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Quality criteria and certification possibilities for paediatric oncology centres vary between countries and are not widely used. An overview of the type and how quality criteria and certifications are used in countries with highly developed healthcare systems is missing. This international cross-sectional survey investigated the use of quality criteria for paediatric oncology centres and whether certification is possible. We sent an online survey to paediatric oncologists from 32 countries worldwide and analysed the survey results and provided regional or national documents on quality criteria and certification possibilities descriptively. Paediatric oncologists from 28 (88%) countries replied. In most countries, the paediatric oncology centres were partly or completely grown historically (75%), followed by the development based on predefined criteria (29%), and due to political reason (25%), with more than one reason in some countries. Quality criteria are available in 20 countries (71%). We newly identified or specified five quality criteria, in addition to those from a previously performed systematic review. Certification of paediatric oncology centres is possible in 13 countries (46%), with a specific certification for paediatric oncology in seven, and a mandatory certification in three of them. The use of quality criteria and certification possibilities are heterogeneous, with quality criteria being more frequently used than certifications. Our study provides an overview of country-specific documents and links with quality criteria, and centre certification possibilities. It can serve as a reference document for stakeholders and may inform an international harmonization of quality criteria and centre certification between countries with similar healthcare systems. [ABSTRACT FROM AUTHOR]

Staff observations are the most common source of data for driving improvements in care. However, the patient perspective should also be considered, and healthcare complaints offer concrete details that health organizations might otherwise overlook and that can highlight areas for learning and improvement in the healthcare system. However, because of the diverse nature of patient complaints, systematic analyses can be challenging. This study aimed to identify and prioritize areas for improvement using a data-driven approach to analysing patient complaints. The Danish version of the Healthcare Complaints Analysis Tool was used to categorize the content of complaint letters. All complaints managed by the national complaints authority, compensation claims to the Patient Compensation Association, and locally managed complaints that were filed directly at Odense University Hospital from 2017 to 2021 were included. Proportional reporting ratios (PRRs) were used to measure and display the top five signals of disproportionality and rank them by excess complaints at the hospital level and when divided into department types. The study included 6366 complaints containing 13 156 problems (on average, 2.1 problems mentioned per complaint letter). Surgical departments had the highest number of complaints (3818), followed by medical (1059), service (439), and emergency departments (239). Signal 1 of disproportionality, relating to quality problems during ward procedures, had the highest excess reporting of 1043 complaints at the hospital level and a PRR of 1.61 and was present in all department types. Signal 2, relating to safety problems during the examination and diagnosis stage, had an excess reporting of 699 problems and a PRR of 1.86 and was also present in all department types. Signal 3, relating to institutional problems during admission, had the highest PRR of 3.54 and was found in most department types. Signals 4 and 5, relating to environmental problems during ward procedures and care on the ward, respectively, had PRRs of 1.5 and 1.84 and were present in most department types. The study found that analysing patient complaints can identify potential areas for hospital improvement. The study identified recurring issues in multiple departments, including quality problems during ward procedures, safety problems during the examination, institutional problems during admission, and environmental problems on the ward. The study highlights disproportionality analysis of complaints as a valuable tool to monitor patient concerns systematically. [ABSTRACT FROM AUTHOR]

This paper empirically analyzes the evolution of the quality of the sites included in the UNESCO World Heritage List (WHL) from 1972 till 2016 and verifies how consideration of quality affects the conclusions of the literature about the politics of the WHL. The quality of a site is proxied by the number of criteria set by UNESCO that the site satisfies. The analysis shows that, under a fixed stock of cultural and natural capital, as a country increases the number of sites in the WHL, their marginal quality decreases, because countries propose sites of decreasing quality over time. Contrary to previous studies focusing just on the number of sites included in the list, considering quality shows that the country's lobbying power does not matter for inclusion in the WHL, while the quality of its administration does. These results are robust to tests of the stability of the UNESCO evaluation criteria over time and to changes of econometric estimators. [ABSTRACT FROM AUTHOR]

Objective: To compare clinical vignettes and objective structured clinical examinations (OSCE) as methods for assessing the quality of intrapartum care among skilled providers in rural primary-level health facilities in Tanzania. Methods: Cross-sectional study conducted at six health facilities in the Simiyu region of Tanzania. Providers were assessed using OSCE and clinical vignettes in spontaneous delivery, neonatal resuscitation, and management of postpartum hemorrhage. Trained researchers used a structured clinical checklist. The frequencies of items are presented as percentages and the agreement of the methods of assessment are reported using kappa statistics (high: kappa > 0.80, moderate: kappa = 0.60-0.80, low: kappa < 0.60). Results: Most healthcare providers were female (60.7%), registered nurses by training (29.0%), and worked in a dispensary (56.1%), with an average age of 33 years and an average of 7.4 years of experience in their respective professions. Five items had high agreement between OSCE and clinical vignettes: postpartum vital signs every 15 min, oxytocin within 1 min of birth, diagnosis of postpartum hemorrhage, elevating legs of the mother, and deciding on manual compression of the uterus. Conclusion: OSCE and clinical vignettes should be viewed as complimentary to one another in the assessment of provider knowledge and skill, with priority given to OSCE, particularly in intrapartum care. [ABSTRACT FROM AUTHOR]

Background: There exist wide variations in healthcare quality within the National Health Service (NHS). A shorter hospital length of stay (LOS) has been implicated as premature discharge, that may in turn lead to adverse consequences. We tested the hypothesis that a short LOS might be associated with increased risk of readmissions within 28 days of hospital discharge and also post-discharge mortality.Methods: We conducted a single-centred study of 32 270 (46.1% men) consecutive alive-discharge episodes (mean age = 64.0 years, standard deviation = 20.5, range = 18-107 years), collected between 01/04/2017 and 31/03/2019. Associations of LOS tertiles (middle tertile as a reference) with readmissions and mortality were assessed using observed/expected ratios, and logistic and Cox regressions to estimate odds (OR) and hazard ratios (HR) (adjusted for age, sex, patients' severity of underlying health status and index admissions), with 95% confidence intervals (CIs).Results: The observed numbers of readmissions within 28 days of hospital discharge or post-discharge mortality were lower than expected (observed: expected ratio < 1) in patients in the bottom tertile (<1.2 days) and middle tertile (1.2-4.3 days) of LOS, whilst higher than expected (observed: expected ratio > 1) in patients in the top tertile (>4.3 days), amongst all ages. Patients in the top tertile of LOS had increased risks for one readmission: OR = 2.32 (95% CI = 1.86-2.88) or ≥2 readmissions: OR = 6.17 (95% CI = 5.11-7.45), death within 30 days: OR = 2.87 (95% CI = 2.34-3.51), and within six months of discharge: OR = 2.52 (95% CI = 2.23-2.85), and death over a two-year period: HR = 2.25 (95% CI = 2.05-2.47). The LOS explained 7.4% and 15.9% of the total variance (r2) in one readmission and ≥2 readmissions, and 9.1% and 10.0% of the total variance in mortality with 30 days and within six months of hospital discharge, respectively. Within the bottom, middle and top tertiles of the initial LOS, the median duration from hospital discharge to death progressively shortened from 136, 126 to 80 days, whilst LOS during readmission lengthened from 0.4, 0.9 to 2.8 days, respectively.Conclusion: Short LOS in hospital was associated with favourable post-discharge outcomes such as early readmission and mortality, and with a delay in time interval from discharge to death and shorter LOS in hospital during readmission. These findings indicate that timely discharge from our hospital meets the aims of the NHS-generated national improvement programme, Getting It Right First Time. [ABSTRACT FROM AUTHOR]

Hospital-based medical records are abstracted to create International Classification of Disease (ICD) coded discharge health data in many countries. The 'main condition' is not defined in a consistent manner internationally. Some countries employ a 'reason for admission' rule as the basis for the main condition, while other countries employ a 'resource use' rule. A few countries have recently transitioned from one of these approaches to the other. The definition of 'main condition' in such ICD data matters when it is used to define a disease cohort to assign diagnosis-related groups and to perform risk adjustment. We propose a method of harmonizing the international definition to enable researchers and international organizations using ICD-coded health data to aggregate or compare hospital care and outcomes across countries in a consistent manner. Inter-observer reliability of alternative harmonization approaches should be evaluated before finalizing the definition and adopting it worldwide.

ObjectiveTo describe hospitals' organizational arrangements relevant to the abstraction of administrative data, to report on the completeness of administrative data collected and to assess associations between organizational arrangements and completeness of data submission.DesignA cross-sectionalStudy designutilizing administrative data.Setting and participantsRandomly selected hospitals from seven European countries (The Czech Republic, France, Germany, Poland, Portugal, Spain, and Turkey).Main outcome measuresCompleteness of data submission for four quality indicators: mortality after acute myocardial infarction, stroke and hip fractures and complications after normal delivery.ResultsIn general, hospitals were able to produce data on the four indicators required for this research study. A substantial proportion had missing data on one or more data items. The proportion of hospitals that was able to produce more detailed indicators of relevance for quality monitoring and improvement was low and ranged from 40.1% for thrombolysis performed on patients with acute ischemic stroke to 63.8% for hip-fracture operations performed within 48 h after admission for patients aged 65 or older. National factors were strong predictors of data completeness on the studied indicators.ConclusionsAt present, hospital administrative databases do not seem to be an appropriate source of information for comparison of hospital performance across the countries of the EU. However, given that this is a dynamic field, changes to administrative databases may make this possible in the near future. Such changes could be accelerated by an in-depth comparative analysis of the issues of using administrative data for comparisons of hospital performances in EU countries.

ObjectiveTo define a checklist that can be used to assess the performance of a department and evaluate the implementation of quality management (QM) activities across departments or pathways in acute care hospitals.DesignWe developed and tested a checklist for the assessment of QM activities at department level in a cross-sectional study using on-site visits by trained external auditors.Setting and participantsA sample of 292 hospital departments of 74 acute care hospitals across seven European countries. In every hospital, four departments for the conditions: acute myocardial infarction (AMI), stroke, hip fracture and deliveries participated.Main outcome measuresFour measures of QM activities were evaluated at care pathway level focusing on specialized expertise and responsibility (SER), evidence-based organization of pathways (EBOP), patient safety strategies and clinical review (CR).ResultsParticipating departments attained mean values on the various scales between 1.2 and 3.7. The theoretical range was 0-4. Three of the four QM measures are identical for the four conditions, whereas one scale (EBOP) has condition-specific items. Correlations showed that every factor was related, but also distinct, and added to the overall picture of QM at pathway level.ConclusionThe newly developed checklist can be used across various types of departments and pathways in acute care hospitals like AMI, deliveries, stroke and hip fracture. The anticipated users of the checklist are internal (e.g. peers within the hospital and hospital executive board) and external auditors (e.g. healthcare inspectorate, professional or patient organizations).

ObjectiveThe assessment of integral quality management (QM) in a hospital requires measurement and monitoring from different perspectives and at various levels of care delivery. Within the DUQuE project (Deepening our Understanding of Quality improvement in Europe), seven measures for QM were developed. This study investigates the relationships between the various quality measures.DesignIt is a multi-level, cross-sectional, mixed-method study.Setting and participantsAs part of the DUQuE project, we invited a random sample of 74 hospitals in 7 countries. The quality managers of these hospitals were the main respondents. Furthermore, data of site visits of external surveyors assessing the participating hospitals were used.Main outcome measuresThree measures of QM at hospitals level focusing on integral systems (QMSI), compliance with the Plan-Do-Study-Act quality improvement cycle (QMCI) and implementation of clinical quality (CQII). Four measures of QM activities at care pathway level focusing on Specialized expertise and responsibility (SER), Evidence-based organization of pathways (EBOP), Patient safety strategies (PSS) and Clinical review (CR).ResultsPositive significant associations were found between the three hospitals level QM measures. Results of the relationships between levels were mixed and showed most associations between QMCI and department-level QM measures for all four types of departments. QMSI was associated with PSS in all types of departments.ConclusionBy using the seven measures of QM, it is possible to get a more comprehensive picture of the maturity of QM in hospitals, with regard to the different levels and across various types of hospital departments.

Abstract Background The Australian Commission on Safety and Quality in Health Care released a set of national standards which became a mandatory part of accreditation in 2013. Standard 9 focuses on the identification and treatment of deteriorating patients. The objective of the study was to identify changes in the characteristics and perceptions of rapid response systems (RRS) since the implementation of Standard 9. Methods Cross-sectional study of Australian hospitals. Baseline data was obtained from a pre-implementation survey in 2010 (220 hospitals). A follow-up survey was distributed in 2015 to staff involved in implementing Standard 9 in public and private hospitals (276 responses) across Australia. Results Since 2010, the proportion of hospitals with formal RRS had increased from 66 to 85. Only 7% of sites had dedicated funding to operate the RRS. 83% of respondents reported that Standard 9 had improved the recognition of, and response to, deteriorating patients in their health service, with 51% believing it had improved awareness at the executive level and 50% believing it had changed hospital culture. Conclusions Implementing a national safety and quality standard for deteriorating patients can change processes to deliver safer care, while raising the profile of safety issues. Despite limited dedicated funding and staffing, respondents reported that Standard 9 had a positive impact on the care for deteriorating patients in their hospitals.

Background: The high variability in the types and number of measures adopted to evaluate childcare across European countries makes it necessary to investigate country practices to identify trends in setting national priorities in the assessment of child well-being.Objective: This paper intends to investigate country practices under the lens of variability to explore possible trends in setting national priority in the evaluation of childcare. In particular, it analyses variability considering to what extent this depends on the tendency of adopting a broad vision (i.e. selecting measures for a larger variety of aspects) or whether this is influenced by the choice of adopting an in-depth approach (i.e. using more measures to analyse a specific aspect).Methods: An ad hoc questionnaire was administered to a national expert in each country and yielded 352 measures. To analyse variability, the breadth in the number of aspects considered was explored using a convergence index, while the depth in the distribution of measures in each aspect was investigated by computing a coefficient of variation. Countries were grouped by adopting a hierarchical clustering approach.Results: There is a high variability across countries in the selection of measures that cover different aspects of childcare. Preferences in the distribution of measures are significant even at the domain level and in countries that use a limited number of measures and become more evident at the category and sub-category levels. The statistical analysis clusters countries in four main groups and two outliers. The in-depth distribution of measures focused on a specific aspect shows a homogeneous pattern, with the identification of two main groups of countries.Conclusions: A limited set of measures are shared across countries hampering a robust comparison of paediatric models. The selection of measures shows that the evaluation is closely related to national priorities as resulting from the number and types of measures adopted. Moreover, a range of a reasonable number of measures can be hypothesized to address the quality of childcare under a multi-dimensional perspective. [ABSTRACT FROM AUTHOR]

Currently, outpatient care in the UK is expensive and needs improvement, with traditional systems having been identified as no longer fit for purpose. Making sustainable changes to outpatient appointment systems is vital in order to meet increasing demands and cost. Shifting to data and technology-driven outpatient care may be one way to tackle these demands. As technology becomes more diverse and accessible, its implementation into healthcare systems can make services more efficient and help with transitioning from outdated practices to more effective protocols. Patient Recorded Outcome Measures (PROMs) and home-monitoring devices could be the key step in identifying which patients require input and help shift to more data-driven appointment scheduling based on clinical need, rather than at regular intervals of time. Virtual care and technology-driven service provision could also revolutionise outpatient systems, maintaining high quality care while improving accessibility to patients. Patient involvement and empowerment while making these changes will assist shared decision making surrounding their care and allow them to be champions of their own health, helping clinicians to provide a patient-centred service. Understanding how these may be implemented will help clinicians take an active role in the development of these practices. [ABSTRACT FROM AUTHOR]

Value-based healthcare has been introduced in 2006. Ten years later, this concept is adopted by a growing number of healthcare organizations. However, little is known about the practical implementation of value-based healthcare within hospitals. While working on the implementation of value-based healthcare in Dutch heart care, physicians are confronted with three main challenges that still need to be addressed to make value-based healthcare successful. First, it will require a shift in our thinking to actually use outcomes as drivers for quality improvement instead of as end points in scientific studies. Secondly, it will require tools for linking outcomes to quality of care processes enabling quicker and continuous improvement cycles. Finally, platforms are needed where benchmarking on outcomes is connected to an open learning and sharing environment where physicians can discuss good care delivery practices. [ABSTRACT FROM AUTHOR]

Quality Problem: As discharge letters (DL) hold important information for healthcare professionals and especially for general practitioners, rapid and efficient finalization is required. We describe a project aiming to reduce DL submission within 8 days in our Urology Department (UD), as required by the local Hospital Board (HB).Initial Assessment and Choice Of Solution: A team was built in UD with staff members and one external expert to study the root causes of delayed DL creation and develop sustainable strategies to improve and monitor the process, including habits changing, training and application of Little's Law.Implementation and Evaluation: The study started on January 2015 and ended up on March 2016, involving 908 and 616 DL for old and new process, respectively. The new process decreased the average delay of DL completion from 24.88 days to 14.7 days. Standard deviation of total average delay for DL completion fell from 10.1 days to 7.5 days. We identified four steps needed to DL creation and allowed maximum 2 days for every step completion. No additional resources were employed.Lessons Learned: We were able to improve the process of DL creation, by analysing its steps and reducing their variability. This can be easily transposed to other medical departments. [ABSTRACT FROM AUTHOR]

All countries want to improve the health of their populations and to improve the quality of care and patient safety. Consequently, there is an ongoing need to assess and document population health, the quality of care and patient safety using valid and reliable data. This requires the ability to monitor the same individuals over time as they receive prevention, diagnostics, treatments, care and rehabilitation and experience improvements or deteriorations in their health or healthcare. This is, however, a challenge for most healthcare systems. A prerequisite to such data is the unique personal identifier. This perspective on quality paper describes the experience with the unique personal identifier in Denmark, based on the Danish Civil Registration System (DCRS) as a tool for research in epidemiology, health services research, quality improvement and patient safety. DCRS has been celebrating its 50 years anniversary. [ABSTRACT FROM AUTHOR]

Objectives: To determine whether optimal patient experiences with healthcare is associated with enhanced and efficient use of healthcare resources and cost.Design: Retrospective cohort study.Setting and Participants: The study population consisted of pooled participants from the 2010-13 Medical Expenditure Panel Survey cohort of adults ≥18 years with a regular healthcare provider and ≥1 visit to a healthcare provider within the survey year. Using a self-administered questionnaire, individual responses to questions related to healthcare experience were used to develop a weighted average for each of these patient-centered care matrices (ease of access to healthcare, patient-provider communication, shared decision-making and overall patient satisfaction).Intervention: None.Outcome Measures: The outcomes of interest included (1) emergency room (ER) visits and hospital stay, (2) annual healthcare costs incurred by the respondents.Results: Overall the study population consisted of 47 969 individuals ≥18 years representing nearly 130 million US non-institutionalized adults. Compared with individuals with a poor report on healthcare experience, participants with positive reports were less likely to utilize the ER and had a lower annual healthcare expenditure. This relationship between patient experience and healthcare expenditure was not demonstrated with shared decision-making and overall patient satisfaction.Conclusion: Our study findings suggest that there is an association between patient experience with healthcare, health resource utilization and healthcare expenditure. Further studies are needed to assess if interventions focused to enhance patient experiences can improve healthcare efficiency. [ABSTRACT FROM AUTHOR]

Objective: To establish aspirational 'gold standards' for a suite of System-Level Measures (SLMs) being used by Counties Manukau Health (CM Health), a New Zealand (NZ) District Health Board.Design: This study employed a multi-stage, multi-method modified Delphi consensus process.Setting: The Delphi consensus process involved virtual (email) communication between participants (Round 1) and a structured face-to-face meeting (Round 2) held in Auckland, NZ.Participants: Participants comprised of health professionals, managers, academics and quality improvement experts with an interest in the use of SLMs.Interventions: Participants in the first round received a letter requesting their participation in an anonymous Delphi. The second round involved national and international health system experts taking part in a structured, facilitated face-to-face meeting. Participants reviewed 15 SLMs in total. The SLMs all related to the three domains of the Triple Aim: Population Health, e.g. life expectancy at birth; Patient Experience of Care, e.g. rate of adverse events; and Cost and Productivity, e.g. healthcare expenditure per capita.Main Outcome Measures: For a proposed gold standard to be agreed and established for each SLM.Results: Twelve participants took part in Round 1, with 19 participating in Round 2. The process established agreement on a gold standard for each of the 15 reviewed SLMs.Conclusion: We demonstrated that the Delphi consensus process can be used to establish gold standards for a suite of SLMs used by a NZ Health Board (CM Health). [ABSTRACT FROM AUTHOR]

The Danish government launched a new National Quality Programme (NQP) in healthcare in 2015. It has changed the focus from old public management in terms of accreditation, regulation, rules and standards to new public governance focusing on delivering high quality healthcare and outcomes of value for the patients, health professionals and the Danish healthcare system. The NQP aims to strengthen the focus on continuous quality improvement and the launch of the programme was accompanied by a decision to phase out accreditation of public hospitals. The NQP includes 1) eight specific national quality goals, 2) a national educational programme for quality management, and 3) establishment of quality improvement collaboratives. Since the establishment of the NQP the indicator results have improved in several important clinical areas. However, causal conclusions related to the effect of the NQP cannot yet be made. This perspective on quality paper aims to give a short introduction to the NQP and documented outcomes. [ABSTRACT FROM AUTHOR]

Staff observations are the most common source of data for driving improvements in care. However, the patient perspective should also be considered, and healthcare complaints offer concrete details that health organizations might otherwise overlook and that can highlight areas for learning and improvement in the healthcare system. However, because of the diverse nature of patient complaints, systematic analyses can be challenging. This study aimed to identify and prioritize areas for improvement using a data-driven approach to analysing patient complaints. The Danish version of the Healthcare Complaints Analysis Tool was used to categorize the content of complaint letters. All complaints managed by the national complaints authority, compensation claims to the Patient Compensation Association, and locally managed complaints that were filed directly at Odense University Hospital from 2017 to 2021 were included. Proportional reporting ratios (PRRs) were used to measure and display the top five signals of disproportionality and rank them by excess complaints at the hospital level and when divided into department types. The study included 6366 complaints containing 13 156 problems (on average, 2.1 problems mentioned per complaint letter). Surgical departments had the highest number of complaints (3818), followed by medical (1059), service (439), and emergency departments (239). Signal 1 of disproportionality, relating to quality problems during ward procedures, had the highest excess reporting of 1043 complaints at the hospital level and a PRR of 1.61 and was present in all department types. Signal 2, relating to safety problems during the examination and diagnosis stage, had an excess reporting of 699 problems and a PRR of 1.86 and was also present in all department types. Signal 3, relating to institutional problems during admission, had the highest PRR of 3.54 and was found in most department types. Signals 4 and 5, relating to environmental problems during ward procedures and care on the ward, respectively, had PRRs of 1.5 and 1.84 and were present in most department types. The study found that analysing patient complaints can identify potential areas for hospital improvement. The study identified recurring issues in multiple departments, including quality problems during ward procedures, safety problems during the examination, institutional problems during admission, and environmental problems on the ward. The study highlights disproportionality analysis of complaints as a valuable tool to monitor patient concerns systematically., (© The Author(s) 2023. Published by Oxford University Press on behalf of International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: To present an update on incidence and mortality from adverse effects (AEs) of medical treatment in the UK, its four countries and nine English regions between 1990 and 2013.Design: Descriptive epidemiological study on AEs of medical treatment. AEs are shown as a single cause-of-injury category from the Global Burden of Disease (GBD) 2013 study.Data Sources: The GBD 2013 interactive data visualisation tools 'Epi Visualisation' and 'GBD Compare'.Outcome Measures: The means of incidence and mortality rates with 95% uncertainty intervals (UIs). The estimates are age-standardised.Results: Incidence rate was 175 and 176 cases per 100 000 men, 173 and 174 cases per 100 000 women in 1990 and 2013, in the UK (UI 170-180). The mortality from AEs declined from 1.33 deaths (UI 0.99-1.5) to 0.92 deaths (UI 0.75-1.2) per 100 000 individuals in the UK between 1990 and 2013 (30.8% change). Although mortality trends were descending in every region of the UK, they varied by geography and gender. Mortality rates in Scotland, North East England and West Midlands were highest. Mortality rates in South England and Northern Ireland were lowest. In 2013, age-specific mortality rates were higher in males in all 20 age groups compared with females.Conclusions: Despite gains in reducing mortality from AEs of medical treatment in the UK between 1990 and 2013, the incidence of AEs remained the same. The results of this analysis suggest revising healthcare policies and programmes aimed to reduce incidence of AEs in the UK. [ABSTRACT FROM AUTHOR]

Background: Despite criticisms that many quality improvement (QI) initiatives fail due to incomplete programme theory, there is no defined way to evaluate how programme theory has been articulated. The objective of this research was to develop, and assess the usability and reliability of scoring criteria to evaluate programme theory diagrams.Methods: Criteria development was informed by published literature and QI experts. Inter-rater reliability was tested between two evaluators. About 63 programme theory diagrams (42 driver diagrams and 21 action-effect diagrams) were reviewed to establish whether the criteria could support comparative analysis of different approaches to constructing diagrams.Results: Components of the scoring criteria include: assessment of overall aim, logical overview, clarity of components, cause-effect relationships, evidence and measurement. Independent reviewers had 78% inter-rater reliability. Scoring enabled direct comparison of different approaches to developing programme theory; action-effect diagrams were found to have had a statistically significant but moderate improvement in programme theory quality over driver diagrams; no significant differences were observed based on the setting in which driver diagrams were developed.Conclusions: The scoring criteria summarise the necessary components of programme theory that are thought to contribute to successful QI projects. The viability of the scoring criteria for practical application was demonstrated. Future uses include assessment of individual programme theory diagrams and comparison of different approaches (e.g. methodological, teaching or other QI support) to produce programme theory. The criteria can be used as a tool to guide the production of better programme theory diagrams, and also highlights where additional support for QI teams could be needed. [ABSTRACT FROM AUTHOR]

Objectives: To determine if adapting a widely-used triage scale into a computerized algorithm in an electronic health record (EHR) shortens emergency department (ED) triage time.Design: Before-and-after quasi-experimental study.Setting: Urban, tertiary care hospital ED.Participants: Consecutive adult patient visits between July 2011 and June 2013.Intervention: A step-wise algorithm, based on the Emergency Severity Index (ESI-5) was programmed into the triage module of a commercial EHR.Main Outcome Measures: Duration of triage (triage interval) for all patients and change in percentage of high acuity patients (ESI 1 and 2) completing triage within 15 min, 12 months before-and-after implementation of the algorithm. Multivariable analysis adjusted for confounders; interrupted time series demonstrated effects over time. Secondary outcomes examined quality metrics and patient flow.Results: About 32 546 patient visits before and 33 032 after the intervention were included. Post-intervention patients were slightly older, census was higher and admission rate slightly increased. Median triage interval was 5.92 min (interquartile ranges, IQR 4.2-8.73) before and 2.8 min (IQR 1.88-4.23) after the intervention (P < 0.001). Adjusted mean triage interval decreased 3.4 min (95% CI: -3.6, -3.2). The proportion of high acuity patients completing triage within 15 min increased from 63.9% (95% CI 62.5, 65.2%) to 75.0% (95% CI 73.8, 76.1). Monthly time series demonstrated immediate and sustained improvement following the intervention. Return visits within 72 h and door-to-balloon time were unchanged. Total length of stay was similar.Conclusion: The computerized triage scale improved speed of triage, allowing more high acuity patients to be seen within recommended timeframes, without notable impact on quality. [ABSTRACT FROM AUTHOR]

Objective: This study examined the associations between trauma mortality and quality of care indicators currently used in Japan.Design: This is a retrospective two-level discrete-time survival analysis. Quality indicators were derived from the 2012-2013 annual hospital survey conducted by the Ministry of Health, Labour and Welfare. Trauma mortality data were derived from the Japan Trauma Data Bank for the period of April 2012 to March 2013.Setting: Tertiary care centers designated as emergency and critical care centers (ECCCs) in Japan.Participants: The analysis included 12 378 patients aged ≥15 years with blunt trauma and an Injury Severity Score ≥9, registered to the data bank from 91 ECCCs.Intervention: Quality of care indicators examined in the annual hospital survey.Main Outcome Measures: Deaths within 30 days.Results: Of the 12 378 patients, 660 (5%) died within 30 days. Higher indicator score was significantly associated with lower mortality risk (hazard ratio [HR] for the second, third and fourth quartiles vs. lowest quartile 0.61, 0.55 and 0.52, respectively). Factors significantly associated with lower mortality risk were, higher patient volume (HR for the highest vs. lowest quartile, 0.74), director's qualification as specialist (HR 0.57) or consultant (HR 0.58), review of patient arrival process (HR 0.68), triage functions (HR 0.69), availability of psychiatrists (HR 0.75) and operating room being ready 24-h (HR 0.81).Conclusions: The study identified certain indicators associated with trauma patient mortality. Further refinement of indicators is required to specifically identify what needs changing. [ABSTRACT FROM AUTHOR]

Purpose: To systematically review the available evidence about hospital discharge communication practices and identify which practices were preferred by patients and healthcare providers, improved patient and provider satisfaction, and increased patients' understanding of their medical condition.Data Sources: OVID Medline, Web of Science, ProQuest, PubMed and CINAHL plus.Study Selection: Databases were searched for peer-reviewed, English-language papers, published to August 2016, of empirical research using quantitative or qualitative methods. Reference lists in the papers meeting inclusion criteria were searched to identify further papers.Data Extraction: Of the 3489 articles identified, 30 met inclusion criteria and were reviewed.Results Of Data Synthesis: Much research to date has focused on the use of printed material and person-based discharge communication methods including verbal instructions (either in person or via telephone calls). Several studies have examined the use of information technology (IT) such as computer-generated and video-based discharge communication practices. Utilizing technology to deliver discharge information is preferred by healthcare providers and patients, and improves patients' understanding of their medical condition and discharge instructions.Conclusion: Well-designed IT solutions may improve communication, coordination and retention of information, and lead to improved outcomes for patients, their families, caregivers and primary healthcare providers as well as expediting the task for hospital staff. [ABSTRACT FROM AUTHOR]

Objective: To contribute to a better understanding of volume-outcome relationships in surgery by exploring Dutch surgeons' views on the underlying mechanism.Design: A qualitative study based on face-to-face semi structured interviews and an inductive content analysis approach.Setting: Interviews were conducted in eight hospitals in the Netherlands (2 university, 4 teaching and 2 general).Participants: Twenty surgeons (gastrointestinal, vascular and trauma).Main Outcome Measure(s): Dutch surgeons' views on volume-outcome relationships in surgery and the underlying mechanism.Results: The majority of surgeons believed volume is related to outcomes after surgery. Interviewees highlighted the importance of both focus and skills when describing the underlying mechanism. Focus was visible on three levels: hospital, surgeon and team. Focus on a hospital level referred to investing in specific infrastructure and dedicated personnel. Surgeons described both the benefits and downsides of surgeons' increased focus to a certain surgical subspeciality. And their experiences on the importance of working with fixed, procedure-specific teams. The positive influence of caseload on technical and nontechnical skills was acknowledged, as well as the benefits of combining skills by operating together. Although a basic skill set should be maintained, this does not necessarily require high volume.Conclusions: Focus and skills are important explanatory factors in volume-outcome relationships according to Dutch surgeons. This suggests that both high- and low-volume providers should enable specialized, fixed teams for complex surgeries and focus on maintenance of both their technical and nontechnical skills. By uncovering the underlying mechanism, imperfect quality indicators such as volume can be supplemented or replaced. [ABSTRACT FROM AUTHOR]

Objective: To elucidate the association between health-related quality of life and shared decision-making among patients in Hong Kong after adjustment for potential confounding variables.Design: A telephone survey was conducted with patients attending all public specialist outpatient clinics in Hong Kong between July and December 2014. The Specialist Outpatient Patient Experience Questionnaire and EQ-5D questionnaire were used to evaluate shared decision-making and quality of life, respectively. We performed a Tobit regression analysis to examine the associations between shared decision-making and quality of life after adjustment for known social, economic and health-related factors.Setting: Twenty-six of the Hospital Authority's specialist outpatient clinics.Participants: Patients aged 18 years or older who attended one of the Hospital Authority's specialist outpatient clinics between July and November 2014.Main Outcome Measure(s): Shared decision-making and quality of life score.Results: Overall, 13 966 patients completed the study. The group reporting partial involvement in decision-making had slightly higher EQ-5D scores than the 'not involved' group and the 'fully involved' group. EQ-5D scores were higher among subjects who were younger, male, and had a higher level of education. Respondents living alone and living in institutions scored lower on the EQ-5D than patients living with families.Conclusions: Important differences in the relationship between the attitudes towards shared decision-making and quality of life were identified among patients. These associations should be taken into consideration when promoting patient-centred care and improving health professional-patient communication. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the effectiveness of unannounced versus announced surveys in detecting non-compliance with accreditation standards in public hospitals.Design: A nationwide cluster-randomized controlled trial.Setting and Participants: All public hospitals in Denmark were invited. Twenty-three hospitals (77%) (3 university hospitals, 5 psychiatric hospitals and 15 general hospitals) agreed to participate.Intervention: Twelve hospitals were randomized to receive unannounced surveys (intervention group) and eleven hospitals to receive announced surveys (control group). We hypothesized that the hospitals receiving the unannounced surveys would reveal a higher degree of non-compliance with accreditation standards than the hospitals receiving announced surveys. Nine surveyors trained and employed by the Danish Institute for Quality and Accreditation in Healthcare (IKAS) were randomized into teams and conducted all surveys.Main Outcome Measure: The outcome was the surveyors' assessment of the hospitals' level of compliance with 113 performance indicators-an abbreviated set of the Danish Healthcare Quality Programme (DDKM) version 2, covering organizational standards, patient pathway standards and patient safety standards. Compliance with performance indicators was analyzed using binomial regression analysis with bootstrapped robust standard errors.Results: In all, 16 202 measurements were acceptable for data analysis. The risk of observing non-compliance with performance indicators for the intervention group compared with the control group was statistically insignificant (risk difference (RD) = -0.6 percentage points [-2.51-1.31], P = 0.54). A converged analysis of the six patient safety critical standards, requiring 100% compliance to gain accreditation status revealed no statistically significant difference (RD = -0.78 percentage points [-4.01-2.44], P = 0.99).Conclusions: Unannounced hospital surveys were not more effective than announced surveys in detecting quality problems in Danish hospitals.Trial Registration Number: ClinicalTrials.gov NCT02348567, https://clinicaltrials.gov/ct2/show/NCT02348567?term=NCT02348567. [ABSTRACT FROM AUTHOR]

Objective: To determine the effective coverage of obstetric care in a rural Tanzanian region and to assess differences in effective coverage by wealth.Design: Cross-sectional structured interviews.Setting: Pwani Region, Tanzania.Participants: The study includes 24 rural, government-managed, primary healthcare clinics and their catchment populations. From January-April 2016, we conducted a household survey of a census of women with recent deliveries, health worker knowledge surveys and facility audits.Main Outcome Measures: We explored the proportion of women receiving quality care through the cascade and conducted an equity analysis by wealth.Results: In total, 2,910 of 3,564 women (81.6%) reported delivering their most recent child in a health facility, 1,096 of whom delivered in a study facility. Using a minimum threshold of quality, the effective coverage of obstetric care was 25%. Quality was lowest in the emergency care dimensions, with the average score on the provider knowledge tests at 47% and the average provision of basic emergency obstetric services below 50%. The wealthiest 20% of women were 4.1 times as likely to deliver in facilities offering at least the minimum threshold of quality care through the cascade compared to the poorest 80% of women (95% confidence interval: 1.5-11.3).Conclusions: Effective coverage of delivery care is very low, particularly among poorer women. Health worker knowledge caused the sharpest decline in effective coverage. Measures of effective coverage are a better performance measure of under-resourced health systems than utilization. Equity analyses can further identify important discrepancies in quality across socio-economic levels.Trial Registration: ISRCTN 17107760. [ABSTRACT FROM AUTHOR]

Objective: To examine how consumer engagement (CE) can be promoted through Australian accreditation programmes.Design: A nation-wide qualitative study completed in 2012.Setting: All eight Australian States and Territories.Participants: Two-hundred and fifty-eight healthcare stakeholders from the acute, primary and aged care sectors.Intervention: Forty-seven individual and group interviews were undertaken. Questions elicited views on the dimensions and utility of CE promotion by accreditation programmes.Main Outcome Measure: Healthcare stakeholders' views on the dimensions and utility of CE promotion by accreditation programmes.Results: Four mechanisms of CE promotion were identified. Two involved requirements for health service organizations to meet CE-related standards related to consumer experience and satisfaction surveys, and consumer participation in organizational governance processes. Two mechanisms for promoting CE through accreditation processes were also identified, concerning consumer participation in the development and revision of standards, and the implementation of accreditation surveys. Accreditation programmes were viewed as important drivers of CE, yet concerns were raised regarding the organizational investments needed to meet programmes' requirements.Conclusions: Accreditation programmes use diverse mechanisms as levers for change to promote CE in healthcare. These mechanisms and their inter-relationships require careful consideration by accreditation agencies and health policymakers to maximize their potential benefits, while maintaining stakeholder engagement in programmes. [ABSTRACT FROM AUTHOR]

Denmark has unique opportunities for quality measurement and benchmarking since Denmark has well-developed health registries and unique patient identifier that allow all registries to include patient-level data and combine data into sophisticated quality performance monitoring. Over decades, Denmark has developed and implemented national quality and patient safety initiatives in the healthcare system in terms of national clinical guidelines, performance and outcome measurement integrated in clinical databases for important diseases and clinical conditions, measurement of patient experiences, reporting of adverse events, national handling of patient complaints, national accreditation and public disclosure of all data on the quality of care. Over the years, Denmark has worked up a progressive and transparent just culture in quality management; the different actors at the different levels of the healthcare system are mutually attentive and responsive in a coordinated effort for quality of the healthcare services. At national, regional, local and hospital level, it is mandatory to participate in the quality initiatives and to use data and results for quality management, quality improvement, transparency in health care and accountability. To further develop the Danish governance model, it is important to expand the model to the primary care sector. Furthermore, a national quality health programme 2015-18 recently launched by the government supports a new development in health care focusing upon delivering high-quality health care-high quality is defined by results of value to the patients. [ABSTRACT FROM AUTHOR]

Objective: To examine the association between compliance with hospital accreditation and 30-day mortality. Design: A nationwide population-based, follow-up study with data from national, public registries. Setting: Public, non-psychiatric Danish hospitals. Participants: In-patients diagnosed with one of the 80 primary diagnoses. Intervention: Accreditation by the first version of The Danish Healthcare Quality Programme for hospitals from 2010 to 2012. Compliance were assessed by surveyors on an on-site survey and awarded the hospital as a whole; fully (n = 11) or partially accredited (n = 20). A follow-up activity was requested for partially accredited hospitals; submitting additional documentation (n = 11) or by having a return-visit (n = 9). Main Outcome Measure(s): All-cause mortality within 30-days after admission. Multivariable logistic regression was used to compute odds ratios (ORs) for 30-day mortality adjusted for six confounding factors and for cluster effect at hospital level. Results: A total of 276 980 in-patients were identified. Thirty-day mortality risk for in-patients at fully (n = 76 518) and partially accredited hospitals (n = 200 462) was 4.14% (95% confidence interval (CI):4.00-4.28) and 4.28% (95% CI: 4.20-4.37), respectively. In-patients at fully accredited hospitals had a lower risk of dying within 30-days after admission than in-patients at partially accredited hospitals (adjusted OR of 0.83; 95% CI: 0.72-0.96). A lower risk of 30-day mortality was observed among in-patients at partially accredited hospitals required to submit additional documentation compared with in-patients at partially accredited hospitals requiring a return-visit (adjusted OR 0.83; 95% CI: 0.67-1.02). Conclusion: Admissions at fully accredited hospitals were associated with a lower 30-day mortality risk than admissions at partially accredited hospitals. [ABSTRACT FROM AUTHOR]

Objective To evaluate measurement properties of a set of public quality indicators on physical therapy. Design An observational study with web-based collected survey data (2009 and 2010). Setting Dutch primary care physical therapy practices. Participants In 3743 physical therapy practices, 11 274 physical therapists reporting on 30 patients each. Main Outcome Measure(s) Eight quality indicators were constructed: screening and diagnostics (n= 2), setting target aim and subsequent of intervention (n = 2), administrating results (n = 1), global outcome measures (n = 2) and patient's treatment agreement (n = 1). Measurement properties on content and construct validity, reproducibility, floor and ceiling effects and interpretability of the indicators were assessed using comparative statistics and multilevel modeling. Results Content validity was acceptable. Construct validity (using known group techniques) of two outcome indicators was acceptable; hypotheses on age, gender and chronic vs. acute care were confirmed. For the whole set of indicators reproducibility was approximated by correlation of 2009 and 2010 data and rated moderately positive (Spearman's ρ between 0.3 and 0.42 at practice level) and interpretability as acceptable, as distinguishing between patient groups was possible. Ceiling effects were assessed negative as they were high to extremely high (30% for outcome indicator 6–95% for administrating results). Conclusion Weaknesses in data collection should be dealt with to reduce bias and to reduce ceiling effects by randomly extracting data from electronic medical records. More specificity of the indicators seems to be needed, and can be reached by focusing on most prevalent conditions, thus increasing usability of the indicators to improve quality of care. [ABSTRACT FROM PUBLISHER]

Objective The purpose of this study was to develop and validate a generic questionnaire to evaluate experiences and reported outcomes in patients who receive treatment across a range of healthcare sectors. Design Mixed-methods design including focus groups, pretests and field test. Setting The patient questionnaire was developed in the context of a nationwide program in Germany aimed at quality improvements across the healthcare sectors. Participants For the field test, 589 questionnaires were distributed to patients via 47 general practices. Main Measurements Descriptive item analyzes non-responder analysis and factor analysis (PCA). Retest coefficients (r) calculated by correlation of sum scores of PCA factors. Quality gaps were assessed by the proportion of responders choosing a response category defined as indicating shortcomings in quality of care. Results The conceptual phase showed good content validity. Four hundred and seventy-four patients who received a range of treatment across a range of sectors were included (response rate: 80.5%). Data analysis confirmed the construct, oriented to the patient care journey with a focus on transitions between healthcare sectors. Quality gaps were assessed for the topics ‘Indication’, including shared-decision-making (6 items, 24.5–62.9%) and ‘Discharge and Transition’ (10 items; 20.7–48.2%). Retest coefficients ranged from r = 0.671 until r = 0.855 and indicated good reliability. Low ratios of item-non-response (0.8–9.3%) confirmed a high acceptance by patients. Conclusions The number of patients with complex healthcare needs is increasing. Initiatives to expand quality assurance across organizational borders and healthcare sectors are therefore urgently needed. A validated questionnaire (called PEACS 1.0) is available to measure patients' experiences across healthcare sectors with a focus on quality improvement. [ABSTRACT FROM PUBLISHER]

Objective To understand how patient-reported quality is related to adverse events (AEs). Design Random sample telephone survey. Setting Sixteen acute care Massachusetts hospitals. Participants Two thousand and five hundred and eight-two of 4163 (62% response rate) eligible adult patients. Main Outcome Measures Patients hospitalized from 1 April 2003 to 1 October 2003 provided global quality ratings and whether they experienced AEs. Service recovery, defined as efforts by a service provider to return customers to a state of satisfaction after a lapse in service, was operationalized as high participation in one's care, timely discharge and disclosure of the circumstances of an AE. Results Of respondents, 82% rated the quality as high and 23% reported one or more AEs. Patients with no AEs gave higher quality ratings (85 vs. 77 or 62% for patients with 1 or 2+ AEs, respectively, P < 0.001). Patients were more likely to rate the quality high if they reported high participation (86 vs. 53%), or felt discharge timing was just right (85 vs. 64%); for those with AEs, ratings were higher among those reporting disclosure (82 vs. 66%) (all P < 0.01). In adjusted analyses, patients with AEs experiencing all three service recovery components rated their quality higher (86 vs. 68%, P < 0.01). Conclusions Patients with AEs rate the quality of care lower than others. However, patients with AEs who experienced ‘service recovery’ as we defined it rated their quality of care at levels similar to those who did not experience AEs. Hospitals seeking to improve quality ratings might consider efforts to ensure patient safety and to address AEs in a transparent and responsive way. [ABSTRACT FROM AUTHOR]

Objective To assess the relationship between hospital patients' quality of care ratings and their experiences with health-related information exchanges and communication during hospitalization. Design Cross-sectional multivariate dimensional analysis of data from a quality of care experience questionnaire of hospital patients comparing scores across three levels of reported satisfaction. Setting and participants Five thousand nine hundred and fifty-two patients from a Swiss University Hospital responded to the questionnaire at discharge during 2010. Main outcome measures Survey questions measuring patients' evaluation of quality of care, patient loyalty and overall satisfaction. Results Different levels of reported satisfaction are associated with differing experiences of health-related information and communication during a hospital stay. Conclusions Patients who report lower satisfaction appear to attribute to the hospital staff enduring negative dispositions from behaviours that may be due to specific situational contexts. Negative experiences appear to influence scores on most other communication and information domains. Patients who report higher satisfaction, in contrast, appear to differentiate negative experiences and positive experiences and they appear to relativize and compartmentalize negative experiences associated with their hospital stay. [ABSTRACT FROM AUTHOR]

Objective Many patients with schizophrenia are not treated in line with evidence-based guidelines. This study examines the large-scale implementation of the National Multidisciplinary Guideline for schizophrenia in the Netherlands. Design Observational, prospective study, with repeated measurement. Setting Thirty mental healthcare teams in different regions of the Netherlands. Participants Three hundred and fifty-nine clinicians with different professional backgrounds and 1489 patients suffering from schizophrenia. Intervention(s) Six evidence-based interventions for schizophrenia were implemented, in the context of a quality improvement collaborative: assertive community treatment (ACT) or its adapted version functional assertive community treatment (FACT), cognitive behavioural therapy, psycho-education, family interventions, individual placement support and pharmacotherapy. Main Outcome Measure(s) Professional performance, social functioning and relapse rates. Results Improved professional performance, in line with guidelines. Availability of (F)ACT improved from 23 to 60%. Individual Placement Support improved from 20 to 53%. Complete care plans were composed for 38% of the patients and routine outcome monitoring was introduced in most teams. Social functioning improved slightly (HoNOS mean: from 6.2 to 5.6). Relapse rates did not improve during the course of the study. Conclusions An intensive implementation programme can result in an improved delivery of evidence-based care, increased continuity of care and slightly improved outcomes for individuals with schizophrenia. More rigorous research designs have to confirm these findings. [ABSTRACT FROM AUTHOR]

Objective Despite widespread interest in many jurisdictions in monitoring and improving the quality of stroke care delivery, benchmarks for most stroke performance indicators have not been established. The objective of this study was to develop data-derived benchmarks for acute stroke quality indicators. Design Nine key acute stroke quality indicators were selected from the Canadian Stroke Best Practice Performance Measures Manual. Participants A population-based retrospective sample of patients discharged from 142 hospitals in Ontario, Canada, between 1 April 2008 and 31 March 2009 (N = 3191) was used to calculate hospital rates of performance and benchmarks. Intervention The Achievable Benchmark of Care (ABC™) methodology was used to create benchmarks based on the performance of the upper 15% of patients in the top-performing hospitals. Main Outcome Measures Benchmarks were calculated for rates of neuroimaging, carotid imaging, stroke unit admission, dysphasia screening and administration of stroke-related medications. Results The following benchmarks were derived: neuroimaging within 24 h, 98%; admission to a stroke unit, 77%; thrombolysis among patients arriving within 2.5 h, 59%; carotid imaging, 93%; dysphagia screening, 88%; antithrombotic therapy, 98%; anticoagulation for atrial fibrillation, 94%; antihypertensive therapy, 92% and lipid-lowering therapy, 77%. ABC™ acute stroke care benchmarks achieve or exceed the consensus-based targets required by Accreditation Canada, with the exception of dysphagia screening. Conclusions Benchmarks for nine hospital-based acute stroke care quality indicators have been established. These can be used in the development of standards for quality improvement initiatives. [ABSTRACT FROM AUTHOR]

Objective To examine the potential for using routinely collected administrative data to compare the quality and safety of stroke care at a hospital level, including evaluating any bias due to variations in coding practice. Design A retrospective cohort study of English hospitals' performance against six process and outcome indicators covering the acute care pathway. We used logistic regression to adjust the outcome measures for case mix. Setting Hospitals in England. Participants Stroke patients (ICD-10 I60–I64) admitted to English National Health Service public acute hospitals between April 2009 and March 2010, accounting for 91 936 admissions. Main Outcome Measure The quality and safety were measured using six indicators spanning the hospital care pathway, from timely access to brain scans to emergency readmissions following discharge after stroke. Results There were 182 occurrences of hospitals performing statistically differently from the national average at the 99.8% significance level across the six indicators. Differences in coding practice appeared to only partially explain the variation. Conclusions Hospital administrative data provide a practical and achievable method for evaluating aspects of stroke care across the acute pathway. However, without improvements in coding and further validation, it is unclear whether the cause of the variation is the quality of care or the result of different local care pathways and data coding accuracy. [ABSTRACT FROM AUTHOR]

Objective To measure the relative efficiency of primary care (PC) in turning their structures into services delivery and turning their services delivery into quality outcomes. Design Cross-sectional study based on the dataset of the Primary Healthcare Activity Monitor for Europe project. Two Data Envelopment Analysis models were run to compare the relative technical efficiency. A sensitivity analysis of the resulting efficiency scores was performed. Setting PC systems in 22 European countries in 2009/2010. Main Outcome Measures Model 1 included data on PC governance, workforce development and economic conditions as inputs and access, coordination, continuity and comprehensiveness of care as outputs. Model 2 included the previous process dimensions as inputs and quality indicators as outputs. Results There is relatively reasonable efficiency in all countries at delivering as many as possible PC processes at a given level of PC structure. It is particularly important to invest in economic conditions to achieve an efficient structure–process balance. Only five countries have fully efficient PC systems in turning their services delivery into high quality outcomes, using a similar combination of access, continuity and comprehensiveness, although they differ on the adoption of coordination of services. There is a large variation in efficiency levels obtained by countries with inefficient PC in turning their services delivery into quality outcomes. Conclusions Maximizing the individual functions of PC without taking into account the coherence within the health-care system is not sufficient from a policymaker's point of view when aiming to achieve efficiency. [ABSTRACT FROM AUTHOR]

Objectives To determine whether, and under what circumstance, US hospital employment of non-US-educated nurses is associated with patient outcomes. Design Observational study of primary data from 2006 to 2007 surveys of hospital nurses in four states (California, Florida, New Jersey and Pennsylvania). The direct and interacting effects of hospital nurse staffing and the percentage of non-US-educated nurses on 30-day surgical patient mortality and failure-to-rescue were estimated before and after controlling for patient and hospital characteristics. Participants Data from registered nurse respondents practicing in 665 hospitals were pooled with patient discharge data from state agencies. Main Outcomes Measure(s) Thirty-day surgical patient mortality and failure-to-rescue. Results The effect of non-US-educated nurses on both mortality and failure-to-rescue is nil in hospitals with lower than average patient to nurse ratios, but pronounced in hospitals with average and poor nurse to patient ratios. In hospitals in which patient-to-nurse ratios are 5:1 or higher, mortality is higher when 25% or more nurses are educated outside of the USA than when <25% of nurses are non-US-educated. Moreover, the effect of having >25% non-US-educated nurses becomes increasingly deleterious as patient-to-nurse ratios increase beyond 5:1. Conclusions Employing non-US-educated nurses has a negative impact on patient mortality except where patient-to-nurse ratios are lower than average. Thus, US hospitals should give priority to achieving adequate nurse staffing levels, and be wary of hiring large percentages of non-US-educated nurses unless patient-to-nurse ratios are low. [ABSTRACT FROM AUTHOR]

Objective To examine the associations of four distinct nursing care organizational models with patient safety outcomes. Design Cross-sectional correlational study. Using a standardized protocol, patients' records were screened retrospectively to detect occurrences of patient safety-related events. Binary logistic regression was used to assess the associations of those events with four nursing care organizational models. Setting Twenty-two medical units in 11 hospitals in Quebec, Canada, were clustered into 4 nursing care organizational models: 2 professional models and 2 functional models. Participants Two thousand six hundred and ninety-nine were patients hospitalized for at least 48 h on the selected units. Main Outcome Measure Composite of six safety-related events widely-considered sensitive to nursing care: medication administration errors, falls, pneumonia, urinary tract infection, unjustified restraints and pressure ulcers. Events were ultimately sorted into two categories: events ‘without major’ consequences for patients and events ‘with’ consequences. Results After controlling for patient characteristics, patient risk of experiencing one or more events (of any severity) and of experiencing an event with consequences was significantly lower, by factors of 25–52%, in both professional models than in the functional models. Event rates for both functional models were statistically indistinguishable from each other. Conclusions Data suggest that nursing care organizational models characterized by contrasting staffing, work environment and innovation characteristics may be associated with differential risk for hospitalized patients. The two professional models, which draw mainly on registered nurses (RNs) to deliver nursing services and reflect stronger support for nurses' professional practice, were associated with lower risks than are the two functional models. [ABSTRACT FROM PUBLISHER]

Purpose Being able to compare hospitals in terms of quality and safety between countries is important for a number of reasons. For example, the 2011 European Union directive on patients' rights to cross-border health care places a requirement on all member states to provide patients with comparable information on health-care quality, so that they can make an informed choice. Here, we report on the feasibility of using common process and outcome indicators to compare hospitals for quality and safety in five countries (England, Portugal, The Netherlands, Sweden and Norway). Main Challenges Identified The cross-country comparison identified the following seven challenges with respect to comparing the quality of hospitals across Europe: different indicators are collected in each country; different definitions of the same indicators are used; different mandatory versus voluntary data collection requirements are in place; different types of organizations oversee data collection; different levels of aggregation of data exist (country, region and hospital); different levels of public access to data exist; and finally, hospital accreditation and licensing systems differ in each country. Conclusion Our findings indicate that if patients and policymakers are to compare the quality and safety of hospitals across Europe, then further work is urgently needed to agree the way forward. Until then, patients will not be able to make informed choices about where they receive their health care in different countries, and some governments will remain in the dark about the quality and safety of care available to their citizens as compared to that available in neighbouring countries. [ABSTRACT FROM PUBLISHER]

Objective To measure the effective coverage of a program to control type 2 diabetes. Design Observational study combining multiple data sources. Setting Hidalgo state, Mexico. Participants Adults without social security health benefits and patients with a diagnosis of diabetes participating in the program. Main outcome measures Detection of diabetes; glucose, cholesterol, triglyceride and blood pressure control; education; diabetic retinopathy, diabetic foot and nephropathy prevention. Results Only 7.1% of individuals with diabetes participated in the control program. Fasting glucose and HbA1c values were available for 95.6 and 35.6 of patients, respectively. There were measurements of total cholesterol (52.1%), triglyceride (50.6%) and blood pressure (99.6%). Educative activities were realized for 64.8% of patients. The most important gaps were related with detection of illness, low-density lipoprotein cholesterol control, glucose control with HbA1c and nephropathy prevention. Effective coverage of these medical actions was 6.22, 5.07, 5.01 and 0.34%, respectively. Conclusions The greatest challenge to overcome is the detection of individuals with illness because a large number of individuals with type 2 diabetes do not use health services and the health system does not systematically search them out. Medical actions that require resources that must be paid for by patients tend to be used less and to be of lower quality. The use of effective coverage to measure the performance of diabetes care program provides practical information to improve health services. [ABSTRACT FROM AUTHOR]