Quality in health care : QHC最新文献

{"title":"Developing valid cost effectiveness guidelines: a methodological report from the north of England evidence based guideline development project.","authors":"M Eccles, J Mason, N Freemantle","doi":"10.1136/qhc.9.2.127","DOIUrl":"https://doi.org/10.1136/qhc.9.2.127","url":null,"abstract":"Over the last decade clinical practice guidelines have become an increasingly familiar part of clinical care. Defined as “systematically developed statements to assist both practitioner and patient decisions in specific circumstances”,1 they are viewed as useful tools for making care more consistent and efficient and for closing the gap between what clinicians do and what scientific evidence supports.2 The broad interest in clinical guidelines is international34 and has its origin in issues that most healthcare systems face: rising healthcare costs; variations in service delivery with the presumption that at least some of this variation stems from inappropriate care; and the intrinsic desire of healthcare professionals to offer, and patients to receive, the best care possible. Within the UK there is ongoing interest in the development of guidelines5 and a fast developing clinical effectiveness agenda within which guidelines figure prominently.67\u0000\u0000During the same 10 year period the methods of developing guidelines have steadily improved, moving from solely consensus methods to methods that take explicit account of relevant evidence. This improvement should make guidelines more valid; guidelines are valid if “when followed, they lead to the improvements in health status and costs predicted by them”.1 In order to maximise validity, three areas of the guideline development process are important8–10: \u0000\u00001. identification and synthesis of the evidence should be done using the methods of systematic review11 to maximise the appropriate identification of evidence;\u0000\u00002. the guideline development group should be appropriately multidisciplinary to ensure full discussion of relevant evidence, associated service delivery issues, and the appropriate construction of recommendations;\u0000\u00003. the recommendations in the guideline should be clearly and explicitly linked to the evidence supporting them.\u0000\u0000To date, however, most guidelines have taken a relatively narrow view of evidence, focusing predominantly on effectiveness …","PeriodicalId":20773,"journal":{"name":"Quality in health care : QHC","volume":"9 2","pages":"127-32"},"PeriodicalIF":0.0,"publicationDate":"2000-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/qhc.9.2.127","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21895108","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Improving care for people with diabetes.","authors":"M Pierce","doi":"10.1136/qhc.9.2.82","DOIUrl":"https://doi.org/10.1136/qhc.9.2.82","url":null,"abstract":"","PeriodicalId":20773,"journal":{"name":"Quality in health care : QHC","volume":"9 2","pages":"82"},"PeriodicalIF":0.0,"publicationDate":"2000-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/qhc.9.2.82","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21895110","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Organisational culture and quality of health care.","authors":"H T Davies, S M Nutley, R Mannion","doi":"10.1136/qhc.9.2.111","DOIUrl":"https://doi.org/10.1136/qhc.9.2.111","url":null,"abstract":"“ A student of management and organisation theory could only be stunned by how little the efforts to improve quality [in health care] have learnt from current thinking in management and from the experience of other industries .” Christian Koeck BMJ 1998; 317: 1267–8. \u0000\u0000Health policy in much of the developed world is concerned with assessing and improving the quality of health care. The USA, in particular, has identified specific concerns over quality issues12 and a recent report from the Institute of Medicine pointed to the considerable toll of medical errors.3 In the UK a series of scandals has propelled quality issues to centre stage45 and made quality improvement a key policy area.6\u0000\u0000But how are quality improvements to be wrought in such a complex system as health care? A recent issue of Quality in Health Care was devoted to considerations of organisational change in health care, calling it “the key to quality improvement”.7 In discussing how such change can be managed, the authors of one of the articles asserted that cultural change needs to be wrought alongside structural reorganisation and systems reform to bring about “a culture in which excellence can flourish”.8 A review of policy changes in the UK over the past two decades shows that these appeals for cultural change are not new but have appeared in various guises (box 1). However, talk of “culture” and “culture change” beg some difficult questions about the nature of the underlying substrate to which change programmes are applied. What is “organisational culture” anyway? It is to this issue that this paper is addressed.Many previous policy reforms in the National Health Service (NHS) have invoked the notion of cultural change. In the early 1980s the reforms inspired by Sir Roy Griffiths led …","PeriodicalId":20773,"journal":{"name":"Quality in health care : QHC","volume":"9 2","pages":"111-9"},"PeriodicalIF":0.0,"publicationDate":"2000-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/qhc.9.2.111","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21895106","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Clinical governance in primary care groups: the feasibility of deriving evidence-based performance indicators.","authors":"A McColl,&nbsp;P Roderick,&nbsp;H Smith,&nbsp;E Wilkinson,&nbsp;M Moore,&nbsp;M Exworthy,&nbsp;J Gabbay","doi":"10.1136/qhc.9.2.90","DOIUrl":"https://doi.org/10.1136/qhc.9.2.90","url":null,"abstract":"<p><strong>Objectives: </strong>To test the feasibility of deriving comparative indicators in all the practices within a primary care group.</p><p><strong>Design: </strong>A retrospective audit using practice computer systems and random note review.</p><p><strong>Setting: </strong>A primary care group in southern England.</p><p><strong>Subjects: </strong>All 18 general practices in a primary care group.</p><p><strong>Main outcome measures: </strong>Twenty six evidence-based process indicators including aspirin therapy in high risk patients, detection and control of hypertension, smoking cessation advice, treatment of heart failure, raised cholesterol levels in those with established cardiovascular disease, and the treatment of atrial fibrillation. Feasibility was tested by examining whether it was possible to derive these indicators in all the practices; the problems and constraints incurred when collecting data; the variations in indicator values between practices in both their identification of diseases and in the uptake of various interventions; the possible reasons for these variations; and the cost of generating such indicators.</p><p><strong>Results: </strong>It was possible to derive eight indicators in all practices and in three practices all 26 indicators. The median number of indicators derived was 12 with two practices able to generate eight. There was considerable variation in the use of computers between practices and in the ability and ease of various practice computer systems to generate indicators. Practices varied greatly in the identification of diseases and in the uptake of effective interventions. Variation in identification of ischaemic heart disease could not be explained by a higher prevalence in practices with a more deprived population. The cost of generating these indicators was 5300 Pounds.</p><p><strong>Conclusion: </strong>Comparative evidence-based indicators, used as part of clinical governance in primary care groups, could have the potential to turn evidence into everyday practice, to improve the quality of patient care, and to have an impact on the population's health. However, to derive such indicators and to be able to make meaningful comparisons primary care groups need greater conformity and compatibility of computer systems, improved computer skills for practice staff, and appropriate funding.</p>","PeriodicalId":20773,"journal":{"name":"Quality in health care : QHC","volume":"9 2","pages":"90-7"},"PeriodicalIF":0.0,"publicationDate":"2000-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/qhc.9.2.90","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21893404","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Validation of an outcome scale for use in adult psychiatric practice.","authors":"R McClelland,&nbsp;P Trimble,&nbsp;M L Fox,&nbsp;M R Stevenson,&nbsp;B Bell","doi":"10.1136/qhc.9.2.98","DOIUrl":"https://doi.org/10.1136/qhc.9.2.98","url":null,"abstract":"<p><strong>Objective: </strong>To clarify the usefulness, acceptability, sensitivity, and validity of version 4 of the Health of the Nation Outcome Scale (HoNOS), a scale developed to meet the requirement for a clinically acceptable outcome scale for routine use in mental illness services.</p><p><strong>Design: </strong>Patients with a range of mental illnesses were rated on the HoNOS at the beginning and end of an episode by interviews with mental health professionals.</p><p><strong>Subjects: </strong>934 patients from eight diagnostic categories were rated by 129 mental health professionals at 17 sites; 250 were also rated on a range of comparison scales.</p><p><strong>Outcome measures: </strong>Comparison of patients' scores at the beginning and end of an episode using individual item scores, dimensional subscores, and the total score.</p><p><strong>Results: </strong>HoNOS scores decreased by almost 50% between the beginning and end of episodes. They varied with the severity of the setting and discriminant analysis showed that the HoNOS had a moderate level of discriminatory power. Correlation analysis showed acceptable levels of agreement with independent scales, although the accuracy of ratings of some items at the beginning of an episode was affected by information deficits.</p><p><strong>Conclusion: </strong>The findings indicate that HoNOS is sensitive to change across time and to differences in illness type and severity, and has a sufficient degree of both construct and criterion related validity to fulfil the requirements of a mental health outcome scale for routine use in clinical settings.</p>","PeriodicalId":20773,"journal":{"name":"Quality in health care : QHC","volume":"9 2","pages":"98-105"},"PeriodicalIF":0.0,"publicationDate":"2000-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/qhc.9.2.98","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21893406","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Do patients matter? Contribution of patient and care provider characteristics to the adherence of general practitioners and midwives to the Dutch national guidelines on imminent miscarriage.","authors":"M Fleuren,&nbsp;M van der Meulen,&nbsp;D Wijkel","doi":"10.1136/qhc.9.2.106","DOIUrl":"https://doi.org/10.1136/qhc.9.2.106","url":null,"abstract":"<p><strong>Objective: </strong>To assess the relative contribution of patient and care provider characteristics to the adherence of general practitioners (GPs) and midwives to two specific recommendations in the Dutch national guidelines on imminent miscarriage. The study focused on performing physical examinations at the first contact and making a follow up appointment after 10 days because these are essential recommendations and there was much variation in adherence between different groups of providers.</p><p><strong>Design: </strong>Prospective recording by GPs and midwives of care provided for patients with symptoms of imminent miscarriage.</p><p><strong>Setting: </strong>General practices and midwifery practices in the Netherlands.</p><p><strong>Subjects: </strong>73 GPs and 38 midwives who agreed to adhere to the guidelines; 391 patients were recorded during a period of 12 months.</p><p><strong>Main measures: </strong>Adherence to physical examinations and making a follow up appointment were measured as part of a larger prospective recording study on adherence to the guidelines on imminent miscarriage. Patient and care provider characteristics were obtained from case recordings and interviews, respectively. Multilevel analysis was performed to assess the contribution of several care provider and patient characteristics to adherence to two selected recommendations: the number of recommended physical examinations at the first contact and the number of days before a follow up appointment took place.</p><p><strong>Results: </strong>In the multilevel model explaining variance in adherence to physical examinations, the care provider's acceptance of the recommendations was the most important factor. Severity of symptoms and referral to an obstetrician were significant factors at the patient level. In the model for follow up appointments the characteristics of the care provider were less important. Referral to an obstetrician and probability diagnosis were significant factors at the patient level.</p><p><strong>Conclusions: </strong>The study showed that characteristics of both the patient and care provider contribute to the variability in adherence. Furthermore, the contribution of the characteristics differed per recommendation. It is therefore advised that the contribution of both patient and care provider characteristics per recommendation should be carefully examined. If implementation is to be successful, strategies should be developed to address these specific contributions.</p>","PeriodicalId":20773,"journal":{"name":"Quality in health care : QHC","volume":"9 2","pages":"106-10"},"PeriodicalIF":0.0,"publicationDate":"2000-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/qhc.9.2.106","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21895105","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Are routine outcome measures feasible in mental health?","authors":"G Thornicroft,&nbsp;M Slade","doi":"10.1136/qhc.9.2.84","DOIUrl":"https://doi.org/10.1136/qhc.9.2.84","url":null,"abstract":"Can mental health outcome measures be developed which meet the following three criteria: (1) standardised, (2) acceptable to clinicians, and (3) feasible for ongoing routine use? We shall argue that the answers at present are “yes”, “perhaps”, and “not known”, respectively.\u0000\u0000Standardised ratings of outcomes of interest to patients and clinicians which go beyond symptom severity have been available for almost two decades. Some are composite global ratings, which include disability,1 while most measure specific domains of patient or carer function such as quality of life, needs, or satisfaction.23 When assessed against an array of psychometric characteristics,45 many of these scales have been shown to be well constructed in terms of their validity, reliability, and sensitivity. There is strong evidence therefore that the first criterion has been satisfied. …","PeriodicalId":20773,"journal":{"name":"Quality in health care : QHC","volume":"9 2","pages":"84"},"PeriodicalIF":0.0,"publicationDate":"2000-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/qhc.9.2.84","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21895112","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A question sheet to encourage written consultation questions.","authors":"C Cunningham,&nbsp;R Newton","doi":"","DOIUrl":"","url":null,"abstract":"<p><strong>Problem: </strong>Interviews with parents and children attending a hospital paediatric neurology clinic indicated they had difficulties in asking questions during consultations.</p><p><strong>Aim: </strong>To set up a process to enable parents and children to get the information they wanted.</p><p><strong>Background and setting: </strong>Two paediatric neurology clinics in separate hospitals in Greater Manchester, UK with a similar client group run by one consultant.</p><p><strong>Design: </strong>Various styles of question sheets were evaluated. The one that was chosen asked patients to write down questions and hand these to the doctor at the beginning of the consultation. Question sheets were given to all patients attending one clinic over a 13 week period.</p><p><strong>Strategies for change: </strong>Use of sheets: number of patients taking or refusing a sheet, with reasons for refusal, were recorded. Doctors noted those who handed questions sheets to them Satisfaction with sheets: patients completed a short feedback form after the consultation Effect on consultations: evaluated through interviews with the doctors.</p><p><strong>Effects of change: </strong>In total, 66 (41%) of the 162 patients offered the sheet declined: 14 had already prepared questions; eight being seen for the first time felt they did not know what to ask. Seventeen had used the sheet on a previous visit and did not need it again; 19 gave no reason; the rest said they had no questions. Seventy six (47%) patients produced a sheet in the consultation. Of those using the sheet, 64 (84%) liked it and 61 (80%) found it useful. Fifty two (68%) wished to use it at future consultations. The doctors reported that through questions articulated on the sheets many issues, fears, and misunderstandings emerged which otherwise would not have been identified. Concerns about increasing consultation time and clinical disruption did not materialize. In contrast, doctors reported patients to be taking more initiative and control, particularly on subsequent visits. None of these changes was noted in the comparison clinic.</p><p><strong>Lessons learnt: </strong>An attractive, clear question sheet proved a simple but effective intervention in the consultation. Parents felt empowered to take control. The approach may have wider applicability, but implementation requires staff training and support to ensure its continuing use; this ensures medical staff adjust to a new consultation format, and that clinic nurses see the value of the sheets and continue to provide them.</p>","PeriodicalId":20773,"journal":{"name":"Quality in health care : QHC","volume":"9 1","pages":"42-6"},"PeriodicalIF":0.0,"publicationDate":"2000-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1743498/pdf/v009p00042.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21692549","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Public disclosure of performance data: learning from the US experience.","authors":"M N Marshall,&nbsp;P G Shekelle,&nbsp;S Leatherman,&nbsp;R H Brook","doi":"10.1136/qhc.9.1.53","DOIUrl":"https://doi.org/10.1136/qhc.9.1.53","url":null,"abstract":"The medical profession has, until recently, largely dictated standards of medical practice. If doctors completed their training and became licensed by the state they were trusted by the general public to provide clinical care with minimal obligation to show that they were achieving acceptable levels of performance.\u0000\u0000Several factors have caused this situation to change. A societal trend towards greater openness in public affairs has been fuelled by the ready availability of information in many areas of life outside of the health sector. A slow realisation of wide variation in practice standards1, 2 and occasional dramatic public evidence of deficiencies in quality of care3, 4 have led to demands by the public and government for greater openness from healthcare providers. The availability of computerised data and major advances in methods of measuring quality5 have allowed meaningful performance indicators to be developed for public scrutiny. The result has been advocacy for the use of standardised public reports on quality of care as a mechanism for improving quality and reducing costs.6–8\u0000\u0000Publication of data about performance is not, however, new. In the 1860s Florence Nightingale highlighted the differences in mortality rates of patients in London hospitals,9 and in 1917 an American surgeon complained that fellow surgeons failed to publish their results because of fear that the public might not be impressed with the results.10\u0000\u0000In most developed countries there is now an increasing expectation that healthcare providers should collect and report information on quality of care, that purchasers should use the information to make decisions on behalf of their population, and that the general public has a right to access that information. Organisations in the US have been publishing performance data, in the form of “report cards” or “provider profiles”, for over …","PeriodicalId":20773,"journal":{"name":"Quality in health care : QHC","volume":"9 1","pages":"53-7"},"PeriodicalIF":0.0,"publicationDate":"2000-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/qhc.9.1.53","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21692551","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A framework for effective management of change in clinical practice.","authors":"M Wilcock,&nbsp;I Mackenzie","doi":"10.1136/qhc.9.1.80","DOIUrl":"https://doi.org/10.1136/qhc.9.1.80","url":null,"abstract":"","PeriodicalId":20773,"journal":{"name":"Quality in health care : QHC","volume":"9 1","pages":"80"},"PeriodicalIF":0.0,"publicationDate":"2000-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/qhc.9.1.80","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"21691771","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}