Quality assurance in the emergency room

Observations from Mortality Trends at The Children's Hospital, Accra, 2003-2013

Objective

Facility-based studies provide an unparalleled opportunity to assess interventions deployed in hospitals to reduce child mortality which is not easily captured in the national data. We examined mortality trends at the Princess Marie Louise Children’s Hospital (PML) and related it to interventions deployed in the hospital and community to reduce child mortality and achieve the Millennium Development Goal 4 (MDG 4).

Methods

The study was a cross-sectional review of data on consecutive patients who died at the hospital over a period of 11 years, between 2003 and 2013. The total admissions for each year, the major hospital-based and population-based interventions, which took place within the period, were also obtained.

Results

Out of a total of 37,012 admissions, 1,314 (3.6%) deaths occurred and admissions tripled during the period. The average annual change in mortality was -7.12% overall, -7.38% in under-fives, and -1.47% in children ≥5 years. The majority of the deaths, 1,187 (90.3%), occurred in under-fives. The observed decrease in under-five (and overall) mortality rate occurred in a specific and peculiar pattern. Most of the decrease occurred during the period between 2003 and 2006. After that there was a noticeable increase from 2006 to 2008. Then, the rate slowly decreased until the end of the study period in 2013. There was a concomitant decline in malaria mortality following a pattern similar to the decline observed in other parts of the continent during this period. Several interventions might have contributed to the reduction in mortality including the change in malaria treatment policy, improved treatment of malnutrition and increasing paediatric input.

Conclusion

Under-fives mortality at PML has declined considerably; however, the reduction in mortality in older children has been minimal and thus requires special attention. Data collection for mortality reviews should be planned and commissioned regularly in hospitals to assess the effects of interventions and understand the context in which they occur. This will provide benchmarks and an impetus for improving care, identify shortfalls and ensure that the gains in child survival are maintained.

Combined quality function deployment and logical framework analysis to improve quality of emergency care in Malta

Purpose

– The purpose of this paper is to develop an integrated patient-focused analytical framework to improve quality of care in accident and emergency (A & E) unit of a Maltese hospital.

Design/methodology/approach

– The study adopts a case study approach. First, a thorough literature review has been undertaken to study the various methods of healthcare quality management. Second, a healthcare quality management framework is developed using combined quality function deployment (QFD) and logical framework approach (LFA). Third, the proposed framework is applied to a Maltese hospital to demonstrate its effectiveness. The proposed framework has six steps, commencing with identifying patients’ requirements and concluding with implementing improvement projects. All the steps have been undertaken with the involvement of the concerned stakeholders in the A & E unit of the hospital.

Findings

– The major and related problems being faced by the hospital under study were overcrowding at A & E and shortage of beds, respectively. The combined framework ensures better A & E services and patient flow. QFD identifies and analyses the issues and challenges of A & E and LFA helps develop project plans for healthcare quality improvement. The important outcomes of implementing the proposed quality improvement programme are fewer hospital admissions, faster patient flow, expert triage and shorter waiting times at the A & E unit. Increased emergency consultant cover and faster first significant medical encounter were required to start addressing the problems effectively. Overall, the combined QFD and LFA method is effective to address quality of care in A & E unit.

Practical/implications

– The proposed framework can be easily integrated within any healthcare unit, as well as within entire healthcare systems, due to its flexible and user-friendly approach. It could be part of Six Sigma and other quality initiatives.

Originality/value

– Although QFD has been extensively deployed in healthcare setup to improve quality of care, very little has been researched on combining QFD and LFA in order to identify issues, prioritise them, derive improvement measures and implement improvement projects. Additionally, there is no research on QFD application in A & E. This paper bridges these gaps. Moreover, very little has been written on the Maltese health care system. Therefore, this study contributes demonstration of quality of emergency care in Malta.