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Using evaluation research methods to improve quality.

The idea of evaluation, or the measurement of a person, a service or a programme against some type of yardstick, has been around for a long time. In everyday language, the term evaluation is used to refer to everything from employee performance appraisal, to informal opinions about whether a particular service appears to be working well, to carefully planned and executed programmes of evaluation. In the past, librarians have tended to rely on their own professional judgement as a primary means of informal evaluation, and as long as the librarian was considered competent by others in the organization, this method seemed to work reasonably well. In the rapidly changing fiscal climate of the 1990s, greater demands for accountability are altering the standards of evaluation, and informal methods based on professional judgement are less and less likely to be seen as adequate. Formal evaluation is becoming even more important as management strategies, such as total quality management (TQM) and continuous quality improvement (CQI), are adopted--strategies that rely on gathering and using data for measuring service quality. Although programme jargon such as TQM and CQI may change in the future, it is likely that the evaluation process inherent in these approaches will continue to be an important management tool for deciding on the allocation of scarce resources.

Canada↗

Estimating the cost-effectiveness of quality-improving interventions in oral anticoagulation management within general practice.

OBJECTIVES: A clinical trial, "Belgian Improvement Study on Oral Anticoagulation Therapy (BISOAT)," significantly improved the quality after implementing four different quality-improving interventions in four randomly divided groups of general practitioners (GPs). The quality-improving interventions consisted of multifaceted education with or without feedback reports on their performance, international normalized ratio (INR) testing by the GP with a CoaguChek device or computer-assisted advice for adapting oral anticoagulation therapy. The quality improvement in INR control versus baseline was similar in the four groups. The aim of the current study was to calculate the cost-effectiveness and influencing factors of the four quality-improving interventions compared with usual care. METHODS: Activity-based costing techniques with questionnaires were used to determine the global costs per patient per month in the different intervention groups. Effectiveness data were obtained from the BISOAT study. Cost-effectiveness was expressed as cost per additional day within a 0.5 range from INR target. RESULTS: The one-time cost of multifaceted education was 49,997 euro for the whole study. Monthly continuous costs per intervention ranged between 37 euro and 54 euro per patient. Using the CoaguChek in combination with the multifaceted education was associated with net savings and quality improvement, hence dominated usual care. Sensitivity analyses showed improved cost-effectiveness with extended duration and with increased program size. CONCLUSION: Implementation of the combination multifaceted education with the use of the CoaguChek is a cost-effective new organizational model of oral anticoagulation management in general practice.

Administration, Oral↗

Effects of a statewide physician-led quality-improvement program on the quality of cardiac care.

BACKGROUND: Several states have implemented mandatory public reporting of outcomes of cardiac revascularization procedures. Washington is the first to develop a nonmandatory, physician-led reporting program with public accountability and universal hospital participation. The purpose of this study was to determine whether quality improvement interventions resulted in the correction of data deficiencies and performance outliers for cardiac revascularization procedures. METHODS: From 1999 through 2003, there were 18 hospitals with coronary bypass surgery and interventional cardiology programs and 12 with only the latter. All patients > or =18 years undergoing 24372 isolated coronary bypass surgeries and 59,656 percutaneous coronary interventions were included. After 1999 to 2001 data were analyzed in early 2002, the Clinical Outcomes Assessment Program implemented a 6-step quality-improvement intervention to measure and remeasure data quality, process compliance, and performance. RESULTS: In 2003, 4 of the 18 surgery programs had 1 statistical outlier with respect to 4 performance measures, whereas 2 of 30 coronary intervention programs were mortality outliers. For bypass surgery, all programs maintained full compliance with program standards by adhering to timely and reliable submission of data, developing plans to address performance outliers, and demonstrating that outlier status did not persist from baseline to remeasurement. For coronary interventions, 1 program was a persistent outlier for mortality in 2002 and 2003. CONCLUSIONS: The Clinical Outcomes Assessment Program has successfully monitored cardiac care patterns in Washington State over a 5-year period. Most hospitals that perform coronary revascularization procedures meet acceptable performance standards.

Aged↗

Use of an ER audit to build recommendations for improving quality of care. Part I: Initial audit and recommendations.

This paper documents a complete audit of the Regina Health District's Emergency rooms. The issues examined were triage, non-urgent visits, waiting times, and information management. The results, presented in the two studies following, describe the initial audit and recommendations, as well as the follow-up research and subsequent recommendations. Our findings demonstrate how an audit can effectively monitor the functioning of the Emergency Room (ER) and provide data essential to continuous quality improvement.

Analysis of Variance↗

A model for improving quality in nephrology settings.

Continuous quality improvement (CQI) programs have been instituted in many health care organizations over the last decade. PDCA, a tool composed of planning (P), doing (D), checking (C), and acting (A), has proved to be very useful in the CQI problem-solving process. The use of the PDCA tool described in this article resulted in the successful resolution of a hepatitis B outbreak in a Brazilian hemodialysis population and can serve as a model methodology for improving care in nephrology settings.

Brazil↗

Informatics, imaging, and healthcare quality management: imaging quality improvement opportunities and lessons learned form HCFA's Health Care Quality Improvement Program.

This article examines the use of population-based healthcare data at the interface among radiology, healthcare informatics, and health services research for the purposes of healthcare quality management. To illustrate these concepts, we draw on experience with Health Care Financing Administration's Medicare Health Care Quality Improvement Program (HCQIP). We present two HCQIP efforts that have identified opportunities to improve the delivery of imaging services, specifically studies of the diagnosis and management of congestive heart failure and cerebrovascular disease. The examples demonstrate from a population-level perspective that there are opportunities to enhance the quality of imaging practice by reducing the magnitude of imaging practice variability, implementing evidence-based guidelines, and optimizing the communication of imaging study findings to physicians who are responsible for subsequent diagnostic and therapeutic decisions. Additional research is required in specific clinical domains of radiology to determine if implementation of evidence-based imaging guidelines and enhanced clarity in the interpretation and communication of diagnostic imaging will improve health outcomes.

Centers for Medicare and Medicaid Services, U.S.↗

Improving quality at Parkview.

Parkview Episcopal Medical Center in Pueblo, CO, has been implementing a continuous quality improvement (CQI)-driven organization since April 1988. Under the leadership of Michael Pugh, the medical center's president and CEO, Parkview has made great progress in this effort. However, there is much more to be accomplished in the years to come.

Accounts Payable and Receivable↗

Generalizability and persistence of a multifaceted intervention for improving quality of care for rural patients with type 2 diabetes.

OBJECTIVE: Most quality improvement efforts for type 2 diabetes have neglected cardiovascular risk factors and are limited by a lack of information about generalizability across settings or persistence of effect over time. RESEARCH DESIGN AND METHODS: We previously reported 6-month results of a controlled study of an intervention that improved cardiovascular risk factors for rural patients with type 2 diabetes. We subsequently provided the identical intervention to the control region after the main study was completed. The primary outcome was 10% improvement in systolic blood pressure, total cholesterol, or HbA(1c). We compared the previously reported 6-month effect of the original intervention with the effect of the crossed-over intervention to the former control region and remeasured outcomes in the original intervention region 12 months later. RESULTS: Our analysis included 200 original intervention and 181 crossed-over intervention subjects. The age of the population was 62.4 +/- 12.4 years (mean +/- SD), and 54.3% were women. A similar proportion of patients in the crossed-over intervention group achieved improvement in the primary composite outcome compared with the original intervention group (38 vs. 44%, respectively; P = 0.29). In adjusted analyses, we observed less improvement in blood pressure (adjusted odds ratio 0.40 [95% CI 0.17-0.75]) but greater improvements in total cholesterol (1.86 [0.93-3.7]) with the crossed-over intervention compared with the original intervention. We observed sustained improvements in total cholesterol and HbA(1c) levels in the original intervention group, whereas previous large gains in control of blood pressure diminished over time. CONCLUSIONS: We found that our intervention was generalizable across settings, and its effect persisted over time. Nevertheless, without ongoing intervention or reinforcement, we noted some loss of the original benefits that had accrued. Future translational work should incorporate interventions such as ours into ongoing systems of rural care.

Aged↗

Continuous improvement, quality control, and cost containment in clinical laboratory testing. Effects of establishing and implementing guidelines for preoperative tests.

OBJECTIVE: To develop guidelines for laboratory tests ordered before admission for elective surgery. DESIGN: A seven-step continuous quality improvement process. SETTING: The Departments of Laboratory Medicine, Surgery, and Anesthesia of the University of Massachusetts Medical Center, a 384-bed, teaching, tertiary-care facility. PARTICIPANTS: Core group of the Department of Laboratory Medicine and the Laboratory Medical Advisory Committee. INTERVENTION: Guidelines were developed for laboratory tests ordered before elective surgery. They were divided into four major groups as well as by age and gender. After an intense educational effort, consent was obtained from the majority of surgeons, who agreed to delegate the ordering of tests to the nurses and anesthesiologists who examine patients before surgery. MAIN OUTCOME MEASURE: Charts chosen at random by the medical records department for the period prior to implementation of guidelines were reviewed and compared with records 1 and 2 years later. RESULTS: Reductions of 50% and 60% in the first and second years, respectively, in the overall number of tests ordered per patient were demonstrated. An improvement in the appropriateness of tests was also documented: 81% in the first year and 86% in the second year, compared with 65% appropriateness prior to implementation of guidelines. A 1-year savings of $66,981 and an overall 2-year savings of $75,995 were documented. CONCLUSIONS: We have described an approach that involves a sustained educational effort and collaboration of nurses and physicians and have presented specific guidelines for preoperative testing. A major decrease in the number of tests ordered, an increase in their appropriateness, and marked fiscal savings were documented.

Child, Preschool↗

Can mental health integration in a primary care setting improve quality and lower costs? A case study.

OBJECTIVE: To describe the successful implementation of an evidence-based, integrated quality improvement mental health program in a primary care setting. SUMMARY: Intermountain Healthcare (IHC) has aligned resources around a conceptual framework that emphasizes clinic and community accountability, family and consumer health focused on recovery rather than disease, and enhanced decision making through partnerships and automation. The mental health integration system includes an integrated team led foremost by the patient and family with vital defined roles for primary care providers, care managers, psychiatrists, advanced practice registered nurses, support staff, and the National Alliance for the Mentally Ill. Pharmacists have assumed training functions on the team and have the potential to play more vital roles. CONCLUSION: The IHC experience demonstrates that mental health services can be effectively integrated into everyday practice in a primary care setting. Clinical and financial burden can be decreased for the health care team, patients, and family.

Cooperative Behavior↗

Improving quality or shifting diagnoses? What happens when antibiotic prescribing is reduced for acute bronchitis?

BACKGROUND: A quality improvement project in an academic practice demonstrated a reduction in antibiotic prescribing for acute bronchitis. However, it was unclear whether this represented a reduction in antibiotic use or whether physicians assigned new diagnoses to the same patients to avoid scrutiny and continue to use antibiotic therapy. OBJECTIVE: To examine whether a substantial amount of diagnostic shifting occurred while antibiotic prescribing for acute bronchitis decreased during a 14-month period (from January 1, 1996, to February 28, 1997). METHODS: All patient diagnoses of acute bronchitis, acute sinusitis, upper respiratory tract infection, and pneumonia were determined for the 14 months of the acute bronchitis intervention. The relative distribution of patients among these 4 diagnostic categories was compared to determine if the percentage of patients with acute bronchitis decreased while those with acute sinusitis and pneumonia increased during the acute bronchitis intervention. RESULTS: The percentage of patients with the diagnosis of acute bronchitis remained unchanged during the 14-month period while antibiotic use for this condition decreased from 66% of cases to less than 21% of cases. Instead of the patients being assigned a different diagnosis such as acute sinusitis so that antibiotic prescribing would not be scrutinized, as we hypothesized, the relative number of diagnoses for acute sinusitis compared with acute bronchitis actually declined during the 14 months. No change was noted in the relative frequency of acute bronchitis cases compared with pneumonia cases. CONCLUSION: During a 14-month period when an intervention was successful at reducing antibiotic use for acute bronchitis, there was no evidence that physicians shifted patients from the diagnosis of acute bronchitis to other diagnoses.

Acute Disease↗

[German and American consultant psychiatrists evaluate their function. A contribution to quality improvement in consultation psychiatry].

There is an increasing interest in scientific and practical aspects of C/L psychiatry in Germany. The every day C/L work in Germany still differs substantially from the American one. In contrast to Germany and other European countries, C/L psychiatry in the USA has developed into a subspecialty with multiple activities in research and patient care during the last 3 decades. This study was conducted in Germany and the USA in order to evaluate and compare the training and patient care in C/L psychiatry, as assessed by consultants doing the every day C/L work. 227 C/L psychiatrists participated in the study in both countries. There are significant differences in theoretical and practical C/L psychiatry is obviously more comprehensive. American C/L psychiatrists take more time for consultations, do more follow-ups, and more frequently organize psychiatric or psychotherapeutic outpatient after-care. These results are suited to support activities to improve quality in Germany C/L psychiatry.

Cross-Cultural Comparison↗

Exploring nursing home staff's perceptions of communication and leadership to facilitate quality improvement.

Leadership and clinical staff were surveyed to explore communication and leadership in nursing homes. Registered nurses and other professionals perceived communication as better than their nursing colleagues did. Overall, results suggest all factors of communication could improve. In terms of leadership, licensed practical nurses perceived less clarity of expectations, encouragement of initiative, and support than other groups. The study provides insight into what is organizationally necessary to improve quality of care in nursing homes.

Attitude of Health Personnel↗

An integrative model for organization-wide quality improvement: lessons from the field.

This article describes a model of CQI that is designed to characterize the elements necessary for successfully improving quality at an organization-wide level; describe and understand the organizational dynamics in implementing an organization-wide effort; and aid in diagnosing and solving common implementation challenges. Three cases illustrate the model and how it can be used.

Health Services Research↗

The administrative and clinical rationale for the total organization approach to continuous quality improvement.

In our view TQM and CQI represent important innovations in the continuing effort to develop higher performance organizations. Never before has the need been so great to improve quality while at the same time constraining, or reducing, costs. An increasing number of health care organizations can document their experiences that as quality goes up, costs can come down. The contribution of these new approaches is in some sense the wedding of many long established methodologies--the scientific method, statistical quality control, planning, joint problem solving, participative management, and empowerment of the work force. While this recognition could lend support to those who label this new model a fad, that perception denies the linkage of TQM/CQI to the greater stream of innovations pushing us toward ever-greater organizational excellence. Can we not take the philosophy and methods that are potentially useful and try them experimentally? Let our empirical tests tell us of their contribution. We believe the concepts and procedures of TQM/CQI will help us to be better in years to come, even though we highly respect our starting point.

Economic Competition↗

[Measuring patient satisfaction in inpatient gynecology: significant quality improvements].

In the present study a validated questionnaire was used to measure patient satisfaction in a clinic of gynecology in a regional hospital. The goal was to assess problems, to solve them, and to increase patient satisfaction. A 50-item questionnaire was applied to assess satisfaction scores of 60 gynecology patients in 1996, and of 185 patients in 1998/99. The overall degree of patient satisfaction amounted to 74.2 +/- 22.7% increasing two years later to 78.0 +/- 25.8%. This represents a significant improvement and can be considered as success to improve quality. A significant increase of the satisfaction scores was obtained in four domains: 1. Information about the planned intervention, 2. courtesy and willingness to explain the procedures of the anesthesiologists, 3. cleanliness and 4. comfort of room. The present study confirms that validated assessment of patient satisfaction allows to identify problems and to solve them with appropriate corrective measures. This results in an increase of patient satisfaction.

Female↗

Data presentation for quality improvement.

Efforts to improve quality of medical care often involve large data sets. Reviewing laboratory results over time for a cohort of patients is particularly problematic: traditional statistics conflate case to case variations with day to day variations (within a case). To help solve this problem, we propose using sparklines for case by case review and a modified box-plot for overall data review. We demonstrate these data presentations using fingerstick glucose values.

Audiovisual Aids↗

The cost of efforts to improve quality.

BACKGROUND: Virtually all hospitals in the United States report that they engage in efforts to improve quality, such as continuous quality improvement (CQI). Little is known about the costs of these efforts and whether they are associated with improved outcomes or lower patient-care costs. OBJECTIVES: The principal objective of this study was to provide benchmark data on the costs of efforts to improve quality. The authors also attempted to determine if quality improvement expenditures are correlated with outcomes and/or condition-specific hospital costs. METHODS: Detailed information on the cost of quality improvement was obtained from hospitals participating in a broad study of CQI activities. These data were correlated with patient outcomes and condition-specific costs. The subjects were medium to large hospitals throughout the United States. Senior managers provided budgetary information on direct costs of quality improvement, and details about meetings associated with quality improvement. They also provided summary medical bills for all patients undergoing total hip replacement and coronary artery bypass graft surgery. The billing information was combined with data provided by the Health Care Finance Administration to estimate condition-specific costs. Patients were directly surveyed to obtain information about satisfaction and outcomes. RESULTS: There is a wide range of expenditures on quality improvement activities. Meeting costs are a substantial percentage of total costs. Neither total costs nor meeting costs are correlated with condition-specific costs. DISCUSSION: Hospital managers can be expected to insist on evidence that quality improvement expenditures produce tangible benefits. This article provides benchmark estimates of those benefits and a methodology for further research.

Hospital Costs↗