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PubMed1998

A report card on continuous quality improvement.

Efforts to incorporate the principles of continuous quality improvement (CQI) into health care have been underway for about ten years. In order to understand the lessons of this decade of experience, senior organizational leaders and experts in the field of health care were interviewed. This select group agreed that there have been concrete accomplishments: the tactic of assigning blame for mistakes to individuals is gradually giving way to an emphasis on detecting problems with process; there is a new focus on the health care customer; and many valuable projects have been inaugurated. Nevertheless, the interviews underlined the reality that the movement has not yet made a sizable impact on the U.S. health care system. Until there is a profound, organization-wide recognition of the need for change, universal commitment to CQI principles will not be achieved.

Attitude of Health Personnel↗
PubMed2001

Principles in practice: reflections on a 'postpositivist' approach to evaluation research.

User participation is currently seen as an ethically appropriate way to proceed when researching disadvantaged groups and it is encouraged by funding agencies. However, the literature rarely discusses the methodological and practical implications for researchers attempting to incorporate user participation into evaluation studies which are informed from an epistemologically opposed (positivist) research paradigm. The paper explores this issue by drawing on the evaluation of a community-based smoking intervention to describe and reflect upon the recruitment, training and employment of local residents as survey interviewers. While the evaluation methodology adopts a quasi-experimental approach, the appointment of local residents as survey interviewers reflects an alternative (interpretive) research tradition. The combined strategy constitutes a postpositivist methodology in that it combines a data collection strategy more akin to interpretive social science while retaining a positivistic epistemological framework. The paper describes some logistics of this approach and problems encountered during the course of survey. While many of the problems described may be routinely associated (although seldom aired) with survey work, particularly in disadvantaged areas, the paper suggests they are also a function of the postpositivist research strategy which we adopted. The failure to involve interviewers in the conception and development of the evaluation meant that they lacked identification with our endeavour and this had practical implications for the survey interviewing. Although the survey was successfully executed and the employment of local residents was a valuable and worthwhile experience, the authors recognize that this narrow conception of user involvement meant that many of the potential benefits (both to the research and the participants) associated with participatory approaches were forfeited.

Community Participation↗
PubMed1997

Assessment of exposure to environmental tobacco smoke.

We present a theoretical framework for assessment of exposure to environmental tobacco smoke (ETS), and review current methods in order to provide guidelines for different types of studies. Exposure assessment should include both a quantitative dimension and consideration of time-specificity of exposure. The ultimate aim is to measure the concentrations of ETS encountered by an individual for different time periods in various microenvironments. The first step is to identify an indicator of ETS. Personal monitoring of air nicotine and respirable suspended particulates (RSPs) are the most direct assessment methods. Indirect assessment methods include stationary measurements of tobacco smoke constituents in different microenvironments and/or questionnaire-derived information, modelled with time-activity information. Biomarkers, such as nicotine and/or cotinine in body fluids or hair, can be used as surrogate measures of dose, although they are usually affected by individual processes in the body after exposure. The best approach to assess ETS exposure will depend on the aim of the study, the health outcome, and the resources. Personal monitoring of nicotine or RSPs is the best method in studies of short-term health effects with small study samples. Stationary measurements of indoor air nicotine or RSPs are suitable for overall monitoring of ETS in different microenvironments over time. Questionnaires and interviews are suitable when studying health outcomes with a long latency period and rare diseases requiring large study populations. Cotinine in body fluids and nicotine concentration in hair can be used to assess cumulative exposure over days or months, respectively. A combination of different methods is often the best approach.

Biomarkers↗
PubMed1997

Maternal interview reports of family history of birth defects: evaluation from a population-based case-control study of orofacial clefts.

Accurate family histories of birth defects are critical for risk assessment and etiologic investigations. Typically, information about family history of birth defects is ascertained from interviews with birth mothers of index children; however, the quality of these interviews is rarely assessed. We evaluated family history information provided by case (n = 28) and control (n = 29) mothers who participated in a population-based, case-control study of orofacial clefts. Interview responses from mothers were compared to questionnaire reports collected by mail from first- and second-degree parental relatives. A total of 345 case and 380 control adult relatives completed questionnaires. These relatives also provided reports for 130 case and 169 control offspring. To examine the quality of birth defect reports, the sensitivity and specificity of birth mother responses were calculated. Sensitivity for presence (yes/no) of a birth defect was 31% for case mothers and 9% for control mothers. Specificity for case and control mothers was 98% and 97%, respectively. Interview responses from mothers who participate in family genealogy were more likely to be concordant with relative reports than were responses from mothers who do not participate in family genealogy. Case mother responses were more likely to be concordant than control mother responses. These results suggest that reliance on interview reports from birth mothers may lead to an underestimation of the occurrence of birth defects in relatives. Future investigations should explore methods to improve the quality of informant reports about family histories of birth defects. One alternative approach is discussed.

Case-Control Studies↗
PubMed1981

Evaluation and training of medication adherence counselors in a clinical trial: application of a skill inventory to video-recorded interviews.

This report describes the procedures and feasibility of an integrated evaluation and training program developed at the Baylor-Methodist Lipid Research Clinic to examine the skills used by the clinic's professional staff in conducting medication adherence interviews with participants in the Coronary Primary Prevention Trial (CPPT). The specific aims of this project were to evaluate the staff's interviewing and counseling skills, identify strengths and deficits, provide needed training, and reexamine the staff's skills following this training. Each of five staff members conducted two 20-minute video-recorded interviews with two different simulated CPPT participants. A trained observer reviewed the video-recordings and evaluated, by an Inventory for Interviewing and Counseling Skills for Adherence to Medication (IICS-AM), each staff member's possession and frequency of use of 17 interviewing skills and 10 counseling skills. The 27 skills on the IICS-AM were selected from the literature as being most frequently recommended for effective interviewing and counseling for medication adherence. These rating data were used to design a 14-week training program to acquire and promote the use of these skills. Following training, the video-recorded interview procedure was repeated and the data analyzed to identify the effects of the training program. The integrated evaluation and training procedures used in this project offer a practical, objective method for examining, improving, and monitoring the skills of the adherence counseling staff in a clinic participating in a multicenter clinical trial.

Audiovisual Aids↗
PubMed2003

Intra- and interpersonal consequences of experimentally induced concealment.

Secrecy, concealment, and thought suppression are assumed to be important aspects of psychopathology. However, most studies address these from an intrapersonal perspective. This study investigates both the intra- as well as the interpersonal consequences of experimentally induced concealment. Two experiments are described in which non-clinical participants were given a concealment instruction (i.e. avoid talking about a certain topic) in a conversation with an interviewer. In the neutral condition there was no such restraint. Interviewees were more tense and more aware during the concealment condition than during the neutral condition, whereas the interviewers were not aware of the participants' avoidance of the concealment topic. The second counterbalanced experiment replicated the results from the initial experiment. The hypotheses were supported that concealment can be induced experimentally leading to thought suppression and elevated levels of discomfort in the concealing individuals, without their conversation partners noticing. Implications for clinical practice are discussed.

Adult↗
PubMed1999

[The evaluation of preoperative anesthetic visit in our hospital].

The preoperative visit by an anesthetist has been thought to be important for the assessment of patient and to communicate with them. However, there are few reports on the visit in Japan until now. The effect of preoperative anesthetic visit in our hospital was estimated by interviewing patients just before surgery who had received a visit by their anesthetist. The answers from sequential 346 scheduled surgical patients for 8 weeks were obtained. Only 72 patients were able to recall the name of their anesthetists. About half of patients believed that anesthetist just had put the patient to sleep and relieved them from pain. We measured the number of treatments each patient could remember that had been explained by the anesthetist on the visit, and found it was unexpectedly small at the interview. These data suggest that our preoperative visit may not be satisfying in view of making good relationship between patients and anesthetists, and educating patients for recent anesthesia. We should make an effort to educate the patients about up-to-date and reasonable anesthesia.

Adolescent↗
PubMed1994

Objective system for interviewer performance evaluation for use in epidemiologic studies.

In this paper, the authors present an objective system to evaluate interviewer performance for use in epidemiologic studies. With this quality control system, all study interviews are audio-taped, and a random sample of interviews are coded according to interviewer behaviors, such as whether the interviewer asked the questions exactly as written and used the probes appropriately. With the use of data obtained from a large case-control study of colon cancer, the authors observed that 94.2% of all questions were asked in the same manner by all interviewers and that 89.5% of all probing behaviors were appropriate. They show that questions that required additional interviewer behaviors were more likely to result in variation in response that can be attributed to the interviewer. These findings have implications for study design and interpretation of study results. From simulations, the authors have estimated the impact of uncorrected interviewer variability on study power and ability to detect disease associations. Uncorrected interviewer variability could decrease study power from 84% to 56%. From simulations, the authors observed that odds ratios could be biased downward from 1.8 to 1.3. These findings illustrate the importance of using a continuous quality control program in epidemiologic research.

Epidemiologic Methods↗
PubMed1981

Evaluating reasons for nursing turnover: comparison of exit interview and panel data.

Data from a study of nursing turnover are used to compare findings based on two techniques for evaluating the reasons for resignations within the same population of hospital nurses during one year. The techniques are: (1) exit interviews, in which resigning nurses were asked to report in an open-ended format their major reasons for leaving their jobs; and (2) a prospective panel study, in which nurses who resigned are compared with nurses who remained, and actual turnover is predicted. Results show that due to the absence of a comparison group of remaining nurses and of baseline data, causal inferences based on exit interview data alone are overly simplistic and misleading for management purposes. Results of the panel study are more informative, although implications for hospital management are more complex. Use of the prospective panel design is recommended for hospitals concerned with evaluating nursing job conditions during a period of high turnover and staff nurse shortages.

Evaluation Studies as Topic↗
PubMed1990

Hospital preparation: the children's story.

This paper reports on the self-identification of hospital preparation learning needs of rural children, both before and after their hospital experience. Children who were scheduled for a hospital admission were interviewed in their home settings 1 to 2 weeks before their hospital admissions. The interviews were replicated 1 week after discharge from the hospital. Changes in knowledge acquisition and learning needs from the pre-hospital to the post-hospital state were examined. The study identifies from the child's perspective the type of information and program delivery method most appropriate to meeting the psychosocial needs of children related to a planned hospital stay.

Canada↗
PubMed1987

Telephone assessment of parents' knowledge of home-care treatments and readmission outcomes for high-risk infants and toddlers.

Medical technology is enabling many high-risk infants and toddlers to be cared for at home. However, techniques for evaluation of home-care and discharge-planning outcomes have not been well documented. Using 60 subjects, we performed telephone assessment of home-care givers' knowledge base in basic knowledge of treatment, operation and maintenance of supplies and equipment, and vendor information, using standard questions, 48 hours following discharge from the hospital. Families giving apnea monitoring or Broviac catheter care as a single treatment scored 100% in all three areas. However, the scores for care givers providing gastrostomy care (54%, 100%, and 91%), tracheostomy care (80%, 70%, and 50%), or total parenteral nutrition (88%, 50%, and 100%) as single treatments were lower. Care givers providing multiple home-care treatments had the lowest scores (65%, 65%, and 76%). However, care givers of patients who were subsequently readmitted scored well (80%, 85%, and 85%), and none of the readmissions were due to a failure of home-care management. Telephone assessment 48 hours after discharge can be used to document home-care and discharge-planning outcomes for high-risk infants and toddlers.

Evaluation Studies as Topic↗
PubMed2006

Mental health research, ethics and multiculturalism.

In this paper we examine ethical issues relevant to conducting mental health research with refugees and immigrant communities that have cultural orientations and social organisation that are substantially different to those of the broader Australian community, and we relate these issues to NH&MRC Guidelines. We describe the development and conduct of a mental health research project carried out recently in Melbourne with the Somali community, focusing on ethical principles involved, and relating these to the NH&MRC National Statement on Ethical Conduct in Research Involving Humans, and the NH&MRC document Values and Ethics: Guidelines for Ethical Conduct in Aboriginal and Torres Strait Islander Health Research. The experience of conducting mental health research with the Somali community highlights the fact that the principles of inclusion and benefit enunciated in the NH&MRC document Values and Ethics are particularly pertinent when conducting research with refugees and immigrant communities that are culturally distant to those of the broader Australian community. These principles inform issues of research design and consent, as well as guiding respectful engagement with the participating community and communication of the research findings.

Attitude to Health↗
PubMed1984

Evaluation of a family asthma program.

This article presents the results of an evaluation of a 12-hour patient education program for children with asthma and their parents. Ninety-two of 147 participants (63%) completed the 1-year follow-up. The effectiveness of the family asthma program (FAP) was measured by a "knowledge of asthma" questionnaire administered before and at the last session; it demonstrated a significant improvement for parents (p less than 0.001) and children (p less than 0.01). The "multidimensional health locus of control scales" (administered to a subgroup of 42 adults and 29 children before and 3 mo after the FAP) demonstrated a significant change in attitude toward asthma for both parents (p less than 0.05) and children (p less than 0.005), indicating an interest to assume more responsibility for self-management. In addition, eight variables were measured in the children before the FAP was started and longitudinally on a monthly basis for 1 yr after completion of the FAP. Three of these variables demonstrated a significant change: total activities were increased (p less than 0.001), unscheduled health-care visits were decreased (p less than 0.005), and school absences were decreased (p less than 0.005). Four variables did not reach statistical significance but did change in the expected direction: medication score, 10% decrease; emergency treatments, 24% decrease; hospital admissions, 44% decrease; school activities, 5% increase. These results demonstrate that this FAP effectively complemented medical care and provided a useful preparation for self-management.

Adolescent↗
PubMed1998

Human factors in technology replacement: a case study in interface design for a public transport monitoring system.

This paper describes ergonomic issues raised during a project to provide a replacement real-time bus route control system to a large public transport company. Task and system analyses highlighted several deficiencies in the original system architecture, the human-machine interfaces and the general approach to system management. The eventual live prototype replaced the existing original system for a trial evaluation period of several weeks. During this period a number of studies was conducted with the system users in order to measure any improvements the new system, with its ergonomic features, produced over the old. Importantly, the results confirmed that (a) general responsiveness and service quality were improved, and (b) users were more comfortable with the new design. We conclude with a number of caveats which we believe will be useful to any group addressing technology impact in a large organisation.

Attitude↗
PubMed2006

Diagnostics and biomarker development: priming the pipeline.

The decrease in the rate at which novel medical products are reaching the market, despite major scientific achievements and investment that might have predicted otherwise, is causing much concern. Although this 'pipeline problem' has often been discussed in the context of drug development, it is also crucial to examine the unique characteristics of the pipeline for biomarkers and diagnostics. Here, we characterize the pipeline problem for biomarkers and diagnostics, and consider what steps could be taken to solve it.

Biomarkers↗
PubMed2002

Will the new Australian health privacy law provide adequate protection?

Amendments to the original Privacy Act (1988) come at a key point in time, as a national medical record system looms on the Australian horizon. Changes to The Privacy Act have the potential to define a level of information privacy prior to the implementation of such a system. We have therefore collected expert opinions on the ability of the Health Privacy Guidelines (enacted in December 2001 under The Privacy Act and hereafter more specifically known as Health Privacy Legislation) to ensure the privacy and security of patient information. We conclude that the legislation is flawed in its capacity to withstand an increasingly corporatised health sector. Deficiencies in consent requirements, together with feeble enforcement capabilities, mean The Legislation cannot effectively ensure that personally identifiable information will not end up in corporate third party hands. To significantly bolster the new legislation, we argue that it should be supplemented with explicit health data legislation and privacy auditing.

Access to Information↗
PubMed2003

Community participation in externally funded health projects: lessons from Cambodia.

This article provides lessons learned on establishing effective community participation in two externally funded, NGO-implemented health projects working at district level in Cambodia. The first project was implemented in accordance with the Cambodian national guidelines on community participation. The second - using lessons and experiences gained as a result of the first project - worked with Buddhist pagoda volunteers. Primary research was conducted in both settings to assess the effectiveness of the two participation strategies. The article concludes that the success of community participation in externally funded health projects with relatively short implementation timeframes requires engagement with existing community-based organizations and agencies. In Cambodia, where Theravada Buddhism is the dominant religion, pagodas and associated volunteers appear to represent such an organization. Community participation structured around pagoda volunteers - who are held in high esteem within their local communities - is more effective and sustainable than newly (and externally) established community structures with formally elected representatives. Pagodas and associated volunteers in rural Cambodia offer the advantages of effective leadership, local organization, resource mobilization and management. It is recommended that programmes and agencies wishing to adopt community participation strategies in health utilize participatory research to identify the most appropriate local organization to lead such initiatives.

Adolescent↗