Instrument For Quality Assurance Research Articles

Organisation von Studienteilnahmen in der hämatoonkologischen Praxis

Organisation of Study Inclusion in Private Practices for Haematology and Oncology Haemato-oncological studies in private practices for haematology and oncology have been identified as an important instrument for quality assurance in the treatment of haemato-oncological patients. As the organisational structures of private practices for haematology and oncology are usually highly complex the inclusion into studies needs a high motivation and binds resources. Workflow was observed in four private practices for haematology and oncology. With this data, suggestions for a common workflow model for study inclusion in private practices were elaborated and are discussed in this article. A common workflow-model of study inclusion for private practices is illustrated in two flow charts. If patients are to be successfully included in studies, additional structures and resources have to be implemented. Beyond this the necessary steps for study inclusion must be incorporated into the everyday routine of the practices.

Psychometric properties of the parental stressor scale: infant hospitalization.

This article reports the development and psychometric properties of the Parental Stressor Scale: Infant Hospitalization (PSS:IH), an instrument designed to measure parents' perceptions of stress associated with having their infant admitted to the hospital. Eighty-one mothers and 43 fathers of medically fragile, hospitalized infants.Design and methods Psychometric study of the PSS:IH, an instrument that was adapted from the Parental Stressor Scale: Neonatal Intensive Care Unit (PSS:NICU) using literature review, parent interviews, and professional experts. Psychometric analysis was conducted from data collected in a longitudinal study of parents of medically fragile infants. Main outcome measure PSS:IH. Correlation coefficients demonstrate its internal consistency reliability. Construct validity is supported by significant correlations between the PSS:IH scores during hospitalization with maternal distress after discharge. The PSS:IH can be used as an outcome assessment instrument for quality assurance and in clinical research. Additional research could evaluate the scale for use in different populations and settings.

Patient satisfaction with psychiatric services. Findings of a key date survey

The aim of this study was to gain more empirical ideas for the concept of patient satisfaction and its usefulness as an instrument for quality assurance by analyzing the relationship between inpatient experiences and inpatient satisfaction with psychiatric services. Data were obtained from 91 inpatients of the Psychiatric Hospital of the Ludwig-Maximilians-University in Munich (85% of all patients who had been in hospital at least 3 weeks and who could be asked) by questionnaires on a fixed day. Patients had been asked about their overall satisfaction as well as their experiences with special aspects of the services.Overall satisfaction was high, but there was a remarkable amount of adverse experience with components concerning patient information and time with a psychiatrist offered to the patients. The results give evidence that communication and empathy of the medical staff are key indicators of patient satisfaction and dissatisfaction. Furthermore, results suggest that global satisfaction scores should not be used as an instrument of quality assurance.

Preventive health care measures before and after start of renal replacement therapy.

To describe utilization of preventive health care measures in patients with chronic kidney disease (CKD), both in the year prior to onset of renal replacement therapy (RRT), and in the first year of RRT. We identified a large cohort of patients with CKD in the New Jersey Medicaid and Medicare programs with fixed enrollment into the cohort at 1 year prior to RRT. We applied commonly used quality assurance instruments (Health Plan Employer Data and Information Set measures) and defined levels and correlates of use of preventive care measures before and after RRT. These included mammography, Pap smear testing, prostate cancer screening, diabetic eye exams, and glycosylated hemoglobin testing (HbA1c). We employed logistic regression models with adjustment for age, race, gender, comorbidity, timing of first nephrologist contact, socioeconomic status, and calendar year of first RRT. Overall, screening rates were low with the exception of diabetic eye exams. Prostate cancer screening, diabetic eye exams, and HbA1c testing were performed less often after onset of RRT compared to the year before (P < .05). Although screening rates before RRT improved considerably over the period of observation for these measures (P < .05), this was not the case once patients were on RRT. Preventive health care interventions remain underutilized among RRT patients. Greater attention to such preventive measures could lead to significant improvements in the health status of such vulnerable patients. Thus, quality improvement of the general health care for patients on RRT should become a priority in renal health policy.

An analysis of the completion of physiotherapy clinical records in Gauteng Province.

The purpose of this study was to rate the completion of physiotherapy assessment, treatment and progress records in the Gauteng province of South Africa. There is a dearth of literature on physiotherapy patient records, yet it has been demonstrated that clinical records have significant implications for quality of care, resource allocation, research and for professional litigation.A combined retrospective and prospective research design, using a quality assurance instrument was used to rate the completeness of physiotherapy records obtained from multiple study sites. Breakdown in clinical recording in the following areas is described:areas of care (private and public sectors),patient conditions (e.g. orthopaedic and surgical)patient categories (in and out patients),section of the record (e.g. demographics, physical examination), andproviders of care (physiotherapists, physiotherapy assistants and physiotherapy students).The 644 records analyzed scored a mean overall completion rate of 64%. There was a significant difference observed in overall record completion (p = 0.0004) between private and public sector providers. Significant differences were also observed for each section of the record. Factors most associated with a high degree of completion of physiotherapy patient records included; private sector physiotherapy services, use of pre-formatted assessment charts and clinicians’ participation in relevant continuing education.Physiotherapy patient records in Gauteng were found to be incomplete. The implications of this finding in an increasingly competitive global, national, corporate and domestic healthcare arena include; physiotherapy service quality, professional litigation, resource allocation and policy development, as well as professional growth, development and satisfaction with ones’ career. Recommendations on how the physiotherapy profession can improve clinical recording from an educational, clinical and managerial perspective are suggested.

Can the classification of patients for phase B, C and D of neurological rehabilitation be done by FIM(tm) scores?

The classification of patients for phase B, C and D of neurological rehabilitation follows the suggestions of the Bundesarbeitsgemeinschaft für Rehabilitation (BAR) based on defined clinical criteria and on neurological rehabilitation assessment. The focus of this study is to define the intervals of the complete FIM(tm)-index, intervals covered empirically as well as by evaluations of physicians, that permit utmost accuracy in assigning patients to phase B, C and D of neurological rehabilitation. Therefore, data records of 3686 patients from 4 neurological rehabilitation centres were evaluated. The patients' functional autonomy was classified by FIM(tm) on admission, in intervals of 14 days and at discharge, at the same time all patients in addition were assigned to phases B, C or D by the rehabilitation centre physicians. Statistical analysis of a total of 11,247 links of the phase classifications and FIM-indexes at 6 measurement points showed that correct correlation to phase B, C and D could be obtained on average in 79 to 89 % of the cases, based on the assumption that 18 - 36 points of the FIM-index assign to phase B, 37 - 90 points to phase C and 91 - 126 points to phase D. Discrimination between phases B and C could be obtained accurately in an average of 84 %, discrimination between phases C and D in an average of 89 %. Conformance of the FIM-intervals with TAR-based groups of care efforts compared to the evaluation by physicians indicate that the FIM(tm) represents the need for care with greater validity. If assignment to phases B, C and D would have been done on the basis of the FIM-index instead of evaluation by a physician, 8,9 % fewer patients would on admission have been classified for phase C but, instead, 4,5 % more patients for phase B and 4,4 % for phase D. In case of using the FIM-intervals for classification, 12,1 % more phase B patients could have changed to phases C or D. Of the phase C cases, 17,7 % could have been transferred to phase D before discharge. The number of phase D patients would have remained unchanged comparing admission and discharge. FIM-orientated classification for the phases of neurological rehabilitation offers considerable advantages: operationalized criteria, possibility of statistical evaluation, objectiveness, reliability, validity, reproducibility of the decisions, sensitivity to change, prognostic sensitivity, and suitability as an instrument for internal and external quality assurance.

Care-as-service, care-as-relating, care-as-comfort: understanding nursing home residents' definitions of quality.

This study explored how nursing home residents define quality of care. Data were collected through in-depth interviews and were analyzed using grounded dimensional analysis. Residents defined quality in three ways: (a) Care-as-service residents focused on instrumental aspects of care. They assessed quality using the parameters of efficiency, competence, and value. (b) Care-as-relating residents emphasized the affective aspects of care, defining quality as care that demonstrated friendship and allowed them to show reciprocity with their caregivers. (c) Care-as-comfort residents defined quality as care that allowed them to maintain their physical comfort, a state that required minute and often repetitive adjustments in response to their bodily cues. Residents' perceptions of care quality have implications for long-term care practice. The integration of these perceptions into quality assurance instruments could improve the usefulness of tools designed to obtain resident input.

Evaluation of missed diagnoses for patients admitted from the emergency department.

To define a quality assurance instrument to evaluate errors in diagnostic processes made by physicians in the emergency department (ED). This was a retrospective clinical investigation of inpatient ED records. Over a six-year period, 5,000 medical records of admitted patients were randomly selected for evaluation. Each record was initially examined by one of five physician evaluators. If the primary ED diagnosis differed from the primary discharge diagnosis, the ED record was inspected to determine reasons for the misdiagnosis. The authors considered several aspects of the diagnostic process, including patient history, tests ordered, interpretation of clinical data, choice and performance of procedures, injury pattern recognition, reasoning, and evaluation. Records that demonstrated errors in the diagnostic process were reevaluated for the same diagnostic process errors by a sixth physician. Disagreements regarding suspected errors in the diagnostic process were settled by discussion. Finally, to determine potential medical consequences of the misdiagnosis, one individual reviewed the complete medical records of patients whose ED medical records were scored with errors by both evaluators. Interevaluator reliability was assessed using Cochran's Q-test with a selected series of medical records. Twenty-eight records (0.6%) were found to contain one or more errors in the diagnostic process that contributed to misdiagnosis. For these patients appropriate diagnosis was not made until one to 16 days after admission. Three patients of 18 whose records were available for detailed review may have suffered complications that resulted, in part, from the delay in diagnosis and subsequent treatment. Significant interevaluator reliability for identification of errors in the diagnostic process was obtained (p > 0.1). A two-tiered evaluation of ED records selected by inconsistent initial and final diagnoses can be used reliably to screen for errors in the diagnostic process made by emergency physicians (EPs). The rate of physician error contributing to a misdiagnosis is very low, suggesting that EPs are delivering quality patient care.

Quality assurance in ENT tumor surgery

Quality control is of special importance in head and neck oncology since the quality of medical care constitutes a vital parameter for the diseased patient. In contrast to other medical specialties, no quality assurance program for head and neck cancer patients has yet been established in Germany. Therefore, a survey was conducted to assess the quality assurance instruments that are in use today in otorhinolaryngology-head and neck (ORL-HNS) centers. In a nationwide survey, questionnaires were sent out to 146 German ORL-HNS departments (the return rate was 75%). 56% of all departments apply dedicated quality assurance processes, and 38% have appointed a formal quality assurance officer. Interdisciplinary oncological conferences are held in the vast majority of all departments with the participation of radiation oncologists in 86 (78%), medical oncologists in 84 (76%), diagnostic radiologists in 82 (74%), and pathologists in 73 (66%). Morbidity-mortality conferences are held in seven departments (6%). A standardized follow-up of oncological patients is carried out in 95 units (86%), and 53 departments use computer-assisted data bases to organize their follow-up data (48%). A wide variety of documentation systems is in use throughout the country: 78 units (71%) offer formal follow-up to their oncological patients. This survey documents a wide-spread interest in quality assurance procedures. Many individual efforts are being undertaken. However, no uniform quality assurance or auditing system is currently in use in Germany nor is a commonly accepted data base available. The ability to offer oncological follow-up within the national social security system is generally considered indispensable for the maintenance of high-quality oncological care in ORL-HNS departments.

Computer-assisted tool (QUAST) for documentation and quality assurance in pain treatment

In chronic pain patient's diagnostic and therapy planning many complex information must be evaluated and analysed. The variety of data cannot be mastered without assistance of a database tool adapted to these special need. On the base of FileMaker Pro 5.0, a user-friendly and analysis-oriented database environment for documentation and quality assurance in pain therapy (QUAST) has been developed. QUAST has been tested for 2 years by 23 pain clinics in Germany including data of more than 14.000 patients. Among patients'demographic and clinical data all 335 fields of the validated German pain questionnaire are included in QUAST together with psychometric test procedures (CES, SES, PDI, SF-36). We developed a outcome questionnaire for the evaluation of treatment - related changes of outcome variables (103 fields), a daily questionnaire (11 fields) and a protocol to assess the effects of neural and other blockades (144 fields). All data of therapy and outcome can be documented (total number of the fields: 2661). The test results (e. g. in the form of total or compound scores) can be analysed and printed. For pain related diagnoses, procedures, blockades, drugs, expected and unexpected events hierarchical coding systems (altogether 72,157 data records) have been developed. These can be assigned automatically to coding systems like ICD-10 or ICP-M. Due to its ability of export into other databases and already enclosed routines QUAST permits an internal assurance of quality of process and outcome in pain management. It also can be an instrument of an external quality assurance. QUAST is at present the only computer system available in Germany, to fulfil the required prerequisites for adequate quality control.

Field Testing of Stabilized Soil

Remediation of a Superfund site in Stratford, Connecticut, involved stabilization of the subgrade with portland cement. Part of the remediation site was to be used as a parking area. The stabilized soil was to be covered with natural base/subbase course materials and capped with an asphalt concrete cover. During the course of the remediation, a base-course layer could not be placed prior to the onset of winter. A field study was conducted to quantify any changes in the mechanical properties of the open stabilized subgrade subjected to freeze-thaw cycling during the winter of 1996-1997. Field evaluation was conducted with pavement industry tools: the Clegg impact hammer and the dynamic cone penetrometer. Evaluation results show the viability of the Clegg hammer as an instrument for quality assurance and also show that there can be up to 50% loss in compressive strength of the subgrade within the uppermost layer of the material caused by freeze-thaw cycling.

The Geriatric Minimum Data Set (Gemidas) of the Federal Association of Clinical Geriatric Facilities e. V. as an instrument for quality assurance in inpatient geriatrics

Geriatric medicine in Germany is faced with an increasing demand for continuous documentation and evaluation of its effectiveness and efficiency. Hence, the Federal Association (FA) of Clinical Geriatric Departments (Bundesarbeitsgemeinschaft der Klinisch-Geriatrischen Einrichtungen e.V.) has funded a working group on improving quality management in geriatrics by developing criteria for quality standards. In 1996, the FA working group achieved consensus on the definition of the Geriatric Minimum Data Set (Gemidas) which covered (i) core information about a patient's age, sex, living arrangement, and (ii) basic characteristics of the hospital course such as location prior to admission and past discharge, leading and accompanying diagnoses, newly prescribed technical aids, objective functional status on admission and at discharge (e.g., Barthel Index (BI), Timed Up & Go (TUG), and intensity of professional care (PPR)), as well as subjectively evaluated attainment of treatment goals. This initial report describes the instrument and presents analyses of its feasibility for routine clinical practice and data consistency. Twenty out of 27 hospitals (74%) integrated Gemidas successfully in daily routine, 75% of which (15 hospitals, total n = 10,567 patients) instantaneously collected data on constant numbers of patients per month. Multivariate regression analyses used to decompose variances of the instrument's central indicators (e.g., BI, TUG, PPR) revealed a satisfactory dimensionality and high consistency (e.g., covering 59% of variance in BI with 53% of variance uniquely attributable to patient characteristics), as well as sensitivity to differences between hospitals (e.g., 12% of variance in duration of stay uniquely attributable to hospital differences after controlling for patients' characteristics). Gemidas appears to be a feasible quality assurance instrument in geriatrics, suitable for compiling its data into a central registry database, which may then be used for analyses across and between hospitals. However, some modifications are still necessary and more detailed analyses needed, before final recommendations can be made.

Incident monitoring in psychiatry.

Critical Incident Monitoring (CIM) as an instrument of quality assurance (QA) has received increasing attention in recent years. The present study was developed to explore a potential role for CIM in QA for clinical psychiatry. A questionnaire was sent to psychiatrists and requested retrospective reporting of clinical incidents, and a pilot study of an inpatient-based incident reporting system was performed. All Fellows of the Royal Australian and New Zealand College of Psychiatry (RANZCP) were sent a questionnaire. Eight psychiatric inpatient services were invited to participate in the pilot study. The returns of the questionnaires were aggregated and analysed to reveal a relatively small number of separate incident types, with little difference between the 'adverse outcome' and 'near-miss' categories. Similar results were found with the pilot study. It was concluded that the development of a unified incident reporting system for use by psychiatric clinicians and psychiatric services may add usefully to existing quality improvement processes.

Performance assessment of patient dosimetry services and X-ray quality assurance instruments used in diagnostic radiology

Experiences of the Regional Radiation Physics and Protection Service (RRPPS) in performance assessment of diagnostic X-ray QA instrumentation and on-patient dosemeters are recounted. Issues relating to the provision of realistic and reproducible reference conditions for calibrated X-irradiations are considered and summary statistics from test measurements of dose and kVp meters are provided. For both dose and kVp meters it is indicated that as many as 25% of instruments used in routine use in the U.K. may require some adjustment before they can truly be said to be performing as the manufacturer intended. Results from intercomparison exercises for patient dosimetry services are also discussed. It is apparent that, for those centres participating in the exercise, dose assessments are generally being obtained to within a bias and a relative standard deviation of less then 10%.

International standards in medical education: assessment and accreditation of medical schools'--educational programmes. A WFME position paper. The Executive Council, The World Federation for Medical Education.

WFME has recently decided to extend its 'International Collaborative Programme for the Reorientation of Medical Education', aiming at the implementation of its educational policy at the institutional level. The first objective is to stimulate educational institutions to formulate their own plans for change and for quality improvement to align with international standards. The second objective is to establish a system to assure minimum quality standards for medical school programmes. Both objectives can be accomplished by publishing a World Register of Medical School, which will constitute an instrument of quality assurance in medical education. The Register should specify designation of a World Register Accreditation of medical schools, which fulfil internationally accepted and approved standards of medical education programmes. The accreditation could be differentiated in various categories.

Esho Quality Assurance Guidelines for Regional Hyperthermia

The Technical Committee and the Clinical Committee of the ESHO evaluated the experience of the institutes which are active in clinical regional hyperthermia using radiative equipment. Based on this evaluation, QA guidelines have been formulated. The focus of these guidelines lies on what must be done not on how it should be done. Subjects covered are: treatment planning, treatment, treatment documentation, requirements and characterization of equipment, safety aspects, hyperthermia staff requirements and instrumentation for quality assurance.

Quality assurance in benign thyroid diseases surgery

Quality assurance (or quality management) in surgery is of topical interest. Together with the Institute of Biomedical Engineering and Informatics of the Ilmenau Technical University, we have developed the computer-assisted documentation system SCHILDDOK to improve quality assurance in benign thyroid surgery in our hospital. SCHILDDOK has been recognized as a new concept and has been integrated in the daily work routine. That way, documentation does no longer mean an additional workload, but constitutes a productive part of routine work. According to our previous experiences SCHILDDOK appears to be an exceedingly valuable tool in internal quality assurance particularly because of its standardized data recording. The databadse SCHILDDOK could also be employed as an instrument of external quality assurance in various hospitals. By interconnecting them in a computer-network a comparison of the complication rate in these hospitals would be possible. If the results are checked by a superordinate institution. This would be equivalent to an external audit. There have to be uniform definitions to guarantee comparability of the data. Our suggestion is to define the rate of recurrent nerve paresis as the rate of newly occurring recurrent nerve pareses related to the side operated on. As standardized definition for the recurrent goitre we suggest: a goitre recurring at the operated side. In our opinion you can enhance quality assurance with SCHILDDOK in benign thyroid, diseases surgery.

Well-being and treatment satisfaction in adults with diabetes: a Swedish population-based study.

In order to implement the St Vincent Declaration programme, instruments for quality assurance of medical outcomes as well as measures of psychological outcomes of diabetes care had to be developed. This paper presents baseline values for three questionnaires measuring psychological Well-being, Treatment Satisfaction and General Health among a representative sample of adult people with diabetes in Sweden consisting of 423 individuals of which 153 were insulin treated and 270 were diet/tablet-treated. Cronbach's alpha indicated that each of the Well-being and Treatment Satisfaction subscales was internally reliable, alphas ranging from 0.66-0.88. Factor analysis resulted in identification of five subscales (depression, anxiety, positive well-being, treatment satisfaction and metabolic control). There was no relation between any of the quality of life subscales with HbA1c, BMI, duration of diabetes, frequency of blood glucose tests per day, insulin regimens or diabetic complications. Females reported a more negative impact of diabetes on daily life compared with males (p < 0.001). In conclusion, the Well-being and Treatment Satisfaction scales are reliable for quality assurance purposes in diabetes while the briefer general health instrument provides a useful assessment of the global impact of a chronic disease.

The European Conformity Assessment Procedures and the Quality Assurance Instruments for Personal Protective Equipment in the Internal Market.

Conformity assessment procedures prescribed by European legislation are presented and their concrete implementation is illustrated by the example of personal protective equipment (PPE). The different categories of PPE defined by Council Directive 89/686/EEC are explained with reference to the applicable conformity assessment elements. Quality assurance of production is presented as the central element of the conformity assessment procedure for complex PPE. Special emphasis is put on the necessity of having a regular exchange of views and information among notified bodies in Europe. Ways in which third countries can eventually carry out conformity assessment on the basis of a contract with the European Community Commission are explained.

Goal Attainment Scaling as a Method of Monitoring the Progress of People with Severe Learning Disabilities

This paper describes a small pilot project carried out in Bradford in 1991/92, with the aim of assessing the efficacy of goal attainment scaling (GAS) as a tool for setting, monitoring and evaluating goals for people with learning disabilities who attended a day centre. GAS was found to be effective in that service users made good progress towards their goals, and staff found the system simple and quick to use. Since the day centre pilot project the GAS programme has been developed further and introduced into other parts of the learning disabilities service. Following the introduction of a training package aimed at equipping staff with a basic knowledge and understanding of GAS, it is anticipated that staff in both day and residential services will be able to take more of a leading role in the implementation and monitoring of GAS in their own establishments. It is envisaged that the wider implementation of GAS will not only assist in meeting the individual needs of the service's clients, but will also be a valuable quality assurance instrument which will help services evaluate their own performance.