Journal of quality in clinical practice最新文献

Abstract The quality-of-care in health as a phenomenon is developing through small incremental steps. Some suggest this approach is too slow and more rapid change is warranted. It is possible to achieve more rapid change by reaching a ‘tipping point’ or a critical level. To reach a critical level requires (i) identifying key people, (ii) having an idea that sticks, and (iii) having the right context. Examples from selected aspects of quality in health-care including the use of report cards, recognition and remedial action for adverse events, the substantial reviews of health systems for quality-of-care suggest the critical level has been achieved. However, when the three rules for reaching the ‘tipping point’ are examined closely, it would seem that much more work is required to transform quality in health-care from a snowball into an avalanche.

Abstract In order to determine the nature and extent of drug-related hospitalisation in Australia, the Australian National Hospital Morbidity Collection, the Quality in Australian Health Care Study and Australian studies assessing drug-related hospital admissions were reviewed. The incidence figures, drugs and conditions most commonly implicated, and estimates of avoidability of medication-related problems were compared. The three data sources were found to provide consistent results, with all sources implicating cytotoxics, antirheumatics, anticoagulants, corticosteroids, antihypertensives and cardiovascular agents in medication-related hospitalisations. Estimates of the extent of the problem were also consistent, suggesting that at least 80 000 medication-related hospitalisations occur in Australia each year; between 32% and 69% of these hospitalisations were considered avoidable. It was concluded that medication-related hospitalisations are a major public health problem in Australia. The avoidability estimates suggest that much can and should be done to reduce this problem.

Abstract A major initiative to implement a clinical pathway for myocardial infarction has provided a model on which to further develop pathways within our organization. Two of the primary objectives were to reduce time to thrombolysis and length of stay. Two years after the implementation of the myocardial infarction pathway there has been a reduction in the thrombolysis times from 80 to 49 min and in length of stay from 7.28 to 6.13 days. These results highlight significant improvements in patient and process outcomes. There is heightened awareness about best practice for patients who have sustained myocardial infarctions.

A study was undertaken to identify the causes that contributed to poor quality pathology services for hospitalized patients with acute myocardial infarction. Through the use of continuous quality improvement (CQI) strategies, the procedure involved a systematic process analysis which assessed the types and sources of variation, and possible causal factors for changes in performance. Thirteen suspected causes of poor quality were identified and data collected to confirm or reject their involvement. The study demonstrated that even strongly suspected causes of poor quality need to be confirmed by data. We found that 23% of the suspected root causes were not substantiated by the data collected. The CQI approach was process driven and should be adaptable to other clinical situations and not just pathology services.

Abstract A multidisciplinary workshop was held in order to identify strategies likely to produce a reduction in adverse drug events, by targeting hospital systems involved in drug prescribing, dispensing and administration. Strategies identified at the workshop included: (i) improving the education and practice development of medical and nursing staff, concerning drug therapy and safe prescribing principles; (ii) introducing and using information technology and electronic prescribing processes; (iii) implementing the Australian Pharmaceutical Advisory Council (APAC) national guidelines to achieve the continuum of quality use of medicines between hospitals and the community; (iv) enhancing the importance of medication history taking as a routine part of the admission process; (v) instituting individual patient supply as the standard method of drug distribution in hospitals; and (vi) stimulating the hospital-based clinical pharmacy workforce.

Abstract In an attempt to improve the reporting rate of adverse drug reactions the Adverse Drug Reaction Advisory Committee approached the Australian Council on Healthcare Standards Care Evaluation Program to develop a set of indicators to improve healthcare standards by heightening awareness amongst clinical staff of the morbidity, mortality and financial implications of adverse drug reactions. Ten clinical indicators addressing: (i) reporting of adverse drug reactions; (ii) adherence to treatment protocols for anaphylaxis; (iii) monitoring of warfarin; and (iv) monitoring of streptokinase, were field tested in ten Australian health-care organizations, to determine that the data were available, that the indicators were relevant to clinical practice and that the measures were achievable. Based on the results of this field test, six adverse drug reaction clinical indicators will be introduced into the Australian Council on Healthcare Standards Evaluation and Quality Improvement Program from January 1999.

Abstract There is considerable evidence that a large number of patients suffer adverse events arising from their health-care management. A significant proportion of these iatrogenic injuries occur as a result of medication errors. Before prevention strategies can be developed, it is necessary to understand the types of errors that are occurring. In order to set priorities, it is necessary to identify the frequency and impact of the various types of medication errors. To fully investigate medication incidents, it is necessary to classify the information in a way that allows the frequencies, causes and contributing factors to be analysed. The development of a sub-branch of the ‘Generic Occurrence Classification’, specific to medication incidents, allows this analysis to occur.

Abstract A responsibility of Government is to ensure that safe and efficacious medicines are available for people, from local industry, to treat illness and to maintain health. However, the cost of these medications to the public must be such that access is not denied because of financial barriers. Accessibility alone does not ensure that health outcomes are maximized. It is also necessary to have in place structures and processes which involve all stakeholders in ensuring the quality use of medicines. All of these components need to be incorporated in a national, co-ordinated policy which acts as a reference point for appropriate drug use, policy development and evaluation.

Abstract Routine statistics provide only limited support to doctors and managers responsible for the management of surgical waiting lists. Therefore, a study developed a PC-based model that could assist medium-term planning activities that, for example, aim to reduce excessive waiting times. The model allows the user to create scenarios that describe possible future activity levels and calculates how these will affect waiting list behaviour. A key feature of the model is that it recognizes that a waiting list consists of different categories of patients that move through the list at different speeds. The model can be used with routinely available data. The model was tested at three sites where it proved capable of providing valuable insights and assisting doctors and managers to better understand waiting list dynamics. However, although the model quantified the changes required to reduce waiting times, the sites could not always implement these changes owing to resource constraints.

Abstract Inpatient discharge surveys at Middlemore hospital, a 600 bed hospital in South Auckland, New Zealand, consistently rate communication and co-ordination of care as parameters in need of improvement. A case management model of care was suggested as a means of achieving this. The objective of this study was to determine the effectiveness of care co-ordination in an acute general medical setting in a pilot study over a 4 week period. A care co-ordinator identified 18 patients with complex problems among 48 patients admitted to a single medical ward under the care of a single multidisciplinary team, with their care being co-ordinated over the entire episode of illness. A control group of 59 similarly complex patients admitted to other wards and teams without care co-ordination over the same period was also studied and the outcomes compared. Communication and co-ordination, discharge information, involvement in discharge planning and information on post-discharge services were rated by the study patients as good or very good by 77, 85, 69 and 77%, respectively, compared with 62, 30, 41 and 45% in the control group. The same parameters were rated as poor or very poor by 13, 30, 36 and 15% of the control patients, compared with 0% in all these measures in the study group. Twenty-one clinical staff involved in the study agreed that there was an improvement in care co-ordination with respect to efficiency, reduction of workload and better communication, with approval ratings being 71, 76 and 76%, respectively. There was no difference in Average Length of Stay between the control and study groups, but three of the patients in the control group may have had their preventable readmissions within 10 days avoided if their care had been co-ordinated during their initial admission.