Journal of quality in clinical practice最新文献

Abstract A planned surgical admission is a major event for a patient and, when cancelled, not only causes great distress to the patient and relatives but is also a frustrating waste of resources if a fully staffed operating theatre lies idle. At Westmead Hospital, a bed management team was established with the appointment of a Clinical Nurse Consultant as Bed Manager to co-ordinate admissions in conjunction with all staff involved in the processing of surgical patients. Despite a reduced number of available surgical beds, throughput was maintained with a significantly reduced number of cancelled booked cases, which decreased to zero and have remained so since the end of 1995. It has been found that it is possible to achieve a situation where all booked surgical patients can be admitted as planned while still providing for emergency patients. This requires a co-ordinated approach with an emphasis on teamwork led by a dedicated Bed Manager working with medical and nursing staff on surgical wards together with the bookings office, pre-admission clinic, operating theatre and anaesthetics department.

Abstract A retrospective audit of inpatient falls at the Gold Coast Hospital was conducted in August 1996. This collaborative approach of occupational therapy and nursing staff aimed to reduce the number of patients falling while they were hospital inpatients. From the first audit a number of high risk patient groups, activities and ward environments were identified and a falls prevention program implemented. A second audit conducted 2 years later demonstrated a decrease in falls and related injuries. This paper discusses the findings of the falls audit and presents the ‘Fall STOP’ falls prevention program that was initiated.

Abstract There is increasing recognition that many quality management initiatives in health care are undertaken without the appropriate development of a responsive and supportive organizational environment. In the present study, a multidisciplinary team was empowered to make appropriate changes in order to improve a variety of problem areas that affected the total pathology service of the hospital. Major changes were initially undertaken to develop a quality management environment. The four elements found to be important to the creation of the Total Quality Management (TQM) environment were change in management culture, development of teamwork, focus on customers, and continuous feedback to staff. The accomplishment of the TQM was assessed and confirmed using criteria developed by the Pathology Project TQM Team. As the TQM approach is process driven, it should be adaptable to other clinical situations and not just to pathology services. Potential barriers to achieving the required organizational environment are also explored.

Abstract All John Hunter Hospital readmission data for October 1998 were examined. Twenty-four readmissions out of 3081 total admissions (0.8%) were defined as adverse events (unplanned readmissions) being nominally due to inappropriate medical management. The 24 adverse events comprised 5.5% of the 437 readmissions. A further five readmissions occurred because scheduled theatre was cancelled. Remaining readmissions were due to the condition of the patient in each case. Of the 16 highly preventable adverse events, 10 were allocated to the minor temporary category of severity. It is difficult to evaluate these readmission rates because there are no comparable findings in other Australian studies. The adverse events showed no particular association with patient age, sex, hospital of original admission or hospital specialty. While they were technically preventable, after medical record review a senior clinician identified these as extremely difficult cases, indicating that better outcomes may not have been possible.

Abstract Rehabilitation at home is a new ‘technology’ which has been promoted as an efficient alternative to hospital rehabilitation for older patients with conditions such as fractured hip. In Australia, no formal description of elderly patients with fractured hips likely to be eligible for home rehabilitation has been made and the acceptability of such services is unclear. Using information obtained prospectively from a consecutive sample of 188 patients with a fractured hip we describe the characteristics of older adults who were eligible for a trial examining home versus hospital rehabilitation. While staff assessed 36% of patients as eligible, only 20% were both eligible and agreeable. Reasons for refusal to participate included a preference for inpatient rehabilitation (26%), family reluctance (26%) and anxiety regarding the ability to manage at home (16%). Our results suggest that home rehabilitation is suitable for the least disabled group but is still unacceptable to many elderly patients and their families. As the population ages and hip fractures increase, home rehabilitation in its current form will have little impact on future bed needs.

Abstract Increasing integration of health care and health services research has resulted in an overlap between disciplines involved in the evaluation of clinical practice. We have examined the relationships of quality assurance (QA), medical technology assessment (TA), clinical epidemiology (CE) and evidence-based medicine (EBM) from an historical perspective. Clinicians, patients and administrators need local information on effectiveness of routine care. Information from trials alone, efficacy data, will not suffice nor can it be culled from administrative databases designed for other purposes. The current activities of QA should be therefore be expanded to include the study of the effectiveness of interventions in terms of appropriateness of use, patient outcomes and study of the determinants of outcomes, as seen from the perspective of doctors, patients, administrators and policy makers, using data collected during the course of routine patient care. With the assistance of information technology, with methodological support and multidisciplinary cooperation, clinicians can do this as part of a more broadly defined clinical research. Quality assurance and TA both evolved with the objective of studying clinical care but have quite different historical roots, complementary perspectives and objectives, use different methods and involve a different set of practitioners. Quality assurance is a type of ‘formative’ evaluation conducted in the clinical setting using indicators as flags of process or outcome events of interest, simple surveys and audit studies. Its primary aim is to achieve incremental improvement rather than to simply pass judgement. An important underlying assumption is that health care behaves as a complex dynamic system. Technology assessment, a form of summative evaluation with an orientation towards policy, synthesises information from formal scientific studies of efficacy in the form of clinical trials and studies of cost-effectiveness. For the evaluation of the impact of any technology more complex than a drug, the complementary contributions of both of these disciplines is needed, and QA and TA should work cooperatively in tandem with the support of CE and EBM.