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Performance management tools commonly used in business, such as incentives and the balanced scorecard, can be effectively applied in the public healthcare sector to improve quality of care. The province of Alberta applied these tools with the Institute for Health Improvement Learning Collaborative method to accelerate adoption of a clinical care pathway for hip and knee replacements. The results showed measurable improvements in all quality dimensions, including shorter hospital stays and wait times, higher bed utilization, earlier patient ambulation, and better patient outcomes.

A quasi-experimental study tested a clinical benchmarking tool (Essence of Care) to improve bowel-related care for older people living in six care homes. In the intervention care homes, district nurses and care home staff used the clinical benchmarking tool to discuss and plan how to improve bowel care for residents. In the control care homes, staff were provided with detailed information about the residents and continence services contact details. The intervention was acceptable to care home and district nursing staff, and possible to incorporate into existing working patterns. The study did not demonstrate a significant reduction in bowel-related problems, although there was evidence in one care home of reduction in episodes of avoidable faecal incontinence. At an individual level of care, there were observable benefits, and examples of person-centred care were prompted through participating in the intervention and improved staff awareness. Clinical benchmarking tools can be used to structure discussion between district nurses and care home staff to review and plan care for residents. However, it takes time to achieve change and embedding this kind of approach requires either robust pre-existing working relationships or the involvement of a facilitator.

Benchmarking, a management approach for implementing best practices at best cost, is a recent concept in the healthcare system. The objectives of this paper are to better understand the concept and its evolution in the healthcare sector, to propose an operational definition, and to describe some French and international experiences of benchmarking in the healthcare sector. To this end, we reviewed the literature on this approach's emergence in the industrial sector, its evolution, its fields of application and examples of how it has been used in the healthcare sector. Benchmarking is often thought to consist simply of comparing indicators and is not perceived in its entirety, that is, as a tool based on voluntary and active collaboration among several organizations to create a spirit of competition and to apply best practices. The key feature of benchmarking is its integration within a comprehensive and participatory policy of continuous quality improvement (CQI). Conditions for successful benchmarking focus essentially on careful preparation of the process, monitoring of the relevant indicators, staff involvement and inter-organizational visits. Compared to methods previously implemented in France (CQI and collaborative projects), benchmarking has specific features that set it apart as a healthcare innovation. This is especially true for healthcare or medical-social organizations, as the principle of inter-organizational visiting is not part of their culture. Thus, this approach will need to be assessed for feasibility and acceptability before it is more widely promoted.

Although information is available to guide hospitals and clinics on the medical aspects of disaster surge, there is little guidance on how to manage the expected surge of persons needing psychological assessment and response after a catastrophic event. This neglected area of disaster medicine is addressed by presenting a novel and practical quality improvement tool for hospitals and clinics to use in planning for and responding to the psychological consequences of catastrophic events that create a surge of psychological casualties presenting for health care. Industrial quality improvement processes, already widely adopted in the healthcare sector, translate well when applied to disaster medicine and public health preparedness. This paper describes the development of the tool, presents data on facility preparedness from 31 hospitals and clinics in Los Angeles County, and discusses how the tool can be used as a benchmark for targeting improvement. The tool can serve to increase facility awareness of which components of disaster preparedness and response must be addressed through hospitals' and clinics' existing quality improvement programs. It also can provide information for periodic assessment and evaluation of progress over time.

Quality of care measurement and reporting at the provider, hospital, or health system level has become increasingly common in health systems around the world. Health system performance reports, whether they be confidentially distributed to the provider or made available to the public, are not only used as a stimulus for quality improvement, but can also be used to inform policy, apportion funding, or in rare cases, punish poorly performing providers. In this review, we outline several principles of quality of healthcare measurement and performance reporting, and describe a framework for optimal performance reporting that provides the greatest opportunity for the desired outcome-health system improvement. The quality reporting framework and roadmap that we present invokes opportunities for improving care in the domain of surgical oncology.

Objective: To examine the reliability of quality measures to assess physician performance, which are increasingly used as the basis for quality improvement efforts, contracting decisions, and financial incentives, despite concerns about the methodological challenges., Study Design: Evaluation of health plan administrative claims and enrollment data., Methods: The study used administrative data from 9 health plans representing more than 11 million patients. The number of quality events (patients eligible for a quality measure), mean performance, and reliability estimates were calculated for 27 quality measures. Composite scores for preventive, chronic, acute, and overall care were calculated as the weighted mean of the standardized scores. Reliability was estimated by calculating the physician-to-physician variance divided by the sum of the physician-to-physician variance plus the measurement variance, and 0.70 was considered adequate., Results: Ten quality measures had reliability estimates above 0.70 at a minimum of 50 quality events. For other quality measures, reliability was low even when physicians had 50 quality events. The largest proportion of physicians who could be reliably evaluated on a single quality measure was 8% for colorectal cancer screening and 2% for nephropathy screening among patients with diabetes mellitus. More physicians could be reliably evaluated using composite scores (<17% for preventive care, >7% for chronic care, and 15%-20% for an overall composite)., Conclusions: In typical health plan administrative data, most physicians do not have adequate numbers of quality events to support reliable quality measurement. The reliability of quality measures should be taken into account when quality information is used for public reporting and accountability. Efforts to improve data available for physician profiling are also needed.

We examined research and implementation activities presented at the Centre for Rheumatic Diseases 2007 Conference and other selected literature to identify common themes and posit some "next steps" required to develop self-management programs in the Australian context. Self-management and self-management support are key aspects of optimal chronic disease care, and are effective if implemented appropriately. Health literacy is the foundation for self-management programs and should be fostered within the whole population. We should invest in research and evaluation of self-management because the evidence base is under-developed and inherently difficult to expand. Because patient, carer, clinician and organisational engagement with self-management and self-management support programs are uneven, we need to prioritise activities designed to engage known hard-to-reach groups. We should strive to improve integration of self-management into clinical, educational and workplace contexts. Education and psychological theories can help guide self-management support.

This study provides evidence for reliability (the Cronbach alpha of .76-.94) and construct validity of the Patient-Family-Centered Care Survey developed by the researchers in collaboration with FKP Architects, used to measure and benchmark practice within pediatric institutions. The survey evaluates progress of integrating patient-family-centered care over time and can be triangulated with measurements of desired patient and institutional outcomes.

The balanced scorecard (BSC) has become increasing popular in healthcare organizations. A recent study conducted at the University Health Network in Toronto explored the extent to which the BSC has focused and aligned various organizational units and departments around shared goals and objectives. The evaluation also assessed the BSC's impact on front-line staff and how the development and rollout of the BSC should be modified in the next planning iteration.

Measurements will include mortality, appropriate care, efficiency, harm avoidance, patient satisfaction. Improving health of communities is one of program's primary aims. Goal is to move 50% of participants into the top quartiles for all measures.

This document was written by Task Force 3 of DentEd III, which is a European Union funded Thematic Network working under the auspices of the Association for Dental Education in Europe (ADEE). It provides a guide to assist in the harmonisation of Dental Education Quality Assurance (QA) systems across the European Higher Education Area (EHEA). There is reference to the work, thus far, of DentEd, DentEd Evolves, DentEd III and the ADEE as they strive to assist the convergence of standards in dental education; obviously QA and benchmarking has an important part to play in the European HE response to the Bologna Process. Definitions of Quality, Quality Assurance, Quality Management and Quality Improvement are given and put into the context of dental education. The possible process and framework for Quality Assurance are outlined and some basic guidelines/recommendations suggested. It is recognised that Quality Assurance in Dental Schools has to co-exist as part of established Quality Assurance systems within faculties and universities, and that Schools also may have to comply with existing local or national systems. Perhaps of greatest importance are the 14 'requirements' for the Quality Assurance of Dental Education in Europe. These, together with the document and its appendices, were unanimously supported by the ADEE at its General Assembly in 2006. As there must be more than one road to achieve a convergence or harmonisation standard, a number of appendices are made available on the ADEE website. These provide a series of 'toolkits' from which schools can 'pick and choose' to assist them in developing QA systems appropriate to their own environment. Validated contributions and examples continue to be most welcome from all members of the European dental community for inclusion at this website. It is realised that not all schools will be able to achieve all of these requirements immediately, by definition, successful harmonisation is a process that will take time. At the end of the DentEd III project, ADEE will continue to support the progress of all schools in Europe towards these aims.

This article describes the importance and role of 4 stages of formative evaluation in our growing understanding of how to implement research findings into practice in order to improve the quality of clinical care. It reviews limitations of traditional approaches to implementation research and presents a rationale for new thinking and use of new methods. Developmental, implementation-focused, progress-focused, and interpretive evaluations are then defined and illustrated with examples from Veterans Health Administration Quality Enhancement Research Initiative projects. This article also provides methodologic details and highlights challenges encountered in actualizing formative evaluation within implementation research.

Thirty-nine municipalities in the Netherlands conducted a pilot study to develop and try out a methodology to compare the quality of their sewerage management. The participants chose a multidimensional benchmarking with an emphasis on the aim of improving the working processes within sewerage management. A second goal was accountability to the stakeholders. The benchmarking methodology was based as well on analysing data within a "balanced-score-card" system as on intensive exchange of knowledge and experiences. The pilot resulted in a state of the art overview of the quality of sewerage management in the Netherlands. However, above all, it resulted in the shocking fact that the work is carried out in many different ways which cannot be explained by technical reasons or local circumstances. To pinpoint best practices and actually implement these improvements the learning process must continue after the analysis and presentation of the data. A start has been made to form regional specialist networks for further discussion and exchange of experiences.

Essence of Care and its nine standards were introduced in February 2001 (Department of Health, 2001). These standards require a lot of work from benchmarking groups in clinical areas, and the translation of the national guidance into workable local practice is proving demanding for most organisations. This article describes one trust's use of an electronic toolkit for benchmarking.

The performance of the emergency department significantly improved after implementing the balanced scorecard including hours of continuing education attended by the staff, staff job satisfaction, the rate of incomplete laboratory tests within 30 minutes, the average monthly inappropriate return rate, and hospital profit. The results can assist administrators plan for the future. Although this was a pilot program for implementing a balanced scorecard in an emergency department, the indicators used in this study may also be reasonable for a hospital that has limited resources.

The care bundle is a new concept in critical care, which is currently being promoted by the National Health Service Modernisation Agency for Critical Care. Care bundles originated in North America and are described best as groups of evidence-based practice interventions. The theory behind care bundles is that when several evidence-based interventions are grouped together in a single protocol, it will improve patient outcome. Care bundles are relatively easy to develop, implement and audit, and provide practitioners with a practical method for implementing evidence-based practice. This article describes the care bundle and offers practical suggestions about how to develop, implement and audit them in practice.

The nursing shortage has turned the national spotlight onto the need to improve the conditions under which nurses work. The American Nurses Credentialing Center Magnet Recognition Program offers an evidence-based model for nurse leaders interested in transforming the practice climate. The author describes a community hospital's experience in using the magnet standards as the framework for change. The author describes 5 successful standard-driven strategies that have strengthened department infrastructure and refined processes for retaining a professional nurse workforce.

Since Kaplan and Norton published their article proposing a balanced scorecard, the concept has been widely adopted by industry and health care provider organizations. This article reviews the use of the balanced scorecard in health care and concludes that the balanced scorecard: (1) is relevant to health care, but modification to reflect industry and organizational realities is necessary; (2) is used by a wide range of health care organizations; (3) has been extended to applications beyond that of strategic management; (4) has been modified to include perspectives, such as quality of care, outcomes, and access; (5) increases the need for valid, comprehensive, and timely information; and (6) has been used by two large-scale efforts across many health care organizations in a health care sector, which differ, namely in the units of analysis, purposes, audiences, methods, data, and results.

This article provides healthcare administrators and managers with a framework and model for developing a balanced scorecard and demonstrates the remarkable success of this process, which brings focus to leadership decisions about the allocation of resources. This scorecard was developed as a top management tool designed to structure multiple priorities of a large, complex, integrated healthcare system and to establish benchmarks to measure success in achieving targets for performance in identified areas. Significant benefits and positive results were derived from the implementation of the balanced scorecard, based upon benchmarks considered to be critical success factors. The network's chief executive officer and top leadership team set and articulated the network's primary operating principles: quality and efficiency in the provision of comprehensive healthcare and support services. Under the weighted benchmarks of the balanced scorecard, the facilities in the network were mandated to adhere to one non-negotiable tenet: providing care that is second to none. The balanced scorecard approach to leadership continuously ensures that this is the primary goal and focal point for all activity within the network. To that end, systems are always in place to ensure that the network is fully successful on all performance measures relating to quality.

Objective: Multidisciplinary teams from 11 medical center neonatal intensive care units collaborated in a quality improvement project with a focus on family-centered care., Methods: Through a process of self-analysis, literature review, benchmarking site visits, and expert consultation, 10 potentially better practice (PBP) areas were defined. Improvement activities in 4 of the 10 areas are given as examples of successes and challenges that individual centers encountered. The 4 areas are vision and philosophy, unit culture, family participation in care, and families as advisors., Results: Centers were at different places for all of the PBPs at the beginning and throughout the collaboration. Seven centers developed or revised their vision or philosophy of care statements about family-centered care. Incorporating the vision and philosophy of care into performance appraisals, hiring of new personnel, and changing unit culture to a more family-centered practice were more challenging than developing the statements. Full parent participation in care requires unrestricted access to the neonatal intensive care unit. The shift from considering parents to be "visitors" to being partners in caring for their child was more difficult for centers with restricted visitation policies. All centers developed, expanded, or started plans for establishing family advisory councils. The experience of 2 centers is described., Conclusions: Family-centered care is more of a journey than a destination. Collaborating centers in this project found themselves at different places in that journey. Through perseverance in implementing the PBPs, all have moved further along the path.

Objective: Despite increased knowledge and improving technology, chronic lung disease (CLD) rates in extremely low birth weight infants have remained constant for 20 years. One reason for this is an ineffective translation of research-proven improvements into practice. The Neonatal Intensive Care Quality Improvement Collaborative Year 2000 (NIC/Q 2000) was created to provide participating nurseries the tools necessary to effect change. The objective of this study was to develop and implement a process that uses quality improvement techniques to collaboratively improve CLD rates., Methods: Nine member hospitals of the NIC/Q 2000 collaborative formed a focus group aiming to decrease CLD rates. The focus group established goals and outcome measures, created a list of potentially better practices (PBPs) based on available literature, benchmarked and performed site visits, encouraged individual site implementation of PBPs, developed a database, and measured outcomes., Results: The goal "decrease CLD rates in extremely low birth weight infants" was established. Nine PBPs were identified, and 57 PBPs were implemented by the 9 participating sites. Twelve site visits were conducted, and a 435-patient database of infants with a mean birth weight of 789 g was established., Conclusions: Collaborative use of quality improvement techniques resulted in creation of a logical, efficient, and effective process to improve CLD rates. Group creation of PBPs, based on literature review and reinforced with site visits, internal data analysis, and improved individual site outcomes, resulted in accelerated and effective change, unlikely to occur if attempted outside of the collaborative.

Objective: The purpose of this article is to describe how a neonatal intensive care unit (NICU) was able to reduce substantially the use of postnatal dexamethasone in infants born between 501 and 1250 g while at the same time implementing a group of potentially better practices (PBPs) in an attempt to decrease the incidence and severity of chronic lung disease (CLD)., Methods: This study was both a retrospective chart review and an ongoing multicenter evidence-based investigation associated with the Vermont Oxford Network Neonatal Intensive Care Quality Improvement Collaborative (NIC/Q 2000). The NICU specifically made the reduction of CLD and dexamethasone use a priority and thus formulated a list of PBPs that could improve clinical outcomes across 3 time periods: era 1, standard NICU care that antedated the quality improvement project; era 2, gradual implementation of the PBPs; and era 3, full implementation of the PBPs. All infants who had a birth weight between 501 and 1250 g and were admitted to the NICU during the 3 study eras were included (era 1, n = 134; era 2, n = 73; era 3, n = 83). As part of the NIC/Q 2000 process, the NICU implemented 3 primary PBPs to improve clinical outcomes related to pulmonary disease: 1) gentle, low tidal volume resuscitation and ventilation, permissive hypercarbia, increased use of nasal continuous positive airway pressure; 2) decreased use of postnatal dexamethasone; and 3) vitamin A administration. The total dexamethasone use, the incidence of CLD, and the mortality rate were the primary outcomes of interest. Secondary outcomes included the severity of CLD, total ventilator and nasal continuous positive airway pressure days, grades 3 and 4 intracranial hemorrhage, periventricular leukomalacia, stages 3 and 4 retinopathy of prematurity, necrotizing enterocolitis, pneumothorax, length of stay, late-onset sepsis, and pneumonia., Results: The percentage of infants who received dexamethasone during their NICU admission decreased from 49% in era 1 to 22% in era 3. Of those who received dexamethasone, the median number of days of exposure dropped from 23.0 in era 1 to 6.5 in era 3. The median total NICU exposure to dexamethasone in infants who received at least 1 dose declined from 3.5 mg/kg in era 1 to 0.9 mg/kg in era 3. The overall amount of dexamethasone administered per total patient population decreased 85% from era 1 to era 3. CLD was seen in 22% of infants in era 1 and 28% in era 3, a nonsignificant increase. The severity of CLD did not significantly change across the 3 eras, neither did the mortality rate. We observed a significant reduction in the use of mechanical ventilation as well as a decline in the incidence of late-onset sepsis and pneumonia, with no other significant change in morbidities or length of stay., Conclusions: Postnatal dexamethasone use in premature infants born between 501 and 1250 g can be sharply curtailed without a significant worsening in a broad range of clinical outcomes. Although a modest, nonsignificant trend was observed toward a greater number of infants needing supplemental oxygen at 36 weeks' postmenstrual age, the severity of CLD did not increase, the mortality rate did not rise, length of stay did not increase, and other benefits such as decreased use of mechanical ventilation and fewer episodes of nosocomial infection were documented.

Objective: Six neonatal intensive care units (NICUs) that are members of the Vermont Oxford National Evidence-Based Quality Improvement Collaborative for Neonatology collaborated to reduce infection rates. There were 7 centers in the original focus group, but 1 center left the collaborative after 1 year. Nosocomial infection is a significant area for improvement in most NICUs., Methods: Six NICUs participating in the Vermont Oxford Network made clinical changes to address 3 areas of consensus: handwashing, line management, and accuracy of diagnosis. The summary statements were widely communicated. Review of the literature, internal assessments, and benchmarking visits all contributed to ideas for change., Results: The principle outcome was the incidence of coagulase-negative staphylococcus bacteremia. There was an observed reduction from 24.6% in 1997 to 16.4% in 2000., Conclusions: The collaborative process for clinical quality improvement can result in effective practice changes.

Objective: Part of the process of deriving and refining the CARE (communication, accountability, respect, empowerment) focus group's potentially better practices (PBPs) for multidisciplinary teamwork was to evaluate and experience the PBPs through implementation., Methods: The 4 neonatal intensive care units (NICUs) in the CARE focus group each worked with implementation of the PBPs. The choice of initial PBP and method of implementation was left up to each NICU's core team., Results: The experience of each of the PBPs that is reported was selected from only 1 of the NICUs. These are summarized and described in a plan-do-study-act type of format., Conclusions: There was no ideal PBP with which to start. The intertwined nature of all of the PBPs provided additional opportunities to implement other PBPs. A change seemed to be a matter first of vocabulary, then of tentative acceptance, followed by gradual integration into the culture. Change was facilitated when there was acknowledgment of a need to do things differently by the NICU leadership. Although the validity of the PBPs and their importance in cultural change have yet to be confirmed, once there was a persisting intent to change, the makeup of the NICU culture moved to embrace change as part of its culture.

Objective: The Vermont Oxford Network (VON) CARE Group was formed in response to the need to create organizational cultures supportive of change and quality improvement., Methods: The CARE Group consisted of team members from 4 participating neonatal intensive care units (NICUs). All CARE Group members chose to work on multidisciplinary teamwork for the duration of the Neonatal Intensive Care Quality Improvement Collaborative Year 2000. A questionnaire was developed by the CARE Group and administered to the 4 focus group NICUs. The survey focused on 6 domains of the organization: unit coordination, working in the NICU, leadership, management of disagreements, authority, and unit culture. Benchmarking visits were completed to supplement the information found in the survey and the literature., Results: Seven potentially better practices (PBPs) were developed on the basis of the surveys, benchmark visits, and literature reviews. The PBPs include 1) a clear, shared NICU purpose, goals, and values; 2) effective communication among and between teams and team members; 3) leaders lead by example; 4) nurture a collaborative NICU environment with trust and respect; 5) live principled standards of conduct and standards of excellence; 6) nurture competent and committed teams and team members; and 7) commit to effective and positive conflict management., Conclusions: The CARE Group successfully used quality improvement methods and collaboration to delineate principles and practices of multidisciplinary teamwork.

Objective: Using an evidence-based approach, a Vermont Oxford Network focus group whose goal was to reduce brain injury developed and implemented a number of potentially better practices. Each center approached implementation of the practices differently. Reducing the incidence of intraventricular hemorrhage and periventricular leukomalacia are important for improving long-term outcomes for low birth weight infants., Methods: Implementation approaches for some but not all of the practices at the various centers are discussed. The practices reviewed include optimal peripartum management, such as resuscitation, avoidance of hypothermia, optimal surfactant delivery, early neonatal management by the most experienced providers, and measures to minimize pain and stress. Additional practices include maintenance of neutral head positioning, fluid volume therapy for hypotension, indomethacin prophylaxis, ventilator management, avoidance of routine suctioning, and limiting the use of sodium bicarbonate and postnatal dexamethasone., Results: Approaches to implementation were center specific, and results vary. Although some practices were easier to implement than others, communication, education, and leadership were critical to the process., Conclusions: The quality improvement multidisciplinary approach is a useful tool for finding ways to reduce the incidence of intraventricular hemorrhage and periventricular leukomalacia.

Objective: The desire for evidence-based clinical guidelines for nutritional support of the preterm infant has been identified. Published evidence has not yielded clear guidelines about the best method of delivery, substrate use, or appropriate outcome measure to evaluate nutrition support. In addition, reports on research of nutrition support often fail to give the most rudimentary process necessary to improve quality in various unit settings., Methods: The Vermont Oxford Network "Got Milk" focus group developed eight potentially better practices for nutrition support, implementation strategies for these practices, and a comprehensive appraisal process to measure nutrition outcome in preterm infants., Results: After implementation of the potentially better practices, all participating institutions showed earlier initiation of nutrition support, earlier attainment of adequate energy intakes, reduced delay in reaching full enteral feeds, more consistent nutrition support practice, decreased length of stay, cost savings, and improved growth at time of discharge., Conclusions: Development and implementation of evidence-based better nutrition support practices in neonates led to improved nutrient intake and growth with reduced length of stay and related costs. Consistent, comprehensive, multidisciplinary appraisal of practice is an integral component of improving nutrition outcomes in the neonatal population.

Objective: Neonatal care providers from 5 institutions formed a multidisciplinary focus group with the purpose of identifying potentially better practices, the implementation of which would lead to a reduction in the incidence of intracranial hemorrhage and periventricular leukomalacia in very low birth weight infants., Methods: Practices were analyzed, 4 benchmark neonatal intensive care units were identified and evaluated, and the literature was assessed using an evidence-based approach. The work was also reviewed by a nationally respected expert., Results: Ten potentially better clinical practices were identified. In addition, variability in cranial ultrasound practice, related to both procedural process and interpretation, was identified as a confounding problem in evaluating quality. Using the same process, potentially better cranial ultrasound practices were also identified., Conclusions: Implementation of these practices will improve clinical outcomes as well as the reliability of sonogram interpretation, the basis for evaluating the quality of the team's work.

Objective: Technological and scientific advances have progressively decreased neonatal morbidity and mortality. Less attention has been given to meeting the psychosocial needs of the infant and family than on meeting the infant's physical needs. Parents' participation in making decisions and caring for their child has often been limited. Environments designed for efficient technological care may not be optimal for nurturing the growth and development of sick neonates or their families. Eleven centers collaborating on quality improvement tried to make the care of families better by focusing on understanding and improving family-centered care., Methods: Through internal process analysis, review of the evidence, collaborative learning, and benchmarking site visits to centers of excellence in family-centered care, a list of potentially better practices was developed. Choice of which practices to implement and methods of implementation were center specific. Improvement goals were in 3 areas: parent-reported outcomes, staff beliefs and practices, and clinical outcomes in length of stay and feeding practices. Measurement tools for the first 2 areas were developed and pilots were conducted., Results: Length of stay and feeding outcomes were not different before the collaboration (1998) and at the formal end of the collaboration (2000)., Conclusions: Prospective parent-reported outcomes are being collected, and the staff beliefs and practices questionnaire will be repeated in all centers to determine the impact of the project in those areas.

Objective: Six neonatal intensive care units (NICUs) that are members of the Vermont Oxford National Evidence-Based Quality Improvement Collaborative for Neonatology collaborated to reduce infection rates. There were 7 centers in the original focus group, but 1 center left the collaborative after 1 year. The objective of this study was to develop strategies to decrease nosocomial infection rates in NICUs., Methods: The process included a comprehensive literature review, internal practice analyses, benchmark studies, and development of practical experience through rapid-cycle changes, subsequent analysis, and feedback. This process led to 3 summary statements on potentially better practices in handwashing, approach to nosocomial sepsis evaluations, and central venous catheter management., Results: These statements provide a basis for an evidence-based approach to lowering neonatal intensive care unit nosocomial infection rates., Conclusions: The 2-year process also led to changes in the culture and habits of the institutions involved, which should in turn have long-term effects on other aspects of quality improvement.

Objective: Adherence to basic quality improvement principles enhances the implementation of potentially better practices (PBPs) and requires extensive planning and education. Even after PBPs have been identified and acknowledged as desirable, effective implementation of these practices does not occur easily. The objective of this study was to identify and assess implementation strategies that facilitate quality improvements in the respiratory care of extremely low birth weight infants., Methods: The 9 members of the Neonatal Intensive Care Quality Improvement Collaborative Year 2000 Reducing Lung Injury focus group identified 9 PBPs in a evidence-based manner to decrease chronic lung disease in extremely low birth weight newborns. Each site implemented several or all PBPs based on a site-specific selection process. Each site was asked to submit 1 or more examples of experiences that highlighted effective implementation strategies. This article reports these examples and emphasizes the principles on which they are based., Results: The 9 participating institutions implemented a total of 57 PBPs (range: 1-9; median: 5). Including previous implementation, the 9 participating institutions implemented a total of 70 of a possible 81 PBPs before or during the study period (range: 5-9; median: 8). We report 7 approaches that facilitated PBP implementation: information availability, feedback, perseverance, collaboration, imitation, recognition of implementation complexity, and tracking of process indicators., Conclusions: Quality improvement efforts are enhanced by identifying and then implementing PBPs. In our experience, implementation of these PBPs can be difficult. Implementation strategies, such as those identified in this article, can improve the chances that quality improvement efforts will be effective.

Healthcare is ever changing environment and with the Joint Commission for the Accreditation of Hospital Organization (JCAHO) emphasis on quality improvement during the past several years, and the cost-focused healthcare reforms of the 1990s, benchmarking with peer comparison, and more recently benchmarking against competitors, has taken on a new emphasis. All acute healthcare organizations accredited by JCAHO now require participation in a program titled ORYX, which is designed to use comparisons with other organizations and promote national benchmarks. The knowledge management system designed assists clinical engineering department to convert vast amounts of available data into information, which is ultimately transformed into knowledge to enable better decision-making. The systems assist in using the data as a comparison tool, to compare the performance internally and also compare performance with peer organizations using the same measures within the same measurement system. Collectively, these applications support better, faster data-driven decisions. This tool provides fast and easy access to financial and quality metrics to clinical engineering department managers, which increases their ability to perform sophisticated analysis to develop accurate models and forecasts, and make timely, data driven decisions. The project also provides a platform by means of which clinical engineering departmental procedures, data, and methods can be assessed and shared among institutions.

Even though the balanced scorecard (BSC) has become a highly popular performance management tool, usage in local public sector National Health Service (NHS) organisations is still rare. This paper conditionally outlines some grounds in supporting such usage. In particular underlying conceptual concerns with the BSC system and its implementation pitfalls require full consideration. This paper then outlines some factors to be taken into account for "successful" BSC implementation in a NHS multi-agency setting. These findings emerged from a series of focus groups that took place with contributors drawn from all the key organisations within the Bradford Health Action Zone. Finally, this paper argues that if key criteria are met, successful implementation of the BSC may then proceed. However, "blind" BSC implementation without consideration of these factors may result in potential "failure".

Benchmarking provides data necessary to evaluate an organization against norms for various administrative and clinical purposes. There are many different types of statistical comparisons used to benchmark one organization against others, or against itself over time. Careful selection of benchmarking strategies can give an organization confidence in the results, thereby maximizing the usefulness of the data for decision making and performance improvement.

The need to change will catch up with an organization whether it overtly incorporates a change and evolution program or, less desirably, has to inefficiently react to and recover from change forced from the outside. The latter approach can be devastating in terms of staff morale, patient well-being, cost and revenues, staff retention, and organizational pride. It is far wiser to embrace, learn about, and efficiently incorporate the new practices and approaches in home health care that will result from progressively more emphasis on benchmarking, understanding and using the valuable benchmark information internally, and by virtue of understanding and using such information, contribute constructively to the evolution of home health care both externally and internally.

Although there are many valid applications for comparative data--sometimes simply "knowing where you stand" is valuable--it is time for home care agencies to use benchmarking that moves beyond that point. Benchmarking is integral to organizational and management strategies whose ultimate goal is to improve, and not simply measure, performance. Peer benchmarks can be a critical resource in addressing the full spectrum of management challenges.

The balanced scorecard represents a technique used in strategic management to translate an organization's mission and strategy into a comprehensive set of performance measures that provide the framework for implementation of strategic management. This article develops an incremental approach for decision making by formulating a specific balanced scorecard model with an index of nonfinancial as well as financial measures. The incremental approach to costs, including profit contribution analysis and probabilities, allows decisionmakers to assess, for example, how their desire to meet different health care needs will cause changes in service design. This incremental approach to the balanced scorecard may prove to be useful in evaluating the existence of causality relationships between different objective and subjective measures to be included within the balanced scorecard.