Understanding patient-centered care in the context of total quality management and continuous quality improvement

BACKGROUND

Implementing patient-centered care (PCC) requires a fundamental shift in thinking-from how to best provide a wide variety of independent services to how to effectively combine individual service components into an integrated health care experience that meets patient needs and preferences.

DISCUSSION

PCC attempts to improve patient care by organizationally and physically moving selected service functions such as basic laboratory, pharmacy, admitting/discharge, medical records, housekeeping, and material support services to patient care areas, thus effecting an organizational restructuring. PCC creates teams composed of multiskilled or cross-trained individuals capable of providing more of the services directly on the patient care unit. Extensive redesign of the basic work processes as proposed by PCC advocates may result in significant changes in employee job scope, task responsibilities, professional autonomy, and reporting relationships. From the employee's perspective such changes may be neither warranted nor welcomed. Therefore, critical PCC implementation issues include obtaining employee buy-in and establishing appropriate incentive structures to facilitate the desired changes. How does PCC fit in with the popular improvement philosophies of total quality management (TQM) and continuous quality improvement (CQI)? Inherent within TQM and CQI is the belief that it is wiser to maximize efforts to design a product or process to be right the first time and to minimize resources devoted to inspection and repair caused by poor processes. PCC builds upon previous TQM/CQI health care efforts by focusing on ways to reduce the white space handoff problem by examining what, if any, changes in underlying structures and processes may be required. In the PCC hospital, TQM/CQI can function as intended, as a methodology for examining and improving the process of care and patient-care outcomes, regardless of internal departmental or profession-based organizational boundaries.

CONCLUSION

For hospitals to remain competitive in today's rapidly changing environment, it is becoming necessary to reevaluate both how they are organized and how their work processes have been designed and controlled. The groundwork already laid by TQM/CQI initiatives will facilitate the more fundamental and long-lasting improvements derived from the redesign of the patient-care unit as prescribed by the goals of PCC.

Respiratory rate predicts cardiopulmonary arrest for internal medicine inpatients

OBJECTIVE

To assess whether vital sign measurements could identify internal medicine patients at risk for cardiopulmonary arrest.

DESIGN

Retrospective case-control study comparing 72 hours of pre-arrest vital sign measurements with 72 hours of vital sign measurements for patients from the same units who did not experience cardiopulmonary arrest.

SETTING

Twelve non-intensive care internal medicine units at a large midwestern academic medical center.

PATIENTS

Cases included all 59 inpatients who had experienced cardiopulmonary arrest between May 1989 and December 1990; patients who were designated do-not-resuscitate (DNR) or had less than 72 hours of vital sign recordings were excluded. Controls included 91 inpatients without cardiopulmonary arrest who were matched for units and who had 72 hours of vital sign recordings.

RESULTS

The occurrence of one or more respiratory rates > 27 breaths per minute over a 72-hour period had a sensitivity of 0.54 and a specificity of 0.83 (odds ratio = 5.56, 95% CL = 2.67-11.49) in predicting cardiopulmonary arrest. Other respiratory rate thresholds were also predictive of arrest. The ability of respiratory rate to predict arrest was stronger in units with high incidences of arrest relative to units with low incidences, for example, in units for the management of gastrointestinal disease (sensitivity = 1.00, specificity = 0.86) and renal disease (sensitivity = 0.69, specificity = 0.87). Respiratory rate remained a significant predictor (p < 0.001) after controlling for patient age and gender. Pulse rate and blood pressure were not predictive of cardiopulmonary arrest.

CONCLUSIONS

Using elevated respiratory rates as a signal for focused diagnostic studies and therapeutic interventions in internal medicine patients may be useful in reducing the incidence of subsequent cardiopulmonary arrest, and lowering associated morbidity and mortality.

Overcoming the barriers to implementation of TQM/CQI in hospitals: myths and realities

Many health care organizations are attempting to rapidly implement total quality management (TQM) and continuous quality improvement (CQI) philosophies and concepts. In the case of hospitals, a number of issues resulting from traditional organizational design and management practices as well as the characteristics of health care professionals pose significant challenges to rapid implementation. Recognizing and developing strategies to address these challenges, along with realizing that TQM and CQI represent viable processes for conducting organizational "preventive maintenance," may help in changing the focus of quality assessment and enhancement initiatives from processes that are "broken" to processes that should be "fixed" before they "break." This article discusses strategies for overcoming some of the major barriers and challenges to successful TQM and CQI implementation to the hospital setting.

Methods of determining the prevalence of changes in vital signs among internal medicine inpatients

OBJECTIVE

To investigate the prevalence of changes in vital signs and methods of summarizing these changes.

DESIGN

A survey of vital sign values for all eligible inpatients over a three-day period.

PATIENTS

All 91 patients who remained for an entire three-day period in January 1991 on 1 of 11 nonintensive care internal medicine units in the medical center.

RESULTS

Prevalence of changing vital signs varied by type of vital sign, inpatient unit, and method of computation. A method of computation that relies on daily extreme vital sign values. Pulse rates and blood pressure were more variable than respiratory rates.

CONCLUSIONS

Mean daily pulse rates and blood pressure may be useful for quality assessment purposes, whereas individual readings may be more appropriate for respiratory rates. Computation of expected rates of changing vital signs should be tailored to inpatient unit type.

Shifting the financial burden: the VA ambulatory care discharge policy

The Department of Veterans Affairs is a primary source of health care services for many of the nation's uninsured and underinsured. Changes in congressionally mandated eligibility criteria and limited increases in appropriations have forced the Department to adopt a policy of discharging chronic but stable outpatients who have been treated for non-service-connected health conditions. Survey data from one VA medical center suggest that many, but not all, of those discharged: 1) have either Medicare or private insurance coverage; 2) have not sought or found alternative physician services in their local communities; 3) have discontinued taking previously prescribed medications; 4) report worsened health status since discharge; and, 5) have been hospitalized. In general, discharged patients from the lowest income group report the greatest financial access barriers. Preliminary analyses of the discharge policy suggest the potential for decreased access to needed medical services due to financial factors and cost-shifting from the VA to patients and other federal, state and local payers and providers.

Methods for estimating days of hospitalization due to nosocomial infections

While there is little agreement at the individual patient level of analysis, estimates of mean NI-attributed days of stay for the two methods were essentially the same. The lack of agreement at the individual patient level may reflect fundamental differences in the methods used to derive these estimates: incorporation of noninfected patient data versus exclusive reliance on data from infected patients; and, focus on length of stay rather than the actual care being received. The potential advantages of the AEP-based method include the following: 1) all patients with NI can be included in developing estimates; 2) estimates are based on the care provided rather than simple length of stay differences; 3) data on which to form the NI-day estimates are readily available in the medical record; 4) the AEP is a validated and commonly used utilization review instrument; 5) the AEP-based method has acceptable reliability; 6) this method is designed to provide individual and group estimates of NI-attributed days; 7) because every day of stay is reviewed, additional information is available, which results in greater precision of study of the development, diagnosis, and treatment of the NI relative to the other care that originally brought the patient into the hospital. The AEP-based method for estimating NI-days is a promising alternative to the historical cohort approach. Additional applications of this approach are encouraged to further assess its reliability,validity, and additional information yield.

Evaluating the validity of blood glucose monitoring strip interpretation by experienced users

This study examined interpretations of blood glucose monitoring strips (BGMS) by patients and registered nurses (RNs) experienced in strip use. Visual interpretations of whole and bisected BGMS were compared with readings obtained with a reflectance meter. For whole strips, statistically significant differences were found when mean values of patient interpretations were compared with two of the three RNs and the meter. A significant difference was found between the average meter values and those for a third RN. When bisected strips were interpreted, a significant interaction effect was found between reader and strip condition. The RNs systematically underestimated bisected strips when compared with whole strips, whereas patients consistently underestimated both whole and bisected strips. The findings support the need for development of quality assurance monitors to evaluate users of patient self-care technologies such as BGMS.

The clinical microbiology laboratory as an aid in infection control. The application of molecular techniques in epidemiologic studies of methicillin-resistant Staphylococcus aureus

A microbiologic surveillance study was performed in order to estimate the point prevalence, source, and nosocomial acquisition of methicillin-resistant Staphylococcus aureus (MRSA) within the Iowa City Veterans Affairs Medical Center (IC VAMC). Immediately following the microbiologic surveillance study, a cluster of nosocomial MRSA infections was detected by routine infection control surveillance. An epidemiologic investigation was conducted and all isolates of MRSA detected during the microbiologic surveillance study and the subsequent cluster of nosocomial infections were characterized by restriction endonuclease analysis of plasmid DNA (REAP). REAP subtyping defined a total of ten distinct subtypes from 24 patients infected or colonized with MRSA. The documentation of a single subtype of MRSA (subtype A2) in nine patients from the surgical service, eight of which were hospitalized in the surgical intensive care unit, provided convincing evidence of a breakdown of infection control practices in that unit. REAP subtyping was a highly discriminating means of identifying different subtypes among the various isolates of MRSA and was useful in directing infection control efforts to specific problem areas within the hospital. Molecular typing methods, such as REAP, when used appropriately in conjunction with careful epidemiologic investigation provide an effective approach to the investigation and control of the spread of MRSA within the hospital.

The occupational history in the primary care setting

PURPOSE

To assess the need for services in occupational medicine, we determined the prevalence of reported occupational exposures in patients seen in the primary care setting. In addition, we evaluated the validity of our survey instrument.

PATIENTS AND METHODS

All patients (n = 1,112) seen over a 3-month period of time in the Primary Care Clinic at the Iowa City Veterans Affairs Medical Center were considered eligible for this study. A survey instrument was developed to obtain specific information regarding occupational exposures. The questionnaire was administered to 534 or 48% of all eligible patients. The validity of the survey instrument was evaluated by comparing chest radiographs in subjects with a history of exposure to asbestos, coal dust, or silica to those in patients who were not exposed to any of these agents.

RESULTS

We found that almost 75% of the patients reported prior occupational exposure to at least one potentially toxic agent, and over 30% claimed exposure to at least four potentially toxic agents. The validation study indicated that the reported exposure history for asbestos, coal dust, and silica is significantly associated with anticipated changes on chest radiographs. These findings suggest that this easily administered survey instrument is valid for pneumoconiotic dust exposures and may also be valid for other potentially toxic exposures.

CONCLUSION

Data from our study indicate that patients seen in the ambulatory care setting may have clinically significant occupational exposures that are relevant to their medical condition.

Rural hospitals and the provision of agricultural occupational health and safety services

Agriculture is one of the most dangerous work environments in the United States. Ironically, there is a near-total absence of occupational health and safety services being provided to agricultural workers. While many of the agricultural occupational hazards could be addressed through health and safety services provided by rural hospitals, the absence of dedicated funds to pay for these services is a major barrier. The ability of rural hospitals to provide these services and specific issues related to the unique character and problems in implementing agricultural occupational health and safety services are discussed.

Implications of acquired oxacillin resistance in the management and control of Staphylococcus aureus infections

Refinements in testing for resistance to penicillinase-resistant penicillins (PRP) in Staphylococcus aureus have resulted in confusion in classifying isolates as PRP susceptible or resistant. Specifically, a group of organisms has been identified that produce large amounts of beta-lactamase and appear borderline resistant. These organisms have been called "occult resistant" or "acquired oxacillin-resistant" S. aureus (AORSA). A retrospective study was conducted to evaluate the implication of this in vitro phenomenon in managing patients with AORSA infections. Among 134 patients with S. aureus infections, 89 were infected with oxacillin-susceptible S. aureus (OSSA), 26 with AORSA, and 19 with oxacillin-resistant S. aureus (ORSA). There were no significant differences in outcomes when OSSA and AORSA infections were treated with PRP (chi 2MH = .990; P = .32). These results do not suppor the contention that AORSA infections should be managed differently from OSSA infections. Identifying AORSA may not be helpful in guiding antimicrobial therapy or predicting the outcome of infections with AORSA.

Cost of nosocomial infection: relative contributions of laboratory, antibiotic, and per diem costs in serious Staphylococcus aureus infections

This study reports an analysis of the relative importance of laboratory antibiotic, and per diem costs of caring for 58 patients with serious Staphylococcus aureus nosocomial infections. Laboratory costs accounted for 2%, antibiotics for 21%, and per diem costs for 77% of total infection-related costs. Only 45% of patients were hospitalized for additional days specifically because of infection, but these patients stayed an average of 18 extra days. Nosocomial infections with S. aureus resistant to penicillinase-resistant penicillins (PRP) were more frequently associated with additional infection-related days of hospitalization than were PRP-susceptible infections. The cost of PRP-resistant infections was also significantly greater than PRP-susceptible infections, primarily because of the costs of additional days of hospitalization. Rational strategies to control costs of nosocomial infection should focus on two approaches: (1) prevention and (2) reduction of acute hospital days attributable to infections.

Evaluation of laboratory methods for the classification of oxacillin-resistant and oxacillin-susceptible Staphylococcus aureus

The purpose of this study was to examine the efficacy of the oxacillin disk diffusion test and the methicillin and oxacillin agar screen tests as predictors of oxacillin resistance as defined by the reference broth microdilution method. A total of 444 clinical isolates of Staphylococcus aureus collected from individual patients over a four-year period were tested by (1) the oxacillin disk diffusion test, with particular attention to the presence of fine growth of a resistant subpopulation within the zone of inhibition (Ox Grow interpretive criteria); (2) the agar screen method using agar plates with 4% NaCl and either 6 mg/L oxacillin or 10 mg/L methicillin; and (3) the oxacillin and methicillin broth microdilution test methods with 2% NaCl supplementation. Overall, 62 (14%) isolates were resistant and 382 (86%) isolates were susceptible to oxacillin with the use of the reference broth microdilution system. The results indicate that the disk diffusion test with the use of the Ox Grow criteria had a high sensitivity (94%) and negative predictive value (98%) but a low specificity (67%) and positive predictive value (32%) when compared with the reference broth dilution test. Similarly, the agar screen tests had a high sensitivity (95-97%) and negative predictive values (99%) but low specificity (64-74%) and positive predictive values (30-37%). These data indicate that the agar screen tests and the oxacillin disk test with the use of the Ox Grow interpretive criteria may be useful as screening tests for detecting resistance to the penicillinase-resistant penicillins but that all resistant isolates should be confirmed by the reference broth dilution method because of the large number of false-resistant screening test results.

Variation from standards in Staphylococcus aureus susceptibility testing

In an effort to assess the degree of methodologic variation and adherence to current guidelines for detection of methicillin-resistant Staphylococcus aureus (MRSA), the authors surveyed the susceptibility testing practices of all 162 microbiology laboratories in the Veterans Administration (VA) system. Completed questionnaires were returned by 136 (84%) of the laboratories. Overall, 96 (71%) laboratories used disk diffusion testing, 54 (40%) used manual broth dilution, and 36 (26%) used an automated method. The percentage of MRSA detected ranged from 0 to 52%, with a mean of 10%. In general, fewer than 60% of laboratories followed the current susceptibility testing guidelines for key methodologic variables such as inoculum preparation, duration of incubation, and medium supplementation. Failure to adhere to these guidelines may result in suboptimal detection of MRSA.

Use of the appropriateness evaluation protocol for estimating the incremental costs associated with nosocomial infections

Existing methods for estimating additional days of hospital stay due to nosocomial infections (NI) have a number of documented limitations. An alternative method described in this paper uses the Appropriateness Evaluation Protocol (AEP) to determine whether each day of acute inpatient care is appropriate based on the need for care of the NI, original cause of hospitalization (OC), or combined NI-OC requirements. Using this method to identify specific days of hospitalization due to Staphylococcus aureus nosocomial infection, we find: 1) length of stay is increased for only a minority of patients (38%); 2) an average of 20 additional days of stay occurred for patients with 1 or more days attributed to NI; and 3) an average of 52% of length of stay of patients with 1 or more days attributed to NI can be attributed to the NI. Application of the AEP-based method is a useful alternative for identifying additional days of stay due to NI.

Variation in methicillin-resistant Staphylococcus aureus occurrence by geographic location and hospital characteristics

A survey of 162 Veterans Administration Medical Center (VAMC) laboratories performing antimicrobial susceptibility testing was performed to determine variation in reported rates of methicillin-resistant Staphylococcus aureus (MRSA) isolation by geographic location and hospital characteristics. Of the 162 VAMC laboratories surveyed, 136 (84%) provided usable data. The percentage of S aureus isolates reported as resistant to methicillin ranged from 0% to 52% with a mean value of 10% among the 136 survey respondents. MRSA were isolated in every VA Medical District and 96% of all respondent laboratories reported isolating at least one MRSA isolate during the preceding year. These data are considered an underestimate of the time MRSA rate in the VA system due to the fact that many laboratories failed to follow key methodologic guidelines for optimal detection of MRSA. A positive correlation was found between MRSA isolation rate and several measures of hospital size and activity including total beds, total admissions, and total antimicrobial susceptibility tests performed. Geographic clustering of MRSA isolation was observed with distinct areas of very high and very low percentages of S aureus isolates reported as MRSA. The data suggest that the geographic distribution of MRSA within the VA system should be monitored closely for evidence of spread from areas with high-MRSA rates to areas of mid- or low-MRSA rates. Evidence of increased MRSA isolation within these areas may necessitate increased caution in patient referral and transfer patterns within the VA system.

Ambulatory care patient classification

Efficient, cost-effective use of resources is important in every aspect of health care. As ambulatory care continues to grow, it becomes an increasingly important area for managerial attention. Few tools which are specific to the outpatient environment have been developed. This paper has suggested an approach to developing a specific instrument to assist in controlling costs in the ambulatory unit: the ambulatory patient classification system.

Determinants of turnover among nursing department employees

A causal model of turnover, or quitting, among hospital nursing department employees was evaluated. This model includes job satisfaction, organizational commitment, and intent to leave as intervening variables that mediate 13 determinants of turnover. The sample consisted of 841 female nursing department employees selected from five hospitals in a western state. Attitudinal and background data were obtained through a mail questionnaire survey, and turnover was monitored for 18 months following the survey. Intent to leave had a strong direct effect on turnover while kinship responsibility, job satisfaction, and organizational commitment had indirect effects on turnover through intent to leave. Task repetitiveness, autonomy, promotional opportunities, and fairness of rewards were important determinants of jobs satisfaction and thus provide a mechanism whereby hospital management may enhance commitment to the organization while reducing turnover.

Formulating a managerial strategy for part-time nurses

The implementation of the federal Medicare Diagnosis Related Groupings (DRGs)-based prospective payment system (PPS) has caused nursing administrators to examine staffing policies and strategies closely. A critical component under nursing management's control is the use of part-time nurses to solve scheduling, cost, and quality-of-care problems. This article analyzes past and future use of part-time nurses.