Quality in health care : QHC最新文献

Aims: To describe the views of key healthcare professionals on the changes they considered to be important in the reduction of major trauma mortality between 1988 and 1995 in Leeds.

Methods: Qualitative unstructured interviews with a purposive sample of 10 healthcare professionals deemed to be key personnel by an experienced consultant who had provided acute trauma care throughout the relevant period. Each interview was tape recorded and transcribed; each transcript was analysed for important themes by two independent researchers who then discussed their results to resolve any differences in interpretation.

Results: Three categories of change became evident: "policy", "infrastructure", and "philosophy of care". Each of these categories seemed to be equally important. Policy changes identified as important were the Royal College of Surgeons of England's report into trauma care (1988), the setting of standards for paramedic training, and the national audit of major trauma outcomes. Important infrastructure changes identified were training in advanced trauma life support, decreased ambulance response times, reorganisation towards "consultant led" hospital services, and an emphasis on quality monitoring. Changes in philosophy of care were increases in levels of teamwork, commitment, communication, and confidence. Together these facilitated an overall restructuring and refocusing of care.

Conclusions: No individual change is seen as dominant for improved care, but rather a strategic mixture of facilitating national and regional policy guidance, organisational restructuring, and congruent professional attitudes were integral components leading to the observed changes. Improving outcomes in other areas is likely to involve an integrated series of changes which must be managed as a total system.

Objective: To evaluate patients' views on the process and outcome of day surgery in Scotland, and to study patients' satisfaction with care in a range of specific procedures.

Design: Questionnaires completed by a census of day case surgery patients within a band of 25 procedures under the umbrella of five broad groups: (1) general surgery; (2) urology; (3) gynaecology; (4) orthopaedics; (5) ear, nose, and throat; ophthalmology.

Setting: 13 hospitals in six health board areas in Scotland.

Subjects: During the period 1995-6, 5069 day case patients were asked to complete a questionnaire within two weeks of their operation and discharge from hospital.

Main outcome measures: Arrangements before admission; immediate postoperative symptoms and complications; problems experienced after discharge; readmission after discharge.

Results: A response rate of 68% was obtained from 13 sites ranging from 43% to 82%. The overall satisfaction score was 85. A total of 894 patients (26%) experienced pain after surgery and 783 (23%) had relatively minor medical problems after discharge. In total, 265 (7.8%) patients were readmitted to hospital after discharge. Few notable differences existed between specialties or hospitals in terms of satisfaction scores, although notable pain was experienced more frequently in gynaecology and general surgery patients. Readmission was more common for urological procedures.

Conclusion: Overall, patient satisfaction with day case surgery was high. Dissatisfaction was largely related to waiting times between admission, operation, and discharge. The amount of pain experienced also had a notable impact on the level of patient satisfaction. Day surgery is not without complications, with 26% of patients experiencing notable degrees of pain; 23% having minor medical problems after discharge; and 8% of respondents having to reattend hospital with problems relating to their original operations.

There has been growing interest in recent years in the application of the principles of evidence-based medicine (EBM), although implementation is complex. Scientific, organisational, and behavioural factors all combine to shape clinical behaviour change. Case study based qualitative data are presented which illuminate such processes within one clinical setting (elective orthopaedics), drawn from a larger study. It is suggested that (1) there are alternative models of what constitutes "evidence" in use; (2) scientific knowledge is in part socially constructed; and (3) clinical professionals retain a monopoly of technical knowledge. The implication is that there may be severe obstacles to the rapid or broad implementation of EBM.

Objectives: To assess the reliability, validity, and responsiveness of a new quality of life measure, the patient generated index (PGI) of quality of life, in patients with four common clinical conditions.

Design: Prospective one year follow up study.

Setting: Outpatient departments and four general practices in Grampian, Scotland.

Subjects: 1746 patients consulting a general practitioner in one of four practices, or referred to outpatients from all Grampian practices over a four month period, with low back pain, menorrhagia, suspected peptic ulcer, and varicose veins.

Main outcome measures: Postal questionnaire including the PGI, SF-36 health survey, and clinically derived condition specific measures of disease severity.

Results: Test-retest reliability was satisfactory for group comparisons (intraclass correlation coefficient 0.65). Validity was confirmed by the observed association of the PGI with the SF-36, condition specific instruments, and sociodemographic variables. For low back pain, the PGI and the SF-36 pain scale were found to be most responsive to clinical change. For patients with menorrhagia and suspected peptic ulcer, only the condition specific instruments detected larger changes than the PGI.

Conclusions: It is possible to develop a patient generated index of quality of life that not only assesses the extent to which patients' expectations are matched by reality but also satisfies criteria of reliability and responsiveness to change. Further work is required to make the PGI more acceptable and meaningful to patients, but it is believed that it offers an exciting new approach to the evaluation of medical care.