Quality Assurance in the EORTC Randomized Trial 22922/10925 Investigating the Role of Irradiation of the Internal Mammary and Medial Supraclavicular Lymph Node Chain Works

BACKGROUND AND PURPOSE

A quality assurance (QA) program in conjunction with the EORTC trial investigating the role of adjuvant internal mammary and medial supraclavicular irradiation in stage I-III breast cancer is presented. The results of a dummy run procedure and of an individual case review are compared to each other. The effects of recommendations based on QA procedures on the protocol compliance are evaluated.

MATERIAL AND METHODS

Prior to protocol activation all participating institutes were asked to produce treatment plans according to the guidelines of the protocol based on manual outlines of an average patient. Thereafter, they were asked to provide data on each of their first six randomized patients.

RESULTS

The dummy run provided a lot of information on specific treatment techniques. In the individual case review, additional patient- and tumor-related data were collected, showing the use of anatomic information for treatment planning. A comparison between both procedures revealed that the individual case reports concurred more accurately with protocol guidelines than the dummy run.

CONCLUSION

It was observed that the number of systematic protocol deviations was substantially decreased in trial patients compared to the dummy run case. Therefore, it is concluded that this extensive QA program had a positive effect on the consistency of all institutes participating in the trial.

Bronson Methodist Hospital: Journey to Excellence in Quality and Safety

BACKGROUND

Bronson Healthcare Group, a 343-bed not-for-profit health care system serving all of southwest Michigan and northern Indiana, has as its flagship Bronson Methodist Hospital, the recipient of the 2005 Malcolm Baldrige National Quality Award.

OVERALL APPROACH TO QUALITY AND SAFETY

The Baldrige criteria were used to formalize Bronson's approach to performance excellence. The strategic plan is condensed and communicated via a "Plan for Excellence" focused on three strategies: clinical excellence, customer and service excellence, and corporate effectiveness.

ADDRESSING THE INSTITUTE OF MEDICINE (IOM) QUALITY AIMS

Initiatives include clinical scene investigation (a system for reporting and investigating sentinel and atypical events), a strategy for educating staff in the Situation-Background-Assessment-Recommendations (SBAR) communication technique, and mandatory influenza immunization for health care staff (safety), patient health literacy needs and a health information center (patient centeredness); methods to reduce bloodstream and ventilator-acquired pneumonia infections (effectiveness); a physician portal for access to forms, test results, and patient information (efficiency); restaurant-style pagers for patients and families while waiting (timeliness); and community outreach (equity).

CHALLENGES AND LESSONS LEARNED

Bronson's journey to excellence continues with more accountability for hand-off communication and teamwork, enhancing a non-punitive environment for patient safety reporting, and further incorporating patient and family involvement.

Quality of delivery of the Standard Days Method as compared with contraceptive pills in Rwanda

BACKGROUND AND METHODOLOGY

Replicating a Peruvian study, this research introduced the Standard Days Method (SDM) into Rwanda Ministry of Health clinics and evaluated client counselling on the new method against that given for contraceptive pills. Providers received technical reinforcement concerning established methods in addition to SDM training. To evaluate their quality of care, simulated clients implemented a service test in visits to 20 clinics.

RESULTS

As in Peru, providers exchanged significantly more relevant information with clients who chose SDM than with those who chose pills. Also, a minority of providers posed barriers to SDM access by refusing to give SDM tools to the client until she brought her partner for consultation.

CONCLUSIONS

The findings of this study confirm that SDM counselling is generally satisfactory, although SDM training needs adjustment, and that the rigour of providers' pill counselling remains below capacity.

Impact of heart disease and quality of care on minority populations in the United States

Heart disease is a leading cause of death across all populations in the United States. In 1985, the Secretary's Task Force on Black and Minority Health recognized the existence of widespread health disparities for heart disease and related risk factors among minorities in America. Inequalities in heart health and healthcare continue to exist. This review compares measures of heart disease and healthcare for white, African-American, Asian/Pacific Islander, American-Indian/Alaska-Native and Hispanic/Latino populations. Lack of healthcare data for minorities continues to be a barrier to understanding the nature and extent of heart disease and related risk factors for these groups. In combination with programs that address preventive measures to reduce risk factors for heart disease, the integration of quality improvement measures has developed as an important strategy for reducing cardiovascular health disparities. Improved data collection and reporting, enhanced use of information technology, and promotion of cultural competency hold potential for improving the quality of cardiac care and reducing health disease for all Americans.

The public hospital mission at Seattle's Harborview Medical Center: high-quality care for the underserved and excellence in medical education

United States public hospitals and medical schools commonly enter into partnerships that serve the patient care, education, and research missions of both institutions. Harborview Medical Center, the county hospital in Seattle, Washington, and the University of Washington School of Medicine (UWSOM) have enjoyed a long affiliation that began at the medical school's founding 60 years ago. A formal agreement in 1967 turned over responsibility for all Harborview operations to UWSOM at a time when Harborview's facilities had fallen into serious disrepair and public hospitals were closing across the United States. All faculty and staff based at Harborview are employed by the University of Washington. By the mid-1970s a revitalization was underway at Harborview. The Medic One paramedic program drew national acclaim for pioneering prehospital emergency cardiac care, and the trauma and burn centers grew rapidly to meet specialized intensive care needs of the Pacific Northwest. Today, the success of the trauma, specialty surgery, and rehabilitation services have allowed Harborview to consistently maintain a positive operating margin while caring for the county's uninsured and indigent patients ($98 million in charity care in 2005). The hospital also offers nationally recognized residency programs and supports nationally and internationally acclaimed research. Harborview faces significant challenges for the future, including rapid growth of the indigent patient load, continually changing expectations for physician training, and growing cost pressures.

Implementation of a national metrology network of radionuclides used in nuclear medicine

The Nuclear Medicine Services (NMS) in Brazil routinely use dose calibrators to measure the activity of solutions containing radiopharmaceuticals. These solutions are administered to patients with the intention to diagnose or treat illnesses. However, for optimal results, the activity of these radiopharmaceuticals must be determined as accurately as possible. The National Laboratory for Ionizing Radiation Metrology (LNMRI) led, since 1998, a comparison program for activity measurements of radiopharmaceuticals administered to patients in the NMS with the purpose promoting quality control. This program has been carried out successfully in Rio de Janeiro, but there is a need to implement it around the country. This can be resolved through the implementation of a network of regional laboratories at various locations throughout the national territory. Currently, such a network is active at a second site, located in Brasília, covering the needs of the Center-West Region, and at a third site, located in Porto Alegre, in the South Region. This work presents the results of comparisons for the radiopharmaceuticals nuclides 131I and 99Tcm and proves that the implementation of a radionuclide metrology network is feasible and viable.

Therapieallergene zur spezifischen Immuntherapie

The marketing authorization of allergen preparations for specific immunotherapy (SIT) for subcutaneous injection (SCIT) and sublingual immunotherapy (SLIT) at the Paul-Ehrlich-Institut (PEI) insures that the quality, safety, and efficacy of these medicinal products is proven. As finished products, these medicinal products are subject to official batch control tests, which provide evidence that only those products are marketed which conform to the specifications laid down in the marketing authorization procedure. Products for SIT prepared for a patient on the basis of the physician's prescription - so-called named patient products - cannot be subjected to a marketing authorization review. Therefore, they are not subject to the pharmaco-surveillance by the PEI regarding quality, safety and efficacy. This article describes the different marketing authorization procedures in the European Union (EU) and addresses the problems related to the marketing authorization requirements.

AQA, HQA collaborate on national quality strategy

Coordinating measurement activities will give patients and providers a better look at quality across the entire continuum of care. Organizations say collaboration will make quality measurement more accurate and more efficient. Newly launched AQA pilot programs will benefit from formation of steering committee.

ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 Appropriateness Criteria for Cardiac Computed Tomography and Cardiac Magnetic Resonance Imaging

Under the auspices of the American College of Cardiology Foundation (ACCF) together with key specialty and subspecialty societies, appropriateness reviews were conducted for 2 relatively new clinical cardiac imaging modalities, cardiac computed tomography (CCT) and cardiac magnetic resonance (CMR) imaging. The reviews assessed the risks and benefits of the imaging tests for several indications or clinical scenarios and scored them based on a scale of 1 to 9, where the upper range (7 to 9) implies that the test is generally acceptable and is a reasonable approach, and the lower range (1 to 3) implies that the test is generally not acceptable and is not a reasonable approach. The mid-range (4 to 6) indicates an uncertain clinical scenario. The indications for these reviews were drawn from common applications or anticipated uses, as few clinical practice guidelines currently exist for these techniques. These indications were reviewed by an independent group of clinicians and modified by the Working Group, and then panelists rated the indications based on the ACCF Methodology for Evaluating the Appropriateness of Cardiovascular Imaging, which blends scientific evidence and practice experience. A modified Delphi technique was used to obtain first and second round ratings of clinical indications after the panelists were provided with a set of literature reviews, evidence tables, and seminal references. The final ratings were evenly distributed among the 3 categories of appropriateness for both CCT and CMR. Use of tests for structure and function and for diagnosis in symptomatic, intermediate coronary artery disease (CAD) risk patients was deemed appropriate, while repeat testing and general screening uses were viewed less favorably. It is anticipated that these results will have a significant impact on physician decision making and performance, reimbursement policy, and future research directions.

Development and Implementation of Evidence-Based Indicators for Measuring Quality of Acute Stroke Care

Background and Purpose— There is no consensus about indicators for measuring quality of acute stroke care in Germany. Therefore, a standardized process was initiated recently to develop and implement evidence-based indicators for the measurement of quality of acute hospital stroke care.

Methods— Quality indicators were developed by a multidisciplinary board between November 2003 and December 2005. The process was initiated by the German Stroke Registers Study Group in cooperation with the German Stroke Society, the German Society of Neurology, the German Stroke Foundation, Regional Offices for Quality Assurance and other experts proven in the field. National and international recommendations were considered during the development process. The process was based on a systematic literature review, an independent external evaluation of the process and its results, and a prospective pilot study to evaluate the defined indicators in clinical practice.

Results— Overall a set of 24 indicators was developed to measure performance of acute care hospitals in the 3 health care dimensions structure, process and outcome as well as in 3 treatment phases prehospital, in-hospital/acute and postacute. Practicability of the derived indicators was tested in a prospective pilot study. During a 2-month period, 1006 patients in 13 hospitals were documented. Application of the new indicator set was found to be feasible by participating physicians and hospitals. Median time to document the required information for 1 patient was 5 minutes. Nationwide implementation of the new indicator set within regional registers in Germany started since April 2006.

Conclusions— The development of indicators to measure hospital performance in stroke care is an important step toward improving stroke care on a national level. The chosen standardized evidence-based approach ensures maximal transparency, acceptance and sustainability of the developed indicators in Germany.

Quality of patient referral information for open-access endoscopic procedures

BACKGROUND

Increased demand for endoscopic procedures has led to the provision of these services without prior consultation (open access). The need for accurate medical referral information for these patients is vital for patient safety.

OBJECTIVE

To assess the accuracy of endoscopic referral information.

DESIGN

Over a 4-month study period, patient referral forms were evaluated to determine the accuracy of medical information on patient referral forms by using direct interview with the patient and/or the caregiver. Inconsistencies were validated against medical records.

SETTING

Large academic medical clinic.

PATIENTS

A total of 868 open-access patient referrals for upper endoscopy and colonoscopy services.

MAIN OUTCOME MEASUREMENTS

Referral information about medical diagnoses, medications, allergies, need for antibiotic administration, and current coagulopathies.

RESULTS

Inaccurate medical referral information was provided to the endoscopist in 8.8% of referrals (n = 76). Among referrals containing errors, there were a total of 95 significant medical information errors, which, if left undetected by preprocedure review, could have resulted in serious adverse consequences for patients undergoing endoscopy.

LIMITATIONS

Study limited to an academic clinical setting.

CONCLUSIONS

Patient referrals for endoscopic services in an open-access referral system contain unacceptably high numbers of errors, which place patients at risk for adverse outcomes from endoscopic procedures.

Cincinnati Children’s Hospital Medical Center: Transforming Care for Children and Families

BACKGROUND

Cincinnati Children's Hospital Medical Center pursues its vision to be the leader in improving child health through the creation of new knowledge, education of professionals and the community, and transformation of our health care delivery system.

OVERALL APPROACH TO QUALITY AND SAFETY

The strategic plan focuses on achieving the best medical and quality of life outcomes, patient and family experience of care, and value through horizontal integration of research and delivery system design, thereby accelerating the transfer of new knowledge to the bedside.

CREATING QUALITY FROM THE FAMILY PERSPECTIVE

Family members and patients participate at all levels of the organization, from the organizationwide family advisory council, to unit-based inpatient teams, to serving as family faculty who teach pediatric residents and orient new employees. Family members ensure that children's and parents' voices are heard.

DISCUSSION

Key factors contributing to ongoing transformation include senior leaders' drive for change, focus on perfection or near-perfection goals, vertical alignment in measures, accountability, improvement capability, commitment to internal and external transparency, and focus on measurement and constancy of purpose.

The use of histology in 638 coronial post-mortem examinations of adults: an audit

An audit was performed to determine the effectiveness of histological sampling of forensic post-mortem cases based on a review of three years' data, which comprised 638 adult autopsy cases. During the study period organs and tissues that appeared macroscopically normal and abnormal were extensively sampled. Histology was regarded as in some way contributory (providing, altering or confirming a cause of death) 53% of the time. The use of histology provided the cause of death in 49 (24%) of the 203 cases not given a cause of death after the completion of the macroscopic examination. When an interim cause of death had been supplied following the completion of the gross examination it was changed in 4.8% of cases, but there were no changes of the manner of death. The majority of the histological diagnoses or discrepancies involved the lungs and the heart. All diagnoses relevant to determining the cause of death would have been made if samples had been taken only from the left ventricle, right ventricle, coronary arteries, lungs, kidneys and brain with any tissue or organ that appeared abnormal macroscopically. A macroscopically identified abnormality that appeared to have been responsible for death was not sampled in 20 cases; consequently, more attention will be paid to sampling macroscopically abnormal tissues. As a result of this audit histology sampling practice has been revised and will be re-audited in the future.

[Mortality analysis as a tool for quality improvement in a general surgery service]

OBJECTIVES

The present study aims to propose a method to improve healthcare quality based on systematic analysis of mortality and mortality-related adverse effects.

PATIENTS AND METHODS

We analyzed all deaths in the surgery service between January, 1997 and December, 2003. There were 10,905 hospital admissions and 194 deaths. The mean number of deaths per year was 28 (range 24-36). The mean number of deaths/discharges per year was 1.77 (SD 0.2; range 1.5-2.13). The overall mean age was 80.5 years (SD 9.5; range 47-100). By sex there were 104 women (53.6%) and 90 men (46.6%). During the study period 9,437 patients underwent surgery. We defined the concept of death secondary to a hospital problem (DSHP): this easily objectified concept includes any hospital problem occurring from admission to death associated directly or indirectly with death, or simply precipitating a foreseeable death.

RESULTS

We detected 33 DSHP. Of all deaths, 17% were DSHP. In these DSHP, 37 problems were detected (some deaths involved more than one problem). The most frequent types of problem were three nosocomial infections, 19 problems secondary to therapeutic or diagnostic techniques, seven insufficient evaluations or treatment omissions or delays, and eight harmful incidents. No deaths occurred because of organizational or structural problems. The number of DSHP in relation to discharges was 0.3%.

CONCLUSIONS

We present a system of continuous self-evaluation, in which problems are recognized and a constructive attitude is adopted. The model can be extrapolated to other hospitals but the results must be evaluated in the specific context of each hospital. Nevertheless, the results can be used for monitoring within a single center over a period of years.

[The evaluation of health care outcomes and hospital performance indicators]

INTRODUCTION

The assessment of the performance of health care establishments has undergone a considerable development over the past 15 years in the United States and to a lesser extent in other developed countries.

BACKGROUND

The aim of measurement of performance indicators is to improve the quality of care (outcomes), patient information and the contractual arrangements with purchasers. However, this approach poses numerous methodological problems in the choice of performance indicators as well as the collection and interpretation of data. Specific structural patterns such as social and geographic environment, research and educational assignments, are often inadequately considered. In terms of public health the impact of the publication of these measurements has not been well studied. Based on the data in the literature this revue defines the measures of hospital performance and describes the main studies, their impacts and limitations.

VIEWPOINT

It seems likely that the French public authorities will, in the short term, ask health care establishments to undertake this approach.

CONCLUSIONS

Complimentary studies are needed to clarify the links between performance indicators and health care outcomes.