Quality in health care : QHC最新文献

Objective: To develop review criteria to assess the quality of care for three major chronic diseases: adult asthma, stable angina, and non-insulin dependent diabetes mellitus.

Subjects and methods: Modified panel process based upon the RAND/UCLA (University College of Los Angeles) appropriateness method. Three multiprofessional panels made up of general practitioners, hospital specialists, and practice nurses.

Results: The RAND/UCLA appropriateness method of augmenting evidence with expert opinion was used to develop criteria for the care of the three conditions. Of those aspects of care which were rated as necessary by the panels, only 26% (16% asthma, 10% non-insulin dependent diabetes, 40% angina) were subsequently rated by the panels as being based on strong scientific evidence.

Conclusion: The results show the importance of a systematic approach to combining evidence with expert opinion to develop review criteria for assessing the quality of three chronic diseases in general practice. The evidence base for the criteria was often incomplete, and explicit methods need to be used to combine evidence with expert opinion where evidence is not available.

Objectives: To discover the views of patients about their experiences across the interface between primary and secondary health care, including referral from general practitioners, outpatient and inpatient care, discharge, and aftercare.

Design: A qualitative study involving individual and focus group interviews of patients and interviews of carers.

Subjects: 33 patients who had attended at least one outpatient appointment or had been an inpatient between two and four months previously, and eight carers of patients with chronic conditions.

Setting: Three acute hospitals and one community health service in Leicestershire.

Main outcome measures: Common themes in the views of patients and carers towards their experiences of care.

Results: Five themes emerged. The first four were: "getting in" (access to appropriate care), "fitting in" (orientation of care to the patient's requirements), "knowing what's going on" (provision of information), and "continuity" (continuity of staff and coordination and communication among professionals). The fifth theme was "limbo" (difficulty in making progress through the system), which was influenced by failures in care in relation to the other four themes.

Conclusions: The concept of progress is central to patients' views of care. It involves both progress through the healthcare system and progress towards recovery or adjustment to an altered health state. Patients' views on how well they progress through the healthcare system may be an appropriate indicator for monitoring health service performance.

Objectives: To evaluate the feasibility of a model for continuous quality improvement in small scale general practice and the improvement projects that practices ran after the introduction of continuous quality improvement.

Design: A descriptive study.

Setting: Twenty general practices in the Netherlands tested the model in an intervention period of 18 months.

Intervention: A model for continuous quality improvement adapted for general practice was introduced into the practices using a structured strategy. Practices were supported by trained facilitators.

Main outcome measures: Acceptance at introduction and continued application of the model; the topics of improvement projects that were set up in the practices; whether the improvement projects had been completed; whether they had met the criteria (the use of the "quality cycle" and the Oxford audit score); and whether the self set objectives had been met.

Results: The model was introduced and accepted in all participating practices. Practices started 51 improvement projects. At the end of the study period 33 improvement projects had been completed. Practices chose a wide variety of objectives for these projects; most of them concerned medical or organisational topics. Practices started projects mainly because the topic was felt to be a problem or was causing a bottleneck in the organisation. The quality cycle was used in all projects, but practices did not always collect data and evaluate the outcomes. Fourteen projects could be discerned as "full audit". No differences existed in the quality of improvement projects among the various types of practice or between the topics addressed. At the end of the study period half of the practices continued applying the model.

Conclusion: This study showed that the model was feasible for small scale general practice. However, application of the model tended to disintegrate after the facilitator had left the practice. Practices succeeded reasonably well in running improvement projects. Introduction of continuous quality improvement should particularly focus on this. It is suggested that intensive support is necessary to implement and maintain continuous quality improvement in small scale practices.