Risk adjusted benchmarking of clinical anastomotic leakage rate after total mesorectal excision in the context of an improvement project

Aim Anastomotic leakage (AL) after total mesorectal excision (TME) is a major adverse event. This study evaluates variability in AL between centres participating on a voluntary basis in PROCARE, a Belgian improvement project, and how further improvement of the AL rate might be achieved. Method Between January 2006 and March 2011, detailed data on 1815 patients (mean age 65.5 years, 63% male) who underwent elective TME with colo‐anal reconstruction for rectal cancer were registered by 48 centres. Variability in early clinical AL rate was analysed before and after adjustment for gender, age > 60 years, American Society of Anesthesiologists score of 3 or more and body mass index > 25 kg/m². Results The overall AL rate was 6.7% (95% CI 5.6%–7.9%). Early AL required reoperation in 86.8% of patients. It increased length of hospital stay from 14.7 days to 32.4 days and in‐hospital mortality from 1.1% to 4.8%. Statistically significant variability in AL rate between centres was not observed, either before or after risk adjustment. Nonetheless, further improvement may be achievable in some centres by targeting the adjusted performance of better performing centres. These centres used neoadjuvant treatment, rectal irrigation, mobilization of the splenic flexure, resection of the sigmoid colon, side‐to‐end colo‐anastomosis with or without pouch and defunctioning stoma at primary surgery in a significantly higher proportion of patients than less well performing centres. Conclusion The overall AL rate was low but needs to be interpreted with caution because of incomplete registration. Further improvement might be achieved by adopting the approach of better performing centres.     

Benchmarking Controlled Trial—a novel concept covering all observational effectiveness studies

Abstract

The Benchmarking Controlled Trial (BCT) is a novel concept which covers all observational studies aiming to assess effectiveness. BCTs provide evidence of the comparative effectiveness between health service providers, and of effectiveness due to particular features of the health and social care systems. BCTs complement randomized controlled trials (RCTs) as the sources of evidence on effectiveness. This paper presents a definition of the BCT; compares the position of BCTs in assessing effectiveness with that of RCTs; presents a checklist for assessing methodological validity of a BCT; and pilot-tests the checklist with BCTs published recently in the leading medical journals.     

Exploring variation in pressure ulcer prevalence in Sweden and the USA: benchmarking in action

Aim To compare overall unit‐level pressure ulcer (PU) prevalence, hospital‐acquired pressure ulcer (HAPU) prevalence and prevention strategies, as well as nurse staffing and workload in two hospitals in Sweden with data from the USA. Methods Medical and surgical units in a university hospital and a general hospital in Sweden were compared with 207 hospitals in the USA participating in the Collaborative Alliance for Nursing Outcomes (CALNOC) benchmarking registry. All adult inpatients in university hospital (n = 630), general hospital (n = 253) and CALNOC hospitals (n = 3506) were included in the study. Outcome indicators were pressure ulcer prevalence for all types (PU) and HAPU prevalence, specifically. Process indicators were risk assessment and PU prevention strategies. Structure indicators were nurse staffing (hours of care, and skill mix) and workload (admissions, discharges and transfers). Results The prevalence of PU (categories 1–4) was 17.6% (university hospital) and 9.5% (general hospital) compared with 6.3–6.7% in the CALNOC sample. The prevalence of full thickness HAPU (categories 3 and 4) was 2.7% (university hospital) and 2.0% (general hospital) compared with 0–0.5% in the CALNOC sample. Risk and skin assessment varied between 6% and 60% in the Swedish hospitals compared with 100% in the CALNOC sample. Total hours per patient day were 8.4 in both Swedish hospitals and 9.5 to 9.8 in the CALNOC hospitals Conclusions The findings suggest a link between processes of care and outcomes that is exciting to observe internationally and suggest the opportunity to expedite performance improvement through global benchmarking. Using HAPU as a complement to point prevalence of PU in Sweden has revealed this indicator as a more valid measure for patient care quality.     

Improving midwifery practice: the American College of Nurse-Midwives' benchmarking project

By learning that a much better way of doing something may be possible, midwives can stimulate interest by making changes that previously were thought unnecessary or unachievable. In this way, benchmarking becomes a positive and proactive goal-setting process used to change practice. In addition, by accepting responsibility for managing care and cost and using benchmarking to identify the most efficient and effective methods for meeting all of their customer’s needs, midwives will be able to document their effectiveness in terms of cost, quality, and satisfaction. The resulting improvement in quality of care rendered will reduce medical errors and liability risk. Promotion and evaluation of high quality care are priorities for the midwifery profession. Midwives who value their autonomy must accept the responsibility for maintaining high standards of practice.     

Benchmarking in academic pharmacy departments

Benchmarking in academic pharmacy, and recommendations for the potential uses of benchmarking in academic pharmacy departments are discussed in this paper. Benchmarking is the process by which practices, procedures, and performance metrics are compared to an established standard or best practice. Many businesses and industries use benchmarking to compare processes and outcomes, and ultimately plan for improvement. Institutions of higher learning have embraced benchmarking practices to facilitate measuring the quality of their educational and research programs. Benchmarking is used internally as well to justify the allocation of institutional resources or to mediate among competing demands for additional program staff or space. Surveying all chairs of academic pharmacy departments to explore benchmarking issues such as department size and composition, as well as faculty teaching, scholarly, and service productivity, could provide valuable information. To date, attempts to gather this data have had limited success. We believe this information is potentially important, urge that efforts to gather it should be continued, and offer suggestions to achieve full participation.     

An 11‐country study to benchmark the implementation of recommended nutrition policies by national governments using the Healthy Food Environment Policy Index, 2015‐2018

The Healthy Food Environment Policy Index (Food‐EPI) aims to assess the extent of implementation of recommended food environment policies by governments compared with international best practices and prioritize actions to fill implementation gaps. The Food‐EPI was applied in 11 countries across six regions (2015‐2018). National public health nutrition panels (n = 11‐101 experts) rated the extent of implementation of 47 policy and infrastructure support good practice indicators by their government(s) against best practices, using an evidence document verified by government officials. Experts identified and prioritized actions to address implementation gaps. The proportion of indicators at “very low if any,” “low,” “medium,” and “high” implementation, overall Food‐EPI scores, and priority action areas were compared across countries. Inter‐rater reliability was good (GwetAC2 = 0.6‐0.8). Chile had the highest proportion of policies (13%) rated at “high” implementation, while Guatemala had the highest proportion of policies (83%) rated at “very low if any” implementation. The overall Food‐EPI score was “medium” for Australia, England, Chile, and Singapore, while “very low if any” for Guatemala. Policy areas most frequently prioritized included taxes on unhealthy foods, restricting unhealthy food promotion and front‐of‐pack labelling. The Food‐EPI was found to be a robust tool and process to benchmark governments' progress to create healthy food environments.     

The use of big data in transfusion medicine

‘Big data’ refers to the huge quantities of digital information now available that describe much of human activity. The science of data management and analysis is rapidly developing to enable organisations to convert data into useful information and knowledge. Electronic health records and new developments in Pathology Informatics now support the collection of ‘big laboratory and clinical data’, and these digital innovations are now being applied to transfusion medicine. To use big data effectively, we must address concerns about confidentiality and the need for a change in culture and practice, remove barriers to adopting common operating systems and data standards and ensure the safe and secure storage of sensitive personal information. In the UK, the aim is to formulate a single set of data and standards for communicating test results and so enable pathology data to contribute to national datasets. In transfusion, big data has been used for benchmarking, detection of transfusion‐related complications, determining patterns of blood use and definition of blood order schedules for surgery. More generally, rapidly available information can monitor compliance with key performance indicators for patient blood management and inventory management leading to better patient care and reduced use of blood. The challenges of enabling reliable systems and analysis of big data and securing funding in the restrictive financial climate are formidable, but not insurmountable. The promise is that digital information will soon improve the implementation of best practice in transfusion medicine and patient blood management globally.     

Clinical Engineering Benchmarking Comparison Between Zhejiang Province and American Hospitals

Clinical engineering(CE) has evolved rapidly over the last 25 years in China. Among the 34 provincial-level administrative units within China, the Zhejiang Province is one of the most advanced in terms of healthcare technology maintenance and management. In order to determine Zhejiang's current stage of development and opportunities for further improvement, a comparison of the performance of its CE departments was made against hospitals in the USA. Data were collected from 21 Zhejiang hospitals and compared to those from 270 acute-care hospitals in USA collected by Truven Health Analytics. The benchmarking comparison was made in three categories: operational, financial, and productivity. Within the operational category, the following metrics were compared: equipment inventory size/operating beds, annual repairs/inventory size, and annual scheduled maintenance/inventory size. Within the Financial category, the following metrics were compared: total CE expense/operating beds and total CE expense/total hospital expense. Within the Productivity category, the following metrics were compared: total CE full-time equivalent(FTE)/inventory size and total CE FTE/total hospital expense. These comparisons showed that:(1) While the equipment inventory in Zhejiang tends to be much smaller than USA for hospitals of comparable amount of operating beds, the numbers of repairs and scheduled maintenance per inventory size are similar;(2) The total CE expense/total hospital expense ratio is around 1% in both Zhejiang and USA; however, the total CE expense/operating beds and total CE expense/cost of equipment inventory are significantly lower in Zhejiang than USA;(3) The FTE amount in Zhejiang is significantly higher than in USA relative to both inventory size and total hospital operating expense, but significantly lower relative to the number of operating beds. The fact that repairs and scheduled maintenance are similar in Zhejiang and USA shows that CE leaders are managing equipment in comparable manner. Most of the differences found in the comparisons were traced to a few factors. First, the average length of stay in China is substantially higher than USA, which explains why hospitals in Zhejiang tend to have more operating beds but fewer pieces of equipment. Second, labor cost is significantly lower in China than USA, thus allowing Zhejiang hospitals to employ more workers than their American counterparts. Third, there is significantly difference in the cost of living between China and USA; Finally, being public entities Chinese hospitals are managed and operated in a different manner than American hospitals, which are mostly private, albeit nonprofit organizations. Nonetheless, it is interesting to note that hospitals in both areas spend roughly 1% of their total expenditure for CE. The results suggest that CE in Zhejiang is comparable to USA in terms of managerial excellence but there could be some room for improvement in financial management and productivity.     

Clinical outcomes in residential care: Setting benchmarks for quality

Aim: Australian residential aged care does not have a system of quality assessment related to clinical outcomes, or comprehensive quality benchmarking. The Residential Care Quality Assessment was developed to fill this gap; and this paper discusses the process by which preliminary benchmarks representing high and low quality were developed for it. Methods: Data were collected from all residents (n = 498) of nine facilities. Numerator–denominator analysis of clinical outcomes occurred at a facility‐level, with rank‐ordered results circulated to an expert panel. The panel identified threshold scores to indicate excellent and questionable care quality, and refined these through Delphi process. Results: Clinical outcomes varied both within and between facilities; agreed thresholds for excellent and poor outcomes were finalised after three Delphi rounds. Conclusion: Use of the Residential Care Quality Assessment provides a concrete means of monitoring care quality and allows benchmarking across facilities; its regular use could contribute to improved care outcomes within residential aged care in Australia.     

Ensuring quality cancer care: a follow-up review of the Institute of Medicine's 10 recommendations for improving the quality of cancer care in America

Responding to growing concerns regarding the safety, quality, and efficacy of cancer care in the United States, the Institute of Medicine (IOM) of the National Academy of Sciences commissioned a comprehensive review of cancer care delivery in the US health care system in the late 1990s. The National Cancer Policy Board (NCPB), a 20-member board with broad representation, performed this review. In its review, the NCPB focused on the state of cancer care delivery at that time, its shortcomings, and ways to measure and improve the quality of cancer care. The NCPB described an ideal cancer care system in which patients would have equitable access to coordinated, guideline-based care and novel therapies throughout the course of their disease. In 1999, the IOM published the results of this review in its influential report, Ensuring Quality Cancer Care. The report outlined 10 recommendations, which, when implemented, would: 1) improve the quality of cancer care, 2) increase the current understanding of quality cancer care, and 3) reduce or eliminate access barriers to quality cancer care. Despite the fervor generated by this report, there are lingering doubts regarding the safety and quality of cancer care in the United States today. Increased awareness of medical errors and barriers to quality care, coupled with escalating health care costs, has prompted national efforts to reform the health care system. These efforts by health care providers and policymakers should bridge the gap between the ideal state described in Ensuring Quality Cancer Care and the current state of cancer care in the United States.