Improving quality of care in general practices by self-audit, benchmarking and quality circles

Organizational Expectations Regarding Documentation Practices in Athletic Training

CONTEXT

Although guidance is available, no nationally recognized standard exists for medical documentation in athletic training, leaving individual organizations responsible for setting expectations and enforcing policies. Previous research has examined clinician documentation behaviors; however, the supervisor's role in creating policy and procedures, communicating expectations, and ensuring accountability has not been investigated.

OBJECTIVE

To investigate supervisor practices regarding support, hindrance, and enforcement of medical documentation standards at an individual organization level.

DESIGN

Mixed-methods study.

SETTING

Online surveys and follow-up interviews.

PATIENTS OR OTHER PARTICIPANTS

We criterion sampled supervising athletic trainers (n = 1107) in National Collegiate Athletic Association member schools. The survey collected responses from 64 participants (age = 43 ± 11 years; years of experience as a supervisor = 12 ± 10; access rate = 9.6%; completion rate = 66.7%), and 12 (age = 35 ± 6 years; years of experience as a supervisor = 8 ± 5) participated in a follow-up interview.

DATA COLLECTION AND ANALYSIS

We used measures of central tendency to summarize survey data and the consensual qualitative research approach with a 3-person data analysis team and multiphase process to create a consensus codebook. We established trustworthiness using multiple-analyst triangulation, member checking, and internal and external auditing.

RESULTS

Fewer than half of supervisors reported having formal written organization-level documentation policies (n = 45/93, 48%) and procedures (n = 32/93, 34%) and an expected timeline for completing documentation (n = 24/84, 29%). Participants described a framework relative to orienting new and existing employees, communicating policies and procedures, strategies for holding employees accountable, and identifying purpose. Limitations included lack of time, prioritization of other roles and responsibilities, and assumptions of prior training and record quality.

CONCLUSION

Despite a lack of clear policies, procedures, expectations, prioritization, and accountability strategies, supervisors still felt confident in their employees' abilities to create complete and accurate records. This highlights a gap between supervisor and employee perceptions, as practicing athletic trainers have reported uncertainty regarding documentation practices in previous studies. Although supervisors perceive high confidence in their employees, clear organization standards, employer prioritization, and mechanisms for accountability surrounding documentation will result in improved patient care delivery, system outcomes, and legal compliance.

Patient-Reported Quality of Care for Osteoarthritis in General Practice in South Tyrol, Italy: Protocol for Translation, Validation and Assessment of the OsteoArthritis Quality Indicator Questionnaire (OA-QI)

BACKGROUND

Evidence-based recommendations for the treatment of knee and hip osteoarthritis are similar internationally. Nevertheless, clinical practice varies across countries. Instruments for measuring quality have been developed to improve health care through targeted interventions. Studies on health service quality must consider the structural and cultural characteristics of countries, because each of their strengths and weaknesses differ. However, such instruments for health-related patient-reported outcomes for osteoarthritis have not yet been validated in German and Italian languages.

OBJECTIVES

In order to be able to set targeted measures for the improvement of prevention and non-surgical treatment of osteoarthritis in South Tyrol, Italy, the quality of care must be recorded. Therefore, the aim of the project is to update, translate, and validate the OsteoArthritis Quality Indicator (OA-QI) questionnaire version 2, an established and validated questionnaire in Norwegian and English, for Germany and Italy. The second aim is to determine the quality of care for osteoarthritis of the hip and knee in a sample of patients who consult general practice in South Tyrol, and for comparison with patients who are admitted to rehabilitative spa-treatments for osteoarthritis in the state of Salzburg, Austria.

DISCUSSION

The results of this study will enable the identification and closure of gaps in osteoarthritis care. Although it is expected that body weight and exercise will play special roles, other areas of nonsurgical care might also be involved.

Effect of Quality Control Circle Activity Nursing Combined with Respiratory Function Exercise Nursing on Patients with Esophageal Cancer

Objective. To explore the effect of quality control circle activity nursing combined with respiratory function exercise nursing on esophageal cancer patients’ immune function and nutritional status. Methods. The clinical case data of 119 esophageal cancer patients admitted to our hospital were selected as the research objects from May 2019 to July 2021. They were divided into the quality control circle activity care group (QCCAC) (9 cases dropped due to incomplete case data, n= 50) and respiratory function exercise care group (10 cases dropped due to incomplete case data, n=50) by the random number table method, the respiratory function exercise care group was treated with respiratory function exercise care, while the QCCAC group was treated with QCCAC. Changes in lung function, immune function, and nutritional status before and after nursing were compared in the two groups of patients. Results. Before nursing, there was no significant difference in pulmonary function indexes, immune function indexes, and the level of nutritional status indicators between the two groups ( $P>0.05$ ). After nursing, the finger pulse oxygen saturation, vital capacity (VC), respiratory rate, forced vital capacity (FVC), deep inspiratory volume (IC), and maximum ventilation (MVV) of the QCCAC improved, and the QCCAC group was significantly higher than the respiratory function exercise care group ( $P<0.05$ ). After nursing, the QCCAC’s CD3+, CD4+, IgG, IgM, and IgA levels increased, and the QCCAC group was significantly higher than the respiratory function exercise care group. The CD8+ level decreased, and the QCCAC was lower than the respiratory function exercise care group ( $P<0.05$ ). After continuous nursing, the QCCAC’s D-lactic acid, DAO, FFMI, Hb, ALB, PA, and other nutritional evaluation indexes all increased, and the QCCAC was significantly higher than the respiratory function exercise care group ( $P<0.05$ ). Conclusion. Quality control circle activity nursing combined with respiratory function exercise nursing can effectively improve the immune function, respiratory function, and nutritional status of esophageal cancer patients.

Are quality promotion initiatives in Austrian and Italian general practices associated with higher patient satisfaction and quality of life? Results from the interventional study 'IQuaB'

The objective was to assess the changes in quality of life (QoL) and patient satisfaction of chronically ill patients in general practices in Salzburg (Austria) and South Tyrol (Italy) after implementation of a combined intervention addressing quality of care of general practitioners (GPs). Furthermore, the correlation between QoL/patient satisfaction and quality of care provided by the GPs (measured by a quality score based on quality indicators [QIs]) was investigated. The non-controlled pre-post study involved GPs and patients with chronic conditions. The intervention consisted of self-audit, benchmarking and quality circles. QIs were extracted in the participating practices in 2012 (preintervention) and 2014 (postintervention). Before and after the intervention, a patient survey was conducted including EQ-5D (measuring health-related QoL), a patient participation scale and parts of the European Task Force on Patient Evaluations of General Practice questionnaire (measuring patient satisfaction). Mann-Whitney U-tests, chi-square tests and Spearman's rank correlation were applied for statistical analysis. Fifty-six GPs participated in the study. 1,710 patients returned the questionnaire in 2012, and 1,374 in 2014. Mean EQ-5D index (QoL) was similar in Salzburg and South Tyrol in both years: 2012 Salzburg 0.85 (95% CI 0.84-0.87), South Tyrol 0.85 (95% CI 0.84-0.86); 2014 Salzburg 0.84 (95% CI 0.83-0.86), South Tyrol 0.84 (95% CI 0.83-0.86). Patient satisfaction was higher in Salzburg than in South Tyrol at baseline (EUROPEP: mean percentage of best response 61.5% vs. 49.1%, p < 0.000) and also at follow-up (61.9% vs. 49.2%; p < 0.000). No significant correlation between quality score and QoL/patient satisfaction was detected. Thus, the impact of the intervention was not significant within the intermediate time periods analysed in the study. Improvements in quality of care do not necessarily also improve patient-relevant outcomes, which are probably more associated with other factors than with medical quality (e.g. availability of the GP, waiting times and communication-related issues).

Expert-based medication reviews to reduce polypharmacy in older patients in primary care: a northern-Italian cluster-randomised controlled trial

BACKGROUND

Evidence regarding clinically relevant effects of interventions aiming at reducing polypharmacy is weak, especially for the primary care setting. This study was initiated with the objective to achieve clinical benefits for older patients (aged 75+) by means of evidence-based reduction of polypharmacy (defined as ≥8 prescribed drugs) and inappropriate prescribing in general practice.

METHODS

The cluster-randomised controlled trial involved general practitioners and patients in a northern-Italian region. The intervention consisted of a review of patient's medication regimens by three experts who gave specific recommendations for drug discontinuation. Main outcome measures were non-elective hospital admissions or death within 24 months (composite primary endpoint). Secondary outcomes were drug numbers, hospital admissions, mortality, falls, fractures, quality of life, affective status, cognitive function.

RESULTS

Twenty-two GPs/307 patients participated in the intervention group, 21 GPs/272 patients in the control group. One hundred twenty-five patients (40.7%) experienced the primary outcome in the intervention group, 87 patients (32.0%) in the control group. The adjusted rates of occurrence of the primary outcome did not differ significantly between the study groups (intention-to-treat analysis: adjusted odds ratio 1.46, 95%CI 0.99-2.18, p = 0.06; per-protocol analysis: adjusted OR 1.33, 95%CI 0.87-2.04, p = 0.2). Hospitalisations as single endpoint occurred more frequently in the intervention group according to the unadjusted analysis (OR 1.61, 95%CI 1.03-2.51, p = 0.04) but not in the adjusted analysis (OR 1.39, 95%CI 0.95-2.03, p = 0.09). Falls occurred less frequently in the intervention group (adjusted OR 0.55, 95%CI 0.31-0.98; p = 0.04). No significant differences were found regarding the other outcomes. Definitive discontinuation was obtained for 67 (16.0%) of 419 drugs rated as inappropriate. About 6% of the prescribed drugs were PIMs.

CONCLUSIONS

No conclusive effects were found regarding mortality and non-elective hospitalisations as composite respectively single endpoints. Falls were significantly reduced in the intervention group, although definitive discontinuation was achieved for only one out of six inappropriate drugs. These results indicate that (1) even a modest reduction of inappropriate medications may entail positive clinical effects, and that (2) focusing on evidence-based new drug prescriptions and prevention of polypharmacy may be more effective than deprescribing.

TRIAL REGISTRATION

Current Controlled Trials (ID ISRCTN: 38449870), date: 11/09/2013.

Quality improvement in chronic care by self-audit, benchmarking and networking in general practices in South Tyrol, Italy: results from an interventional study

BACKGROUND

Systematic strategies promoting quality of care in general practice are yet under-represented in several European countries.

OBJECTIVE

This interventional study assessed whether a combined intervention (self-audit, benchmarking, quality circles) improved quality of care in Salzburg, Austria and South Tyrol, Italy. The present publication reports the Italian results.

METHODS

We developed quality indicators for general practice in a consensus process based on pre-existing quality programmes. The indicators addressed diagnosis and treatment regarding eight common chronic conditions. A quality score comprising 91 indicators was calculated (0-5 points per indicator depending on fulfilment, maximum 455 points). We collected anonymous data from the electronic health records of the participating physicians in 2012, 2013 and 2014. Wilcoxon signed-rank tests were used for pre-post analysis.

RESULTS

Thirty-six GPs participated in the study. The median quality score increased significantly from 177.0 points at baseline to 272.0 points at the second follow-up (P = 0.000). Improvements concerned process and intermediate outcome indicators particularly between baseline and the first follow-up.

CONCLUSION

Performance was relatively low at baseline and improved considerably, mainly in the first study period. The intervention investigated in this study can serve as a model for future quality programmes. A customized electronic health record for the implementation of this intervention as well as standardized and consistent documentation by GPs is a prerequisite. Use of a limited set of quality indicators (QIs) and regular QI modification is probably advisable to increase the benefits. Long-term prospective studies should investigate the impact of QI-based interventions on end-result outcomes.

Strategies to Overcome Therapeutic Inertia in Type 2 Diabetes Mellitus: A Scoping Review

The objectives of this review were to: 1) examine recent strategies and component interventions used to overcome therapeutic inertia in type 2 diabetes mellitus (T2DM), 2) map strategies to the causes of therapeutic inertia they target and 3) identify causes of therapeutic inertia in T2DM that have not been targeted by recent strategies. A systematic search of the literature published from January 2014 to December 2019 was conducted to identify strategies targeting therapeutic inertia in T2DM, and key strategy characteristics were extracted and summarized. The search identified 46 articles, employing a total of 50 strategies aimed at overcoming therapeutic inertia. Strategies were composed of an average of 3.3 interventions (range, 1 to 10) aimed at an average of 3.6 causes (range, 1 to 9); most (78%) included a type of educational strategy. Most strategies targeted causes of inertia at the patient (38%) or health-care professional (26%) levels only and 8% targeted health-care-system-level causes, whereas 28% targeted causes at multiple levels. No strategies focused on patients' attitudes toward disease or lack of trust in health-care professionals; none addressed health-care professionals' concerns over costs or lack of information on side effects/fear of causing harm, or the lack of a health-care-system-level disease registry. Strategies to overcome therapeutic inertia in T2DM commonly employed multiple interventions, but novel strategies with interventions that simultaneously target multiple levels warrant further study. Although educational interventions are commonly used to address therapeutic inertia, future strategies may benefit from addressing a wider range of determinants of behaviour change to overcome therapeutic inertia.

The quality of COPD care in German general practice-A cross-sectional study

OBJECTIVES

Chronic Obstructive Pulmonary Disease (COPD) is a common health problem to be dealt with in primary care. Little is known about the quality of care provided for patients with COPD in Germany. Therefore, we wanted to assess the current quality of care delivered by a primary care network (PCN) for patients with COPD.

METHODS

A cross-sectional study was conducted in collaboration with a primary care network (PCN). All patients of the PCN aged 40 years and older with a diagnosis of COPD were identified through electronic health records (EHR). A set of quality indicators (QIs) developed in accordance with current COPD-guidelines were appraised through numerical data retrieved from the EHR.

RESULTS

In total, 2,568 patients with COPD were identified. Their mean age was 67 (SD±12) years, 49% were male. Thirty-five percent had a parallel diagnosis of asthma. There was no documentation of any spirometry for 54% of patients; 29% had a spirometry within the previous year. An influenza vaccination was documented for 37% within the preceding 12 months; 12% received a pneumococcal vaccination in the last 6 years. Smoking status was documented for 44% within the last year.

CONCLUSION

The quality of care for patients with COPD in the PCN seemed suboptimal, despite the presence of a Disease Management Program (DMP). This finding is likely to apply widely to German general practice. Quality assessment through currently available EHR data was challenging due to non-standardized and insufficient documentation.

Quality circles for quality improvement in primary health care: Their origins, spread, effectiveness and lacunae- A scoping review

Quality circles or peer review groups, and similar structured small groups of 6–12 health care professionals meet regularly across Europe to reflect on and improve their standard practice. There is debate over their effectiveness in primary health care, especially over their potential to change practitioners’ behaviour. Despite their popularity, we could not identify broad surveys of the literature on quality circles in a primary care context. Our scoping review was intended to identify possible definitions of quality circles, their origins, and reported effectiveness in primary health care, and to identify gaps in our knowledge. We searched appropriate databases and included any relevant paper on quality circles published until December 2017. We then compared information we found in the articles to that we found in books and on websites. Our search returned 7824 citations, from which we identified 82 background papers and 58 papers about quality circles. We found that they originated in manufacturing industry and that many countries adopted them for primary health care to continuously improve medical education, professional development, and quality of care. Quality circles are not standardized and their techniques are complex. We identified 19 papers that described individual studies, one paper that summarized 3 studies, and 1 systematic review that suggested that quality circles can effectively change behaviour, though effect sizes varied, depending on topic and context. Studies also suggested participation may affirm self-esteem and increase professional confidence. Because reports of the effect of quality circles on behaviour are variable, we recommend theory-driven research approaches to analyse and improve the effectiveness of this complex intervention.

Systematic Review and Meta-analysis of the Effectiveness of Implementation Strategies for Non-communicable Disease Guidelines in Primary Health Care

BACKGROUND

As clinical practice guidelines represent the most important evidence-based decision support tool, several strategies have been applied to improve their implementation into the primary health care system. This study aimed to evaluate the effect of intervention methods on the guideline adherence of primary care providers (PCPs).

METHODS

The studies selected through a systematic search in Medline and Embase were categorised according to intervention schemes and outcome indicator categories. Harvest plots and forest plots were applied to integrate results.

RESULTS

The 36 studies covered six intervention schemes, with single interventions being the most effective and distribution of materials the least. The harvest plot displayed 27 groups having no effect, 14 a moderate and 21 a strong effect on the outcome indicators in the categories of knowledge transfer, diagnostic behaviour, prescription, counselling and patient-level results. The forest plot revealed a moderate overall effect size of 0.22 [0.15, 0.29] where single interventions were more effective (0.27 [0.17, 0.38]) than multifaceted interventions (0.13 [0.06, 0.19]).

DISCUSSION

Guideline implementation strategies are heterogeneous. Reducing the complexity of strategies and tailoring to the local conditions and PCPs' needs may improve implementation and clinical practice.

Setting the Benchmark for the Ground and Air Medical Quality in Transport International Quality Improvement Collaborative

OBJECTIVE

Critical care transport (CCT) supports regionalization of medical care. Focus on the quality of CCT care prompted the development of the Ground and Air Medical qUality in Transport (GAMUT) Quality Improvement collaborative database which tracks consensus quality metrics. The Institute of Medicine recommends benchmarking of comparative data to accelerate improvement. Herein, we report the strategies and rationale for GAMUT QI Collaborative benchmarking.

METHODS

The GAMUT database includes >350 programs internationally with >200,000 annual patient contacts. Evidence-based literature review performed in May 2016 and October 2017 identified benchmarking strategies were evaluated and summarized, specific to the GAMUT metrics. Statistical analyses include simple statistics and weighted expectation calculations for benchmark examples (Pearson chi-square with Bonferroni adjusted post-hoc z tests).

RESULTS

Evidence-based literature search yielded 70 articles, and 31 were selected for inclusion in our evidence table. 5 evidence-based benchmark strategies were considered: average (mean), average (median), adjusted benchmark (based on expected outcome), Achievable Benchmark of Care (ABC), and Delphi. ABC threshold establishes a higher target (90th percentile) forcing more programs to achieve higher performance.

CONCLUSION

Benchmarking is not well-suited for a single strategy and requires customized consideration based on each metric, though adjusted benchmark and ABC generally set higher performance benchmarks.

Factors affecting the effectiveness of quality control circles in a hospital using a combination of fuzzy VIKOR and Grey Relational Analysis

Background:

One of the techniques used to achieve productivity, employees’ job satisfaction and higher quality goods and services, as well as to solve the problems by using a team, is the formation of quality control circles. Quality control circles enable managers to meet the organization’s and employees’ needs through making effective use of resources and facilities. On the other hand, the quality of services is always affected by uncertainty and ambiguous and implicit judgments, which make its measurement uncertain.

Aim:

The present study aimed to identify important factors affecting the effectiveness of quality control circles in a hospital, as well as rank them using a combination of fuzzy VIKOR and Grey Relational Analysis (GRA).

Methodology:

This was an applied, cross-sectional and descriptive–analytical study conducted in 2016. The study population consisted of five academic members and five experts in the field of nursing working in a hospital, who were selected using a purposive sampling method. Also, a sample of 107 nurses was selected through a simple random sampling method using their employee codes and the random-number table. The required data were collected using a researcher-made questionnaire which consisted of 12 factors. The validity of this questionnaire was confirmed through giving the opinions of experts and academic members who participated in the present study, as well as performing confirmatory factor analysis. Its reliability also was verified (α=0.796). The collected data were analyzed using SPSS 22.0 and LISREL 8.8, as well as VIKOR–GRA and IPA methods.

Results:

The results of ranking the factors affecting the effectiveness of quality control circles showed that the highest and lowest ranks were related to ‘Managers’ and supervisors’ support’ (Š = 6.80, [Formula: see text] = 0.36) and ‘Group leadership’ (Š = 2.63, [Formula: see text] = 0.98). Also, the highest hospital performance was for factors such as ‘Clear goals and objectives’ and ‘Group cohesiveness and homogeneity’, and the lowest for ‘Reward system’ and ‘Feedback system’, respectively.

Conclusion:

The results showed that although ‘Training the members’, ‘Using the right tools’ and ‘Reward system’ were factors that were of great importance, the organization’s performance for these factors was poor. Therefore, these factors should be paid more attention by the studied hospital managers and should be improved as soon as possible. Applying quality control circles in any organization is very helpful and provides opportunities for maximum use of employees’ creativity, initiative and skills in reaching their and their organization’s goals and objectives, and prepares favorable working conditions for the employees’ optimal performance through increasing the managers’ sense of responsibility and commitment.