The trials, tribulations and achievements of implementing quality management

Quality initiatives in the 1960s included Mortality and Morbidity Studies. In the 1970s Retrospective Audit was developed. In the 1980s Quality Assurance was the favoured option and was strongly promoted by The Australian Council on Healthcare Standards. In the 1990s the trend established across business and industrial organizations has been towards Quality Management. Health care services today are taking up this challenge and embarking on a new Quality journey. The importance of Quality Leadership in preventing frustration, rework and demotivation for individual participants of the organization should not be underestimated in implementing this Quality process.

Carrot and stick: state mechanisms to influence private provider behavior

The behavior of private sector health care providers will depend critically on the environment within which they operate. A bewildering array of possible regulatory and incentive setting structures exist. Most developing countries have the basic legislation for regulation, but there are frequently difficulties in enforcing such controls. While process aspects of quality of care regulation are often the responsibility of professional organizations, these organizations may have limited incentives to be active in ensuring high quality medical car.e There has been less experience with the use of incentives to encourage appropriate behavior amongst private providers: this appears a promising area for further work. Above all, adequate information is essential both for the enforcement of regulations and the application of incentive mechanisms.

Patient satisfaction in VA medical centers and private sector hospitals: a comparison

For the first time, we have data that can validly compare the satisfaction level of inpatients in Department of Veterans Affairs (VA) medical centers and private sector hospitals. It shows the satisfaction levels to be very similar. Since the VA will soon be changing its survey, this has been a very short time window. It may never recur. In addition to the general finding, there are some interesting comparisons regarding specific questions. For example, satisfaction with VA physicians, who are salaried and assigned to patients, is just as high as satisfaction with private physicians who are paid by fee and selected by the patient. This would seem to be critical information in the debate over U.S. health care reform.

[Suicide in Sanremo during the period of 1975-1990]

The aim of this study is to consider the quantity features and variations in time of suicide in Sanremo during the period 1975-1990. The authors have carefully analyzed the source of their data, reading through the Coroner's registers and excluding all those cases of doubtful interpretation where the suicidal intention was only suspected, but not proven. The authors take into account different aspects such as: sociodemographic variables (sex; age; civil state; educational level; social position; geographical origin); method variables and correlations with psychiatric illness.

Ethical issues in Australian hospitals

OBJECTIVE

To identify the most common ethical issues of concern in Australian hospitals.

DESIGN

A descriptive study using data collected by means of a questionnaire.

PARTICIPANTS

Seven hundred and thirty-nine (74%) hospital administrators and employees nominated by hospital administrators in Australian public and private hospitals.

RESULTS

Over half the respondents reported that ethical concerns had been raised in relation to: making "not for resuscitation orders"; the treatment of patients with HIV and AIDS; interprofessional conflict; and the allocation of resources.

CONCLUSION

"End of life" concerns, patient autonomy issues, questions of resource distribution, and communication difficulties commonly raise ethical concerns in Australian hospitals.

A large private university hospital system. The Johns Hopkins Oncology Center

Clinical trials are a major commitment for a university-based comprehensive cancer center. In 1992, The Johns Hopkins Hospital registered 3508 new patients with cancer and, from this large population, 2880 patients were entered in clinical trials (many patients participated in more than one protocol). The Oncology Center, one of many departments at Johns Hopkins that conducts clinical research, participates in phase I and II new drug trials, phase III comparative studies, and, increasingly, in epidemiologic and prevention research. This calls for much broader participation by community hospitals and for many more patients who normally would not come to Johns Hopkins for their care. There are more than 100 protocols available from the Eastern Cooperative Oncology Group, but Johns Hopkins may participate in no more than 20 at any given time. Thus, every research facility must be selective about the trials in which it participates, given the finite number of hours, dollars, and resources available to carry out these programs. The institution provides safeguards to protect the interest of the patient. These include review and annual overseeing of the concept, design, and specifics of the proposed study. The pharmacy and nursing staff play an important role in control of chemotherapy distribution and use. Patients and physicians, however, must understand the questions the study is asking and agree that they are worth answering. There are problems in motivation; information; costs to the patient, hospital, insurers, and the physician; the concept of the placebo; and informed consent. Clinical research is the most ethical way to test drugs, radiation therapy, surgical procedures, or other new treatments. The clinical trial must meet rigorous criteria of design, conduct, and analysis. The patient must understand the issues and be a volunteer. We must make every effort to help patients and physicians get information about clinical trials and to participate if they choose.

Evaluating hospital performance with case-mix-adjusted outputs

In this article, we compared hospital efficiency using a multiple input-output approach in two ways: one way used a straightforward count of inpatient days and outpatient services as outputs; and the second used a case mix-adjusted count of inpatient services and outpatient care as outputs. Our results show that there was no difference when we incorporated the case-mix index, either as a weighting device or as a separate output. However, this result may be due to our having a relatively homogeneous sample, (i.e., large metropolitan hospitals). Variations using this approach may occur when using a more heterogeneous sample, such as comparing hospitals of all sizes or rural versus urban hospitals.

Pharmacy follies

Stuart Anderson describes a national study which failed to find any significant differences between the economic performance of pharmacy services in public and private hospitals.

Informed consent in the regional hospital of Japan--with a particular reference to consent forms

A consent form is a part of medical record, from which one would know how much attention is paid to informed consent. A survey of the consent forms from the various hospitals in the regional area of Japan, Shizuoka prefecture, indicated that the satisfactory consent forms are prepared in the large leading hospitals.

Surveillance of nosocomial infection in private psychiatric hospitals: an exploratory study

BACKGROUND

The vast majority of work published about infection control programs, procedures, and practices addresses general acute care facilities. Consequently, infection-control coordinators at psychiatric hospitals have few established norms or models to use in adapting available standards to the unique needs of psychiatric hospitals and their patients. This descriptive study explored practices for the surveillance of nosocomial infections in private psychiatric hospitals.

METHODS

A survey was mailed to the infection control coordinator of the 284 hospitals belonging to the National Association of Private Psychiatric Hospitals. Questionnaire data were collected anonymously. Surveys were returned by 103 (36%) of the hospitals.

RESULTS

The most frequent criteria used to define the presence of nosocomial infections were the Center for Disease Control guidelines and clinical judgment, used by 38% and 39% of the respondents, respectively. Most (64%) of the respondents indicated that they did calculate a nosocomial infection rate. The most frequent method used to calculate infection rates was based on patient discharges. Sixty-five hospitals (63%) reported their most recent yearly infection rate, which ranged from 0.00 to 0.35, with a median rate of 0.05 (mean, 0.06; SD, 0.07).

CONCLUSIONS

Overall, the findings reflected much variability in respondents' practices in defining nosocomial infections and calculating infection rates. We therefore suggest that both the method used to calculate the rate and facilities' definitions of nosocomial infection be considered when comparing infection rates across facilities.

And how is it over there, across the ocean?

In late February 1989, at the invitation of the Soviet Government, a Department of State-led U.S. Delegation visited the Soviet Union in an effort to assess recent changes in Soviet psychiatry, particularly those affecting human rights and the forensic system. As an outgrowth of the largely positive Soviet response to the U.S. Delegation's visit and its report, a Soviet Delegation spent time in the U.S. on a professional visit. The following report describes the impressions of the organization of psychiatric assistance in the United States as observed by Dr. Yegorov, one member of the Soviet Delegation.

A model of continuous quality improvement for health service organisations

Continuous Quality Improvement (or Total Quality Management) is an approach to management originally used in manufacturing and now being applied in the health services. This article describes a model of Continuous Quality Improvement which has been used in NSW public and private hospitals. The model consists of Ten Key Elements. The first driving force of this model is 'defining quality in terms of customer expectations' of quality. The second driving force emphasises that 'quality improvement is a leadership issue'. Leaders are required to: coordinate staff participation in work process analysis; train staff in the customer service orientation; lead effective meetings and negotiate with both internal and external service partners. Increased staff motivation, quality improvement and reduction in running costs are seen to be the benefits of CQI for health service organisations.

Performance indicators--their place in health care evaluation

OBJECTIVE

To report on some of the more important performance indicators used at St Vincent's Private Hospital, Sydney.

METHOD

Clinical data collected using DRG technology is reviewed by the Clinical Review Committee and its subcommittees. Administrative data and consumer satisfaction sampling by questionnaire are used to provide other performance indices. Performance indicators are reviewed on a quarterly basis to assess quality of care. The importance of definitions and subset analysis is emphasised and the cost effectiveness of using DRG technology to retrieve data is presented.

CONCLUSION

Performance indicators are a cost-effective, sensitive tool to assist in the evaluation of the quality of health care.

Catholic identity, Catholic integrity. A shared faith allows religious and laity to live out their commitments in one another's company

This article is adapted from an address to participants in the Catholic Identity Project, Fordham University, New York City, in April 1991. The project engaged leaders in a process to enable institutional ministries in higher education, health, and social services to maintain their Catholic identity. Proceedings and commentary of the symposium that was part of the project's second phase will be available in spring 1992 from Msgr. Charles J. Fahey, Third Age Center, Fordham University.

Private hospitals and medical ethics

The majority of hospitals in the United Kingdom are public authority hospitals administered according to the National Health Service Act 1977. However, there exist throughout the country a variety of independent hospitals run either as charities or for commercial gain. Elizabeth Macdonald examines the private hospitals' duty of care and the ethical basis from which it stems. She suggests mechanisms to monitor and support ethical standards in private hospitals.