Challenges in sustaining excellence over time

A culture of excellence is not synonymous with a culture of perfection. Perfection is not attainable but excellence is when an infrastructure is developed that can rapidly and effectively adapt to change. Saint Joseph's Hospital in Atlanta, Georgia, is often asked about the challenges faced in developing, and sustaining, a culture of nursing excellence over time. Topics such as organizational hardiness, the emergence of a professional practice model, the development of a clinical nurse advancement program, and the implementation of the Forces of Magnetism and the Essentials of Magnetism will be discussed in relation to sustaining a culture of excellence.

[Comparative analysis of effectiveness of medical care service for patients with stroke in neurological and specialized departments for the treatment of patients with stroke]

A comparative analysis of effectiveness of medical care service for patients with stroke in neurological and a specialized departments for the treatment of patients with stroke has been carried out in the regional hospital. The specialized department had an intensive therapy block that made it possible to conduct twenty-four-hour monitoring of main parameters of vital functions and oxygenotherapy. Patients who were in need of artificial lung ventilation were placed to a department of general reanimation. In the end of the acute period, the level of disability significantly decreased in patients with ischemic stroke. The significant decrease of disability level was found in patients with ischemic as well as with hemorrhagic stroke after 3 months. The results suggest the higher effectiveness of therapy conducted in specialized departments.

Specialty and full-service hospitals: a comparative cost analysis

OBJECTIVE

To compare the costs of physician-owned cardiac, orthopedic, and surgical single specialty hospitals with those of full-service hospital competitors.

DATA SOURCES

The primary data sources are the Medicare Cost Reports for 1998-2004 and hospital inpatient discharge data for three of the states where single specialty hospitals are most prevalent, Texas, California, and Arizona. The latter were obtained from the Texas Department of State Health Services, the California Office of Statewide Health Planning and Development, and the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project. Additional data comes from the American Hospital Association Annual Survey Database.

STUDY DESIGN

We identified all physician-owned cardiac, orthopedic, and surgical specialty hospitals in these three states as well as all full-service acute care hospitals serving the same market areas, defined using Dartmouth Hospital Referral Regions. We estimated a hospital cost function using stochastic frontier regression analysis, and generated hospital specific inefficiency measures. Application of t-tests of significance compared the inefficiency measures of specialty hospitals with those of full-service hospitals to make general comparisons between these classes of hospitals.

PRINCIPAL FINDINGS

Results do not provide evidence that specialty hospitals are more efficient than the full-service hospitals with whom they compete. In particular, orthopedic and surgical specialty hospitals appear to have significantly higher levels of cost inefficiency. Cardiac hospitals, however, do not appear to be different from competitors in this respect.

CONCLUSIONS

Policymakers should not embrace the assumption that physician-owned specialty hospitals produce patient care more efficiently than their full-service hospital competitors.

Outcome related to impact on daily living: preliminary validation of the ORIDL instrument

Background

The challenge of finding practical, patient-rated outcome measures is a key issue in the evaluation of health care systems and interventions. The ORIDL (Outcome in Relation to Impact on Daily Living) instrument (formerly referred to as the Glasgow Homoeopathic Hospital Outcomes Scale or GHHOS) has been developed to measure patient's views of the outcome of their care by asking about change, and relating this to impact on daily life. The aim of the present paper is to describe the background and potential uses of the ORIDL, and to report on its preliminary validation in a series of three studies in secondary and primary care.

Methods

In the first study, 105 patients attending the Glasgow Homoeopathic Hospital (GHH) were followed-up at 12 months and changes in health status were measured by the EuroQol (EQOL) and the ORIDL. In the second study, 187 new patients at the GHH were followed-up at 3, 12, and 33 months, using the ORIDL, the Short Form 12 (SF-12), and the Measure Yourself Medical Outcome Profile (MYMOP). In study three, 323 patients in primary care were followed for 1 month post-consultation using the ORIDL and MYMOP. In all 3 studies the Patient Enablement Instrument (PEI) was also used as an outcome measure.

Results

Study 1 showed substantial improvements in main complaint and well-being over 12 months using the ORIDL, with two-thirds of patients reporting improvements in daily living. These improvements were not significantly correlated with changes in serial measures of the EQOL between baseline and 12 months, but were correlated with the EQOL transitions measure. Study 2 showed step-wise improvements in ORIDL scores between 3 and 33 months, which were only weakly associated with similar changes in SF-12 scores. However, MYMOP change scores correlated well with ORIDL scores at all time points. Study 3 showed similar high correlations between ORIDL scores and MYMOP scores. In all 3 studies, ORIDL scores were also significantly correlated with PEI-outcome scores.

Conclusion

There is significant agreement between patient outcomes assessed by the ORIDL and the EQOL transition scale, the MYMOP, and the PEI-outcome instrument, suggesting that the ORIDL may be a valid and sensitive tool for measuring change in relation to impact on life.

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.

A two‐level EFQM self‐assessment in an Italian hospital

PURPOSE

An assessment of the EFQM excellence model was carried out in Italy's Udine Hospital, aimed at evaluating how first and second-level managers perceived their hospital and individual departments. The study objectives also included identifying strengths and areas requiring improvement and stimulating a quality culture.

DESIGN/METHODOLOGY/APPROACH

Udine's S. Maria della Misericordia Hospital is a large specialised unit in North East Italy and similar to many regional hospitals throughout the country. The survey is a single case study of the hospital and its ten clinical departments. A 153-item questionnaire was completed by 201 experienced respondents.

FINDINGS

Leadership, policy and strategy, partnership and resources were rated highly, whereas people, society and customer results received lower ratings. Several improvement actions were planned, primarily with regard to the results criteria.

PRACTICAL IMPLICATIONS

A two-level self-assessment was successfully carried out in a hospital, giving insight into the organisation's strengths and areas requiring improvement. Through the study, a systemic approach was introduced and quality awareness was heightened.

ORIGINALITY/VALUE

The findings are useful for other hospitals conducting EFQM self-assessment.

[Structural quality of rheumatology clinics for children and adolescents. Paper by a task force of the "Society of Pediatric and Adolescent Rheumatology" and of the "Association of Rheumatology Clinics in Germany"]

Rheumatic diseases in childhood and adolescence differ from those of adulthood according to type, manifestation, treatment and course. A specialized therapy, starting as early as possible, improves the prognosis, can prevent long-term damage and saves the costs of long-term care. Only a specialized pediatric care system can guarantee optimum quality of the processes involved and the results for rheumatology in childhood and adolescence within a global financial system. This requires adequate structural quality of the specialized clinics and departments for pediatric rheumatology. The management of rheumatic diseases in childhood and adolescence is comprehensive and requires a multidisciplinary, specialized and engaged team which can cover the whole spectrum of rheumatic diseases with their various age-dependent aspects. In order to guarantee an adequate, cost-efficient routine, a specialized center which concentrates on inpatient care should treat at least 300 patients with pediatric rheumatic diseases per year. The diagnoses should be divided among the various disease categories with at least 70% of them involving inflammatory rheumatic diseases. For the inpatient care of small children, an accompanying person (parent) is necessary, requiring adequate structures and services. Patient rooms as well as diagnostic (radiography, sonography, etc.) and therapeutic services (physiotherapy, occupational therapy, pool, etc.) must be adequate for small children and school children as well as adolescents. Suitable mother-child units must also be provided and a school for patients is required within the clinic. A pediatric rheumatologist must be available 24 h a day, and it must be possible to reach other specialists within a short time. For painful therapeutic procedures, age-appropriate pain management is obligatory. A continuous adjustment of these recommendations to changing conditions in health politics is intended.

The Effect of Medicare's Prospective Payment System on Patient Satisfaction

OBJECTIVE

To examine the impact of Medicare's Prospective Payment System (PPS) on patient satisfaction at four inpatient rehabilitation hospitals.

DESIGN

Prospective study using a satisfaction survey to examine the effects of Medicare's PPS for rehabilitation hospitals. Surveys were conducted at four affiliated rehabilitation hospitals in the Midwest.

RESULTS

Patient characteristics varied only slightly pre- to post-PPS, and several characteristics were related to overall satisfaction, including motor functional gain, discharge to home, and respondent (patient or proxy). A 12-point increase on a 12-item motor function scale resulted in 1.13 greater odds (95% CI: 1.04, 1.24) of reporting excellent satisfaction. Patient respondents were 1.27 times more likely (95% CI: 1.07, 1.50) than proxies to report excellent satisfaction, and patients discharged home were 1.65 times more likely (95% CI: 1.31, 2.07) to report excellent satisfaction than patients discharged elsewhere. We found an increase in observed satisfaction from 60.3 to 63.4% (P < 0.05) after PPS implementation, despite a decrease in motor FIM gain.

CONCLUSIONS

Patient characteristics such as motor FIM gain, discharge status, and respondent type were significantly associated, although only slightly, with patient satisfaction in inpatient rehabilitation. Percentage of excellent satisfaction improved at these four facilities after PPS implementation, despite declines in motor FIM gain. The improvement may be the result of numerous ongoing quality-improvement initiatives directed at improving patient satisfaction at these facilities.

Surgeon information transfer and communication: factors affecting quality and efficiency of inpatient care

OBJECTIVE

To determine the nature of surgeon information transfer and communication (ITC) errors that lead to adverse events and near misses. To recommend strategies for minimizing or preventing these errors.

SUMMARY BACKGROUND DATA

Surgical hospital practice is changing from a single provider to a team-based approach. This has put a premium on effective ITC. The Information Transfer and Communication Practices (ITCP) Project is a multi-institutional effort to: 1) better understand surgeon ITCP and their patient care consequences, 2) determine what has been done to improve ITCP in other professions, and 3) recommend ways to improve these practices among surgeons.

METHODS

Separate, semi-structured focus group sessions were conducted with surgical residents (n = 59), general surgery attending physicians (n = 36), and surgical nurses (n = 42) at 5 medical centers. Case descriptions and general comments were classified by the nature of ITC lapses and their effects on patients and medical care. Information learned was combined with a review of ITC strategies in other professions to develop principles and guidelines for re-engineering surgeon ITCP.

RESULTS

: A total of 328 case descriptions and general comments were obtained and classified. Incidents fell into 4 areas: blurred boundaries of responsibility (87 reports), decreased surgeon familiarity with patients (123 reports), diversion of surgeon attention (31 reports), and distorted or inhibited communication (67 reports). Results were subdivided into 30 contributing factors (eg, shift change, location change, number of providers). Consequences of ITC lapses included delays in patient care (77% of cases), wasted surgeon/staff time (48%), and serious adverse patient consequences (31%). Twelve principles and 5 institutional habit changes are recommended to guide ITCP re-engineering.

CONCLUSIONS

Surgeon communication lapses are significant contributors to adverse patient consequences, and provider inefficiency. Re-engineering ITCP will require significant cultural changes.

[Implementation of a vascular center using preexistent structures]

Whenever the internal reorganization of hospitals demands the implementation of interdisciplinary healthcare concepts in terms of interdisciplinary competence centers, the structural conflicts caused by subordination of autonomous structural units into centralized functional entities will have to be considered and solved. The Dresden University Vascular Center is an example of an interdisciplinary medical center based on a statute setting up binding rules of standing cooperation. In this case, the positive effects of concentration have been utilized, while leaving all structural units involved autonomous. This requires strict separation and transparent allocation of responsibilities and continuous and committed efforts on management and operating levels as described in the statute. Of course, this kind of close collaboration cannot be prescribed but requires permanent commitment to the general objectives as laid down in the statute and their acceptance as personal work goals.

Employing clinical decision support to attain our strategic goal: the safe care of the surgical patient

Clinical decision support can be employed to increase patient safety and improve workflow efficiencies for physicians and other healthcare providers. Physician input into the design and deployment of clinical decision support systems can increase the utility of the alerts and reduce the likelihood of "alert fatigue." The Hospital for Special Surgery is a 146-bed orthopedic facility that performs approximately 18,000 surgeries a year Efficient work processes are a necessity. The facility began implementing a new electronic health record system in June 2005 and plan to go live in summer 2007. This article reports on some of the clinical decision support rules and alerts being incorporated into the facility's system in the following categories--high-risk, high-frequency scenarios, rules that provide efficiencies and value from the presciber perspective, and rules that relate to patient safety.