the care of patients who may need transfusion, which encompasses anemia management, hemodilution, cell salvage, hemostatic treatment, and other approaches to reducing bleeding and minimizing blood transfusion. PBM in cardiovascular surgery is a “team sport” that involves cardiac and vascular surgeons, anesthesiologists, perfusionist, intensivists, and other health care providers. The current work provides an overview of evidence and practice of PBM at Fuwai Hospital. Implementation of PBM should also take local resource availability and costeffectiveness of different devices, drugs, technologies, and techniques into consideration.     

A survey of medical quality assurance programs in Ontario hospitals.

OBJECTIVE: To determine the prevalence and types of medical quality assurance practices in Ontario hospitals. DESIGN: Survey. SETTING: All teaching, community, chronic care, rehabilitation and psychiatric hospitals that were members of the Ontario Hospital Association as of May 1990. PARTICIPANTS: The person deemed by the chief executive officer of each hospital to be most responsible for medical administration. INTERVENTION: A questionnaire to obtain information on each hospital's use of criteria audit, indicators inventory, occurrence screening and reporting, and utilization review and management (URM) activities. OUTCOME MEASURES: Prevalence of the use of the quality assurance activities, the people responsible for the activities and the relative success of the URM program in modifying physicians' performance. RESULTS: Of the 245 member hospitals participants from 179 (73%) responded. Criteria audits were performed in 136 (76%), indicators inventory in 43 (24%), occurrence screening in 44 (25%), occurrence reporting in 61 (34%) and URM in 123 (69%). In-hospital deaths were reviewed in 157 (88%) of the hospitals. In all, 87 (55%) of the respondents from hospitals that had a URM program or were developing one indicated that their program was successful in modifying physicians' practices, and 29 (18%) reported that it was not successful; 26 (16%) stated that the effect was still unknown, and 16 (10%) did not respond. Seventy (40%) stated that results of tissue reviews were reported at least 10 times per year and 94 (83%) that medical record reviews were reported at least as often. The differences in the prevalence of the quality assurance activities between the hospitals were not found to be significant. CONCLUSIONS: Many Ontario hospitals are conducting a wide variety of quality assurance activities. Further study is required to determine whether the differences in prevalence of these activities between hospitals would be significant in a larger, perhaps national, sample. Strategies are needed to ensure universal involvement and participation in the improvement of the quality of care and the assessment of the cost-effectiveness of health care treatments. Recommendations to achieve these objectives are suggested.     

心脏外科主要手术出血患者输血模式

目的 了解心脏外科主要手术出血患者的围手术期输血模式,为促进临床合理、规范用血提供数据参考。方法 从2015至2016年开展的全国多中心(4家医院)调查中,纳入大血管手术、冠状动脉旁路移植手术、心脏瓣膜手术和先天性心脏病手术患者(≥18岁),描述患者特征及术后结局,探讨其出血情况,围手术期自体、异体血(红细胞、血浆、血小板)的输注模式(比例、输注量及组合方式)。结果 术中心脏瓣膜手术自体血输注比例最高(58.84%),而大血管手术自体血输注量最大(722 ml),且异体血术中输注比例(53.28%)尤其是血小板输注比例(39.34%)显著高于其他手术患者。相对异体红细胞,其他成分在各类手术中的输注时机较为集中,其中单独输注血浆比例在术后1 d最高。随着出血量增加,成分联合输注比例逐渐上升为主要的输血方式。结论 不同心脏手术类型、围手术期阶段或出血量下,患者的输注模式存在差异,需要在了解现况的基础上进一步研究有针对性的输血实践方案,节约血液并提高患者输血安全。     

Physician characteristics and training emphasis considered desirable by leaders of HMOs

Health maintenance organizations (HMOs) are growing rapidly and employing increasing numbers of physicians. It is important for medical educators to know what such organizations consider important physician traits and training experiences for their recruitment and retention of physicians. A survey of all HMOs in the United States in 1986, to which 44 percent responded, indicated that they want the curriculum of medical school and/or residency programs to have increased emphasis on cost-effective use of diagnostic and treatment services, utilization review and quality assurance, the role of primary care "gate-keeper," and financing of health services. The most important criteria in selection of physicians by HMOs were the physician's board eligibility, motivation, bedside manner, adaptability to a changing environment, the ability to work in a team, training being done in a U.S. medical school, and ability to relate to nonphysician staff members and the reputation of the physician's residency program.     

Introducing quality assurance and medical audit into the UCSF medical center curriculum.

The experience gained by a medical school faculty in developing and piloting a course for undergraduate medical students in medical care evaluation led to a similar effort for house staff. It is recognized that if the profession is to fulfill the demand by society for social accountability in the use of resources for health care, medical care assessment and quality assurance mechanisms must become an intimate part of the clinical experience of medical students and house officers. Teaching these subjects requires a theoretical framework; introduction of content and skills appropriate to the level of the student and continuation of progressively more advanced training throughout medical education; use of assessment and quality assurance techniques by clinician-teachers themselves to provide models for the student; and continued evolution of pedagogic approach and course content based on developments in the area.     

晚期妊娠储存式自体输血的护理

[目的]探究确保晚期妊娠储存式自体输血安全性的护理措施。[方法]对2010年1月至2011年11月的52例晚期妊娠孕妇进行储存式自体输血,采取产前监护、心理护理、健康教育、采血前后护理、监护和自血回输等一系列护理方式。记录采血过程孕妇配合、母胎反应,孕妇生命体征、分娩结局及自体输血量等,观察临床护理效果。[结果]52例孕妇在采血过程中均配合良好,生命体征正常且稳定,胎心监护正常,其中1例胎动过多,予吸氧、左侧卧位后好转。在自血回输过程中,产妇无不适反应,母婴安全。[结论]通过有效的护理措施,孕妇的储存式自体输血是相对安全、经济、有效的输血方式,可以取得良好的临床护理效果,有利于提高产科护理质量。     

Formulating priorities for quality assurance activity. Description of a method and its application.

Quality assurance activity seems to have had little documented impact in terms of improving patient health or reducing care costs. One reason may be the lack of a practical and effective decision process for selecting priority areas where improvement of health or any other target outcome will most likely be achieved. This article describes a structured procedure for meeting this need. In addition, results of 14 years of quality assurance experience with structured and nonstructured topic selection procedures in 23 multispecialty group clinics and their associated hospitals are briefly reviewed. On the basis of this experience it is suggested that this priority method is both feasible and practical and can be recommended for application to most quality assurance systems. It is especially suited for planning medical care evaluation studies of the Professional Standards Review Organizations or the performance evaluation projects of the Joint Commission on the Accreditation of Hospitals.     

Quality care—commonplace or chimera

Publicity for (and laterly increased economic stringency which makes more likely), failures of care in the NHS engender concern for care quality while its assurance remains the subject of a fragmented and unhelpful literature. A selective attempt is made to examine some underlying principles by posing and answering three questions. What is the quality of care? What basic principles must be followed in defining `standards''? How then may quality be assured?Any definition of care must be multi-faceted and in common use pervaded with the patients'' pre-occupation with a search for cures. Nevertheless, it is argued that there are gains in restricting the technical use of the term `care'' to those systematic processes of health services and their culture which impinge on the personal experience of patients and which fashion their response.In contemporary society care ought to be designed to restore and enhance the independence, dignity and choice of the patient. Although there is a contrary tendency to abandon problems of care to the professionals, standards for care should be judged ultimately not from the specialised professional but from the viewpoint of lay people whose behaviour in the outside world fashions those norms by which independence, dignity and choice are judged.A number of difficulties in identifying and securing improvements in care are discussed. In particular, it is argued that such is the interdependence of the style of management of an institution and the style of care it provides that enforcement of high quality care is likley to be a contradiction in terms. Only trained and sensitive staff can act intuitively and pre-emptively to prevent even incipient deterioration in care. They cannot carefully foster at all times the independence and dignity of their patients unless they are treated in a similar way as professional employees.As an initial step in improving the quality of care a simple start is urged upon implementing an inventory of checks. These are designed to establish the identification and operation of health care policies and practices which give appropriate recognition to the characteristics of care that patients and public expect, coming as they do from a lay rather than professional world. The article concludes with an appropriate inventory of questions to be put to professionals by those laymen who are increasingly imported into health care management through community representation (in CHCs) and staff participation (in joint consultation) and whose interest and concern should be harnessed appropriately.     

Consumer perceptions of health care services: implications for academic medicine.

The factor analytic development of various measures of consumer perceptions regarding characteristics of doctors and health care services is described. Index scores meeting factor analytic and reliability criteria were used to study the importance of consumer perceptions in relation to behavioral outcomes. Numerous dimensions of consumer perceptions were identified and described, including beliefs about doctor conduct in terms of quality of care and humaneness of health care delivery as well as satisfaction with such enabling components as the continuity of care, availability and convenience of services, and various access mechanisms (cost, payment mechanisms, and ease of emergency care facilities). Measures of these perceptions were shown to be related to differences in several estimates of health services utilization. The use of the index scores which have met empirical criteria is in contrast to the common practice of using individual questionnaire items as the unit of analysis in health care research. Findings are discussed in relation to program planning and evaluation in medical education, and suggestions for future research are noted.     

The reliability of peer assessments of quality of care.

OBJECTIVE--To critically examine the literature regarding the interreviewer reliability of the standard practice of peer assessment of quality of care. DATA SOURCES--Computerized searches of the English-language literature from 1966 through 1990 using MEDLINE, HEALTHLINE, and SCISEARCH databases were performed to identify studies reporting data on interreviewer agreement of implicit evaluations of patient care episodes. STUDY SELECTION--Seventeen studies were identified. Five studies were excluded from this review because of deficiencies in the methods or lack of data on chance-corrected indexes of agreement. DATA EXTRACTION SYNTHESIS--The degree of agreement beyond chance was compared with accepted standards in the 12 remaining studies. Most of these studies found agreement corrected for chance to be in the range regarded as poor, indicating that physician agreement regarding quality of care is only slightly better than the level expected by chance. CONCLUSIONS--Given the magnitude of the resources devoted to quality assurance and the centrality of peer assessment to these efforts, there is a need for a global reexamination of the peer review process. A number of proposals appear to have potential for improving the peer review process including more objective assessment procedures, multiple reviewers, higher standards for reviewers, elimination of systematic reviewer bias, use of outcome judgements, and adoption of practice guidelines.     

临床输血质量管理体系的建立

为确保血液和血液成分的安全和合理使用,必须加强临床输血的质量管理。根据ISO9001:2000标准,文中建立了有效的临床输血质量管理体系,其关键控制点涵盖了人员、设备、试剂、环境、血液储存、运输与发放、输血不良反应和计算机管理系统等。编写的质量管理体系文件包括质量手册、程序文件、标准操作规程和质量记录,所有有效文件必须经授权和受控。     

Hospital characteristics and quality of care.

OBJECTIVE. To compare quality of care measured by explicit criteria, implicit review, and sickness-adjusted outcomes at different types of hospitals. DESIGN. Further analysis of data retrospectively abstracted from medical records to evaluate the effects of prospective payment on quality of care for hospitalized Medicare patients. SETTING. Hospitals in five states were sampled to represent the national Medicare admissions along many dimensions. PATIENTS. A total of 14,008 elderly patients with one of the following five diseases: congestive heart failure, acute myocardial infarction, pneumonia, stroke, or hip fracture. These patients were randomly sampled from those with these diseases in 297 hospitals in two time periods, 1981 to 1982 and 1985 to 1986. OUTCOME MEASURES. Explicit criteria, implicit review, and mortality within 30 days of admission adjusted for sickness at admission. RESULTS. Quality of care ratings for hospital types are similar using explicit criteria, implicit review, and outcomes adjusted for sickness at admission. Quality differences between types of hospitals were large, with the lowest group estimated to have four percentage points higher mortality than major teaching hospitals in a cohort of patients with average mortality of 16%. Quality varies from state to state, but teaching, larger, and more urban hospitals have better quality in general than nonteaching, small, and rural hospitals. Hospital quality persists over time, but small nonteaching hospitals narrowed the gap with better quality hospitals between 1981 and 1986. CONCLUSIONS. The different measures led to consistent and plausible relationships between quality and hospital characteristics. Thus, valid information about hospital quality can be obtained. We need to develop ways to use such information to improve care.     

Implementing university hospital ambulatory care evaluation.

The clinics of a single university hospital center were observed to determine a practical rationale for and impediments to implementing a medical care evaluation program. A quality assurance mechanism is especially important in the ambulatory care setting because of problems with patient compliance, lack of policy continuity, lack of intercommunication among care providers, no counterpart for most inpatient quality-oriented activities, structural defects in many clinics, and general emphasis on the inpatient medicine. Impediments to implementing quality assurance programs include the condition of clinic records and individual charts, lack of established criteria for care, problems of care provider intercommunication during the evaluation process, manpower availability, choice of evaluation method, and method of implementing resulting plans for corrective action.