Improving the care of patients with community-acquired pneumonia: a multihospital collaborative QI project

BACKGROUND: Performance of several processes of care was measured in eight acute care hospitals in Connecticut which provided inpatient treatment to 713 elderly patients with community-acquired pneumonia (CAP). BASELINE DATA ABSTRACTION AND FEEDBACK: Chart review feedback was provided, and the hospitals were requested to design their own quality improvement (QI) interventions, after which reexamination of process of care performance was conducted. HOSPITAL QI INTERVENTIONS: Six of the eight hospitals had submitted QI plans. The quality indicators dealing with timeliness of antibiotic delivery were specifically addressed by five hospitals. However, each hospital also picked one or two other processes of care for intervention. RESULTS: The mean time to antibiotic administration decreased from 5.5 hours (+/- 0.2) to 4.7 hours (+/- 0.3; p < 0.0001), and the percentage of patients who received antibiotics within four hours increased from 41.5% to 61.8% (p < 0.0001). DISCUSSION: This project called for obtaining buy-in from both the clinician and administrative representatives of each hospital early in the process. In this way, the targeted processes of care were likely to have relevance for each of the participating hospitals. Education of practicing physicians and other health professionals, as the method chosen by each hospital to address delays in antibiotic administration, appears to have been successful in this project as part of a multifaceted intervention. The project also helped establish a collegial environment that has served as the basis for more ambitious pneumonia QI projects. SUMMARY AND CONCLUSIONS: Widespread improvements in process of care performance can result from hospitals' participation in Quality Improvement Organization collaboration.     

Understanding sexual activity defined in the HEDIS measure of screening young women for Chlamydia trachomatis

BACKGROUND: Periodic screening of sexually active young women for Chlamydia trachomatis is widely recommended and is now monitored in the Health Plan Employer Data and Information Set (HEDIS). Because little is known about how well the HEDIS measure identifies sexually active women eligible for screening, rates of sexual activity as defined by the measure's specifications were compared with those derived from self-reported sexual behavior and use of sexual health services among privately insured women. METHODS: Using the 1996 MarketScan claims data for privately insured women aged 15-25 years, a measure of sexual activity based on the HEDIS specifications for sexual activity was calculated, that is, claims for Pap tests and pelvic examinations, contraceptive services, pregnancy-related service, and screening and treatment for sexually transmitted diseases. RESULTS: For privately insured women 15-25 years of age, the sexual activity rate was estimated to be 27% based on the HEDIS algorithm using the MarketScan claims data and 60% based on self-reported sexual behavior or 62% based on self-reported use of sexual health services using the 1995 National Survey of Family Growth (NSFG) data. DISCUSSION: Among young, privately insured women, use of claims specified by HEDIS classifies a smaller proportion of young women as sexually active than does use of self-reported survey data on sexual behavior or use of sexual health services. If HEDIS continues to rely on claims data because it is easier or less costly to collect and analyze than survey data, users of this performance measure should be aware that it may underestimate the number of women who are eligible for this screening benefit.     

Setting thresholds for quality indicators derived from MDS data for nursing home quality improvement reports: an update

BACKGROUND: Determining meaningful thresholds to reinforce excellent performance and flag potential problem areas in nursing home care is critical for preparing reports for nursing homes to use in their quality improvement programs. This article builds on the work of an earlier panel of experts that set thresholds for quality indicators (QIs) derived from Minimum Data Set (MDS) assessment data. Thresholds were now set for the revised MDS 2.0 two-page quarterly form and Resource Utilization Groups III (RUGS III) quarterly instrument. SETTING THRESHOLDS: In a day-long session in October 1998, panel members individually determined lower (good) and upper (poor) threshold scores for each QI, reviewed statewide distributions of MDS QIs, and completed a follow-up Delphi of the final results. REPORTING MDS QIS FOR QUALITY IMPROVEMENT: The QI reports compiled longitudinal data for all residents in the nursing home during each quarter and cumulatively displayed data for five quarters for each QI. A resident roster was provided to the nursing home so that the quality improvement team could identify the specific residents who developed the problems defined by each QI during the last quarter. Quality improvement teams found the reports helpful and easy to interpret. SUMMARY AND CONCLUSIONS: As promised in an earlier report, to ensure that thresholds reflect current practice, research using experts in a panel to set thresholds was repeated as needed. As the MDS instrument or recommended calculations for the MDS QIs change, thresholds will be reestablished to ensure a fit with the instrument and data.     

Taking the national guideline for care of acute myocardial infarction to the bedside: developing the guideline applied in practice (GAP) initiative in Southeast Michigan.

BACKGROUND: The Guideline Applied in Practice (GAP) program was developed in 2000 to improve the quality of care by improving adherence to clinical practice guidelines. For the first GAP project, the American College of Cardiology (ACC) partnered with the Southeast Michigan Quality Forum Cardiovascular Subgroup and the Michigan Peer Review Organization (MPRO) to develop interventions that might facilitate the use of the ACC/AHA Acute Myocardial Infarction (AMI) guideline in the practice setting. Ten Michigan hospitals participated in implementing the project, which began in March 2000. DESIGNING THE PROJECT: The project developed a multifaceted intervention aimed at key players in the care delivery triangle: the physician, nurse, and patient. Intervention components included a project kick-off presentation and dinner, creation and implementation of a customized tool kit, identification and assignment of local nurse and physician opinion leaders, grand rounds site visits, and measurement before and after the intervention. IMPLEMENTING THE PROJECT: The GAP project experience suggests that hospitals are enthusiastic about partnering with ACC to improve quality of care; partners can work together to develop a program for guideline implementation; rapid-cycle implementation is possible with the GAP model; guidelines and quality indicators for AMI are well accepted; and hospitals can adapt the national guideline for care into usable tools focused on physicians, nurses, and patients. DISCUSSION: Important structure and process changes--both of which are required for successful QI efforts--have been demonstrated in this project. Ultimately, the failure or success of this initiative will depend on an indication that the demonstrated improvement in the quality indicators is sustained over time.     

Physician participation in TQM in geriatric medicine

BACKGROUND: Quality improvement (QI) approaches such as total quality management (TQM) and continuous quality improvement (CQI) have great potential for improving the care provided to older people. Geriatricians have the necessary experience and skills to initiate and lead these QI efforts. A national sample of practicing geriatricians was surveyed in 1998 regarding involvement in, satisfaction with, and insights regarding TQM processes in four care settings. RESULTS: Of 537 questionnaires returned in time for analysis, 497 were included for analysis after omitting questionnaires that were undeliverable or unusable (n = 25) and those from respondents who worked fewer than 20 hours per week (n = 15). More than one-third of the respondents (37.1%) reported no TQM activity at all. For the remainder, the primary site for TQM activity was the nursing home (33.0%), the hospital (22.5%), the office (11.4%), and the patient's home (3.7%). A majority of the respondents spent two hours per week or less on TQM projects. Planning an intervention and acting to maintain it in practice after its evaluation were the two stages of the improvement cycle these respondents engaged in most frequently. DISCUSSION: More geriatricians should be encouraged to participate in TQM training and in specific projects to improve systems of care for older people. Incentives to increase participation should be made available. Rapid-cycle improvement may fit better with physicians' culture of working for outcomes that have relatively short turnaround times.     

Improving the pneumococcal immunization rate for patients with diabetes in a managed care population: a simple intervention with a rapid effect

BACKGROUND: Pneumococcal disease kills more people in the United States than any other vaccine-preventable bacterial disease, and a national health objective for the year 2000 is that at least 60% of eligible persons be immunized with pneumococcal vaccine. METHODS: An electronic care monitoring system was used to track immunization of patients with diabetes in a managed care plan who were receiving their care through a staff-model primary care clinic in Guam. In November 1998 a letter was sent to all patients not known to be immunized. The letter invited these patients to attend immunization clinics and waived usual copayment. Standing orders were also created for the clinic nurses to administer pneumococcal vaccines. In addition, a diabetes care status report was placed on each patient's medical record. RESULTS: The immunization rate for the 1,278 actively enrolled patients with diagnosed diabetes increased from 42% in October 1998 to 62% in January 1999. Compared to November 1995, 1996, and 1997, the number of pneumococcal immunizations increased more than 15-fold in November 1998. DISCUSSION: The combined use of patient outreach letters, special immunization clinics, standing orders, and practitioner reminders on medical records resulted in a rapid, marked increase in the pneumococcal immunization rate for patients with diabetes. The electronic care monitoring system is being used to target get interventions for improvement opportunities for an array of diabetes care measures, including regular foot care and eye exams.     

Performance of mammography equipment in the Macedonian breast screening campaign 2008/2009

Breast screening campaign in Macedonia started in the end of 2007 and 19 national mammography departments were included. Contrary to the European Guidelines for Quality Assurance in Mammography Screening, the quality assurance activities were not implemented before the start of the campaign, except at the University Clinic of Radiology, Skopje. The quality control tests were performed for the very first time at 13 mammography units under a licence-obtaining procedure. One of the machines was suspended from clinical and screening practice due to heavy malfunction of the generator, X-ray tube and automatic exposure control (AEC) system. Only 3 of the 13 mammography machines met the criteria for tube voltage (kV) accuracy. Two of the seven AEC systems were calibrated in the optimal optical density (OD) range (OD >1.4). AEC settings corresponded to the recommendations at eight units, while nine units met basic overall image quality criteria. Mean glandular dose (MGD) was higher than the recommended level of 2.5 mGy in four departments. Mean gradient of the film G(0.25-2.0) was below 2.8 at four units. Only two light boxes had a luminance of >1700 cd m(-2) and six rooms had an ambient light level of <50 lx. The findings of this work clearly suggest that the performance of the mammography equipment involved in the campaign in almost 50 % do not supply basic quality criteria for a breast screening programme.     

Quality improvement initiatives in Brazil: a progress report.

BACKGROUND: In 1994 Brazil's Ministry of Health (MOH) introduced a program to provide a supporting environment for quality improvement (QI) initiatives. Yet the five-track QI strategy, which included moving toward outcome indicators, establishing a national accreditation program, emphasizing QI tools, establishing basic clinical guidelines, and enhancing community control, was discontinued in 1998, following the dismissal of the minister of health. The QI program retained only its accreditation activities. ACCREDITATION: The Consortium for Brazilian Accreditation (CBA) began in 1994 to establish an accreditation process compatible with international initiatives. Both the MOH and the CBA have developed standards for hospitals. The Brazilian Manual for the Accreditation of Hospitals is available on the Internet. The CBA has developed a set of standards by adapting the 1996 hospital standards from the Joint Commission on Accreditation of Healthcare Organizations. To developing CBA's role as an accrediting organization, administrative and technical supporting structures were created within the Cesgranrio Foundation and a Joint Commission for Accreditation was established. QUALITY MANAGEMENT INITIATIVES: A growing number of hospitals, clinical laboratories, blood banks, health plans, and other health care services and organizations are seeking International Organization for Standardization (Geneva) certification. Consulting firms in the field of quality management continue to increase the number of their clients in the health sector. CONCLUDING REMARKS: Current QI initiatives represent only a minority of health care services and organizations in the country. Strong efforts need to be made by both the private and public sectors to expand such initiatives throughout Brazil.     

The built environment as a component of quality care: understanding and including the patient's perspective.

BACKGROUND: Although there has been little systematic assessment of how the built environment of health care facilities affects the quality of care, the built environment is a major element of structure of care--one of three facets of quality. Yet in contrast to the growing trend of using consumer perceptions of both processes and outcomes of care in QI activities, quality assessments of the structure of care do not currently rely on patient feedback. PURPOSE OF PROJECT: During the initial phase of a multiphase project, nine focus groups were conducted in 1997 to identify the salient dimensions of experience from the patient's perspective. The content of these focus groups guided the development of assessment tools in the second phase of the project, which began in February 1998. FINDINGS: Participants in three focus groups that were held in each of three settings--ambulatory care, acute care, and long term care--described in detail a variety of reactions to the built environment. Analysis revealed eight consistent themes in what patients and family member consumers look for in the built environment of health care. In all three settings, they want an environment, for example, that facilitates a connection to staff and caregivers, is conducive to a sense of well-being, and facilitates a connection to the outside world. DISCUSSION: Data derived from the focus group research has guided the development of quantitative survey and assessment tools. For each setting, patient-centered checklists and questionnaires are designed to help institutions set priorities for the improvement of facility design from the patient's perspective.     

Simulation study of coordinating layout change and quality improvement for adapting job shop manufacturing to CONWIP control

Constant work-in-process (CONWIP) has been highlighted for its superiority over kanban for application in job shop environments. Smooth operation of CONWIP yet depends on some critical practices, including: layout change (from functional to cellular), quality improvement (QI) and set-up time reduction induced by layout change (STR). Simulation modelling was employed in this study to investigate the coordination of these conditions. QI was experimented with the mean magnitude and probability of occurrence for step shifts (MMSS and POSS, respectively); it has major effects on flow time variability only. If STR is below 60%, a functional layout with push control was found favourable while QI is not effective. STR needs to reach 60% to justify layout change; POSS and MMSS reductions are effective for cellular layouts with CONWIP and push control, respectively. At this stage, promotion of improvement activities should be the major concern for replacing push control with CONWIP. The performance of CONWIP is superior if a 70% or larger STR is achieved. In this case, it enables greater delivery performance upgrade via strengthening the effectiveness of QI in reducing flow time variability. Essential guidelines were ultimately derived for reforming traditional job shop practices, progressing through layout change, towards the realisation of CONWIP.     

Applying quality improvement principles to achieve healthy work organizations

BACKGROUND: Health care has used total quality management (TQM)/quality improvement (QI) methods to improve quality of care and patient safety. Research on healthy work organizations (HWOs) shows that some of the same work organization factors that affect employee outcomes such as quality of life and safety can also affect organizational outcomes such as profits and performance. An HWO is an organization that has both financial success and a healthy workforce. For a health care organization to have financial success it must provide high-quality care with efficient use of scarce resources. To have a healthy workforce, the workplace must be safe, provide good ergonomic design, and provide working conditions that help to mitigate the stress of health care work. INTEGRATING TQM/QI INTO THE HWO PARADIGM: If properly implemented and institutionalized, TQM/QI can serve as the mechanism by which to transform a health care organization into an HWO. To guide future research, a framework is proposed that links research on QI with research on HWOs in the belief that QI methods and interventions might be an effective means by which to create an HWO. Specific areas of research should focus on identifying the work organization, cultural, technological, and environmental factors that affect care processes; affect patient health, safety, and satisfaction; and indirectly affect patient health, safety, and satisfaction through their effects on staff and care process variables. SUMMARY: Integrating QI techniques within the paradigm of the HWO paradigm will make it possible to achieve greater improvements in the health of health care organizations and the populations they serve.     

The 2000 ICSI/IHI Colloquium on Clinical Quality Improvement: "Cultivating Quality--Growing and Nurturing Clinical Quality Improvement in Health Care"

BACKGROUND: Almost 300 people attended the 2000 ICSI/IHI Colloquium on Clinical Quality Improvement, "Cultivating Quality--Growing and Nurturing Clinical Quality Improvement in Health Care," May 11-12, 2000, in St Paul. Sponsored by the Institute for Clinical Systems Improvement (ICSI) and the Institute for Healthcare Improvement (IHI), the annual event featured three keynote speakers--David M. Lawrence, MD (Kaiser Foundation Health Plan, Inc, and Kaiser Foundation Hospitals, Oakland, Calif): Martin P. Eccles, MD (University of Newcastle-upon-Tyne, England); and Maureen Bisognano (IHI). PATIENT SAFETY AND THE U.S. HEALTH CARE SYSTEM: David M. Lawrence, MD, said medicine is trying to use new technologies and meet consumer expectations with a delivery system--a "chassis"--that was designed for another time and a different science. He also described the four chassis stages in medicine. GETTING EVIDENCE INTO PRACTICE: Martin P. Eccles, MD, presented a researcher's view of the reasons evidence is not used in daily practice, a range of strategies for promoting its use, and the strengths and shortcomings of this evidence base. He discussed three areas of evidence--clinical strategies, behavior change strategies--and systems for delivering these strategies--and how they can be used for implementation of practice changes. INNOVATIONS IN INTERACTION: GETTING CLOSER TO OUR PATIENTS: Maureen Bisognano outlined three methods that should be in every health care provider's improvement portfolio: reducing the defects a patient experiences, eliminating costs, and pursuing innovation. Focusing on defects and waste reduction will free up funds for innovation. It is the responsibility of leaders to push for innovation on behalf of patients, or patients will take their business elsewhere.     

The 1999 ICSI/IHI colloquium on clinical quality improvement--"quality: settling the frontier"

BACKGROUND: A Colloquium on Clinical Quality Improvement, "Quality: Setting the Frontier," held in May 1999, covered methods and programs in clinical quality improvement. Leadership and organizational behavior were the main themes of the breakout sessions; specific topics included implementing guidelines, applying continuous quality improvement (CQI) methods in preventive services and primary care, and using systems thinking to improve clinical outcomes. Three keynote addresses were presented. LEADERSHIP FOR QUALITY: James L. Reinertsen, MD (CareGroup, Boston), characterized the financial challenges faced by many health care organizations as a "clarion call" for leadership on quality. "The leadership imperative is to establish an environment in which quality can thrive, despite unprecedented, severe economic pressures on our health systems." LINKING GROUP AND ORGANIZATIONAL KNOWLEDGE TO IMPROVEMENT STRATEGIES: How do we make improvement more effective? G. Ross Baker, PhD (University of Toronto), reviewed what organizational literature says about making teams more effective, understanding the organizational context to enable improvement work, and augmenting existing methods for creating sustainable improvement. For example, he noted the increasing interest among may organizations in rapid-cycle improvement but cautioned that such efforts may work best where problems can be addressed by existing clinical teams (not cross-functional work groups) and where there are available solutions that have worked in other settings. IMPROVING THE ENVIRONMENT FOR QUALITY: Mark Chassin, MD (Mount Sinai School of Medicine, New York), stated that critical tasks for improving quality include increasing public awareness, engaging clinicians in improvement, increasing the investment in producing measures and improvement tools, and reinventing health care delivery, clinical education and training, and QI.     

Selecting quality improvement projects and product mix together in manufacturing: an improvement of a theory of constraints-based approach by incorporating quality loss

The quality of products and processes needs to be improved continuously in today's competitive environments. Unless these improvement efforts are focused properly, companies might not achieve desirable results in terms of sales, quality and productivity. Many quality improvement (QI) approaches have a limited evaluation of the factors involved in the selection of QI projects. Theory of constraints (TOC) has been proposed by some researchers as a remedy for the better selection of QI projects. However, these TOC-based approaches do not accurately capture ongoing product quality and its long-term effects on sales. Quality loss, on the other hand, can be used as a measure of customer dissatisfaction, which in turn determines the sales. The paper proposes an improvement of a TOC-based algorithm by incorporating quality loss with it. Using two simple manufacturing examples, it demonstrates that quality losses affect the product mix and QI project selection. It provides suggestions for further research directions for wider applicability of the proposed approach.     

Use of consumer ratings for quality improvement in behavioral health insurance plans

BACKGROUND: The Consumer Assessment of Behavioral Healthcare Services (CABHS) survey collects consumers' reports about their health care plans and treatment. The use of the CABHS to identify opportunities for improvement, with specific attention to how organizations have used the survey information for quality improvement, is described. METHODS: In 1998 and 1999, data were collected from five groups of adult patients in commercial health plans and five groups of adult patients in public assistance health plans with services received through four organizations (one of three managed behavioral health care organizations or a health system). Patients who received behavioral health care services during the previous year were mailed the CABHS survey. Non-respondents were contacted by telephone to complete the survey. RESULTS: Response rates ranged from 49% to 65% for commercial patient groups and from 36% to 51% for public assistance patients. Promptly getting treatment from clinicians and aspects of care most influenced by health plan policies and operations, such as access to treatment and plan administrative services, received the least positive responses, whereas questions about communication received the most positive responses. In addition, questions about access- and plan-related aspects of quality showed the most interplan variability. Three of the organizations in this study focused quality improvement efforts on access to treatment. DISCUSSION: Surveys such as the CABHS can identify aspects of the plan and treatment that are improvement priorities. Use of these data is likely to extend beyond the behavioral health plan to consumers, purchasers, regulators, and policymakers, particularly because the National Committee for Quality Assurance is encouraging behavioral health plans to use a similar survey for accreditation purposes.     

Using performance measures to identify plans of action to improve care.

BACKGROUND: Health care organizations dedicate enormous time and resources collecting data to measure the performance of physicians, hospitals, and other medical facilities. These measures may reflect outcomes, processes of care, patient perceptions of the quality of care, and resource utilization and cost. However, less thought is given to how the performance data should be used to improve care. The data must be translated into clinically relevant terms that assess the decisions of the clinical staff and the functioning of the systems that support the delivery of care. The processes of care are identified through record review, analysis of the system of care delivery, and patient interview, and are then further assessed to determine the underlying causes. EXAMPLES: Examples, drawn from case studies, are provided to illustrate how to identify and address components of care requiring improvement. DISCUSSION: Physician behavior is an important component of care in all performance measures. Modification of some patterns of behavior, including those of nursing and other support staff, may be needed to reduce some types of error. For this reason it is important to involve physicians in the process of discovering root causes. When the root cause involves the medical care system, an interdisciplinary approach will be needed. This may involve administrators, nurses, pharmacists, home care and discharge planners, and office personnel. One recommended approach to QI is to identify system errors and then design changes in the system to reduce that type of error. CONCLUSION: Performance measures must be translated into the components(s) of care that are implicated in the measure. Once this component has been identified as the reason behind the suboptimal measure, its root cause should be used to structure the most effective intervention.     

Comprehensive dose survey of breast screening in Ireland

The primary purpose of this study was to evaluate the impact of digital mammography screening on breast dose by analysing the results of a patient dose survey of the Irish breast screening programme. Results from the survey were used to determine a dose reference level for the screening programme. Approximately, 100 examinations were acquired for each of the digital mammography systems operational in the screening programme. Each examination consisted of two standard views of each breast. The mean glandular dose for each acquired image was calculated. The dose reference level was established by calculating the 95th percentile of the average mean glandular dose for the average compressed breast thickness of the mediolateral oblique views. The overall average mean glandular dose per examination was 2.72 ± 0.04 mGy. The average compressed breast thickness was 61.4 ± 0.03 mm. The average compression force was 109 ± 7 N. A dose reference level value of 1.75 mGy was established for the screening programme. The results of this clinical dose survey provide a valuable indication of the dose performance of modern full field digital mammographic imaging systems. The results demonstrate clearly the dose benefits of digital mammography. The dose benefit of digital screening was further demonstrated by the establishment of a comparatively lower diagnostic reference level for the screening programme. The comparison of the dose performance of individual X-ray systems with the diagnostic reference level highlights the need for more optimisation within the service.     

Understanding patient willingness to recommend and return: a strategy for prioritizing improvement opportunities.

BACKGROUND: Beginning in April 1995, an ongoing, comprehensive measurement system has been developed and refined at BJC Health System, a regional integrated delivery and financing system serving the St Louis metropolitan area, mid-Missouri, and Southern Illinois, to assess patient satisfaction with inpatient treatment, outpatient treatment, outpatient surgery, and emergency care. This system has provided the mechanism for identifying opportunities, setting priorities, and monitoring the impact of improvement initiatives. METHODS: Satisfaction with key components of the care process among 23,361 patients (7,083 inpatients, 8,885 patients undergoing outpatient tests/procedures, 5,356 patients undergoing outpatient surgery, and 2,037 patients receiving emergency care) at 15 BJC Health System facilities was assessed through weekly surveys administered in April 1995 through December 1996. RESULTS: Structural equation models were developed to identify the key predictors of patient advocation-willingness to return for or recommend care. Across all venues of care the compassion provided to patients had the strongest relationship to patient advocation. Within each venue of care, however, a slightly different set of secondary factors emerged. The resulting models provided important information to help prioritize competing improvement opportunities in BJC Health System. In one hospital, a general medicine unit working for several years with little success to improve its patient satisfaction decided to focus on two primary factors predicting patient advocation: nursing care delivery and compassionate care. Root cause analysis was used to determine why two items-staff willingness to help with questions/concerns and clear explanation about tests and procedures-were rated low. On the basis of feedback from phone interviews with discharged patients, the care delivery process was changed to encourage patients to ask questions. Across the next two quarters, this unit experienced significant improvements in both targeted items. DISCUSSION: The significance of compassionate care and care delivery again speaks not only to the importance of the technical quality of clinical care but also to the customer-focused way in which this care was provided. After the primary predictors of patient advocation were identified, management was able to strategically focus improvement initiatives to maximize their impact. Across the organization, improvement teams scanned their data to find key factors where performance was lacking. Once these key opportunities were identified, the teams developed potential solutions and launched initiatives to improve their performance. SUMMARY AND CONCLUSIONS: Results suggest that some core issues are of extreme importance to patients regardless of whether they are receiving care in an inpatient, outpatient, or emergency setting. The compassion with which care is provided appears to be the most important factor in influencing patient intentions to recommend/return, regardless of the setting in which care is provided.     

Using practical quality improvement approaches and tools in reproductive health services in east Africa.

BACKGROUND: A nonprofit, nongovernment organization, AVSC International provides technical assistance worldwide, including a range of reproductive health services and quality improvement (QI) approaches and tools. Current activities in East Africa involve several hundred sites, including referral hospitals, district-level hospitals, and individual family planning clinics. THE QI PACKAGE: AVSC and its local partners developed Client-Oriented, Provider-Efficient Services (COPE), a problem-solving process and set of tools to involve all levels of site staff members in assessing and improving the services. The COPE tools--self-assessment guides, client interview guides, client flow analyses, and action plans--promote involvement, ownership, and commitment to the QI process. Facilitative supervision and whole-site training complemented AVSC's traditional approaches of medical monitoring and informed choice. Facilitative supervision encourages supervisors and managers to consider staff members as internal customers, whose needs they must meet for staff to be able to meet the needs of external customers (clients). Whole-site training was developed to meet the needs of staff members and providers, who needed to function as a team responsible for providing high-quality services. CASE STUDY: A government hospital that has adopted the entire package of QI approaches, has used the Quality Improvement Quotient self-assessment surveys to track its progress in several elements of high-quality care, including management and supervision, safety, and information and client--provider interactions. For example, maternity ward staff learned how to pass on to their clients information about clients' rights and family planning methods through posters, pamphlets, sample contraceptives, and health talks. LESSONS LEARNED: AVSC's work with local organizations suggests a number of lessons learned, including the following: easy-to-use tools that promote staff involvement and ownership are essential in the QI process, QI requires considerable staff development and capacity building at all levels, and although the QI approaches were initially introduced for a relatively narrow field of services, they are applicable to and have increasingly been used in other departments and wards. (It is difficult, may be impossible, and certainly undesirable, to limit QI activities to one ward or service.) CONCLUSION: Activities in East Africa have shown that QI is possible even in very resource-poor settings. The same principles have guided the process in all the different programs, with some adaptation of the tools used. AVSC program activities are to continue to disseminate the experiences of sites implementing the package of tools and approaches, to advocate for investment in supervision and management capacity building as a means to support continuous quality improvement, and to further study the impact of the QI approaches on service quality.     

Using a quality scorecard to measure and improve medical groups' performance.

BACKGROUND: Blue Cross of California (BCC) uses an annual Quality Scorecard to measure performance of participating medical groups (PMGs) and independent practice associations (IPAs). The scorecard provides information to the PMGs/IPAs on their performance in several domains relative to the average network score. BCC pays annual bonuses to PMGs/IPAs with superior quality performance. A structured intervention was designed to improve the performance of PMGs/IPAs that performed poorly on the scorecard. METHODS: A cohort study was conducted in a large health maintenance organization in California in 1997. All PMGs/IPAs received a detailed summary of the components of the annual quality scorecard. Scorecard components include an annual audit of quality, utilization management, credentialing, and members' rights and responsibilities, grievance rates, member transfer for quality reasons, a satisfaction survey, and a preventive health review. Twenty-two of 124 PMGs/IPAs with more than 1,000 BCC members during 1996 that had scored lower than 1 standard deviation below the mean were targeted. These 22 outlier PMGs/IPAs received additional information indicating that their performance was below average. A BCC quality team subsequently visited the outlier PMGs/IPAs to provide supplementary information on the deficient areas and provide assistance in making improvements. RESULTS: The outlier groups showed significant improvements in the annual audit of quality score, member satisfaction with access, member satisfaction with last visit, overall member satisfaction with PMGs/IPAs, mammography screening, and the total score. CONCLUSIONS: A structured quality improvement intervention in poorly performing PMGs/IPAs was followed by improvements in specific performance measures.