The Commission on Cancer, American College of Surgeons' response to HIPAA

The Commission on Cancer is able to continue serving the CoC-Approved Cancer Programs following enactment of a business associate agreement between each of the programs and the ACoS. Worrisome unintended consequences, potentially threatening the value of the products that the CoC provides cancer patients, providers, and families, were not realized because of the Business Associate role that the CoC assumes with each of the CoC-Approved programs.

[Evaluation of clinical laboratories--assurance of their quality and competence]

Since ISO 15189:2003 was published, the accreditation program of clinical laboratories based on ISO 15189 has been introduced in many countries, except for those in USA where all clinical laboratories must be required to follow the federal law, CLIA'88. It will certainly help the accredited clinical laboratories improve their quality and competence. In relation to the activity of JCTLM, reference measurement laboratories will be accredited, based on ISO 15195 which is now under its review and amendment by ISO/TC212/WG2. In Japan, JCCLS (Japanese Committee for Clinical Laboratory Standards) and JAB (Japan Accreditation Board for Conformity Assessment) cojointly started the accreditation program for clinical laboratories, based on ISO 15189:2003, and a total of 15 laboratories including university hospitals, community hospitals and independent clinical laboratories have been accredited up until the end of 2006.

Clinical indicators: development and applications

Clinical indicators give an indication of the quality of the patient care delivered. They must comply with highquality standards and should be constructed in a careful and transparent manner. Indicators must be relevant to the important aspects of quality of care. There should be adequate research evidence that the recommendations from which they are derived are related to clinical effectiveness, safety and efficiency. They should measure the quality in a valid and reliable manner with little inter- and intra-observer variability so that they are suitable for comparisons between professionals, practices, and institutions. Indicators are selected from research data with consideration for optimal patient care (preferably an evidence-based guideline), supplemented by expert opinion. In the selection procedure, the feasibility, such as their measurability and improvability, is important beside validity and reliability. A clinical indicator should be defined exactly and expressed as a quotient. After a try-out, the measurements and reporting should follow. The report contains an in-depth analysis of causal and contributing factors associated with the measured results. A description of the clinical circumstances and a correction for case mix should be included to allow for a justified interpretation. The indicators must be part of an improvement strategy, for which comparison feedback is often used. We give examples of indicator development and applications in oncology, diabetes care, and the use of antibiotics for treating pneumonia. We explain how comparison with reference data can be used to construct improvement programmes.

Neurologists for patient safety: Where we stand, time to deliver

Neurologists have a professional opportunity, an ethical responsibility, and sound clinical and economic reasons for engaging in efforts to improve patient safety. Better communication with patients and other providers, closer follow-up of consultation cases, and more focused supervision of trainees will help to reduce current patterns of error and misunderstanding. Patient education with attention to health literacy should improve adherence to management plans and help to bridge transitions of care across providers and sites. Through teaching and by example, neurologists can profoundly influence successive generations of clinicians to adopt safer practices, a culture of openness, and enhanced professionalism. The federal Safety and Quality Improvement Act of 2005, once implemented, should increase the evidence basis for safer care through voluntary, legally protected reporting of errors and adverse events within the framework of patient safety organizations.

Development of dosimetry using detectors of diagnostic digital radiography systems

Dosimetry using an imaging plate (IP) of computed radiography (CR) systems was developed for quality control of output of the x-ray equipment. Sensitivity index, or the S number, of the CR systems was used for estimating exposure dose under the routine condition: exposure dose from 1.0 to 1.0 x 10(2) microC kg(-1), tube voltages from 50 to 120 kV, and added filtration from 0 to 4.0 mm Al. The IP was calibrated by using a 6 cc ionization chamber having traceability to the National Standard Ionization Chamber. The uncertainty concerning the fading effect was suppressed less than 1.9% by reading the latent image 4 min+/-5 s after irradiation at the room temperature 25.9+/-1.0 degrees C. The S number decreased linearly on the logarithmic graph regardless of the beam quality as exposure dose increased. The relationship between the exposure dose (E) and the S number was fitted by the equation E=a' X S(-b). The coefficient a' decreased when the added filtration and the tube voltage were increased. The coefficient b was 0.977+/-0.007 in all beam qualities. The dosimetry using the IP and the equation can estimate the exposure dose in a range from 9.0 x 10(-2) to 5.0 microC kg(-1) within an uncertainty of +/-5% required by the Japanese Industry Standard. This dose range partially included the doses under routine condition. The doses between 1.0 and 1.0 x 10(2) microC kg(-1) under the routine condition can be shifted to the 5% region by using an absorber. The IP dosimetry is applicable to the quality control of the CR systems.

The role of post-implant dosimetry in the quality assessment of prostate implants. The RAH experience

The quality of a prostate implant using radioactive I-125 seeds can be assessed by performing post-implant dosimetry, which therefore has to be a reliable evaluation tool. At the RAH, we have noticed large variations in post-implant dosimetric parameters compared to the pre-implant data. The purpose of this study was to investigate the cause of these differences. Post-implant dosimetry was performed 4 weeks after implant on 15 prostate cancer patients. The CT images of the pelvis were exported to the planning system, where contouring of the target (prostate) was executed by 6 clinicians, followed by the post-implant dosimetry performed by a physicist. Pre- and post-implant dosimetric parameters were analyzed and compared. The average target volume based on the ultrasound measurements was 35.8 cc. Post-implant CT volumes were determined and averaged over the 15 patients by each clinician, and their average values vary from 28.9 cc to 67.9 cc. Beside the under/overestimation of the target on the CT there was also a "shift" in the target base on the ultrasound image. By comparing pre-implant and post-implant dosimetric parameters we have encountered a significant discrepancy between target volumes based on ultrasound image and CT image. It was concluded that the accuracy of target coverage was partially connected to the poorer quality of the CT image compared to the ultrasound scan, patient's anatomy, but mostly to the poor implantation of the base.

The 8 dimensions of quality

Healthcare providers can better develop strategies for achieving and maintaining high-quality care by reviewing quality of care laws and metrics in relation to eight dimensions of quality: Reporting. Documentation. Quantity or access to care. Patient satisfaction. Provider reputation. Clinical processes. Utilization review. Medical necessity determinations.

Interobserver and intraobserver variation in day 3 embryo grading

OBJECTIVE

Variations in pregnancy rates (PR) between IVF programs are due to multiple factors, including embryo quality. Standardized embryo grading systems have been developed to improve communication between embryologists and clinicians. However, these grading systems have not been validated. We sought to quantify both interobserver and intraobserver variability using a standardized day 3 embryo grading system (Veeck scale).

DESIGN

Prospective, sample-randomized, controlled, blinded study.

SETTING

University hospital.

PATIENT(S)

Twenty-six practicing embryologists.

INTERVENTION(S)

Observation and grading of 35 video clips of day 3 embryos.

MAIN OUTCOME MEASURE(S)

Interobserver and intraobserver variability. Embryologists were also assessed by education level, years of experience, size of IVF program, and type of grading system used. Kappa scores and intraclass correlation coefficients were calculated.

RESULT(S)

Practicing embryologists differed from control (Lucinda Veeck) by as much as two grades, despite using the same grading system (Kappa = 0.24, interclass correlation coefficient = 0.98). There was also variability in grading the same embryo (Kappa = 0.69, interclass correlation coefficient = 0.88). Programs with higher cycle numbers per year had lower variability.

CONCLUSION(S)

There is substantial interobserver variability and moderate intraobserver variability among embryologists. Such variability could alter both the expected quality of embryos transferred, as well as the number transferred, both of which directly impact IVF program success.

[How does executive staff of home care nursing services estimate the situation of palliative care?]

Experts criticise heavily the current situation of palliative care in the home care setting in Germany. They claim that the education in palliative care of all involved professional groups should be improved and specialized services should be adjusted. Only few is known in this context about the perspectives and attitudes of nursing staff, who is significantly involved in palliative care. Therefore, interviews with executive stuff of home care nursing services in the Federal State of Brandenburg were performed in the context of an evaluative opinion survey. 88 of 100 planned interviews took place. The nursing services estimated the current situation predominantly good. This does not support the experts' opinions found in the literature. Nevertheless, the respondents saw serious needs for improvements, in particular concerning psycho-social issues. Although palliative patients numerically seem to be in the background of every day work life, great interest in further qualification and new concepts of care was shown. So far, only few home care nursing services employ palliative care-trained staff.

[Evidence based guidelines and clinical pathways: complementation or contradiction?]

Even methodological sound guidelines will only achieve their goals when the recommendations are transferred into practice. Guideline introduction and dissemination must therefore be accompanied by active implementation measures. For inpatient care clinical pathways can serve as tools, especially taking advantage of their sequential character. Complementary evidence based guidelines can serve as an optimal source of systematically appraised evidence in developing clinical pathways. Considering them is of major help to assure that the content of clinical pathways is in accordance with evidence. The article highlights methodological requirements in guideline and pathway development and gives prospects on how both tools can be used together.

The safety of bronchoscopy in a pulmonary fellowship program

STUDY OBJECTIVE

To determine the complication rate from supervised training bronchoscopy in a single pulmonary fellowship program, and to examine the effects of fellow and faculty experience on this complication rate.

DESIGN

A retrospective review of preexisting quality improvement data from one center for the time period July 1, 1991, until June 30, 2005, was performed. The data were stratified based on the fellow year group and the staff experience level. The types of complications were recorded.

SETTING

The study was performed at an accredited pulmonary and critical care fellowship program at a military medical center in the United States.

PARTICIPANTS

Fifty-one pulmonary and critical care medicine fellows and 20 staff supervising physicians performed the bronchoscopies that were included in this study.

RESULTS

A total of 3,538 training bronchoscopies were performed during the study period with 73 complications for a complication rate of 2.06%. The most common complication was pneumothorax. The overall complication rates for first-year fellows (1stYFs), second-year fellows, and third-year fellows were not significantly different from the total complication rate. Training bronchoscopies supervised by junior staff had a complication rate not significantly different from that of senior staff. The cumulative complication rate for the first trimester for 1stYFs was 3.1%, whereas the cumulative complication rate for the second plus the third trimester for 1stYFs was 1.57% (p < 0.05).

CONCLUSIONS

Training bronchoscopy performed during a pulmonary fellowship is a safe procedure in a supervised setting. Patients undergoing bronchoscopy performed by novice bronchoscopists have an increased complication rate during the first trimester of bronchoscopist training.

[Incidence of coercive measures as an indicator of quality in psychiatric hospitals. Problems of data recording and processing, preliminary results of a benchmarking study]

OBJECTIVE

The clinical practice concerning the use of coercive measures in psychiatry should be compared.

METHOD

A common documentation of physical restraint, seclusion, and medication by coercion was introduced among 10 hospitals.

RESULTS

8.4 % of cases treated within the first 6 months of 2004 were exposed to coercive measures with the highest percentage among patients with psychoorganic disorders (32.1 %). The incidence of coercive measures varied highly between different diagnostic groups and hospitals.

DISCUSSION

The processing of the large multi-site data sets yields considerable technical problems. Data interpretation should consider confounding factors such as case mix and hospital structure characteristics.