SANTA vs. public tuberculosis hospitals: the patient experience in the Free State, 2001/2002

This paper reflects on the appropriateness of the decision to close down a non-governmental organisation (NGO), state-aided tuberculosis (TB) hospital in the Free State in 2003. Henceforth hospitalisation of TB patients would take place at public district hospitals. A survey conducted late-2001/early-2002 revealed a more positive patient experience of hospitalisation for TB in public hospitals than in the NGO hospital. Consideration of the patient experience serves to inform the debate concerning continued outsourcing of TB hospital care to NGOs in South Africa. This study discusses comparative findings in respect of patients' biographic and socio-economic characteristics, health beliefs, satisfaction with hospitalisation, experience of stigmatisation, adherence to treatment and absconding from hospital.

Use of hierarchical models to evaluate performance of cardiac surgery centres in the Italian CABG outcome study

Background

Hierarchical modelling represents a statistical method used to analyze nested data, as those concerning patients afferent to different hospitals. Aim of this paper is to build a hierarchical regression model using data from the "Italian CABG outcome study" in order to evaluate the amount of differences in adjusted mortality rates attributable to differences between centres.

Methods

The study population consists of all adult patients undergoing an isolated CABG between 2002–2004 in the 64 participating cardiac surgery centres.

A risk adjustment model was developed using a classical single-level regression. In the multilevel approach, the variable "clinical-centre" was employed as a group-level identifier. The intraclass correlation coefficient was used to estimate the proportion of variability in mortality between groups. Group-level residuals were adopted to evaluate the effect of clinical centre on mortality and to compare hospitals performance. Spearman correlation coefficient of ranks (ρ) was used to compare results from classical and hierarchical model.

Results

The study population was made of 34,310 subjects (mortality rate = 2.61%; range 0.33–7.63). The multilevel model estimated that 10.1% of total variability in mortality was explained by differences between centres. The analysis of group-level residuals highlighted 3 centres (VS 8 in the classical methodology) with estimated mortality rates lower than the mean and 11 centres (VS 7) with rates significantly higher. Results from the two methodologies were comparable (ρ = 0.99).

Conclusion

Despite known individual risk-factors were accounted for in the single-level model, the high variability explained by the variable "clinical-centre" states its importance in predicting 30-day mortality after CABG.

Comparison of services of public, private and foreign hospitals from the perspective of Bangladeshi patients

Despite recent developments in the Bangladesh healthcare sector, there is still great concern about the quality of healthcare services in the country. This study compared the quality of healthcare services by different types of institutions, i.e. public and private hospitals, from the perspective of Bangladeshi patients to identify the relevant areas for development. A survey was conducted among Bangladeshi citizens who were in-patients in public or private hospitals in Dhaka city or in hospitals abroad within the last one year. About 400 exit-interviews were conducted using a structured questionnaire that addressed the probable factors of the quality of healthcare services in 5-point interval scales. The results gave an overview of the perspectives of Bangladeshi patients on the quality of service in three types of hospitals. The quality of service in private hospitals scored higher than that in public hospitals for nursing care, tangible hospital matters, i.e. cleanliness, supply of utilities, and availability of drugs. The overall quality of service was better in the foreign hospitals compared to that in the private hospitals in Bangladesh in all factors, even the 'perceived cost' factor. This paper provides insights into the specific factors of the quality of hospital services that need to be addressed to meet the needs of Bangladeshi patients.

Evaluation of nosocomial infections following cardiovascular surgery

OBJECTIVE

To evaluate nosocomial infections (NI) following cardiovascular surgery (CVS), and to share the first seven-year experience of the infection control commission in a private medical center.

METHODS

Active prospective and laboratory based surveillance program of the hospital from January 1999 to December 2005 was used and all patients who were found to have NIs after CVS during their stay or readmission were included.

RESULTS

A total of 14,502 cardiovascular operations were performed and 416 (2.9%) patients had 494 NIs. The most prevalent infections were surgical site infections (42%) and urinary tract infections (22%). The most frequently isolated microorganisms were coagulase-negative staphylococci (19%), Escherichia coli (16%) and Staphylococcus aureus (16%). A total of 99 patients (24%) died. The mortality rates were high in patients with blood-stream infections (58%) and lower respiratory tract infections (37%). The 2003 was the year with the lowest NI rate when compared to 2000, 2001, 2002, 2004, and 2005 (p< 0.005).

CONCLUSION

This study allowed an evaluation of NIs, including incidence and distribution, following CVS. While carrying on the studies to prevent NIs that are responsible for serious morbidity and mortality, risk factors also need to be identified in order to take preventive measures, other than the ones present.

Social inequalities in perinatal mortality in Belo Horizonte, Brazil: the role of hospital care

OBJECTIVES

We examined the contribution of hospital type and quality of care to perinatal mortality rates in the city of Belo Horizonte, Brazil.

METHODS

We used a cohort study of all births (40953) and perinatal deaths (826) in Belo Horizonte in1999. After adjusting for maternal education and birthweight, we compared mortality rates according to hospital category--defined by a hospital's relation to the national Universal Public Health System (SUS)--and quality of care. We used the Wigglesworth Classification to examine perinatal deaths.

RESULTS

After we controlled for birthweight and maternal education, the highest perinatal death rates were observed in private and philanthropic SUS-contracted hospitals (relative to private, non-SUS-contracted hospitals). Hospital quality was also directly associated with perinatal death rates. Mortality rates were especially high for normal-birthweight babies born in private SUS-contracted hospitals. Intrapartum asphyxia was the leading cause of preventable death.

CONCLUSIONS

In a class-segregated health care system, such as Brazil's, disparities in quality of care between SUS-contracted and non-SUS-contracted hospitals contribute to the unacceptably high rates of perinatal mortality.

The Gateway Paper--health service delivery outside of the public sector in Pakistan

As opposed to preventive healthcare where State mandated healthcare agencies play a pre-dominant role, a number of actors within the healthcare system other than the State play a role in providing personalized curative healthcare within the country. The sector constitutes a set of diverse group of doctors, nurses, pharmacists, traditional healers, drug venders as well as laboratory technicians, shopkeepers and unqualified practitioners. The services they produce include hospitals, nursing homes, maternity clinics, clinics run by a range of healthcare providers, diagnostic facilities and the sale of drugs from pharmacies and unqualified sellers. However, in some cases the distinction between public and private sector is not very clear as many public sector practitioners practice privately, legally and illegally. The sector is fragmented and characterized by a mixed ownership patterns, many types of providers and different systems of medicines. As a viewpoint on the configuration of a proposed health reform within Pakistan, the Gateway Paper flags key issues in relation to this sector. This encompasses lack of a formal regulatory mechanism for private sector providers and their delivery mechanisms, absence of a formal mechanism for building capacity and ensuring quality and absence accreditation arrangements for private hospitals and nursing homes. With this as a context recommendations focus on the nature of regulatory mechanisms and the institutional arrangements necessary support them with particular reference to quality and continuing medical. In regard to traditional medicines directions focus on exploring ways to harnessing the potential within the system in order to leverage its outreach and integrate it with the formal healthcare system. The Paper also stresses on the need to fully exploit the potential within behavioral change interventions in order improve health systems performance in Pakistan and to broaden its scope from lifestyle and prevention behaviors in a health education paradigm to impact the performance of all the actors in the health care system.

Public versus private institutional performance reporting: what is mandatory for quality improvement?

BACKGROUND

In the past 11 years, Ontario has generated institution-level performance report cards on outcomes of coronary artery bypass graft (CABG) surgery. The objective of this study was to evaluate the differences in patient characteristics and outcomes observed during the transition from no reporting to confidential, and ultimately public performance report cards for CABG surgery in a public health system.

METHODS

We used clinical and administrative data to assess crude, expected, and risk-adjusted 30-day mortality rates after isolated CABG surgery in Ontario for 67693 patients from September 1, 1991, to March 31, 2002. Confidence intervals on relative mortality reductions were determined by bootstrapping. We compared 30-day mortality trends to a control outcome (risk-adjusted 30-day all-cause readmission). We analyzed inhospital mortality trends for Ontario compared with the rest of Canada for the period from 1992 to 1998.

RESULTS

The risk-adjusted 30-day mortality rate decreased 29% (95% CI 21-39) from the era of no reporting (1991-1993) to confidential reporting (1994-1998). There was no further decrease with public reporting (1999-2001). The control outcome of 30-day readmission did not decrease across reporting eras. Inhospital mortality fell significantly faster in Ontario during the period of confidential reporting than in other parts of Canada.

CONCLUSION

Ontario CABG mortality outcomes improved sharply after provider results were confidentially disclosed at an institutional level. No such changes were seen for nondisclosed outcomes or regions outside Ontario. Further public reporting of outcomes had no discernible impact on performance. These results are consistent with the hypothesis that confidential disclosure of outcomes was sufficient to accelerate quality improvement in a public system with little competition for patients between hospitals.

The quality of hospital-based antenatal care in Istanbul

The aim of this study was to gather comprehensive data from three hospitals in Istanbul, Turkey, in order to gain in-depth understanding of the quality of antenatal care in this setting. The Bruce-Jain framework for quality of care was adapted for use in evaluating antenatal care. Methods included examination of hospital records, in-depth interviews, exit questionnaires, and structured observations. The study revealed deficiencies in the quality of antenatal care being delivered at the study hospitals in all six elements of the quality-of-care framework. The technical content of visits varied greatly among the hospitals, and an overuse of technology was accompanied by neglect of some essential components of antenatal care. Although at the private hospital some problems with the technical content of care were identified, client satisfaction was higher there, where the care included good interpersonal relations, information provision, and continuity. Providers at all three hospitals felt constrained by heavy patient loads and a lack of resources. Multifaceted approaches are needed to improve the quality of antenatal care in this setting.

[Implementation of quality management in French hospitals: staff interplay and induced changes]

BACKGROUND

French hospitals have been encouraged to develop quality processes, in particular through the implementation of a mandatory accreditation. Our objectives were to study the models of quality management used in hospitals and to identify the induced changes in organisation and practices.

METHODS

This multiple case study related to 9 acute care hospitals selected among the hospitals whose quality process were relatively old. The study was based on interviews related to 78 people including 26 administrative staff members, 33 physicians and 19 chief nurses. Implementation analysis and strategic analysis were applied.

RESULTS

Accreditation played a major part in the institutionalisation of quality processes. Implementation appeared more complete in the small size and private statute hospitals compared to the large public statute hospitals. But the main factors accounting for implementation variability were the level of involvement of the executive directors and participation of doctors in the quality process' leadership. The most important changes were establishment of specific structures, appearance of new professions and elaboration of quality documentation. In the hospitals where the quality process was strongly implemented, there was a trend to the de-compartmentalization between the professions and between the structures and phenomena of employees'development and empowerment.

CONCLUSION

Institutionalisation of quality management is recent and the level of implementation varies greatly among hospitals. Involving doctors remains a major challenge for the development of quality management so that the quality can lead changes in hospital.

Qualidade da atenção ao parto em maternidades do Rio de Janeiro

OBJETIVO: Avaliar a qualidade da atenção durante o processo de trabalho de parto de acordo com normas da Organização Mundial de Saúde. MÉTODOS: Trata-se de estudo do tipo caso-controle, realizado em duas maternidades: pública e conveniada com o Sistema Único de Saúde, no Município do Rio de Janeiro. A amostra foi composta por 461 mulheres na maternidade pública (230 partos vaginais e 231 cesáreas) e por 448 mulheres na maternidade conveniada (224 partos vaginais e 224 cesáreas). De outubro de 1998 a março de 1999, foram realizadas entrevistas com puérperas e revisão de prontuários. Foi construído escore sumarizador da qualidade do atendimento. RESULTADOS: Observou-se baixa freqüência de algumas práticas que devem ser encorajadas, como presença de acompanhante (1% na maternidade conveniada, em ambos os tipos de parto), deambulação durante o trabalho de parto (9,6% das cesáreas na maternidade pública e 9,9% dos partos vaginais na conveniada) e aleitamento na sala de parto (6,9% das cesáreas na maternidade pública e 8,0% das cesáreas na conveniada). Práticas comprovadamente danosas e que devem ser eliminadas como uso de enema (38,4%), tricotomia, hidratação venosa de rotina (88,8%), uso rotineiro de ocitocina (64,4%), restrição ao leito durante o trabalho de parto (90,1%) e posição de litotomia (98,7%) para parto vaginal apresentaram alta freqüência. Os melhores resultados do escore sumarizador foram obtidos na maternidade pública. CONCLUSÕES: As duas maternidades apresentam freqüência elevada de intervenções durante a assistência ao parto. A maternidade pública, apesar de atender clientela com maior risco gestacional, apresenta perfil menos intervencionista que maternidade conveniada. Procedimentos realizados de maneira rotineira merecem ser discutidos à luz de evidências de seus benefícios.

Relationship between accreditation scores and the public disclosure of accreditation reports: a cross sectional study

OBJECTIVE

To examine the association between accreditation scores and the disclosure of accreditation reports.

DESIGN

A cross sectional study.

SETTING

Hospitals participating in an accreditation programme in Japan.

PARTICIPANTS

547 of the 817 hospitals accredited by the Japan Council for Quality Health Care (JCQHC) by January 2003.

MAIN OUTCOME MEASURES

Data on participation in public disclosure of accreditation reports through the JCQHC website were obtained from the JCQHC database. Comments on the disclosure were obtained using a questionnaire based survey.

RESULTS

A total of 508 (93%) of the participating hospitals disclosed their accreditation reports on the JCQHC website. Public hospitals were significantly more committed to public disclosure than private hospitals, and larger hospitals were significantly more likely to participate in public disclosure than smaller hospitals. Accreditation scores were positively related to the public disclosure of hospital accreditation reports. Scores for patient focused care and efforts to meet community needs were significantly higher in actively disclosing hospitals than in non-disclosing hospitals. Among the large hospitals, scores for safety management were significantly higher in hospitals advocating disclosure than in non-disclosing hospitals.

CONCLUSIONS

There was a positive correlation between accreditation scores and public disclosure. Our results suggest that the public disclosure of accreditation reports should be encouraged to improve public accountability and the quality of care. Future studies should investigate the interaction between public disclosure, processes and outcomes.

The Effect of Nursing Care on Overall Patient Satisfaction and Its Predictive Value on Return-to-provider Behavior

OBJECTIVES

To determine the extent of patient satisfaction with care provided at the hospital at all levels and to correlate patients' satisfaction with nursing care, in particular, with their overall satisfaction. Also, to assess the predictive value of patient satisfaction on subsequent return to the hospital.

DESIGN

A survey study of a random sample of 420 inpatients to determine the extent of their satisfaction with the overall care provided at the hospital.

SETTING

A 110-bed private hospital in Kuwait, January 1-March 31, 2004.

RESULTS

The extent of overall patient satisfaction with the quality of care provided at the hospital was found to be quite high (Excellent, 74.7%; Very good, 23.7%). Individually, nursing care received the maximum patient satisfaction ratings (Excellent, 91.9%; Very good, 3.9%). A positive correlation (r = 0.31, P = .01) was noted between patients' perception of nursing care and their overall satisfaction with the health care provided at the hospital. Significant positive correlation (r = 0.36, P = .01) was also found between overall patient satisfaction and their reported intentions of returning and recommending the hospital to others.

CONCLUSIONS

Patient satisfaction surveys can be of great value to health care providers not only in recognizing and improving the quality of care, but also as predictors of return-to-provider behavior of the patients. Overall patient satisfaction is linked with quality nursing care, which, in turn, depends on the quality of leadership practiced at the institution. Transformational leadership behavior promotes nurse satisfaction, which adds to their work effectiveness and motivates them to provide quality patient care.

Monitoring incident report in the healthcare process to improve quality in hospitals

Healthcare organizations are facing growing pressures to adopt intelligent technology to promote quality and safety care in public and private hospitals. In 2000, the Institute of Medicine report also indicated that an estimated 44,000 to 98,000 Americans die annually as a result of preventable medical errors and it appears that information management in hospitals can help the organization to improve the quality level. This paper aims to present an experience in the management of events not compliant with the best practice by monitoring these events in a hospital. We used ISO standard to implement general quality process and quality management. This project consists in proposing the possibility of declaring different dysfunctions and incidents by a simple form integrated into the intranet services of the hospital for the medical, nursing and administrative staff. This should lead to quality management of the medical units.