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To improve the quality of health care, the PHC strategy can be linked to continuous quality improvement (CQI)--also referred to as total quality management (TQM). The linkup--with emphasis on consumer participation--is explained below.
The use of programs to help administrators and staff of health care facilities assess and monitor the quality of services provided is not new. For years, quality assurance (QA) programs have provided generalized sets of standards against which hospitals and other agencies measure their performance. Recently, there has been a trend towards quality improvement (QI) programs which advocate a more proactive response to quality concerns and emphasize a decentralized use of assessment and evaluation findings to continuously improve the care provided. QI is recognized as holding great opportunities for the enhancement of professional nursing practice and the improvement of patient care. In this paper, the process and design of QI was described and the advantages of this approach were recognized.
Quality improvement programs must compete with other health care interventions for limited health care resources. The goal of the research presented here was to develop a model that portrays the mathematical relationship between the size of a quality deficit caused by the noncompliance of health professionals and the cost-effectiveness of a quality improvement program. The model allows the determination of the minimum size of a quality deficit for which it is worth introducing a quality improvement program. If a quality improvement program has already been implemented, the model can be used to define the quality threshold beyond which a reduction in quality becomes economically unattractive. An example considering the reduction of underuse in depression treatment demonstrates that an intervention with a favorable cost-effectiveness ratio may become economically unattractive once the costs for the implementation effort are considered.
In April 1996 the working group of the leading statutory health service officials (Arbeitsgemeinschaft der Leitenden Medizinalbeamten der Länder [AGLMB]) organised a hearing in the course of which the German Medical Association and the National Association of CHI Physicians presented a joint stocktaking of their activities in the discipline of quality assurance during 1955 to 1995. On the basis of this analysis 10 theses have been evolved to develop quality assurance in Germany: (1) quality assurance and quality improvement are in the interest of the medical care of patients. (2) The main task of quality assurance and quality improvement is not the improvement of efficiency. (3) Quality assurance schemes must be problem-orientated and coordinated; there must not be a difference in the quality of out-patient and in-patient medical care. (4) There has to be a systematic evaluation of the suitability of quality assurance schemes. (5) Transparency, communication and cooperation are preconditions for a successful quality assurance and quality improvement. (6) Continuous quality improvement is based on an extensive internal quality assurance. (7) The initiative for the priority development of internal quality assurance procedures must come from external quality assurance. (8) Quality assurance has only a chance of being realised if the individual is convinced and anxious to provide high-quality services, to continuously review and improve his services and to compare them with other services. (9) Quality has its price. (10) Quality assurance and continuous quality improvement are the cornerstones of a quality policy in the health care system. The article concludes with extracts from the checkup and the relevant literature.
Quality improvement methodologies as applied to health care reflect a traditional practitioner-centered approach to defining and improving quality of services. However, health care must reconcile the values, needs, and preferences of providers with those of consumers if effective quality improvement programs are to be developed.
As part of its effort to improve the quality of care in the neonatal intensive care unit at Baylor University Medical Center (BUMC), the unit has participated in the Vermont Oxford Network. This network tracks outcomes and pools data, allowing comparisons and benchmarking. A group of 34 nurseries from the Vermont Oxford Network has collaborated in an innovative quality improvement initiative. This article describes this initiative, called the Neonatal Intensive Care Quality Collaborative 2000 project, and its impact on the neonatal service at BUMC. The project promotes the practice of 4 key habits: the habit for change, the habit for understanding the processes of care, the habit for collaborative learning, and the habit for using evidence-based practices of care.
Continuous quality improvement activities are mandated by the Joint Commission on Accreditation of Healthcare Organizations and the College of American Pathologists. In a recent Needs Assessment Survey of neuropathologists undertaken by the College of American Pathologists, in cooperation with the American Association of Neuropathologists, neuropathologists indicated the need for information regarding continuous quality improvement for neuropathology laboratories. This article suggests activities that may be incorporated in a continuous quality improvement program, including suggested monitors in surgical and autopsy neuropathology, as well as an example of a continuous quality improvement plan.
OBJECTIVE: Using continuous quality improvement principles, we developed a Papanicolaou test recall system with the goal of increasing first and second follow-up Papanicolaou tests after cryotherapy by 20%. DESIGN: An initial study showed rates of 67% for the first follow-up Papanicolaou test and 31% for the second follow-up test. We formed a dysplasia project team. Using continuous quality improvement principles, we instituted a Papanicolaou test recall system. We remeasured first and second follow-up rates for Papanicolaou tests after cryotherapy. The staff and providers were surveyed regarding their acceptance of the system. No attempt was made to control for confounding factors. SETTING: The study was performed at the Family Medicine Clinic in Eau Claire, Wis. This is a community-based, university-administered family practice residency training clinic. PARTICIPANTS: The first 53 consecutive women who had cryotherapy beginning August 1, 1991, were included in the study. All staff and providers were invited to answer a survey questionnaire. INTERVENTION: Patients received a reminder postcard when they were due for a Papanicolaou test. They received a follow-up letter the next month if no Papanicolaou test was done. MAIN OUTCOME MEASURES: First and second follow-up Papanicolaou test rates after cryotherapy. Staff and provider satisfaction as measured by a survey. RESULTS: Eighty-four percent of the women returned for their first follow-up Papanicolaou test, and 53% returned for their second after cryotherapy. Staff and providers supported the recall system. CONCLUSION: Continuous quality improvement principles led to a Papanicolaou test reminder system. Follow-up Papanicolaou test rates appeared to increase by 17% for the first Papanicolaou test and by 22% for the second.
Quality improvement efforts are the focus of leaders in many fields. While we have emerging examples of successful efforts we have fewer presentations of the pathways to follow. This paper offers a general procedure based on a Double Track model. Two procedural processes are offered: (1) at the whole organization level, Track 1, as a strategic means to quality improvement; and (2) at the project level, Track 2, for an operational path to quality improvement work at the team level. It is suggested that successful efforts follow this Double Track effort already and that further identification and elaboration of the pathway will speed diffusion of quality improvement efforts.
A clinical perspective on depression tends to focus on therapy and on medications or psychological interventions that may be helpful to individual patients. A broader view on the treatment enterprise, however, suggests that there are other dimensions to treatment and that opportunities for improving the quality of care and patient outcomes are not limited to innovation in therapeutics. This article examines several of the nonclinical facets of inpatient care, using the frame of a conceptual pyramid to explore the relationships between therapy and its professional, organizational, care-management, and economic concomitants. By drawing on a conceptual pyramid that elucidates several nonclinical dimensions of inpatient treatment for depression, we describe the potential for corresponding quality improvement activities among psychiatric providers. The pyramid suggests that there are multiple opportunities for future interventions to promote quality in inpatient psychiatric care, that those opportunities are considerably more varied than a purely clinical perspective might recognize, and that interventions in nonclinical aspects of the treatment system have the potential to cascade "downward" to affect clinical outcomes over time.
OBJECTIVE: To make measurable improvements in the quality and cost of neonatal intensive care using a multidisciplinary collaborative quality improvement model. DESIGN: Interventional study. Patient demographic and clinical information for infants with birth weight 501 to 1500 g was collected using the Vermont Oxford Network Database for January 1, 1994 to December 31, 1997. SETTING: Ten self-selected neonatal intensive care units (NICUs) received the intervention. They formed 2 subgroups (6 NICUs working on infection, 4 NICUs working on chronic lung disease). Sixty-six other NICUs served as a contemporaneous comparison group. PATIENTS: Infants with birth weight 501 to 1500 g born at or admitted within 28 days of birth between 1994 and 1997 to the 6 study NICUs in the infection group (n = 3063) and the 66 comparison NICUs (n = 21 509); infants with birth weight 501 to 1000 g at the 4 study NICUs in the chronic lung disease group (n = 738). INTERVENTIONS: NICUs formed multidisciplinary teams that worked together under the direction of a trained facilitator over a 3-year period beginning in January 1995. They received instruction in quality improvement, reviewed performance data, identified common improvement goals, and implemented "potentially better practices" developed through analysis of the processes of care, literature review, and site visits. MAIN OUTCOME MEASURES: The rates of infection after the third day of life with coagulase-negative staphylococcal or other bacterial pathogens for infants with birth weight 501 to 1500 g, and the rates of oxygen supplementation or death at 36 weeks' adjusted gestational age for infants with birth weight 501 to 1000 g. RESULTS: Between 1994 and 1996, the rate of infection with coagulase-negative staphylococcus decreased from 22.0% to 16.6% at the 6 project NICUs in the infection group; the rate of supplemental oxygen at 36 weeks' adjusted gestational age decreased from 43.5% to 31.5% at the 4 NICUs in the chronic lung disease group. There was heterogeneity in the effects among the NICUs in both project groups. The changes observed at the project NICUs for these outcomes were significantly larger than those observed at the 66 comparison NICUs over the 4-year period from 1994 to 1997. CONCLUSION: We conclude that multidisciplinary collaborative quality improvement has the potential to improve the outcomes of neonatal intensive care.
BACKGROUND: The role of the hospitalist has evolved over the last decade, with hospitalists increasingly being asked to lead systems-based initiatives to improve the quality of inpatient care. The educational strategy of the Society of Hospital Medicine (SHM) includes development of practice-based resources to support hospitalist-led improvement in clinically important measures of hospital care quality. OBJECTIVE: To develop a resource at the SHM Web site to present quality improvement (QI) principles for systems-based care in the hospital and to help individual hospitalists improve specific patient outcomes. DESIGN: The SHM defined the role of the hospitalist in QI, performed an assessment of the educational needs of hospitalists, and executed a Web-based educational strategy to address these needs. The organization identified the most common cause of preventable inpatient deaths, hospital-acquired venous thromboembolism (VTE), and prioritized the need to improve prophylaxis. RESULTS: This new resource at the SHM Web site presents principles for conducting QI in the hospital. To enable learning that is practice based, the VTE Quality Improvement Resource Room (QI RR) features Ask the Expert, an interactive discussion community, and an original Improvement Workbook, a downloadable project outline and tutorial that hospitalists can use to guide and document steps in an effort aimed at reducing hospital-acquired VTE. CONCLUSIONS: This QI resource serves as a template for the development of subsequent hospital-based resources. User feedback will refine the QI RR and its format so that similar offerings can target other significant inpatient problems. Additional research is needed to evaluate learning and the clinical impact of this quality improvement resource on hospital performance measures and patient outcomes.
During the past several years, the continuous quality improvement (CQI) process has gradually been adapted to the healthcare setting to improve quality without increasing costs. In traditional quality assurance models, quality is measured by the number of accidents or errors occurring. No provision is made for improving the conditions under which the errors occurred. However, continuous quality improvement focuses on the processes used to achieve a goal. These processes may be clinical, financial, or operational issues. Each step in the process is analyzed; then a plan for improvement is tested and refined. The concepts of quality improvement that have been applied in the industrial setting are now being applied in the healthcare arena. Case management and CQI are linked in philosophy and process. The steps of the CQI process can be applied to managed care plans from both a clinical and financial perspective.
The objective of this study was to investigate what happened to improve the quality of care for acute myocardial infarction (AMI) at all 32 nonfederal hospitals in Connecticut and to assess the impact of the Cooperative Cardiovascular Project (CCP) on quality improvement (QI) activities for AMI. We performed a questionnaire study with secondary analyses using the CCP database. On-site interviews were conducted with QI directors at all 32 Connecticut nonfederal hospitals that participated in the Health Care Financing Administration's Cooperative Cardiovascular Project (CCP) in 1992-93 and 1995. The interviews sought information about the makeup of QI departments, specific approaches used to improve the care of patients with AMI, and the perceived value of the CCP to each individual hospital. Results showed that the number of full-time equivalents (FTEs) and FTEs per beds employed in QI departments ranged from 1 to 30 and from 0.4 to 7.9, respectively, with a registered nurse most often serving as the department head (27/32). Over half of the departments (17/32) had additional responsibilities. The majority (25/32) used some combination of physician champions, multidisciplinary QI teams, standing orders, or critical pathways to effect change in AMI care. Finally, 26 of the 32 hospitals believed the CCP was valuable because it provided credible benchmark data, a catalyst for change, or a specific focus on processes of care needing improvement in AMI. Despite great variability in institutional resources, all 32 hospitals used a similar combination of QI approaches to effect change in AMI care. However, there is variable scientific evidence supporting these approaches. Externally sponsored projects such as the CCP appear to play a useful role for individual hospitals. Defining the optimal methods of QI is difficult given that hospitals are using complex combinations of nonstandardized improvement interventions.
INTRODUCTION: Flight following is a key component of an air medical transport service's safety program. National standards require conscientious adherence to flight following. EastCare monitored its compliance with internal flight-following requirements for three years. SETTING: EastCare is a single-helicopter, hospital-based air medical transport service located in a rural region of the southeastern United States. It has a full-time staff of flight nurses, pilots and communications specialists. METHODS: A continuous quality improvement (CQI) process was initiated to delineate specific areas requiring improvement. These areas were discussed at the air medical service's monthly CQI meetings. RESULTS: In 1989, the communications specialists achieved flight following intervals of < or = 15 minutes in 98% of attempts. In 1990 and 1991, the frequency of flight-following intervals of < or = 15 minutes were 98.8% and 99.6%, respectively. The CQI process pointed out educational requirements, technological problems and other areas for improvement. CONCLUSION: The use of a structured CQI process for this service directly contributed to consistently strong compliance in the frequency of flight following.
The health care industry has come under increasing pressure to define, measure and improve the quality of health care services delivered. To set the framework for this discussion, the quality philosophies espoused by the leading experts from the industrial sector, namely, Crosby, Deming and Juran are presented. The differences as well as common themes presented by these experts are discussed. This paper reviews the role of management in a quality improvement process that results in the development of a successful organization.
Health policy in many countries emphasises the public release of comparative data on clinical performance as one way of improving the quality of health care. Evidence to date is that it is health care providers (hospitals and the staff within them) that are most likely to respond to such data, yet little is known about how health care providers view and use these data. Case studies of six US hospitals were studied (two academic medical centres, two private not-for-profit medical centres, a group model health maintenance organisation hospital, and an inner city public provider "safety net" hospital) using semi-structured interviews followed by a broad thematic analysis located within an interpretive paradigm. Within these settings, 35 interviews were held with 31 individuals (chief executive officer, chief of staff, chief of cardiology, senior nurse, senior quality managers, and front line staff). The results showed that key stakeholders in these providers were often (but not always) antipathetic towards publicly released comparative data. Such data were seen as lacking in legitimacy and their meanings were disputed. Nonetheless, the public nature of these data did lead to some actions in response, more so when the data showed that local performance was poor. There was little integration between internal and external data systems. These findings suggest that the public release of comparative data may help to ensure that greater attention is paid to the quality agenda within health care providers, but greater efforts are needed both to develop internal systems of quality improvement and to integrate these more effectively with external data systems.