University of New Mexico, Albuquerque, New Mexico; the Uniformed Services University of the Health Sciences, Bethesda, Maryland; the Northern Navajo Medical Center, Shiprock, New Mexico; the Mid-Columbia Medical Center, The Dalles, Oregon; the University of Texas Rio Grande Valley, Edinburg, Texas; the Alaska Native Medical Center, Anchorage, Alaska; the University of Mississippi Medical Center, Jackson, Mississippi; the Oregon Health and Science University, Portland, Oregon; and the American College of Obstetricians and Gynecologists, Washington, DC.
Since 1970, the American College of Obstetricians and Gynecologists' Committee on American Indian and Alaska Native Women's Health has partnered with the Indian Health Service and health care facilities serving Native American women to improve quality of care in both rural and urban settings. Needs assessments have included formal surveys, expert panels, consensus conferences, and onsite program reviews. Improved care has been achieved through continuing professional education, recruitment of volunteer obstetrician-gynecologists, advocacy, and close collaboration at the local and national levels. The inclusive and multifaceted approach of this program should provide an effective model for collaborations between specialty societies and health care professionals providing primary care services that can reduce health disparities in underserved populations.
The article presents materials of studying of such important problem of health care as standardization of specialized medical care provided in conditions of hospital and modernization of regional health care. The issues of standardization of specialized medical care are considered in medical, economic and social aspects. The implementation of medical standards was determined as one of main tasks of the regional program of modernization of health care. The program was developed with direct involvement of the authors of article. The comparative analysis of classes of diseases and nosologic forms on main indices of hospitalized morbidity and lethality was used for substantiation of priority of implementing medical standards in the region. The questionnaire survey was carried out on sampling of 510 patients of hospitals. The sociological questionnaire survey was applied to sampling of 8732 patients comprised by system of mandatory medical insurance. Such an approach determined reliability of derived results. The expertise of medical standards was implemented by 124 experienced and competent physicians participating in implementation of medical standards. The results of expertise confirmed expediency of implementation of medical standards. Kepy following shortcomings were established: inadequate financing; lacking of modern equipment and analysis techniques in hospitals, etc. The article presents evidences of effectiveness of process of standardization of specialized of medical care provided in hospital conditions. The basis of such an assumption was reliable increasing of level of satisfaction of quality of its organization and achievement of planned indices of "road map" in the section of increasing of salary of medical workers and decreasing of mortality of population because of controllable causes.
Retention and recruitment strategies are essential to address nursing workforce supply and ensure the viability of healthcare delivery in Canada. Knowledge transfer between experienced nurses and those new to the profession is also a focus for concern. The Multi-Employer/United Nurses of Alberta Joint Committee attempted to address these issues by introducing a number of retention and recruitment (R&R) initiatives for nurses in Alberta: in total, seven different programs that were introduced to some 24,000 nurses and employers across the province of Alberta in 2001 (the Transitional Graduate Nurse Recruitment Program) and 2007 (the remaining six R&R programs). Approximately 1,600 nurses participated in the seven programs between 2001 and 2009. Of the seven strategies, one supported entry into the workplace, two were pre-retirement strategies and four involved flexible work options. This project entailed a retrospective evaluation of the seven programs and differed from the other Research to Action (RTA) projects because it was solely concerned with evaluation of pre-existing initiatives. All seven programs were launched without a formal evaluation component, and the tracking of local uptake varied throughout the province. The union and various employers faced challenges in implementing these strategies in a timely fashion, as most were designed at the bargaining table during negotiations. As a result, systems, policy and procedural changes had to be developed to support their implementation after they became available.Participants in the programs indicated improvements over time in several areas, including higher levels of satisfaction with work–life balance, hours worked and their current practice and profession. The evaluation found that participation led to perceived improvements in nurses' confidence, greater control over their work environment, decreased stress levels, increased energy and morale and perceived improved ability to provide high-quality care. However, no formal implementation plan had been developed or made available to assist employers with implementation of the programs. The findings highlight the need for more discipline in communicating, implementing and evaluating initiatives such as those evaluated retrospectively in this project. In particular, key performance indicators, baseline data, monitoring mechanisms and an evaluation plan need to be developed prior to implementation.
Despite the reported success of Lean in health care settings, it is unclear why and how organizations adopt Lean and how Lean transforms work design and, in turn, affects employees' work. This study investigated a cardiology department's journey to adopt and adapt Lean. The investigation was focused on the rationale and evolution of the Lean adoption to illuminate how a department with a long quality improvement history arrived at the decision to introduce Lean, and how Lean influenced employees' daily work. This is an explanatory single case study based on semistructured interviews, nonparticipant observations, and document studies. Guided by a Lean model, we undertook manifest content analysis of the data. We found that previous improvement efforts may facilitate the introduction of Lean but may be less important when forecasting whether Lean will be sustained over time. Contextual factors seemed to influence both what Lean tools were implemented and how well the changes were sustained. For example, adoption of Lean varied with the degree to which staff saw a need for change. Work redesign and teamwork were found helpful to improve patient care whereas problem solving was found helpful in keeping the staff engaged and sustaining the results over time.
To achieve our goal of excellent emergency cardiac care, our institution embarked on a Lean process improvement initiative. We sought to examine and quantify the outcome of this project on the care of suspected acute coronary syndrome (ACS) patients in our emergency department (ED).
Front-line ED staff participated in several rapid improvement events, using Lean principles and techniques such as waste elimination, supply chain streamlining, and standard work to increase the value of the early care provided to patients with suspected ACS. A chart review was also conducted. To evaluate our success, proportions of care milestones (first electrocardiogram [ECG], ECG interpretation, physician assessment, and acetylsalicylic acid [ASA] administration) meeting target times were chosen as outcome metrics in this before-and-after study.
The proportion of cases with 12-lead ECGs completed within 10 minutes of patient triage increased by 37.4% (p
To investigate the use of data from national quality registries (NQRs) in local quality improvement as well as purported key factors for effective clinical use in Sweden.
Comparative descriptive: a web survey of all Swedish hospitals participating in three NQRs with different levels of development (certification level).
Heads of the clinics and physician(s) at clinics participating in the Swedish Stroke Register (Riksstroke), the Swedish National Registry of Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks) and the Swedish Lung Cancer Registry (NLCR).
Individual and unit level use of NQRs in local quality improvement, and perceptions on data quality, organizational conditions and user motivation.
Riksstroke data were reported as most extensively used at individual and unit levels (x¯ 17.97 of 24 and x¯ 27.06 of 35). Data quality and usefulness was considered high for the two most developed NQRs (x¯ 19.86 for Riksstroke and x¯ 19.89 for GallRiks of 25). Organizational conditions were estimated at the same level for Riksstroke and GallRiks (x¯ 12.90 and x¯ 13.28 of 20) while the least developed registry, the NLCR, had lower estimates (x¯ 10.32). In Riksstroke, the managers requested registry data more often (x¯ 15.17 of 20).
While there were significant differences between registries in key factors such as management interest, use of NQR data in local quality improvement seems rather prevalent, at least for Riksstroke. The link between the registry's level of development and factors important for routinization of innovations such as NQRs needs investigation.
Assessing the degree of involvement and participation in thoracic surgical research as well as surgical quality improvement conducted across Canadian institutions is difficult as no common data collection system and no prior studies exist. As a pilot investigation, we designed and conducted a membership survey of the Canadian Association of Thoracic Surgeons (CATS) to evaluate the extent of participation in research and quality improvement processes among thoracic surgeons.
A 45-item needs assessment survey was mailed to all national members of CATS (n = 86) in August 2009. Questions primarily focused on clinical research programs and research activity, research funding, database use and interest, and other methods of quality monitoring.
The 49 completed surveys represented a 57.0% response rate and 28 institutions across Canada. Research in basic and clinical science is conducted by 17.0% and 80.9% of the respondents, respectively. The annual budget of research funds is most commonly between $5000 and $50,000. A total of 72.0% (n = 18) of institutions do not have a formal surgery quality assessment program and 92.3% (n = 24) do not participate in a national or international thoracic surgery database. Ten institutions (38.6%) have a local thoracic surgery database for quality monitoring. Other systems of monitoring surgical quality include formal morbidity and mortality rounds (69.2%; n = 8 institutions), formal evaluation of surgical wait times (73.1%; n = 19 institutions), and patient satisfaction surveys (71.4%; n = 10 institutions). Overall, 97.8% of surgeons would be willing to share data on morbidity and mortality with other centers, and 73.1% have a high or very high level of interest in participating in a national thoracic surgery quality database.
A high level of interest and participation exists in thoracic surgery research. However, more robust quality improvement processes are needed for thoracic surgical oncology services. A national thoracic surgery quality improvement database offers a potential means to improve practice effectiveness, standardize surgical outcomes, and promote thoracic research across Canada.
admission to orthogeriatric units improves clinical outcomes for patients with hip fracture; however, little is known about the underlying mechanisms.
to compare quality of in-hospital care, 30-day mortality, time to surgery (TTS) and length of hospital stay (LOS) among patients with hip fracture admitted to orthogeriatric and ordinary orthopaedic units, respectively.
population-based cohort study.
using prospectively collected data from the Danish Multidisciplinary Hip Fracture Registry, we identified 11,461 patients aged =65 years admitted with a hip fracture between 1 March 2010 and 30 November 2011. The patients were divided into two groups: (i) those treated at an orthogeriatric unit, where the geriatrician is an integrated part of the multidisciplinary team, and (ii) those treated at an ordinary orthopaedic unit, where geriatric or medical consultant service are available on request. Outcome measures were the quality of care as reflected by six process performance measures, 30-day mortality, the TTS and the LOS. Data were analysed using log-binomial, linear and logistic regression controlling for potential confounders.
admittance to orthogeriatric units was associated with a higher chance for fulfilling five out of six process performance measures. Patients who were admitted to an orthogeriatric unit experienced a lower 30-day mortality (adjusted odds ratio (aOR) 0.69; 95% CI 0.54-0.88), whereas the LOS (adjusted relative time (aRT) of 1.18; 95% CI 0.92-1.52) and the TTS (aRT 1.06; 95% CI 0.89-1.26) were similar.
admittance to an orthogeriatric unit was associated with improved quality of care and lower 30-day mortality among patients with hip fracture.
Research on continuous quality improvement (CQI) in community pharmacies lags in comparison to service, manufacturing, and various health care sectors. As a result, very little is known about the challenges community pharmacies face when implementing CQI programs in general, let alone the challenges of implementing a standardized and technologically sophisticated one.
This research identifies the initial challenges of implementing a standardized CQI program in community pharmacies and how such challenges were addressed by pharmacy staff.
Through qualitative interviews, a multisite study of the SafetyNET-Rx CQI program involving community pharmacies in Nova Scotia, Canada, was performed to identify such challenges. Interviews were conducted with the CQI facilitator (ie, staff pharmacist or technician) in 55 community pharmacies that adopted the SafetyNET-Rx program. Of these 55 pharmacies, 25 were part of large national corporate chains, 22 were part of banner chains, and 8 were independent pharmacies. A total of 10 different corporate chains and banners were represented among the 55 pharmacies. Thematic content analysis using well-established coding procedures was used to explore the interview data and elicit the key challenges faced.
Six major challenges were identified, specifically finding time to report, having all pharmacy staff involved in quality-related event (QRE) reporting, reporting apprehensiveness, changing staff relationships, meeting to discuss QREs, and accepting the online technology. Challenges were addressed in a number of ways including developing a manual-online hybrid reporting system, managers paying staff to meet after hours, and pharmacy managers showing visible commitment to QRE reporting and learning.
This research identifies key challenges to implementing CQI programs in community pharmacies and also provides a starting point for future research relating to how the challenges of QRE reporting and learning in community pharmacies change over time.