Integrating baseline health status data collection into the process of care.

BACKGROUND: Health status data are an increasingly important component of outcomes assessment and can be used to facilitate quality assessment and improvement efforts. An enormous challenge to the use of health status data among hospitalized patients, however, is collecting baseline data at the time of treatment, an essential component for risk-adjusting subsequent outcomes. The Mid America Heart Institute of Saint Luke's Hospital (Kansas City, Mo), attempted to integrate the collection of health status assessments within the process of performing coronary revascularization. THE DATA COLLECTION STRATEGY: The data collection strategy was developed for each admission portalelective outpatients (admissions for same-day procedures), inpatients, and emergent cases. Health status data were collected on all patients with coronary artery disease who were receiving a percutaneous coronary intervention or coronary artery bypass graft with no disruption to physician scheduling or nursing staff. RESULTS: In general, patients were agreeable to completing the health status survey. Despite initial efforts to educate the hospital staff about the goal and purpose of health status assessment, staff members who were unaware of the uses of these data seemed to minimize their value. Providing examples of how to use these data relative to the staff member's specific occupational role facilitated buy-in for this project. EPILOGUE: After the pilot study, which lasted until June 1999, data were continually collected for 18 months, through August 2000, even with the cessation of external grant funding for this project. Baseline data collection finally stopped, primarily because of a failure to accommodate data collection into the routine flow of patient care by existing nursing staff.     

Major issues in quality assessment and improvement of clinical hyperbaric services: an international perspective.

The continued rapid worldwide diffusion of clinical hyperbaric facilities has substantially increased interest in clinical quality assessment and service improvement. This paper examines major issues, perspectives, and methods integral to the measurement and improvement of the quality of care provided to hyperbaric patients and their relevance and applicability across different societies. Special focus is directed toward the importance of quality assessment and improvement of clinical hyperbaric care, multiple stakeholder perspectives on improved clinical quality, measurement of clinical outcomes of hyperbaric care, importance of facility accreditation, process improvement methods, and the future importance of quality management in clinical hyperbaric facilities.     

Financial incentives for ambulatory care performance improvement.

BACKGROUND: Measuring and improving the quality of care while curtailing costs are essential objectives in capitated care. As patient care moves from the hospital to outpatient settings, quality management resources must be shifted to ambulatory care process improvement. The Quality Improvement and Efficiency Financial Incentives Program at Stanford University Medical Center was adopted to increase quality improvement efforts and contain costs. THE INCENTIVE PROGRAM: Each department's budget for care of capitated patients was reduced by 5% from the previous year. Return of a reserve fund (10% of payments for specialty care) required completion of substantive quality improvement projects and containing costs. Successful departments were also eligible for bonus funds. Implementation strategies included endorsement by clinical leaders, physician education, use of administrative data to identify project topics and support measurement of quality and cost variables, project templates and time lines, and the availability of clinical quality managers with special expertise in clinical process improvement. RESULTS: Eight of 13 clinical departments developed and implemented 19 ambulatory quality improvement projects to varying degrees. Success in the program was roughly correlated with the potential impact of the incentive on revenues and the status of the lead person selected by the department to spearhead their efforts. Only 5 departments achieved their cost containment goals. DISCUSSION: Financial incentives are one method of encouraging physicians to use clinical process improvement methods. Endorsement by clinical leaders and selection of realistic beginning projects enhance chances for success. The capitated population has attributes that make it an attractive focus for initial quality improvement efforts.     

The strategic use of outcome information

BACKGROUND: Most health care executives see outcome measurement as a technical or tactical matter rather than as a strategic tool. Accordingly, provider investment in outcome measurement and management is relatively small. Nevertheless, outcome information can be key to achieving an organization's strategic objectives. Advances in risk adjustment and improvements in technology for data collection and analysis have made outcome measurement a practical tool for individual hospital use. CASE STUDIES: Strategically integrated outcome measurement efforts can give providers a competitive advantage over organizations that only use outcomes tactically. One of the best examples of an acute care provider that has used outcome information for strategic advantage is Intermountain Health Care (IHC; Salt Lake City). In 1997 IHC made clinical quality and outcomes the primary focus of its five-year strategic plan. To support the new strategy IHC's board of trustees approved the development of an outcome information system that generated data along clinical processes of care and the creation of a new management structure to use these data to hold professionals accountable and to set and achieve clinical improvement goals. From 1996 to 1999, IHC's share of the commercial health care market in Utah increased from roughly 50% to about 62% of the market, with the result that it has stopped actively marketing its services. DISCUSSION: Health care executives will not willingly invest in outcomes until they believe that they have business value. Therefore, making the business case for outcomes can help improve the quality of health care and the lives of individuals.     

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.     

Balancing accountability and improvement: a case study from Massachusetts

BACKGROUND: The Massachusetts Health Quality Partnership (MHQP), a coalition of health care providers and insurers, and business and government organizations, conducted a voluntary statewide survey about patients' experiences with inpatient care at Massachusetts hospitals in 1998, and made the results public. METHODS: MHQP contracted with The Picker Institute (Boston) to conduct the statewide survey about seven dimensions of care for adult medical, surgical, and maternity patients at 58 hospitals across Massachusetts. The communications strategy for public report release was designed to promote fair reporting by the news media and emphasize the improvement goals of performance measurement above evaluation. Along with critical agreements on report design, trial surveys, advertising, and commitments from coalition members about the use of survey results, these measures sought to drive out fear of participation and unfair evaluation. RESULTS: Statewide news media coverage reflected the project's communications goals. Editorial praise for the report was widespread. The project stimulated numerous hospital quality improvement efforts and focused hospital leaders on the need to improve patients' experiences with hospital care. All participating hospitals voluntarily renewed their enrollment for a third survey and public report cycle, and new hospitals joined the project. DISCUSSION: Voluntary public release of performance information by health care providers is possible when the risks, motivations, rewards, and penalties of measurement and public reporting are understood and carefully managed. The goals of public accountability reporting will be realized sooner when it is wedded to the spirit of continuous quality improvement and when providers are engaged as partners at every step of the measurement and reporting process.     

Improved quality data systems through the use of standard electronic data deliverables (EDDs) and environmental data assessment software.

One of the challenges facing professionals in the environmental arena today is the collection and assessment of large amounts of environmental analytical data. The assessment of the quality of that data is essential as multi-million dollar decisions for environmental site cleanups and/or long term monitoring efforts are made based on the analytical results. Also critical to environmental programs is the sharing and access of data across multiple data users. The ability to share data allows for better use of the limited resources available to clean up and monitor contaminated environmental sites. Standardization of electronic deliverables allows for collection of data from multiple data collectors into a single database for use by numerous data users and stakeholders on a project. This paper discusses the benefits of using a standard EDD deliverable format and use of environmental data assessment software tools to do project planning and data assessment throughout the duration of the environmental project.     

Developing a patient complaint tracking system to improve performance

BACKGROUND: Assessing patient satisfaction exclusively through close-ended scaled survey questions may not provide a complete picture of patients' concerns. Only recently has the role of complaint data as a management tool received attention. FORMATION OF THE TEAM AND THE DATABASE: The Complaint Management Team was created in January 1997 at Hartford Hospital (Conn) to develop a coding and reporting mechanism for complaints (negative comments) gathered from patient surveys. Developing the codebook was an evolutionary process. A database was designed to collect three separate complaints and the verbatim text associated with the code. REPORTING: Department-specific, location-specific, and organization wide reports are generated. Quarterly department-specific reports are used to trend the incidence of complaint themes, identify specific locations with problems, and initiate improvement efforts. OVERALL FINDINGS: Since March 1997, most complaints have fallen into five major categories--accommodations (environment), quality of care (care and treatment), respect and caring (humaneness or attitudes and behaviors), timeliness, and communication. The hospital's real estate department has completed a project focused on increasing patient satisfaction with parking. Two projects are still in progress; one is focused on increasing patient satisfaction with respect and staff caring attitude/behaviors, and one on improving satisfaction with the level of noise on the units. DISCUSSION: Approximately 4,000 survey complaints are coded every year. One limitation of the database is that all sources of complaints received throughout the organization are not yet captured. Another limitation is that the outcomes measurement section has exclusive access to the database. CONCLUSIONS: The patient complaint tracking system enables staff, managers, teams, and departments to develop improvement efforts based on quantitative and qualitative 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.     

Lessons from Europe on quality improvement: report on the Velen Castle WHO meeting.

BACKGROUND: In conjunction with the German Ministry of Health, the European Regional Office of the World Health Organization (WHO/EURO) held a workshop, "Experiences with Quality Management in an International Context," at Velen Castle, Velen (Nordrhein-Westfalen), Germany, January 15-17, 1998. The approximately 50 participants were selected in part on the basis of recommendations of their respective countries' health ministries. IMPLEMENTATION AND EVALUATION OF QUALITY MANAGEMENT: Possible ways to introduce quality management ranged from introduction of specific process control projects to total quality management (TQM) and reengineering. STRATEGIES FOR IMPLEMENTING QUALITY MANAGEMENT: Working group sessions identified specific strategies for high-level managers, health care providers, and various kinds of consumers to facilitate quality management. For example, managers need to transmit a vision, create a quality management infrastructure, develop reporting structures, establish a system of incentives, and manage the hospital according to the principles of continuous improvement. QUALITY MANAGEMENT MODELS AND TOOLS: Hospitals and other health care providers in Sweden are testing various methods and systems to assess and improve their organizations' ability to meet patients' demands. Benchmarking is being used as a tool for quality management of diabetes care (DiabCare-France). The benchmarking data are processed centrally and made available to the health care providers in a user-friendly format for application to their own quality improvement processes. Clinical databases-registries containing process and outcome data for a well-defined patient population-can be used for quality and technology assessment, to answer questions of treatment effectiveness, and as an information tool. PRINCIPLES AND STRATEGIES FOR QUALITY MANAGEMENT AND DEVELOPMENT: Successful implementation of quality improvement benefits from local, professional, and national policies and objectives. A balance of incentives can reward efficiency or specific activities. Laws, rules, and regulations can be useful, especially if used sparingly. More education is needed at all levels of the health care system about how to understand and use information and information systems. Research is needed on what processes result in favorable outcomes. Despite optimism about the cost-saving potential of quality improvement efforts, many interventions are likely to be cost-effective without actually saving costs. Public release of performance data requires careful consideration, with participation of the professions.     

Internet-based monitoring and benchmarking in ambulatory surgery centers

BACKGROUND: Each year the number of surgical procedures performed on an outpatient basis increases, yet relatively little is known about assessing and improving quality of care in ambulatory surgery. Conventional methods for evaluating outcomes, which are based on assessment of inpatient services, are inadequate in the rapidly changing, geographically dispersed field of ambulatory surgery. Internet-based systems for improving outcomes and establishing benchmarks may be feasible and timely. METHODS: Eleven freestanding ambulatory surgery centers (ASCs) reported process and outcome data for 3,966 outpatient surgical procedures to an outcomes monitoring system (OMS), during a demonstration period from April 1997 to April 1999. ASCs downloaded software and protocol manuals from the OMS Web site. Centers securely submitted clinical information on perioperative process and outcome measures and postoperative patient telephone interviews. Feedback to centers ranged from current and historical rates of surgical and postsurgical complications to patient satisfaction and the adequacy of postsurgical pain relief. RESULTS: ASCs were able to successfully implement the data collection protocols and transmit data to the OMS. Data security efforts were successful in preventing the transmission of patient identifiers. Feedback reports to ASCs were used to institute changes in ASC staffing, patient care, and patient education, as well as for accreditation and marketing. The demonstration also pointed out shortcomings in the OMS, such as the need to simplify hardware and software installation as well as data collection and transfer methods, which have been addressed in subsequent OMS versions. DISCUSSION: Internet-based benchmarking for geographically dispersed outpatient health care facilities, such as ASCs, is feasible and likely to play a major role in this effort.     

Developing performance measures for alcohol and other drug services in managed care plans. Washington Circle Group

BACKGROUND: Monitoring the quality and availability of alcohol and other drug (AOD) services must be a central tenet of any health-related performance measurement system. The Washington Circle Group (WCG), which was convened by the Center for Substance Abuse Treatment Office of Managed Care in March 1998, has developed a core set of performance measures for AOD services for public- and private-sector health plans. It is also collaborating with a broad range of stakeholders to ensure widespread adoption of these performance measures by health plans, private employers, public payers, and accrediting organizations. CORE PERFORMANCE MEASURES: Four domains were identified, with specific measures developed for each domain: (1) prevention/education, (2) recognition, (3) treatment (including initiation of alcohol and other plan services, linkage of detoxification and AOD plan services, treatment engagement, and interventions for family members/significant others), and (4) maintenance of treatment effects. CONTINUING EFFORTS: Four measures that are based on administrative information from health plans and two measures that require a consumer survey of behavioral health care are undergoing extensive pilot testing. The WCG has reached out to a broad range of stakeholders in performance measurement and managed care to acquaint them with the measures and to promote their investigation and adoption. As results of pilot testing become available, these outreach efforts will continue. CONCLUSIONS: Performance measures for AOD services need to become an integral part of a comprehensive set of behavioral and physical health performance measures for managed care plans.     

Coaching and leadership for the diffusion of innovation in health care: a different type of multi-organization improvement collaborative

BACKGROUND: Health care organizations have suffered a steady decrease in operating margins in recent years while facing increased competition and pressure to provide ever-higher levels of customer service, quality of care, and innovation in delivery methodologies. The ability to rapidly find and implement changes that will lead to strategic improvement is critical. To assist member organizations in dealing with these issues, VHA Upper Midwest launched the Coaching and Leadership Initiative (VHA-CLI) in January 1999. The initiative was intended to develop new methods of collaborating for organizational learning of best practices, with a focus on generalizable change and deliberate leadership supports for deployment, diffusion, and sustainability. The emphasis was on the spread of ideas for improvement into all relevant corners of the organization. STRUCTURE AND PROCESS OF THE COLLABORATIVE: The structure of the VHA-CLI collaborative involved four waves of demonstration teams during 2 years. Each meeting of the collaborative included an executive session, team learning sessions (concepts applied to their improvement projects), and planning for the 6-month action period following the meeting. An important feature of the collaborative is the way in which teams in the various waves overlapped. For example, the Wave 1 team for a given organization came to a learning session in January 1999. At the second collaborative meeting in June 1999, the Wave 1 teams reported on the progress in their pilot sites. This meeting was also the kick-off session for the Wave 2 teams, which could learn about organizational culture and the improvement model from the efforts of their colleagues on Wave 1. Wave 1 teams also learned about and planned for spreading their efforts to other sites beyond the pilot. The pattern of multiple teams stretching across two waves of activity was repeated at every meeting of the collaborative. SUCCESS: Each organization in the collaborative has achieved improved outcomes around its selected clinical topics. In total, 26 teams have made significant improvement in 17 different topic areas. In addition, each organization has been able to successfully spread tested improvements to other individuals, teams, or locations, and the improvement work has become easier and more rapid with each successive cycle. CONCLUSIONS: The learning process initiated by this project will continue for at least another year in the VHA Upper Midwest region and will be expanded as participating organizations in other regions enroll in the VHA's national effort.     

A quality improvement curriculum for medical students

BACKGROUND: Despite frequent recommendations that quality improvement (QI) be incorporated into medical education, reports of this activity are few. A pilot project to develop and implement a curriculum on QI into a family medicine clerkship was conducted in the 1999-2000 academic year. INTERVENTION: A five-part curriculum was developed and implemented on successive weeks of a family medicine clerkship. The curriculum involved students working alone and in small groups. After an orientation to QI principles, students performed a series of chart audits of diabetes care. They then met with QI coordinators from a local health system to review their results. Improvement recommendations were developed and presented to the clinic director. Evaluation included completion of the module, assessment of student knowledge and opinion, and interviews with the QI coordinators. EVALUATION: Two clinic sites and 30 third-year medical (M3) students participated. Each student conducted at least two chart audits, met with the QI coordinators, and developed at least one improvement recommendation. The QI coordinators felt that students were interested in the subject but needed more training in QI principles and more faculty development. Students assessed the curriculum as being moderately effective and useful. DISCUSSION: A curriculum in QI that involved active learning strategies was successfully implemented during a family medicine clerkship. Students viewed the curriculum as being appropriate to their learning. Future efforts should include more work on faculty development and role modeling of QI activity.     

Integrating patient satisfaction into performance measurement to meet improvement challenges

BACKGROUND: A Value Compass has been proposed to guide health care data collection. The "compass corners" represent the four types of data needed to meet health care customer expectations: appropriate clinical outcomes, improved functional status, patient satisfaction, and appropriate costs. Collection of all four types of data is necessary to select processes in need of improvement, guide improvement teams, and monitor the success of improvement efforts. INTEGRATED DATA AT BRYANLGH: BryanLGH Medical Center in Lincoln, Nebraska, has adopted multiple performance measurement systems to collect clinical outcome, financial, and patient satisfaction data into integrated databases. Data integration allows quality professionals at BryanLGH to identify quality issues from multiple perspectives and track the interrelated effects of improvement efforts. A CASE EXAMPLE: Data from the fourth quarter of 1997 indicated the need to improve processes related to cesarean section (C-section) deliveries. An interdisciplinary team was formed, which focused on educating nurses, physicians, and the community about labor support measures. Physicians were given their own rates of C-section deliveries. RESULTS: The C-section rate decreased from 27% to 19%, but per-case cost increased. PickerPLUS+ results indicated that BryanLGH obstetric patients reported fewer problems with receiving information than the Picker norm, but they reported more problems with the involvement of family members and friends. CONCLUSIONS: The data collected so far have indicated a decrease in the C-section rate and a need to continue to work on cost and psychosocial issues. A complete analysis of results was facilitated by integrated performance management systems. Successes have been easily tracked over time, and the need for further work on related processes has been clearly identified.     

Assessing consumer perceptions of inpatient psychiatric treatment: the perceptions of care survey

BACKGROUND: Consumer perceptions of behavioral health care are widely recognized as important quality indicators. This article reports the development and use of the Perceptions of Care (PoC) survey, a standardized public domain measure of consumer perceptions of the quality of inpatient mental health or substance abuse care. The goals were to develop a low-cost, low-burden survey that would address important quality domains, allow for interprogram comparisons and national benchmarks, be useful for quality improvement purposes, and meet accreditation and payer requirements. METHODS: The sample was composed of 6,972 patients treated in 14 inpatient behavioral health or substance abuse treatment programs. The PoC survey was given to patients by program staff in the 24-hour period before discharge. RESULTS: Aggregate reports and ratings of care identified areas that are highly evaluated by consumers, as well as areas that provide opportunities for quality improvement. Factor analysis identified four domains of care, and a 100-point score was developed for each domain. Regression analyses identified significant predictors of perceptions of care for use in computing risk-adjusted scores. Unadjusted and adjusted scores were presented to demonstrate the impact of risk adjustment on quality of care scores and relative ranking of programs. Examples were given of how programs used survey results to improve the quality of care. DISCUSSION: Results demonstrated that the PoC survey is sensitive to detecting differences among inpatient behavioral health programs and can be useful in guiding quality improvement efforts. However, risk adjustment is important for appropriate interpretation of results.     

The forgotten component of the quality triad: can we still learn something from "structure"?

BACKGROUND: Quality assessment was founded on structural measures, such as accreditation status of facilities, credentialing of providers, and type of provider. Recent efforts in measures development have focused on processes and outcomes because research has suggested that structural measures are not strong markers of the quality of care at the health plan or provider levels. Nevertheless, the literature on the quality of health care contains a number of examples illustrating the potential application of structural measures to the assessment of quality. The continued development of measures of structure-which would at least measure aspects of the physical environment, working conditions, organizational culture, and provider satisfaction--may be helpful because generalizing from studies of process and outcome requires specification of the conditions under which these linkages are found. A ROAD MAP FOR MEASURES DEVELOPMENT: The Leapfrog Group of large purchasers has promoted the application of three patient safety "leaps" that are, in essence, structural measures: the use of computerized physician order entry, the selective referral of patients to high-volume providers for certain procedures, and the availability of board-certified critical care specialists in intensive care units. Structural measures, like process and outcomes measures, face the same challenges of standardization, reliability, validity, and portability. Field testing of potential measures will be required to examine the feasibility and added value of these measures in real-world settings. CONCLUSION: Research to date suggests that a new cadre of structural measures of health care quality, which have largely been overlooked in the recent measures development boom, have the potential to fill in important gaps in our ability to assess quality.     

Federal efforts to improve quality of care: the Quality Interagency Coordination Task Force (QuIC)

FORMATION OF THE QUIC: The Quality Interagency Coordination Task Force (QuIC) was established in 1998 to enable the participating federal agencies to coordinate their activities to study, measure, and improve the quality of care delivered by federal health programs; provide people with information to help them in making more informed choices about their care; and develop the research base and infrastructure needed to improve the health care system, including knowledgeable and empowered workers, well-designed systems of care, and useful information systems. STUDY, MEASURE, AND IMPROVE CARE: The QuIC's initial efforts to improve the care delivered in federal health care programs have focused on diabetes, depression, and the effect of working conditions on quality of care. More recently, patient safety efforts are under way to establish a coordinating center that will enable those who are testing methods of reducing errors to share information across their projects and with experts in error reduction. DEVELOP A RESEARCH BASE AND INFRASTRUCTURE: The QuIC has coordinated efforts in credentialing, information on measures of quality, a taxonomy of quality improvement methods, and errors data collection. PROVIDE INFORMATION TO AMERICANS ABOUT HEALTH CARE QUALITY: The QuIC agencies are developing products that will enhance their ability to communicate with the American people about their health care choices: improved gateways for consumer information available from federal agencies, a glossary of commonly used terms, and guidance for producing report cards on quality of care. MOVING THE QUALITY IMPROVEMENT AGENDA FORWARD: Federal efforts to improve quality of care are moving forward in a more integrated fashion on a wide number of fronts.     

Can connected technologies improve sleep quality and safety of older adults and care-givers? An evaluation study of sleep monitors and communicative robots at a residential care home in Japan

A sheet-shaped body vibrometer (SBV) is a type of assistive technology which offers a constant and noninvasive method of recording and monitoring the physical condition and sleep patterns of care recipients. With the aim of creating a safer environment for both care recipients and caregivers, we connected the SBV to a communicative robot (com-robot), to function as an integrated system. The robot has a sensor which activates when a care recipient tries to stand up, whereupon it sends an alert to care staff and speaks to the care recipient. The combined technologies offer an enhanced sense of security, as they watch over older people during the night, visualise sleep patterns and alert care staff. As proof of concept, this study examines the usefulness of this connected system by testing its effectiveness among two types of users (care recipients and professionals) in a residential care home in Japan. For the former, sleep parameters were investigated to see if there was any change over time in and impact on an older person's quality of life. As a measurement of quality of life, the interRAI method was used as a comprehensive assessment tool, based on which a care plan was also created for each care recipient. The interRAI is a nursing care evaluation and nursing care plan creation guideline package that provides unbroken care that can be used at home, in facilities or in the community For the latter, the study tests the level of fatigue among care professionals during night shifts before and after the intervention. For triangulation of data, semi-structured interviews and usability tests were carried out. Despite a few points for improvement, the results highlight multiple benefits for care recipients and professionals of using the SBV and com-robot integrated system in a residential care home.     

The art and science of chart review

BACKGROUND: Explicit chart review was an integral part of an ongoing national cooperative project, "Using Achievable Benchmarks of Care to Improve Quality of Care for Outpatients with Depression," conducted by a large managed care organization (MCO) and an academic medical center. Many investigators overlook the complexities involved in obtaining high-quality data. Given a scarcity of advice in the quality improvement (QI) literature on how to conduct chart review, the process of chart review was examined and specific techniques for improving data quality were proposed. METHODS: The abstraction tool was developed and tested in a prepilot phase; perhaps the greatest problem detected was abstractor assumption and interpretation. The need for a clear distinction between symptoms of depression or anxiety and physician diagnosis of major depression or anxiety disorder also became apparent. In designing the variables for the chart review module, four key aspects were considered: classification, format, definition, and presentation. For example, issues in format include use of free-text versus numeric variables, categoric variables, and medication variables (which can be especially challenging for abstraction projects). Quantitative measures of reliability and validity were used to improve and maintain the quality of chart review data. Measuring reliability and validity offers assistance with development of the chart review tool, continuous maintenance of data quality throughout the production phase of chart review, and final documentation of data quality. For projects that require ongoing abstraction of large numbers of clinical records, data quality may be monitored with control charts and the principles of statistical process control. RESULTS: The chart review module, which contained 140 variables, was built using MedQuest software, a suite of tools designed for customized data collection. The overall interrater reliability increased from 80% in the prepilot phase to greater than 96% in the final phase (which included three abstractors and 465 unique charts). The mean time per chart was calculated for each abstractor, and the maximum value was 13.7 +/- 13 minutes. CONCLUSIONS: In general, chart review is more difficult than it appears on the surface. It is also project specific, making a "cookbook" approach difficult. Many factors, such as imprecisely worded research questions, vague specification of variables, poorly designed abstraction tools, inappropriate interpretation by abstractors, and poor or missing recording of data in the chart, may compromise data quality.