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PubMed1995

Health, education, and the virtues of efficiency.

Managerialism has been seen in recent times as an answer to problems which fall well outside the boundaries of commercial enterprise. This trend can be seen in both education at university level and health. But there are major risks in transporting the techniques and values of the market into domains which serve non-commercial ends. Many of the most desired achievement of both health and education cannot be costed in monetary terms, and many of the activities that can be costed cannot produce profits. Education and health both have aims that are essentially moral, and the intrusion of managerialism undermines the morality and excuses departures from the central functions of both disciplines. This is not to say that efficiency and cost-cutting may not serve the good of education and health, but they cannot replace functions such as teaching, learning, and healing. There is a cogent argument for redefining the functions and structures of management in order to serve the knowledge workers whose role in health and education is indispensable, rather than to devolve increasing responsibility for management to them. The freedom of knowledge workers to practise their professions, to teach, to do research, and to reflect should be increased, rather than diminished progressively by institutional demands for more and more commitment the minutiae of management.

Efficiency, Organizational↗
PubMed1998

Answers from the audit trail.

It's a lot cheaper to develop a compliance plan than fight fraud charges. Trouble is, off-the-shelf wisdom is hard to come by. Here's sage advice from compliance pros on how to put your plan in motion.

Financial Audit↗
PubMed1991

Missed myocardial ischaemia in the accident & emergency department: E.C.G. a need for audit?

Accident & Emergency Department Senior House Officers rely heavily on their ECG interpretation skills in the diagnosis and management of patients with chest pain. This prospective double-blind study was designed to test the accuracy with which Accident & Emergency Senior House Officers interpret ECGs, by comparing their interpretation with that of a Consultant Cardiologist. ECGs from 279 of 314 consecutive patients with chest pain were analysed. Ninety per cent of normal electrocardiographs and 57% of abnormal ECGs were correctly interpreted. Despite the inaccurate interpretation of 43% of abnormal ECGs, 96.5% of the patients in the study were considered to have been managed correctly. Audit of all ECGs recorded in the Accident & Emergency Department should be undertaken by someone with experience of ECG interpretation. New A&E staff should receive training in the interpretation of ECGs.

Cardiology↗
PubMed2000

Rationalised prescribing for community acquired pneumonia: a closed loop audit.

AIMS: To audit the management of community acquired pneumonia before and after the introduction of a protocol. To determine the aetiology of pneumonia using routine investigations and polymerase chain reaction (PCR). METHODS: Retrospective and prospective audit following the introduction of a management protocol. Prospective cases were investigated routinely and with PCR on blood and nasopharyngeal aspirate. RESULTS: There was a significant increase in rational prescribing following introduction of the protocol with 75% of children receiving intravenous penicillin or erythromycin compared with 26% beforehand. Of 89 children in the prospective group, 51 microbiological diagnoses were achieved in 48 children. Seven children had Streptococcus pneumoniae infection, 14 had Mycoplasma infection, six had pertussis, and one had Chlamydia pneumoniae infection. Twenty three children had a viral cause of which respiratory syncytial virus was commonest. CONCLUSIONS: Introduction of the protocol led to improved prescribing. PCR increased the diagnostic yield and the results support the management protocol.

Adolescent↗
PubMed2006

Acute myocardial infarction: quality of care in rural Alberta.

OBJECTIVE: To assess the quality of care of acute myocardial infarction (AMI) in a rural health region. DESIGN: Clinical audit employing multiple explicit criteria of care elements for emergency department and in-hospital AMI management. The audit was conducted using retrospective chart review. SETTING: Twelve acute care health centres and hospitals in the East Central Health Region, a rural health region in Alberta, where medical and surgical services are provided almost entirely by family physicians. PARTICIPANTS: Hospital inpatients with a confirmed discharge diagnosis of AMI (ICD-9-CM codes 410.xx) during the period April 1, 2001, to March 31, 2002, were included (177 confirmed cases). MAIN OUTCOME MEASURES: Quality of AMI care was assessed using guidelines from the American College of Cardiology and the American Heart Association and the Canadian Cardiovascular Outcomes Research Team and Canadian Cardiovascular Society. Quality of care indicators at three stages of patient care were assessed: at initial recognition and AMI management in the emergency department, during in-hospital AMI management, and at preparation for discharge from hospital. RESULTS: In the emergency department, the quality of care was high for most procedural and therapeutic audit elements, with the exception of rapid electrocardiography, urinalysis, and provision of nitroglycerin and morphine. Average door-to-needle time for thrombolysis was 102.5 minutes. The quality of in-hospital care was high for most elements, but low for nitroglycerin and angiotensin-converting enzyme (ACE) inhibitors, daily electrocardiography, and counseling regarding smoking cessation and diet. Few patients received counseling for lifestyle changes at hospital discharge. Male and younger patients were treated more aggressively than female and older patients. Sites that used care protocols achieved better results in initial AMI management than sites that did not. Stress testing was not readily available in the rural region studied. CONCLUSION: Quality of care for patients with AMI in this rural health region was high for most guideline elements. Standing orders, protocols, and checklists could improve care. Training and resource issues will need to be addressed to improve access to stress testing for rural patients. Clinical audit should be at the core of a system for local monitoring of quality of care.

Acute Disease↗
PubMed1995

Preparing for and handling agency inspections for the United Kingdom Department of Health.

This paper indicates some known differences in approach adopted by the United Kingdom Department of Health (DoH) Good Laboratory Practice (GLP) Monitoring Authority from that of other agencies and offers guidance to quality assurance (QA) professionals in dealing effectively with a DoH inspection. The UK GLP Programme contains, at present, just over 100 member laboratories, ranging from one-man pathology outfits to major companies with perhaps over 1000 staff working in compliance. Laboratories in the GLP program are subject to routine inspection every 2 years; without a satisfactory inspection and continued membership in the GLP program, UK laboratories cannot make a formal claim of compliance. Routine inspections occur at 2-year intervals, with a formal period of notice, allowing some preparation to occur. Routine inspections comprise the selection of a small number of studies for audit and inspection of all the facilities. Inspectors look critically at QA and management systems and routinely interview staff to get a feel for the skills, knowledge, competence, and attitude of those who work on nonclinical studies. Study directors are constant targets for the inspectors' inquisition. Throughout the inspection process, inspectors are accompanied by senior QA staff, whose notes are used to ensure that nothing in the final meeting is reported incorrectly or out of context. The inspectors leave after verbal discussion with management of any significant findings. A full written report is typically provided within 3 weeks, to which a written response from management is required within 4 weeks. There is no Freedom of Information program in the UK.

Appointments and Schedules↗
PubMed1997

Randomised controlled trial of reminders to enhance the impact of audit in general practice on management of patients who use benzodiazepines.

OBJECTIVE: To determine whether reminder cards in medical records enhance the effectiveness of audit with feedback in improving the care of patients taking long term benzodiazepine drugs. DESIGN: Randomised trial, practices receiving feedback only in one group and practices receiving feedback plus reminder cards in the other group. SETTING: 18 general practices in Leicestershire. SUBJECTS: Random samples of patients who had been taking a benzodiazepine anxiolytic or hypnotic drug for four weeks or longer. MAIN OUTCOME MEASURES: Entries in medical records indicating compliance with five criteria of care: assessment of suitability for withdrawal; being told about dependency; withdrawal being recommended; withdrawal or continuing medication; and a consultation with the general practitioner in the past year. Data were collected before and after feedback or feedback plus reminders. RESULTS: Of a total population of 125,846 registered with the 18 practices, 2409 (1.9%) had been taking a benzodiazepine for four weeks or longer. Of the 742 in the first samples, 543 (73.2%) were women, the mean (SD) age was 68.7 (14.9) years, and they had been taking a benzodiazepine for 10.1 (6.7) years. The number of patients whose care complied with the criteria rose after the interventions to implement change. The increase was greater in practices receiving feedback plus reminders for only two of the five criteria "told about dependency" increasing from 52 (11.1%) to 118 (25.8%) in the feedback only group, and from 27 (10.5%) to 184 (43.0%) in the feedback plus reminders group; odds ratio (OR) 1.46 (95% confidence interval (95% CI) 1.32 to 5.21); and "consulted in the past year" increasing from 434 (93.1%) to 411 (95.8%) in the feedback only group and 255 (96.6%) to 400 (99.8%) in the feedback plus reminders group, OR (95% CI) 13.5 (2.01 to 330.3). CONCLUSIONS: Reminder cards had only a limited effect and cannot be recommended for routine use. There were improvements in the care of patients of both groups of practices and further studies are indicated to determine the impact of both systematically developed criteria and reminders embedded into restructured medical records.

Aged↗
PubMed1987

Performing a hospital hazardous waste audit.

In this two part article, the author considers hazardous materials audits: what they are, why they should be performed, what they should encompass, and who should perform them. He also describes the actual mechanics of the audit process. In this first segment, the author discusses how an audit differs from a compliance inspection, what the auditor will look for, and why it is important that the auditor have both top level commitment to the process and the resources to accomplish the task. Finally; the issue of how broad a scope is appropriate is discussed.

Environmental Monitoring↗