Outreach education to improve quality of rural ICU care. Results of a randomized trial

This study tests whether an outreach educational program tailored to institutional specific patient care practices would improve the quality of care delivered to mechanically ventilated intensive care unit (ICU) patients in rural hospitals. The study was conducted as a randomized control trial using 20 rural Iowa hospitals as the unit of analysis. Twelve randomly selected hospitals received an outreach educational program. After review of the medical records of eligible patients, a multidisciplinary team of intensive care unit specialists from an academic medical center delivered an educational program with content specific to the findings and capacity of the hospital. The outcome measures included patient care processes, patient morbidity and mortality outcomes, and resource use. Results indicated that the outreach program significantly improved many patient care processes (lab work, nursing, dietary management, ventilator management, ventilator weaning). The program marginally reduced hospital ventilator days. Both total length of stay and ICU length of stay fell markedly in the intervention group (by an average of 3.2 and 2.1 d, respectively), while the control group fell only 0.6 and 0.3 d, respectively. However, these effects did not reach statistical significance. Unfortunately, the program had no detectable effects on the clinical outcomes of mortality or nosocomial events. We conclude that an outreach program of this type can effectively improve processes of care in rural ICUs. However, improving processes of care may not always translate into improvement of specific outcomes.     

PSRO: a new direction for quality assessment in Otolaryngology

At the present time, the University of Michigan Hospital Department of Otorhinolaryngology has an 18-month experience in a quality assessment program directed toward compliance with PSRO legislation. This experience, we hope, provides an approach to the continuing assessment of medical care, whether it is for conforming to a particular legislative action or for the evaluation of patient care. It has been encouraging to the physicians involved that this is a program which is organized at the local level. It is oriented toward the local physician and in most instances will be administered by local physicians. The process of quality assessment has provided a milieu for educational experience and positive action toward correction of medical care problems. It has been said before that this may be the last opportunity for the physician to maintain control at the local level. This may be the opportunity for the profession to proceed with controlled quality assessment before outside agencies intercede.     

Nurse staffing and quality of care in nursing facilities

A study of 198 nursing facilities in Maryland tested the hypotheses that: 1) the presence of more RNs improves the quality of nursing care; and 2) increased numbers of all types of nursing staff improve the quality of nursing care, based on a multidimensional measure of quality of nursing care. Findings indicate that the ratio of RNs to residents is directly related to a measure of resident rights deficiencies. In addition, the ratio of total nursing staff to residents is directly related to a lower overall deficiency index and a higher quality of care score.     

Evaluating and improving pressure ulcer care: the VA experience with administrative data

BACKGROUND: A number of state initiatives are using databases originally developed for nursing home reimbursements to assess the quality of care. Since 1991 the Department of Veterans Affairs (VA; Washington, DC) has been using a long term care administrative database to calculate facility-specific rates of pressure ulcer development. This information is disseminated to all 140 long term care facilities as part of a quality assessment and improvement program. DATA ON PRESSURE ULCER DEVELOPMENT: Assessments are performed on all long term care residents on April 1 and October 1, as well as at the time of admission or transfer to a long term care unit. Approximately 18,000 long term care residents are evaluated in each six-month period; the VA rate of pressure ulcer development is approximately 3.5%. Reports of the rates of pressure ulcer development are then disseminated to all facilities, generally within two months of the assessment date. IMPLICATIONS FOR OTHER QUALITY IMPROVEMENT EFFORTS: The VA's more than five years' experience in using administrative data to assess outcomes for long term care highlights several important issues that should be considered when using outcome measures based on administrative data. These include the importance of carefully selecting the outcome measure, the need to consider the structure of the database, the role of case-mix adjustment, strategies for reporting rates to small facilities, and methods for information dissemination. CONCLUSION: Attention to these issues will help ensure that results from administrative databases lead to improvements in the quality of care.     

Developing and marketing a community pharmacy-based asthma management program

OBJECTIVE: To develop a community pharmacy-based asthma management program and successfully market the program to a managed care organization. SETTING: Community-based ambulatory care. PRACTICE DESCRIPTION: Independent community pharmacy. PRACTICE INNOVATION: Development of a structured, stepwise approach to creating, testing, delivering, and marketing a community pharmacy-based disease management program. MAIN OUTCOME MEASUREMENTS: Peak expiratory flow rates, quality of life, use of health care services, HMO contract renewal. RESULTS: A pharmacy-based asthma management program was developed, pilot tested, and successfully marketed to a local HMO. During the first full year of the program, HMO patients experienced significant improvements in quality of life and decreases in use of health care services, including a 77% decrease in hospitalization, a 78% decrease in emergency room visits, and a 25% decrease in urgent care visits. A contract that pays the pharmacy a flat fee for each patient admitted to the program has recently been renewed for a third year. CONCLUSION: The program has proved to be an effective, practical, and profitable addition to the portfolio of services offered by the pharmacy.     

A quality review of high-dependency patient care

In order to develop strategies to improve high-dependency (HD) patient care, a continuous quality improvement (CQI) study was initiated in August 1994. It sought to establish a system for the collection and evaluation of relevant information concerning medical and nursing management of HD patients. This CQI study followed a high-dependency areas needs analysis undertaken in January, 1994. Conducted over a 12-week period (August-October, 1994) the CQI study involved 92 HD patients who required cardiac and/or respiratory monitoring. The study revealed a low HD bed occupancy rate, inadequate documentation by medical staff of the need for monitoring, and insufficient numbers of nursing personnel specifically educated to care for HD patients. Recommendations include increased consultants surveillance, immediate assessment of HD patients by a medical officer on the ward, a documented plan for monitoring, avoidance of after-hours discharge from operating theatres or intensive care, and the implementation of an education program for HD area nurses.     

Implementing the Health Care Quality Improvement Program in the Medicare ESRD Program: a new era of quality improvement in ESRD

Improving the quality of health care is a central challenge for America's health care system. The mission of the End-Stage Renal Disease (ESRD) program is to promote the quality, effectiveness, and efficiency of ESRD patient care and program administration. The program provides an ideal opportunity to demonstrate the use of information to help clinicians analyze and improve the care they deliver to patients in an ambulatory setting. This is possible because the program has established regional surveillance systems, called ESRD Networks, that gather information on the occurrence and outcomes of treatment of Medicare beneficiaries with ESRD. The Health Care Financing Administration, which is responsible for the administration of the program, and the renal community have worked together since 1990 to identify ways of incorporating new methods of quality improvement into the program. These methods include statistical evaluation of the processes and outcomes of care in dialysis populations; communicating recommended practices with clinical guidelines and algorithms; regional peer review and feedback (ie, technical assistance and/or collaborations for quality improvement); interventions that focus on the provision of assistance for quality improvement efforts; continuing collection and active feedback of data to providers; and a commitment to continue to evaluate and revise quality improvement activities to reflect lessons learned and newly identified needs. These ideas have been included in the 1994-1997 scope of work for the ESRD Networks and is called the ESRD Health Care Quality Improvement Program (HCQIP). This article describes the background for the ESRD HCQIP and the program's elements.     

Primary malignant lymphoma of the bladder: a case report

CONTEXT: Pharmaceutical samples are commonly used in ambulatory care settings. There is limited research on their use or impact on health care providers and patients. OBJECTIVE: To determine the extent of personal use of drug samples over a 1-year period by physicians and medical office staff. DESIGN, SUBJECTS, AND SETTING: An anonymous cross-sectional survey of all physicians, resident physicians, nursing staff, and office staff in a family practice residency. MAIN OUTCOME MEASURE: Quantity of drug samples taken for personal or family use. RESULTS: Of 55 surveys issued, 53 (96%) were returned. A total of 230 separate drug samples were reported taken in amounts ranging from 1 dose to greater than 1 month's supply. Two respondents reported no use of drug samples, while 4 respondents reported taking more than 10 different samples. CONCLUSION: Drug samples are commonly taken by physicians and office staff for personal and family use. The ethical implications of this practice warrant further discussion.     

What influences patients' reports of three aspects of hospital services?

OBJECTIVES: Market forces make it essential to know what policies and actions influence patients' reports of hospital services. No studies have examined the role of patient characteristics, labor quality and staff characteristics, nonlabor resources, managerial practices, and employee attitudes within a single investigation. METHODS: The authors collected, simultaneously, data about labor, management and service processes, nonlabor resources, and employee attitudes on 117 nonintensive medical-surgical inpatient units in 17 hospitals selected from a pool of 69 institutions within a metropolitan area by a stratified random sample. Of the 2,595 patients who agreed to participate, 2,051 (79%) completed telephone interviews regarding their experiences with physical care, education, and pain management services within 26 days of hospital discharge. RESULTS: A significant amount of variation in patients' service reports was explained (adjusted R2 = 0.41 physical care, 0.35 pain management, 0.44 education). Although the predictors varied for each service report, patient characteristics, especially those related to personal resources, had a large explanatory role. A labor assignment pattern that could explain why earlier studies found labor quality and staff characteristics to have only a weak role in the prediction of patients' service reports was noted. CONCLUSIONS: The results related to patient characteristics may indicate opportunities to improve care by confronting service design strategies that erroneously rely on a homogeneous patient population. Measurement challenges identified by this study must be addressed to determine the role of labor quantity and staff characteristics.     

Essential obstetric care: assessment and determinants of quality

This paper reports on a study to develop and to apply methods for measuring the quality of essential obstetric care (EOC) in health centers. Based on a Nigerian guideline and an international guideline, and in consultation with local experts in primary care obstetrics, norms were established for equipment, personnel, supplies and the process of EOC, focusing on critical tasks. A combination of assessment methods was used, including observation of tasks performed during intrapartum care; use of data from records of care kept by midwives during the period of observation; use of data from records kept by midwives in the calendar year preceding the period of observation; exit interviews with clients; and inventories of equipment and supplies. Twelve health centers in three Local Government Areas (LGAs) and 360 clients in labor were included in the study. Quality of care was measured quantitatively as a score, calculated for each task and for each delivery in the health center. The results show that the methods developed are useful for: identifying quality score differences among health centers, and the effects of methods of assessment on quality scores; identifying aspects of EOC requiring improvements within each health center; and identifying factors influencing the quality of care, as a basis for effective quality improvement efforts. Regression models show that the most consistent and important predictor of quality scores is the use of printed forms (i.e. routine records of labor) during intrapartum care. Printed forms served as job aids, providing prompts that reminded midwives to perform specific tasks.     

A blueprint for reducing turnover among nursing assistants: a Louisiana study

For decades, various exposes and reports have painted an unflattering portrait of the nursing home industry across the nation. Nursing homes in Louisiana have endured their fair share of publicity and criticism. The industry in this state has been accused of being preoccupied with profits rather than quality resident care. And, while there is much debate as to the validity of this complaint, there is solid agreement that competent and stable nursing assistants are the key to quality resident care. Unfortunately, the annual turnover rate of these essential employees ranges from 50% to 400%, nationally. This research identified the factors most responsible for the rate of turnover of nursing assistants employed in Louisiana nursing homes. Based upon the results of this study, pay, benefits, workload, and employee-employer relations, are not related to turnover. The analysis revealed that only three issues are associated with turnover--the number of beds, the number of beds per registered nurse, and the number of beds per social service worker. The message is clear: nursing home administrators must be very careful in stretching such resources. The number of beds assigned to an RN, and, in particular, the number of beds per social service worker are management issues that, if overextended, risk the turnover of nursing assistants.     

Managing bowel elimination problems in patients with cancer

PURPOSE/OBJECTIVES: To provide strategies for the assessment and management of bowel elimination disorders and to standardize approaches to prevent bowel disorders. DATA SOURCES: Articles, books, ongoing clinical research. DATA SYNTHESIS: The type and degree of bowel elimination problems vary with the type of tumor and treatment received. Prediction of potential bowel problems based on treatment given dictates a bowel management program to prevent problems and help patients deal with the outcome of the treatment. A standard care plan that includes assessment and intervention for various bowel elimination problems provides specific guidelines for nursing care. CONCLUSIONS: Bowel function in the patient with cancer inevitably will be affected while going through treatment or as the disease progresses. IMPLICATIONS FOR NURSING PRACTICE: Nursing care to relieve these problems can significantly affect the patient's quality of life. As patients are diagnosed with cancer and undergo cancer therapy, they can hope for bowel management through nursing guidance and patient education.     

Review of quality control program for clinical microbiology developed by the Tokyo Metropolitan Government

There are limitations or disadvantages in previous nation wide external quality control (QC) programs. Therefore, the Tokyo Metropolitan Government and the Tokyo Medical Association (TMA) initiated the first regional annual external QC program in 1982. The QC results in chemistry, hematology and immunology have shown rapid improvement. By contrast, some serious problems in microbiology have been revealed. METHODS AND RESULTS: The Tokyo Metropolitan external QC programs consist of so-called "open" and "blind" surveys. Simulated specimens were prepared for open and blind surveys and all laboratories were asked to examine the specimens using routine procedures. All participants were required to report not only their test results such as codes for computer analysis, but also to describe the process. Written answers included the following subjects, procedures, culture characteristics and others: number and type of selective media, incubation conditions, colonial morphology, microscopic and biochemical characteristics of the microorganisms, etc. The survey reports on the identification of some kinds of pathologic organism were inaccurate. Discrepancies between the number of media used for routine procedures and the number used in open survey were detected. CONCLUSIONS: Previous nationwide external QC programs using frozen-dried organisms have been valuable in promoting general improvement in clinical microbiology in Japan, but they have revealed only gross errors. Our 10-year experience has convinced us that additional important information is obtained when using simulated specimens for open and blind surveys. The turnaround time and other aspects of the reporting of results should be monitored. Due to possible legal ramifications of QC surveys, laboratories are now more afraid of making errors than before. The continuing education of laboratory personnel is essential.     

Importance of in vivo dosimetry as part of a quality assurance program in tangential breast treatments

PURPOSE: The investigation of the accuracy and reproducibility in the daily dose delivered in tangential breast treatments with in vivo dose measurements. METHODS AND MATERIALS: In vivo dose measurements performed on the tangential treatment fields of 35 breast cancer patients are analysed for three units: a 6 MV linear accelerator, an old Cobalt unit and a new Cobalt unit. The results are plotted in frequency distributions. Deviations on the mean are often the expression of a systematic error in one of the core procedures of a department. A large spread of the results around the mean indicates a high burden of random set-up errors and/or systematic errors in individual patients. The reproducibility in dose delivery is studied by comparing repetitive checks to their respective mean for investigation of random day-to-day variation. RESULTS: A small systematic error on the entrance dose (+ 1.4%) is detected on the old Cobalt unit due to a discrepancy between measured and published percentage depth dose values. An unexpected systematic overdosage (+ 6%) is detected after implementation of a new software for dose calculation, proving that treatment quality is a process needing continuous monitoring. The transmission measurements demonstrate a systematic error in dose delivery of 1.5 to 3% due to the assumption that the breast is water equivalent when calculating the dose. The large spread of the transmission measurements (sa = 7.7%) shows that the weakest point in the treatment preparation chain is inaccurate acquisition of external body contours, leading to systematic errors in dose delivery for specific patients. The standard deviation for the reproducibility is 3.1% for the old Cobalt unit, vs. 1.6% on the other units, demonstrating the influence of staffing and mechanical characteristics of the units on daily precision in dose delivery. CONCLUSION: In vivo dosimetry is an important tool in a departmental quality assurance program to detect systematic errors in dose delivery, to identify inadequate treatment situations, to investigate weak points in the chain of treatment preparation and to ensure accurate dose delivery for individual patients. The predictive value of a single check for the accuracy in dose delivery during the whole treatment series is high for reproducible treatment methodologies.     

Use of a customer satisfaction survey by health care regulators: a tool for total quality management

OBJECTIVES: To conduct a survey of health care providers to determine the quality of service provided by the staff of a regulatory agency; to collect information on provider needs and expectations; to identify perceived and potential problems that need improvement; and to make changes to improve regulatory services. METHODS: The authors surveyed health care providers using a customer satisfaction questionnaire developed in collaboration with a group of providers and a research consultant. The questionnaire contained 20 declarative statements that fell into six quality domains: proficiency, judgment, responsiveness, communication, accommodation, and relevance. A 10% level of dissatisfaction was used as the acceptable performance standard. RESULTS: The survey was mailed to 324 hospitals, nursing homes, home care agencies, hospices, ambulatory care centers, and health maintenance organizations. Fifty-six percent of provider agencies responded; more than half had written comments. The three highest levels of customer satisfaction were in courtesy of regulatory staff (90%), efficient use of onsite time (84%), and respect for provider employees (83%). The three lowest levels of satisfaction were in the judgment domain; only 44% felt that there was consistency among regulatory staff in the interpretation of regulations, only 45% felt that interpretations of regulations were flexible and reasonable, and only 49% felt that regulations were applied objectively. Nine of 20 quality indicators had dissatisfaction ratings of more than 10%; these were considered priorities for improvement. CONCLUSIONS: Responses to the survey identified a number of specific areas of concern; these findings are being incorporated into the continuous quality improvement program of the office.     

Critical path method: an important tool for coordinating clinical care

BACKGROUND: In May 1991 Mount Clemens General Hospital (MCGH) began investigating the critical path method (CPM) as a tool for extending total quality management in clinical areas. In its search for guidelines on how to develop a critical path program, it found that other hospitals used a variety of approaches. These included employing case managers or outside consultants to develop programs or implementing prepurchased paths. Because these approaches often are difficult to customize for a specific institution and because MCGH wanted to use an internal team, none of these options seemed appropriate. With no definitive guidelines to follow, MCGH developed and implemented its own CPM. METHODS: The developmental process was composed of activities in nine primary categories: literature search, steering group, targeting strategy, paperwork design, gaining consensus, pilot program, preliminary findings, refine program, and full implementation. RESULTS: A pilot was performed to assess if the CPM would be beneficial. Six months into the pilot a preliminary review of coronary artery bypass graft paths was conducted. There were 44 patients in the study group (35 men, 9 women). Twenty-four patients were cared for before the critical path form was available. Preliminary findings indicated a lower rate of complications in patients cared for with the critical path form. The data revealed a 5% complication rate with the critical path compared to a 16.6% rate for those whose care was not guided by the form. In addition, patients with the path on their clipboards had an overall shorter length of stay than patients without the path. It is important to remember that these early data are based on the six-month pilot; they are not considered a conclusive research finding. NEXT STEPS: The next step in the CPM process is to examine other diagnoses that might benefit from a critical path approach. A steering committee composed of representatives from hospital administration, nursing, medical staff, quality assurance and risk management, and total quality management will act as the approval body for investigating and sanctioning other paths for development. CONCLUSION: The primary lesson learned at MCGH is that the CPM is most effective in an environment of communication and commitment. This approach allows clinic and nonclinic staff to talk about how their work influences each other's. CPM provides all caregivers with a common language and encourages everyone to look at the whole patient and the entire care process. The key message of success is: Get a group of people together who are motivated and empowered to move this exciting tool of the future through the necessary steps.