Clinical Performance Indicators Research Articles

Italian hospitals on the web: a cross-sectional analysis of official websites

BackgroundAlthough the use of the Internet for health purposes has increased steadily in the last decade, only a few studies have explored the information provided by the websites of health institutions and no studies on the on-line activities of Italian hospitals have been performed to date. The aim of this study was to explore the characteristics of the contents and the user-orientation of Italian hospital websites.MethodsThe cross-sectional analysis considered all the Italian hospitals with a working website between December 2008 and February 2009. The websites were coded using an ad hoc Codebook, comprising eighty-nine items divided into five sections: technical characteristics, hospital information and facilities, medical services, interactive on-line services and external activities. We calculated a website evaluation score, on the basis of the items satisfied, to compare private (PrHs) and public hospitals, the latter divided into ones with their own website (PubHs-1) and ones with a section on the website of their Local Health Authority (PubHs-2). Lastly, a descriptive analysis of each item was carried out.ResultsOut of the 1265 hospitals in Italy, we found that 419 of the 652 public hospitals (64.3%) and 344 of the 613 PrHs (56.1%) had a working website (p = 0.01). The mean website evaluation score was 41.9 for PubHs-1, 21.2 for PubHs-2 and 30.8 for PrHs (p < 0.001).Only 5 hospitals out of 763 (< 1%) provided specific clinical performance indicators, such as the nosocomial infection rate or the surgical mortality rates. Regarding interactive on-line services, although nearly 80% of both public and private hospitals enabled users to communicate on-line, less than 18% allowed the reservation of medical services, and only 8 websites (1%) provided a health-care forum.ConclusionsA high percentage of hospitals did not provide an official website and the majority of the websites found had several limitations. Very few hospitals provided information to increase the credibility of the hospital and user confidence in the institution. This study suggests that Italian hospital websites are more a source of information on admissions and services than a means of communication between user and hospital.

Development and pilot of clinical performance indicators for English ambulance services

IntroductionThere is a compelling need to develop clinical performance indicators for ambulance services in order to move from indicators based primarily on response times and in light of the changing...

Using Video-Facilitated Feedback to Improve Student Performance Following High-Fidelity Simulation

Background This pilot study evaluated the effect of videotape-facilitated human patient simulator (HPS) practice and guidance on clinical performance indicators. Method Nursing and nurse anesthetist students in the treatment group ( n = 20) participated in HPS practice and guidance using videotape-facilitated debriefing, and the control group ( n = 20) participated in HPS practice and guidance using oral debriefing alone. Results Students in the intervention group were significantly more likely to demonstrate desirable behaviors concerning patient identification, team communication, and vital signs. The role students played in the simulation significantly impacted their performance. When scores of both the intervention and control groups were combined, team leaders, airway managers, and nurse anesthetists had higher mean total performance scores than crash cart managers, recorders, or medication nurses. Conclusion Video-facilitated simulation feedback is potentially a useful tool in increasing desirable clinical behaviors in a simulated environment.

Relationship among Length of Facility Ownership, Clinical Performance, and Mortality

The association between level of performance in achieving guideline-recommended clinical indicators and relative reduction in patient mortality is inconsistent among large dialysis organizations (LDOs). Because growth rates among providers differ, we reasoned that clinical performance and mortality rates in dialysis facilities may be related to length of facility ownership. We examined achievement of clinical performance indicators among prevalent long-term hemodialysis patients who were enrolled in cohorts of DaVita facilities between December 2005 and December 2007. We compared results in 606 facilities owned before December 1, 2004 (existing), with those seen in 504 facilities that were acquired in October 2005 (newly acquired). At baseline, existing compared with newly acquired DaVita facilities showed higher levels of clinical performance and lower patient mortality. These differences persisted up to 2 years for selected outcomes, including dialysis adequacy and anemia management. Substantial improvement was seen in both cohorts for mineral bone disease outcomes; however, 2 years after acquisition, between-cohort differences in relative risk for death were no longer discernible. These findings confirm that intervention to improve quality outcomes in dialysis facilities produces direct benefits that are tangible to patients. Our results also provide new evidence that length of ownership may be a significant factor in determining facility performance within a large dialysis organization.

Pathology processes and emergency department length of stay: the impact of change

Objectives: To determine whether redesign of pathology processes, including indicators of sample priority, could reduce patient length of stay (LOS) in an emergency department (ED), and assess the long-term impact of two indicators of sample priority on pathology clinical performance indicators for ED samples. Design, setting and participants: Two observational studies of de-identified data from standard databases were conducted - a single-site pilot trial of patients attending the ED of one hospital compared with historical controls, and a multisite study of 132 521 full blood count (FBC) requests for patients attending seven EDs that utilised either of two pathology process changes (coloured specimen transport bags alone, or coloured specimen bags plus blood tubes with a priority indicator). Main outcome measures: LOS in the ED was measured for the pilot trial, and collected-to-validated times for FBCs that fulfilled computer algorithm validation rules were measured for the multisite study. Results: In the pilot trial, the redesigned pathology process resulted in a 29-minute reduction (15.6%) in the median ED LOS for all patients (P < 0.001) compared with historical controls. In the multisite study, use of coloured specimen bags plus blood tubes with a priority indicator resulted in an 8-minute reduction (20.1%) in mean collected-to-validated times for FBC requests compared with FBC requests that used coloured specimen bags alone (P<0.001). Conclusions: Our pilot trial revealed a direct relationship between pathology process design and LOS in the ED, suggesting that redesigned pathology processes can significantly reduce LOS in the ED. Our multisite study showed that collecting samples directly into blood tubes with an incorporated priority indicator reduces pathology test turnaround times. These data suggest that LOS in the ED can be significantly reduced by simple changes to pathology processes, such as collecting samples directly into specimen containers with an incorporated priority indicator.

Progress with the European Society for Paediatric Nephrology (ESPN)/ERA-EDTA Registry for children with established renal failure (ERF)

Established renal failure (ERF) in children and young adults is considered a rare disease. Single country data may be underpowered to show any differences or effects of treatment and therefore cooperation between countries is essential to improve the outcome of children with ERF. Until 2007 data collection on children and young adults on renal replacement therapy (RRT) in Europe was limited to that of the European Renal Association–European Dialysis and Transplant (ERA–EDTA) Registry. Within the ERA–EDTA Registry data are collected from national and regional renal registries. As these do not always include paediatric patients, data on children have only been available from a limited part of Europe. The first publication on paediatric patients by the Amsterdam-based ERA–EDTA Registry included data on 3184 patients (aged 0–19 years) from 12 registries in 11 countries, covering a total general population of 80.3 million, who started RRT between 1980 and 2000 [1]. Information was presented on incidence, prevalence, primary renal disease, age at onset of RRT, type of treatment and survival. The data demonstrated an almost 3-fold increase in the prevalence of ERF over 20 years, from 22.9 per million age related population (pmarp) in 1980 to 62.1 pmarp in 2000. The incidence rose from 7.1 pmarp in the 1980–84 cohorts to 9.9 pmarp in the 1985–89 cohorts but then remained stable. In the early cohort haemodialysis was the most common form of first treatment modality, but by 1995–2000 peritoneal dialysis and pre-emptive transplant were increasingly used. Over the 20 years studied the relative risk of death for patients starting dialysis or following their first transplant reduced by 36% and 42%, respectively. A paper on the characteristics and survival of young adults who started RRT during childhood has recently been published [2], and a further study on the effect of timing of transplantation is in progress. In addition, an international study comparing survival between children on haemodialysis and peritoneal dialysis is running in collaboration with other large registries including the USRDS and ANZDATA [3]. Since 2004 preparations have been made for a more comprehensive registry specifically focusing on children, the European Society for Paediatric Nephrology (ESPN)/ERA–EDTA Registry. It was decided that the data collection on children should be expanded not only to include more countries but also to collect much more detailed data on different aspects of ERF management. Initially, established registries from the larger countries were compared to see if a common database could be developed. A paediatric sub-committee of the ERA–EDTA Registry committee was set up to further develop the paediatric aspects of the Registry. This led to a comparison of UK and Italian data that was presented at the ERA–EDTA meeting in Lisbon in ‘Auditing and Advancing Paediatric RRT’. This comparison demonstrated that these two countries not only had very similar populations of children with ERF, but there was also evidence of differences in management, for example of haemodialysis access and time to transplantation. In 2005, with the inclusion of patients from the UK, Italy and Turkey, the total number of incident patients under the age of 15 reported to the ERA–EDTA Registry increased from 2009 to 4280 and details were reported at the ESPN meeting in Istanbul 2005 in ‘The new paediatric EDTA database’. At the same time the ERA–EDTA Registry set out to develop the QUEST (QUality European STudies) initiative [4]. The aim of this initiative is to identify comparable indicators to assess the quality of RRT care among European countries, with the aim of improving outcome across Europe. One of the ways of reaching that objective is to develop and standardize clinical performance indicators to be used for (inter)national benchmarking. Together with national renal registries and societies the ERA–EDTA Registry applied to the European Union for a grant, under the name of NephroQUEST, which was subsequently awarded in 2007. The project was officially launched at a meeting in Amsterdam in November 2007 [5]. It is hoped that this project will support the development of the infrastructure required for data collection in countries without this facility that will then be of benefit to both children and adults with renal failure. The NephroQUEST grant has also provided co-funding for the employment of a part-time dedicated epidemiologist, for the paediatric registry, for 3 years. Contributions to the funding for this post have also been provided by the ERA–EDTA and the ESPN for this period and action is now required to secure long-term funding.

Pathology processes and emergency department length of stay: the impact of change

Objectives: To determine whether redesign of pathology processes, including indicators of sample priority, could reduce patient length of stay (LOS) in an emergency department (ED), and assess the long-term impact of two indicators of sample priority on pathology clinical performance indicators for ED samples. Design, setting and participants: Two observational studies of de-identified data from standard databases were conducted - a single-site pilot trial of patients attending the ED of one hospital compared with historical controls, and a multisite study of 132 521 full blood count (FBC) requests for patients attending seven EDs that utilised either of two pathology process changes (coloured specimen transport bags alone, or coloured specimen bags plus blood tubes with a priority indicator). Main outcome measures: LOS in the ED was measured for the pilot trial, and collected-to-validated times for FBCs that fulfilled computer algorithm validation rules were measured for the multisite study. Results: In the pilot trial, the redesigned pathology process resulted in a 29-minute reduction (15.6%) in the median ED LOS for all patients (P < 0.001) compared with historical controls. In the multisite study, use of coloured specimen bags plus blood tubes with a priority indicator resulted in an 8-minute reduction (20.1%) in mean collected-to-validated times for FBC requests compared with FBC requests that used coloured specimen bags alone (P<0.001). Conclusions: Our pilot trial revealed a direct relationship between pathology process design and LOS in the ED, suggesting that redesigned pathology processes can significantly reduce LOS in the ED. Our multisite study showed that collecting samples directly into blood tubes with an incorporated priority indicator reduces pathology test turnaround times. These data suggest that LOS in the ED can be significantly reduced by simple changes to pathology processes, such as collecting samples directly into specimen containers with an incorporated priority indicator.

Impact of quality strategies on hospital outputs

Context:This study was part of the Methods of Assessing Response to Quality Improvement Strategies (MARQuIS) research project on patients crossing borders, a study to investigate quality improvement strategies in healthcare...

Assessment of urea removal in haemodialysis and the impact of the European Best Practice Guidelines

Dialysis adequacy, assessed by urea kinetics, is an important determinant of patient outcome, and is therefore an important clinical performance indicator. In this perspective, renal registry data may be useful to compare practices across countries. To serve that purpose available data should be comparable and preferably collected using a standardized procedure. The aim of this study, initiated by the European Renal Association-European Dialysis and Transplantation Association (ERA-EDTA) QUality European STudies (QUEST) initiative, was to make an inventory of the different methods used to determine urea kinetic measurements in the light of the European Best Practice Guidelines. Via their national and regional registries, European haemodialysis centres were invited to complete a questionnaire regarding their practice of measuring dialysis adequacy. Fourteen regional or national registries among 51 sent back 255 questionnaires. Great variability in the methodology to assess Kt/V was observed. The urea reduction ratio (URR) was used alone by 37% (in association 46%) of dialysis centres, spKt/V by 25% (35%) and on-line clearance by 4% (12%), whereas only 10% (13%) used eKt/V, as recommended by EBPG. Forty percent of centres measured urea removal less than once a month, 6% of which never measured urea removal and 9% only every 6 months or less frequently. Despite the fact that the use of URR is not recommended by EBPG, it was the most commonly used indicator to measure urea removal, whereas eKt/V was only used by a small minority of centres. This study allowed us to point out the need to standardize definitions and procedures and to develop an effective plan for implementation of the guidelines.

Establishment of a National Danish Hysterectomy Database: Preliminary Report on the First 13,425 Hysterectomies

An estimated 5000 to 6000 hysterectomies are performed each year in Denmark. A nationwide survey disclosed a complication rate of 18%, a median hospital stay of 4 days, and readmission of 8% of patients within 30 days. The Danish Hysterectomy Database (DHD) was established in 2003 to provide a national basis for improving the outcome of hysterectomy. The study population included all women having elective hysterectomy on benign indications in the years 2004-2006. Structured data are registered prospectively by the surgeons providing treatment, and feedback is provided as clinical indicators with defined goals. Annual plenary meetings, elaboration of national clinical guidelines, and parallel causal studies all are elements of the DHD. Hysterectomies carried out in Denmark from 2004 to 2006 numbered 13,425. In 2005, all 31 gynecological departments in Denmark participated in database collaboration; the national response rate was 99%. Data validity was, in general, good, with agreement rates of 82% to 100%. High data completeness of 92% to 100% was documented. Two clinical guidelines, dealing with antibiotic prophylaxis and when to initiate anticoagulant therapy, were implemented during the period under review. The median patient age was 47 years. Participants were healthy or had no more than mild systemic disease with no functional limitations. The median postoperative hospital stay was stable at 2 days. The rate of postoperative surgical infection declined from 4% to 2%; bleeding complications from 8% to 6%; the reoperation rate from 5% to 4%; and the readmission rate from 7% to 5%. Experience with the DHD demonstrates that clinical performance indicators and nationwide collaboration are helpful in monitoring and improving the outcome of hysterectomy.

Clinical Performance Indicators for Percutaneous Coronary Intervention

Quality indicators in cardiology can be used to guide performance at a patient level, or at an organizational level. To positively influence adherence to performance guidelines, policymakers have to ensure that employees are involved in the development of guidelines and indicators. The first phase for selecting performance measures is creating a set of performance indicators. The aim of this study was to identify performance indicators with a high degree of consensus among professionals in daily practice for interventional cardiology. Each of the 50 predefined performance indicators was rated by 17 cardiologists and 17 head nurses (one from each participating center) on a 5-point scale. The cluster of indicators with the highest scores was resubmitted to the participants of the first phase for verification. After the second phase, performance indicators with >90% positive score for inclusion were qualified as key performance indicator (KPI). In the first phase, 24 of 34 response forms were returned (71%). Performance indicators with the highest overall mean scores were complications (4.71), in-hospital delay for patients with acute myocardial infarction (4.67), mortality (4.63), technical result (4.42), and patient satisfaction (4.38). The scores of cardiologists and nurses showed similar patterns. Nineteen indicators were selected for verification. After the second phase, 8 indicators qualified as KPI: complications, data flow, in-hospital delay, frequency of heart team meetings, number of procedures per center, mortality, restenosis rate, and use of protocols. The 8 KPI are both quantifiable and aimed at the catheterization laboratory as a unit.

Establishment of a national Danish hysterectomy database: Preliminary report on the first 13,425 hysterectomies

To describe the concept and early results from the Danish Hysterectomy Database (DHD). Nationwide prospective cohort. Denmark. All women who had undergone an elective hysterectomy for benign indication carried out in 2004-2006. Structured data are registered prospectively by the surgeons involved in the treatment. Data is reported using the Danish National Patient Registry (LPR) and feedback is provided as clinical indicators with well-defined goals. The DHD concept includes annual plenary meetings, elaboration of national clinical guidelines and parallel causal studies. Completeness, data validation and department-identifiable clinical indicators (surgical volume, method of hysterectomy, use of antibiotic and thromboembolic prophylaxis, postoperative hospitalization and bleeding complications, surgical infections, reoperations, readmissions and death within 30 days postoperatively). A total of 13,425 hysterectomies were performed in Denmark from 2004 to 2006. In 2005, all gynecological departments in Denmark (n=31) were included in the database collaboration and the national response rate was 99%. Data validity was good in general (82-100% agreement and kappa=0.40-1.00) and data completeness was high (92-100% in 2006). From 2004 to 2006, two clinical guidelines were implemented, the postoperative hospitalization was stable at median 2 days, the rate of postoperative surgical infections was reduced from 4 to 2%, the rate of bleeding complications from 8 to 6%, the reoperation rate from 5 to 4%, and the readmission rate from 7 to 5%. Clinical performance indicators, audit meetings and nationwide collaboration are useful in monitoring and improving outcome after hysterectomy on a national level. In addition, the DHD offers scope for causal studies about perioperative management.

Symptom pathways from referral to death: measuring palliative care outcomes

This article reports on the first stage of a process to develop a clinical performance indicator for a community-based palliative care service that may inform the development of an agreed set of indicators for the whole sector. The study explores whether symptom data that are routinely collected to plan and monitor the care being provided by a community-based palliative care service also have the potential to be used to audit care against standards, compare services, and inform funders or purchasers. The article looks at the symptom distress scores of patients over the whole episode of their care from referral to death, by constructing pathways for each symptom (pain, insomnia, appetite, nausea, bowel, breathing problems, fatigue and pain). How these data may provide a multi-purpose measure of clinical outcomes is then discussed. It is concluded that, following further research to establish the symptom assessment scale's reliability and validity in different settings, it should be considered for universal adoption by palliative care services.

Benchmarking the UK Military Deployed Trauma System

Benchmarking the UK Military Deployed Trauma System

Acute medical assessment/admission units: clinical performance indicators

PurposeThe purpose of this study is to explore the patterns of referral, reasons for admission or discharge from acute medical assessment/admission units (AMAUs) and the reasons for longer length of stay.Design/methodology/approachDetails relating to consecutive patients were noted on a proforma by medical and nursing staff and were recorded over a three‐month period in 1638 patients. These included evidence of chronicity of disease, level of independence and recent contact with primary care services.FindingsAge is an important factor in deciding admission or discharge. There is evidence that an opportunity for early intervention, to prevent admission, exists in a significant proportion of patients.Practical implicationsThere is a need to develop a more integrated health care system to provide a more co‐ordinated approach to acute medical patients needs, keeping people in their own homes whenever possible.Originality/valueThe increasing number of acute medical admissions provides a challenge throughout the UK. This paper delineates the problem in a typical District General Hospital (DGH) and discusses approaches to decrease admission whilst improving patient care.

Is the Number of Documented Diabetes Process-of-Care Indicators Associated With Cardiometabolic Risk Factor Levels, Patient Satisfaction, or Self-Rated Quality of Diabetes Care?

Simple process-of-care indicators are commonly recommended to assess and compare quality of diabetes care across health plans. We sought to determine whether variation in the number of simple diabetes processes of care across provider groups is associated with variation in other quality indicators, including cardiometabolic risk factor levels, patient satisfaction with care, or patient-rated quality of care. We used cross-sectional survey and chart audit data for 8,733 patients with diabetes who received care from 68 provider groups nested in 10 health plans that participated in the Translating Research Into Action for Diabetes study. Analyses using hierarchical regression models assessed associations of the mean number of seven simple process measures with each of the following: HbA(1c) (A1C), systolic blood pressure (SBP), HDL and LDL cholesterol levels, patient satisfaction with care, and patient-rated quality of care. After adjusting for case-mix differences across groups and plans, an average of one additional documented process of care for each patient in a group or plan was associated with significantly lower mean LDL cholesterol levels (-4.51 mg/dl [95% CI 1.46-7.58]) but not with A1C, SBP, or HDL cholesterol levels. The number of care processes documented was associated with patient satisfaction measures and self-rated quality of diabetes care. Variation in the number of simple process-of-care indicators across provider groups or health plans is associated with differences in patient-centered measures of quality, but assessment of the quality of cardiometabolic risk factor control will require more advanced clinical performance indicators.

Évolution de l'autonomie fonctionnelle en soins de suite gériatriques : un indicateur de performance ?

The objective of this study was to compare the evolution of the level of functional dependence of patients between the time of their hospital admission and release following treatment received in the geriatric medium-term care units, in order to propose this variable as a clinical performance indicator for this type of service. The differential score of physical dependence observed was determined for each hospital stay, and the adjusted significant functional improvement rate (SFI) was calculated for every unit. This adjusted SFI rate was then compared to the overall rate of all of the units combined. The overall SFI rates were 23% in 2004. Seven of the 49 units studied present an adjusted rate significantly inferior to the average rate of the total number of units combined. This study constitutes one of the first performance analyses in the medium-term sector, and the adjusted SFI rate seems to be a pertinent and reliable indicator within this framework.

Improving Patient Retention After Botulinum Toxin Type A Treatment

Botulinum toxin treatments have been associated with consistently high patient satisfaction rates, but calculation of patient retention rates is not routinely performed. Retention measurements serve as critical indicators of clinical performance and can be optimized by evaluation of current office policies and implementation of strategies to improve patient retention. To investigate the reasons patients discontinue botulinum toxin treatments and to evaluate the effect of a single intervention intended to improve patient retention. A retrospective chart review was performed of all patients who received botulinum toxin injections in a private cosmetic dermatology practice over a 2-year time period to determine the patient retention rate. Patients who had discontinued botulinum toxin treatment after a single session were surveyed to discern their reasons for terminating treatment. A change in office policy was instituted wherein all patients who received their first botulinum toxin treatment were required to undergo a 2-week post-treatment evaluation to determine treatment effect and to receive touch-up treatment as necessary. Retention rates were calculated over the 1-year period immediately after initiation of the new policy. The initial patient retention rate was 55%. The most common reasons cited for discontinuance of botulinum toxin treatments were procedural cost, patient failure to re-schedule, perceived lack of product longevity, and clinical effect falling short of expectations. After initiation of the mandatory 2-week post-treatment office evaluation, a 67% patient retention rate was achieved. Managing patient expectations of botulinum toxin treatments and mandatory post-treatment appointments for evaluation of the initial procedure increase the patient retention rate.

Monitoring leave in a secure unit: A clinical performance indicator?

This study is a descriptive survey that arose out of an audit project commenced in 1994 at a medium secure unit in the west of England. The absconsion rate of patients on leave was measured, evaluated on an annual basis, and set against an arbitrarily defined ideal rate. Over the next eight years, apart from one, the clinic consistently met this target. What this indicated in terms of good practice and whether it was a valuable measure of clinical performance is explored. The method and results of this study are described and the authors discuss the potential significance and drawbacks of this kind of evaluation. It is concluded that this single measure is only of value when considered in the context of a range of factors indicating good clinical performance.

Comparing Bloodstream Infection Rates: The Effect of Indicator Specifications in the Evaluation of Processes and Indicators in Infection Control (EPIC) Study

Bloodstream infection (BSI) rates are used as comparative clinical performance indicators; however, variations in definitions and data-collection approaches make it difficult to compare and interpret rates. To determine the extent to which variation in indicator specifications affected infection rates and hospital performance rankings, we compared absolute rates and relative rankings of hospitals across 5 BSI indicators. Multicenter observational study. BSI rate specifications varied by data source (clinical data, administrative data, or both), scope (hospital wide or intensive care unit specific), and inclusion/exclusion criteria. As appropriate, hospital-specific infection rates and rankings were calculated by processing data from each site according to 2-5 different specifications. A total of 28 hospitals participating in the EPIC study. Hospitals submitted deidentified information about all patients with BSIs from January through September 1999. Median BSI rates for 2 indicators based on intensive care unit surveillance data ranged from 2.23 to 2.91 BSIs per 1000 central-line days. In contrast, median rates for indicators based on administrative data varied from 0.046 to 7.03 BSIs per 100 patients. Hospital-specific rates and rankings varied substantially as different specifications were applied; the rates of 8 of 10 hospitals were both greater than and less than the mean. Correlations of hospital rankings among indicator pairs were generally low (rs=0-0.45), except when both indicators were based on intensive care unit surveillance (rs = 0.83). Although BSI rates seem to be a logical indicator of clinical performance, the use of various indicator specifications can produce remarkably different judgments of absolute and relative performance for a given hospital. Recent national initiatives continue to mix methods for specifying BSI rates; this practice is likely to limit the usefulness of such information for comparing and improving performance.