WORLD HOSPITAL DIRECTORY
| More

Hon. H.E. Sir. Dr. Raphael Louis-PM Candidate (2015 - 2020)


World Hospital Map*
* rated as the Best World Hospital Map. Click on the country to select. To deselect clik on the blue ocean

WORLD HOSPITAL DIRECTORY is the one and only largest database of hospitals around the world. There are over 65,000 plus records of hospitals across globe with geo data viz Longitude, Latitude, UTM, GPS, Lombard projection, map, etc, thereby enabling the browsers to know to distance between the searched Hospital and the browsers.

WORLD HOSPITAL DIRECTORY has the World's largest online database of general, multispeciality, eye, dental, children, maternity, cardiac care, orthopedic, nephrology, neurology, diabetic, psychiatric, cancer, ENT, hospice, Rehabilitation, alternate medicine, veterinary hospitals across globe. Discover the complete list of hospitals available in North America, South America, Europe, Asia, Australia, New Zealand, rest of the world and online.

Country:
Subcontinent:
Continent:
Zipcode:
Category:
Show Listings:
Keyword:
 


1CEMIC
CEMIC
Category: General Hospitals
Argentina
South America, America
2Croydon Hospital (Tablelands HSD)
Croydon Hospital (Tablelands HSD)
Category: Mulispeciality Hospitals
Australia
Australia and New Zealand, Oceanic
3Regionaal Hospital Sint-Maria
Regionaal Hospital Sint-Maria
Category: Mulispeciality Hospitals
Belgium
Western Europe, Europe
4Bairro Passo D'areia Farmaconte Dist. Produtos Hospitalares Ltda.
Bairro Passo D'areia Farmaconte Dist. Produtos Hospitalares Ltda.
Category: Mulispeciality Hospitals
Brazil
South America, America
5BCIT - Technology Centre, Health Technology Research Group
BCIT - Technology Centre, Health Technology Research Group
Category: General Hospitals
Canada
North America, America

1.
Why Our Healthcare System Isnt Healthy
Why Our Healthcare System Isnt HealthyMost people are well aware that an estimated 45 million Americans currently do not have healthcare, but is the crisis simply the lack
More >>
2.
Stopping Hospital Infections
Stopping Hospital InfectionsEach year hospitals end up killing twice as many people than automobiles, some 90,000 deaths in the United States. It is not from malpractice, i
More >>
3.
Protect Yourself Against the Flu Vaccine!
Protect Yourself Against the Flu Vaccine!<br />
The vaccine industry insists that their vaccines against the flu serve as the key to a healthy winter. Although there has
More >>
4.
Chinese Medicine
Chinese MedicineChinese Medicine, over 2000 years old, is an ancient form of medicine. Consisting of acupuncture, moxibustion (moxibustion - using material made up of
More >>
5.
Medical Billing Specialist
Medical Billing SpecialistAs Pres. Bush was touring the Midwest, shortly before he was re-elected as President, and even after, he spoke of medical reform centering on
More >>
6.
Nasonex And You: Breathe Easy, Not Sneezy
Nasonex And You: Breathe EasyWhile everybody else is wandering around enjoying the spring weather, are you hiding out in your hermetically-sealed house? Do you dread the star
More >>
7.
Chronic Headaches and Pain Often Can Be Eliminated By A Special Dentist
Chronic Headaches Often Can Be Eliminated By A Special DentistDENVER ? Sometimes as Freud once said a good cigar is just a smoke. A headache, on the other hand, occas
More >>
8.
Physicians, Chiropractors and Physical Therapist Agree on a New Treatment for Low Back Pain
New Treatment for Low Back Pain<br />
One of the most prevalent and difficult health conditions to treat in the physical medicine is low back pain. The difficulty in tre
More >>
9.
Web Therapy: Enhancing Patient Communication with Web Access
Web Therapy: Enhancing Patient Communication with Web AccessAccording to Jennifer Lyons' chart, she's just a bad slip and fall who's lucky enough to be on her way to a full
More >>
10.
Increasing Patient Care and Reducing Liability in Seven Simple Steps
Increasing Patient Care and Reducing Liability in Seven Simple StepsWhen an unconscious patient arrives in the ED, every hospital agrees that timely next of kin notificat
More >>
11.
Cetyl Myristoleate Seperating Fact From Fiction
Cetyl Myristoleate Seperating Fact From FictionI am a strong believer in Cetyl Myristoleate for the treatment of arthritis. For the last three years I have been res
More >>
12.
Medical Tests: What Does a Normal Range Mean?
Medical Tests: What Does a Normal Range Mean?We have a marvelous array of medical tests available to us. Many of them-typically blood-tests-even come with results expressed
More >>
13.
CT and MRI Scans in Neurological Practice
CT and MRI Scans in Neurological Practice

Before computed tomographic (CT) scans became available in the 1970s, there was no good method for imaging the brain. The a
More >>
14.
Alcohol Rehabilitation Centers - Take An Informed Decision
Alcohol Rehabilitation Centers - Take An Informed DecisionAlcohol rehabilitation centers in the United States offer a wide range of treatment programmes for your recovery f
More >>
15.
Contact Lenses and Eye Glasses
Contact Lenses and Eye GlassesHow is Your Vision?
Notice friends getting contact lenses and pulling out eye glasses?

"What do you recommend?"

More >>
16.
Death by Fluoride
Death by FluorideA wee bit of fluoride makes teeth and dentists happy, we're told. Dr. Happy Tooth's smiley face turns into a frown when his favorite decay buster is busted
More >>
17.
10 Steps To Detoxification
10 Steps To DetoxificationTechnology. We live in a grand time of technological development. Computers, the Internet, cell phones, digital cameras and DVDs. But the human body h
More >>
18.
New Surgical Treatment Options for Hernias
New Surgical Treatment Options for HerniasHernia repair is one of the most commonly performed surgical procedures worldwide. In fact, there are over 600,000 hernia repa
More >>
19.
Arthritis Pain Relief : FAQ
Arthritis Pain Relief : FAQA great place to begin taking charge of you arthritis pain relief and prevention planning is by making an appointment with your healthc
More >>
20.
A Surgical Robot Fixes Heart in Brazil
a Surgical Robot Fixes Heart in BrazilBrazilian surgeons used a multi-armed robot to repair a hole in a woman's heart in the first operation of its kind in Latin Americ
More >>
21.
Root Canal Therapy:FAQ
Root Canal Therapy:FAQOverview

A diseased or injured nerve use to mean that you were likely to lose a tooth. This is no longer the case thanks to root
More >>
22.
ADHD - Are there Treatment Options?
ADHD - Are there Treatment Options?As an ADD coach I am often asked about the treatment options available for Attention Deficit Disorder. Generally when someone says "ADD" the f
More >>
23.
7 Tips to Keep Your Fluid Down on Dialysis
7 Tips to Keep Your Fluid Down on DialysisAs any dialysis patient will tell you, keeping your fluid gain between dialysis sessions in check is not only important to your lon
More >>
24.
Testosterone Therapy in XXI Century
Testosterone Therapy in XXI CenturyNowadays many people are familiar with the appellation of "low testosterone level". What does it mean? It mean that male body p
More >>
25.
Stem Cell Research
Stem Cell ResearchHow To Buy Your Way Out Of An Early Death From An Incurable Disease.

How?... With private stem cell research, of course!?Stem cell research
More >>
1.
Maharashtra woos medical tourists
Maharashtra woos medical touristsMany people from the developed world come to India for the rejuvenation promised by yoga and ayurvedic massage, but few consider it a de
More >>
2.
Medical tourism: Need surgery, will travel
Maharashtra woos medical touristsA worldwide market

What's called medical tourism – patients going to a different country for either urgent or elective
More >>
3.
Medical Tourism is Becoming a Huge Industry in India
Diatance LearningMany types of medical treatment in India cost a fraction of what they do in the United States and other Western nations, and citizens from these c
More >>
4.
Medical tourism set to take off in a big way
Medical tourism set to take off in a big wayWith world class healthcare professionals, nursing care and treatment cost almost one-sixth of that in the developed
More >>
5.
India eyeing share in medical tourism pie
India eyeing share in medical tourism pie A NICE blend of top-class medical expertise at attractive prices is helping a growing number of Indian corporate hospitals lure forei
More >>
6.
Are we ready for medical tourism?
Are we ready for medical tourism? The private healthcare industry is quietly facilitating a revolution to enable India to emerge as a health destination. Yet there are the
More >>
7.
Is medical tourism worth the risk?
Is medical tourism worth the risk?Thousands of Britons are heading abroad for cut-price treatment. We investigate the health tourism boom and asks if the benefits o
More >>
8.
Package holiday surgery to beat NHS queue
Package holiday surgery to beat NHS queueA holiday firm is offering 'sun and surgery' package deals to India for patients tired of waiting for the NHS.

Th
More >>
9.
Choosing the right weight loss surgery abroad
Choosing the right weight loss surgery abroadThe reluctance of public healthcare systems and health insurers to fund weight loss surgery means that more and more people are
More >>
10.
The forgotten medical tourism destination
The forgotten medical tourism destinationAn article by medical tourism specialist, Ian Youngman, on one of the world’s leading destinations for medical travelers which seems
More >>
11.
Why medical tourism needs facilitators
Why medical tourism needs facilitatorsFollowing our recent article on "How can patients judge quality in medical tourism?", Caroline Ratner spoke to Mike Silford, who run
More >>
12.
How can patients judge quality in medical tourism?
How can patients judge quality in medical tourism?There's much discussion and hype around the medical tourism world about “quality”. Every hospital, clinic, healthcar
More >>
13.
The importance of social media and the web in medical tourism
The importance of social media and the web in medical tourismMore than most other industries, medical tourism agencies and international patient departments rely heavily on t
More >>
14.
Medical Tourism Destinations: Places That Top The Charts
Medical Tourism Destinations: Places That Top The ChartsMedical tourism is a popular trend among people in the US nowadays. Many Americans are moving abroad to get tr
More >>
15.
Plastic & Cosmetic Surgery Option In Malaysia
Plastic & Cosmetic Surgery Option In MalaysiaMedical Tourism Malaysia is growing at an exponential growth factor. Its enjoying medical tourist from UK, Australia, New Zealand
More >>
16.
Samitivej Medical Tourism, A Lucrative Business
Samitivej Medical Tourism, A Lucrative BusinessSamitivej Wins 2 Prestigious HMA Awards 2008 Path to Being the Largest Medical Tourism

Samitivej, a leading pri
More >>
17.
Jordan pushes medical tourism industry
Jordan pushes medical tourism industryAfter establishing itself as a popular destination for medical care among Arabs in the Middle East, Jordan is now looking to attract more
More >>
18.
Some Frequently Asked Questions about Medical Tourism
Some Frequently Asked Questions about Medical TourismWhat is the quality of care that I can expect? Most of the healthcare centers abroad such as hospitals clinics and diagnostic
More >>
19.
Infertility Treatment in India
Infertility Treatment in IndiaInfertility is the inability to conceive a child by natural means. When a couple finds it difficult to conceive naturally, medication and spe
More >>
20.
Medical Tourism Thailand
Medical Tourism ThailandThailand has been a popular holiday destination of the East which is now a popular medical tourism destination as well. The Thai medical service is on
More >>
21.
Medical Tourism India
Medical Tourism IndiaA medical tourist in India can get the best of both worlds- excellent medical service from experts in the field of medicine and a splendid experience of a
More >>
22.
Digitizing Medical Documents
Digitizing Medical DocumentsIt is a common fact that hospitals and doctors need a patient’s detailed medical history before treating them. But when you have travele
More >>
23.
Roux-en-gastric bypass in India: An Overview
Roux-en-gastric bypass in India: An OverviewRoux-en-gastric bypass in India is very economical and affordable. Low cost but quality treatment attracts many patients of a
More >>
24.
Need a dentist? Come to Croatia
Need a dentist? Come to Croatia



vaporizers



Croatia has decided to take
More >>
25.
India offers hope for those too sick to wait
India offers hope for those too sick to waitEmerging into the teeming chaos of people, cows and honking vehicles outside Bangalore airport, retired teacher John Stauffer wonde
More >>




Abstracts en este numero


Resumos neste numero


Simplified Chinese Abstracts


Traditional Chinese Abstracts


Japanese Abstracts


French Abstracts


Impact of continuity of care on preventable hospitalization and evaluating patient safety indicators between Italy and the USA


Strategies facilitating practice change in pediatric cancer: a systematic review
<sec id="mzw052s1"><st>Purpose</st> <p>By conducting&nbsp;a systematic review, we describe strategies to actively disseminate knowledge or facilitate practice change among healthcare providers caring for children with cancer and we evaluate the effectiveness of these strategies.</p> </sec> <sec id="mzw052s2"><st>Data sources</st> <p>We searched Ovid Medline, EMBASE and PsychINFO.</p> </sec> <sec id="mzw052s3"><st>Study selection</st> <p>Fully published primary studies were included if they evaluated one or more professional intervention strategies to actively disseminate knowledge or facilitate practice change in pediatric cancer or hematopoietic stem cell transplantation.</p> </sec> <sec id="mzw052s4"><st>Data extraction</st> <p>Data extracted included study characteristics and strategies evaluated. In studies with a quantitative analysis of patient outcomes, the relationship between study-level characteristics and statistically significant primary analyses was evaluated.</p> </sec> <sec id="mzw052s5"><st>Results of data synthesis</st> <p>Of 20 644 titles and abstracts screened, 146 studies were retrieved in full and 60 were included. In 20 studies, quantitative evaluation of patient outcomes was examined and a primary outcome was stated. Eighteen studies were &lsquo;before and after&rsquo; design; there were no randomized studies. All studies were at risk for bias. Interrupted time series was never the primary analytic approach. No specific strategy type was successful at improving patient outcomes.</p> </sec> <sec id="mzw052s6"><st>Conclusions</st> <p>Literature describing strategies to facilitate practice change in pediatric cancer is emerging. However, major methodological limitations exist. Studies with robust designs are required to identify effective strategies to effect practice change.</p> </sec>


The effectiveness and variation of acute medical units: a systematic review
<sec id="mzw056s1"><st>Purpose</st> <p>To evaluate the evidence for the effectiveness of acute medical units (AMUs) compared with other models of care and compare the components of AMU models.</p> </sec> <sec id="mzw056s2"><st>Data sources</st> <p>Six electronic databases and grey literature sources searched between 1990 and 2014.</p> </sec> <sec id="mzw056s3"><st>Study selection</st> <p>Studies reporting on AMUs as an intervention for unplanned medical presentations to hospital with the inclusion of all outcome measures/study designs/comparators.</p> </sec> <sec id="mzw056s4"><st>Data extraction</st> <p>Data on study characteristics/outcomes/AMU components were extracted by one author and confirmed by a second.</p> </sec> <sec id="mzw056s5"><st>Data synthesis</st> <p>Seventeen studies of 12 AMUs across five countries were included. The AMU model was associated with a reduction in-hospital length of stay (LOS) in all analyses ranging from 0.3 to 2.6 days; and a reduction in mortality in 12 of the 14 analyses with the change ranging from a 0.1% increase to a 8.8% reduction. Evidence relating to readmissions and patient/staff satisfaction was less conclusive. There was variation in the following components of AMUs: admission criteria, entry sources, functions and consultant work patterns.</p> </sec> <sec id="mzw056s6"><st>Conclusion</st> <p>This review provides evidence that AMUs are associated with reductions in-hospital LOS and, less convincingly, mortality compared with other models of care when implemented in European and Australasian settings. Reported estimates may be affected by residual confounding. This review reports heterogeneity in components of the AMU model. Further work to identify what constitutes the key components of an AMU is needed to improve the quality and effectiveness of acute medical care. This is of particular importance given the escalating demand on acute services.</p> </sec>


Does clinical supervision of health professionals improve patient safety? A systematic review and meta-analysis
<sec id="mzw059s1"><st>Purpose</st> <p>To determine whether clinical supervision (CS) of health professionals improves patient safety.</p> </sec> <sec id="mzw059s2"><st>Data sources</st> <p>Databases MEDLINE, PsychINFO, CINAHL, EMBASE and AMED were searched from earliest date available. Additional studies were identified by searching of reference lists and citation tracking.</p> </sec> <sec id="mzw059s3"><st>Study selection</st> <p>Two reviewers independently applied inclusion and exclusion criteria. Thirty-two studies across three health professions [medicine (<I>n</I>&nbsp;=&nbsp;29), nursing (<I>n</I>&nbsp;=&nbsp;2) and paramedicine (<I>n</I>&nbsp;=&nbsp;1)] were selected.</p> </sec> <sec id="mzw059s4"><st>Data extraction</st> <p>The quality of each study was rated using the Medical Education Research Study Quality Instrument. Risk ratios (RR) were calculated for patient safety outcomes of mortality, complications, adverse events, reoperation following initial surgery, conversion to more invasive surgery and readmission to hospital.</p> </sec> <sec id="mzw059s5"><st>Results of data synthesis</st> <p>Results of meta-analyses provided low-quality evidence that supervision of medical professionals reduced the risk of mortality (RR 0.76, 95% CI 0.60&ndash;0.95, <I>I</I><sup>2</sup>&nbsp;=&nbsp;76%) and supervision of medical professionals and paramedics reduced the risk of complications (RR 0.69, 95% CI 0.53&ndash;0.89, <I>I</I><sup>2</sup>&nbsp;=&nbsp;76%). Due to a high level of statistical heterogeneity, sub-group analyses were performed. Sub-group analyses provided moderate-quality evidence that direct supervision of surgery significantly reduced the risk of mortality (RR 0.68, 95% CI 0.50&ndash;0.93, <I>I</I><sup>2</sup>&nbsp;=&nbsp;33%) and direct supervision of medical professionals conducting non-surgical invasive procedures significantly reduced the risk of complications (RR 0.33, 95% CI 0.24&ndash;0.46, <I>I</I><sup>2</sup>&nbsp;=&nbsp;0%).</p> </sec> <sec id="mzw059s6"><st>Conclusions</st> <p>CS was associated with safer surgery and other invasive procedures for medical practitioners. There was a lack of evidence about the relationship between CS and safer patient care for non-medical health professionals.</p> </sec>


Non-beneficial treatments in hospital at the end of life: a systematic review on extent of the problem
<sec id="mzw060s1"><st>Purpose</st> <p>To investigate the extent of objective &lsquo;non-beneficial treatments (NBTs)&rsquo; (too much) anytime in the last 6 months of life in routine hospital care.</p> </sec> <sec id="mzw060s2"><st>Data sources</st> <p>English language publications in Medline, EMBASE, PubMed, Cochrane library, and the grey literature (January 1995&ndash;April 2015).</p> </sec> <sec id="mzw060s3"><st>Study selection</st> <p>All study types assessing objective dimensions of non-beneficial medical or surgical diagnostic, therapeutic or non-palliative procedures administered to older adults at the end of life (EOL).</p> </sec> <sec id="mzw060s4"><st>Data extraction</st> <p>A 13-item quality score estimated independently by two authors.</p> </sec> <sec id="mzw060s5"><st>Results of data synthesis</st> <p>Evidence from 38 studies indicates that on average 33&ndash;38% of patients near the EOL received NBTs. Mean prevalence of resuscitation attempts for advanced stage patients was 28% (range 11&ndash;90%). Mean death in&nbsp;intensive care unit (ICU) was 42% (range 11&ndash;90%); and mean death rate in a hospital ward was 44.5% (range 29&ndash;60%). Mean prevalence of active measures including dialysis, radiotherapy, transfusions and life support treatment to terminal patient was 7&ndash;77% (mean 30%). Non-beneficial administration of antibiotics, cardiovascular, digestive and endocrine treatments to dying patients occurred in 11&ndash;75% (mean 38%). Non-beneficial tests were performed on 33&ndash;50% of patients with do-not-resuscitate orders. From meta-analyses, the pooled prevalence of non-beneficial ICU admission was 10% (95% CI 0&ndash;33%); for chemotherapy in the last six weeks of life was 33% (95% CI 24&ndash;41%).</p> </sec> <sec id="mzw060s6"><st>Conclusion</st> <p>This review has confirmed widespread use of NBTs at the EOL in acute hospitals. While a certain level of NBT is inevitable, its extent, variation and justification need further scrutiny.</p> </sec>


Getting right to the point: identifying Australian outpatients priorities and preferences for patient-centred quality improvement in chronic disease care
<sec id="mzw049s1"><st>Objectives</st> <p>To identify specific actions for patient-centred quality improvement in chronic disease outpatient settings, this study identified patients&rsquo; general and specific preferences among a comprehensive suite of initiatives for change.</p> </sec> <sec id="mzw049s2"><st>Design and setting</st> <p>A cross-sectional survey was conducted in three hospital-based clinics specializing in oncology, neurology and cardiology care located in New South Wales, Australia.</p> </sec> <sec id="mzw049s3"><st>Participants and measures</st> <p>Adult English-speaking outpatients completed the touch-screen Consumer Preferences Survey in waiting rooms or treatment areas. Participants selected up to 23 general initiatives that would improve their experience. Using adaptive branching, participants could select an additional 110 detailed initiatives and complete a relative prioritization exercise.</p> </sec> <sec id="mzw049s4"><st>Results</st> <p>A total of 541 individuals completed the survey (71.1% consent, 73.1% completion). Commonly selected general initiatives, presented in order of decreasing priority (along with sample proportion), included: improved parking (60.3%), up-to-date information provision (15.0%), ease of clinic contact (12.9%), access to information at home (12.8%), convenient appointment scheduling (14.2%), reduced wait-times (19.8%) and information on medical emergencies (11.1%). To address these general initiatives, 40 detailed initiatives were selected by respondents.</p> </sec> <sec id="mzw049s5"><st>Conclusions</st> <p>Initiatives targeting service accessibility and information provision, such as parking and up-to-date information on patient prognoses and progress, were commonly selected and perceived to be of relatively greater priority. Specific preferences included the need for clinics to provide patient-designated parking in close proximity to the clinic, information on treatment progress and test results (potentially in the form of designated brief appointments or via telehealth) and comprehensive and trustworthy lists of information sources to access at home.</p> </sec>


Impact of continuity of care on preventable hospitalization of patients with type 2 diabetes: a nationwide Korean cohort study, 2002-10
<sec id="mzw050s1"><st>Objective</st> <p>To determine whether patients with greater continuity of care (COC) have fewer preventable hospitalizations.</p> </sec> <sec id="mzw050s2"><st>Design</st> <p>We conducted a cohort study using a stratified random sample of Korean National Health Insurance enrollees from 2002 to 2010. The COC index was calculated for each year post-diagnosis based on ambulatory care visits. We performed a recurrent event survival analysis via Cox proportional hazard regression analysis of preventable hospitalizations.</p> </sec> <sec id="mzw050s3"><st>Study participants</st> <p>A total of 5163 patients newly diagnosed with type 2 diabetes mellitus in 2003&ndash;6 and receiving oral hypoglycemic medication.</p> </sec> <sec id="mzw050s4"><st>Main outcome measure</st> <p>Preventable hospitalization.</p> </sec> <sec id="mzw050s5"><st>Results</st> <p>Of 5163 eligible participants, 6.4% (<I>n</I>&nbsp;=&nbsp;328) experienced a preventable hospitalization during the study period. The adjusted hazard ratio (HR) was 8.69 (95% CI, 2.62&ndash;28.83) for subjects with a COC score of 0.00&ndash;0.19, 7.03 (95% CI, 4.50&ndash;10.96) for those with a score of 0.20&ndash;0.39, 3.01 (95% CI, 2.06&ndash;4.40) for those with a score of 0.40&ndash;059, 4.42 (95% CI, 3.04&ndash;6.42) for those with a score of 0.60&ndash;0.79 and 5.82 (95% CI, 3.87&ndash;8.75) for those with a score of 0.80&ndash;0.99. The difference in cumulative incidence of preventable hospitalizations in patients with COC scores of 0.00&ndash;0.19 relative to those with COC scores of 1.00 was the greatest, at 0.97% points.</p> </sec> <sec id="mzw050s6"><st>Conclusions</st> <p>Greater COC was associated with fewer preventable hospitalizations in subjects with type 2 diabetes.</p> </sec>


Evaluating patient safety indicators in orthopedic surgery between Italy and the USA
<sec id="mzw053s1"><st>Objective</st> <p>To compare patient safety in major orthopedic procedures between an orthopedic hospital in Italy, and 26 US hospitals of similar size.</p> </sec> <sec id="mzw053s2"><st>Design</st> <p>Retrospective analysis of administrative data from hospital discharge records in Italy and Florida, USA, 2011&ndash;13. Patient Safety Indicators (PSIs) developed by the Agency for Healthcare Quality and Research were used to identify inpatient adverse events (AEs). We examined the factors associated with the development of each different PSI, taking into account known confounders, using logistic regression.</p> </sec> <sec id="mzw053s3"><st>Setting</st> <p>One Italian orthopedic hospital and 26 hospitals in Florida with &ge;&nbsp;1000 major orthopedic procedures per year.</p> </sec> <sec id="mzw053s4"><st>Participants</st> <p>Patients &ge;&nbsp;18 years who underwent 1 of the 17 major orthopedic procedures, and with a length of stay (LOS) &gt;&nbsp;1 day.</p> </sec> <sec id="mzw053s5"><st>Intervention</st> <p>Patient Safety management between Italy and the USA.</p> </sec> <sec id="mzw053s6"><st>Main Outcome Measure</st> <p>Patient Safety Indicators.</p> </sec> <sec id="mzw053s7"><st>Results</st> <p>A total of 14&nbsp;393 patients in Italy (mean age&nbsp;=&nbsp;59.8 years) and 131&nbsp;371 in the USA (mean age&nbsp;=&nbsp;65.4 years) were included. US patients had lower adjusted odds of developing a PSI compared to Italy for pressure ulcers (odds ratio [OR]: 0.21; 95% confidence interval [CI]: 0.10&ndash;0.45), hemorrhage or hematoma (OR: 0.42; CI 0.23&ndash;0.78), physiologic and metabolic derangement (OR: 0.08; CI 0.02&ndash;0.37). Italian patients had lower odds of pulmonary embolism/deep vein thrombosis (OR: 3.17; CI 2.16&ndash;4.67) compared to US patients.</p> </sec> <sec id="mzw053s8"><st>Conclusions</st> <p>Important differences in patient safety events were identified across countries using US developed PSIs. Though caution about potential coding differences is wise when comparing PSIs internationally, other differences may explain AEs, and offer opportunities for cross-country learning about safe practices.</p> </sec>


Is inter-rater reliability of Global Trigger Tool results altered when members of the review team are replaced?
<sec id="mzw054s1"><st>Objective</st> <p>To evaluate the inter-rater reliability of results from Global Trigger Tool (GTT) reviews when one of the three reviewers remains consistent, while one or two reviewers rotate.</p> </sec> <sec id="mzw054s2"><st>Design</st> <p>Comparison of results from retrospective record review performed as a cross-sectional study with three review teams each consisting of two non-physicians and one physician; Team I (three consistent reviewers), Team II (one of the two non-physician reviewers or/and the physician from Team I are replaced for different review periods) and Team III (three consistent reviewers different from reviewers in Team I and Team II).</p> </sec> <sec id="mzw054s3"><st>Setting</st> <p>Medium-sized hospital trust in Northern Norway.</p> </sec> <sec id="mzw054s4a"><st>Participants</st> <p>A total of 120 records were selected as biweekly samples of 10 from discharge lists between 1 July and 31 December 2010 for a 3-fold review.</p> </sec> <sec id="mzw054s4"><st>Intervention</st> <p>Replacement of review team members was tested to assess impact on inter-rater reliability and adverse events measurment.</p> </sec> <sec id="mzw054s5"><st>Main Outcome Measure(s)</st> <p>Inter-rater reliability assessed with the Cohen kappa coefficient between different teams regarding the presence and severity level of adverse events.</p> </sec> <sec id="mzw054s6"><st>Results</st> <p>Substantial inter-rater reliability regarding the presence and severity level of adverse events was obtained between Teams I and II, while moderate inter-rater reliability was obtained between Teams I and III.</p> </sec> <sec id="mzw054s7"><st>Conclusions</st> <p>Replacement of reviewers did not influence the results provided that one of the non-physician reviewers remains consistent. The experience of the consistent reviewer can result in continued consistency in interpretation with the new reviewer through discussion of events. These findings could encourage more hospital to rotate reviewers in order to optimize resources when using the GTT.</p> </sec>


Co-creating value through demand and supply integration in senior industry--observations on 33 senior enterprises in Taiwan
<sec id="mzw051s1"><st>Objective</st> <p>With global population aging, great business opportunities are driven by the various needs that the elderly face in everyday living. Internet development makes information spread faster, also allows elderly and their caregivers to more easily&nbsp;access information and actively participate in value co-creation in the services. This study aims to investigate the designs of value co-creation by the supply and demand sides of the senior industry.</p> </sec> <sec id="mzw051s2"><st>Design</st> <p>This study investigated senior industry in Taiwan and analyzed bussiness models of 33 selected successful senior enterprises in 2013. We adopted series field observation, reviews of documentations, analysis of meeting records and in-depth interviews with 65 CEOs and managers.</p> </sec> <sec id="mzw051s3"><st>Setting</st> <p>Thirty-three quality enterprises in senior industry.</p> </sec> <sec id="mzw051s4"><st>Participants</st> <p>Sixty-five CEOs and managers in 33 senior enterprises.</p> </sec> <sec id="mzw051s5"><st>Intervention(s)</st> <p>None.</p> </sec> <sec id="mzw051s6"><st>Main Outcome Measure(s)</st> <p>Value co-creation design, value co-creating process.</p> </sec> <sec id="mzw051s7"><st>Results</st> <p>We constructed a conceptual model that comprehensively describes essential aspects of value co-creation and categorized the value co-creation designs into four types applying for different business models: (i) interaction in experience spaces co-creation design, (ii) on-site interacting co-creation design, (iii) social networking platform co-creation design and (iv) empowering customers co-creation design. Through value co-creation platform design, the senior enterprises have converted the originally passive roles of the elderly and caregivers into active participants in the value co-creation process.</p> </sec> <sec id="mzw051s8"><st>Conclusions</st> <p>The new paradigm of value co-creation designs not only promote innovative development during the interactive process, lead enterprises reveal and meet customers&rsquo; needs but also increase markets and profits.</p> </sec>


Impact of antibiotic stewardship on perioperative antimicrobial prophylaxis
<sec id="mzw055s1"><st>Objective</st> <p>Antibiotic prophylaxis (AP) is useful to prevent antimicrobial overuse, misuse and abuse,&nbsp;as well against the occurrence of surgical site infections (SSIs). This study aimed to describe the implementation of a quality improvement intervention on AP for elective surgery, as informal interviews showed a&nbsp;lower than expected compliance with internal recommendations, and to evaluate intervention's effect in terms of main drug consumption.</p> </sec> <sec id="mzw055s2"><st>Design</st> <p>A quality improvement intervention on all elective cases within 14 main surgical departments was performed. SQUIRE 2.0 guidelines were used in designing and reporting.</p> </sec> <sec id="mzw055s3"><st>Setting</st> <p>The intervention was implemented in an Italian Teaching Hospital 2 years after the adoption of internal evidence-based AP recommendations.</p> </sec> <sec id="mzw055s4"><st>Participants</st> <p>Professionals involved in elective surgery.</p> </sec> <sec id="mzw055s5"><st>Intervention(s)</st> <p>The intervention was structured into two phases: a survey was conducted during two non-consecutive&nbsp;weeks period (April&ndash;May 2013) to assess the adherence to the international guidelines in AP; survey's results were presented and discussed with all the surgical teams (December 2013&ndash;April 2014).</p> </sec> <sec id="mzw055s6"><st>Main outcome measure(s)</st> <p>Impact on cefazolin consumption (in defined daily doses per 100 procedures).</p> </sec> <sec id="mzw055s7"><st>Results</st> <p>Data of AP for 653 surgical procedures in terms of type, timing, duration, excess and defect were analyzed. An optimal AP rate resulted in 48.1% cases. Reduction in cefazolin use&nbsp;(&ndash;21.5%) and cost (&ndash;22.9%) was registered.</p> </sec> <sec id="mzw055s8"><st>Conclusions</st> <p>Though results cannot be generalized to all hospital populations, the implemented intervention is likely to improve AP consequently improving quality of care and reducing costs. Further studies are needed to evaluate specific outcomes such as rate of SSIs and antibiotic resistance.</p> </sec>


Safety climate and attitude toward medication error reporting after hospital accreditation in South Korea
<sec id="mzw058s1"><st>Objective</st> <p>This study compared registered nurses&rsquo; perceptions of safety climate and attitude toward medication error reporting before and after completing a hospital accreditation program. Medication errors are the most prevalent adverse events threatening patient safety; reducing underreporting of medication errors significantly improves patient safety. Safety climate in hospitals may affect medication error reporting.</p> </sec> <sec id="mzw058s2"><st>Design</st> <p>This study employed a longitudinal, descriptive design. Data were collected using questionnaires.</p> </sec> <sec id="mzw058s3"><st>Setting</st> <p>A tertiary acute hospital in South Korea undergoing a hospital accreditation program.</p> </sec> <sec id="mzw058s4"><st>Participants</st> <p>Nurses, pre- and post-accreditation (217 and 373); response rate: 58% and 87%, respectively.</p> </sec> <sec id="mzw058s5"><st>Interventions</st> <p>Hospital accreditation program.</p> </sec> <sec id="mzw058s6"><st>Main outcome measures</st> <p>Perceived safety climate and attitude toward medication error reporting.</p> </sec> <sec id="mzw058s7"><st>Results</st> <p>The level of safety climate and attitude toward medication error reporting increased significantly following accreditation; however, measures of institutional leadership and management did not improve significantly. Participants&rsquo; perception of safety climate was positively correlated with their attitude toward medication error reporting; this correlation strengthened following completion of the program.</p> </sec> <sec id="mzw058s8"><st>Conclusions</st> <p>Improving hospitals&rsquo; safety climate increased nurses&rsquo; medication error reporting; interventions that help hospital administration and managers to provide more supportive leadership may facilitate safety climate improvement. Hospitals and their units should develop more friendly and intimate working environments that remove nurses&rsquo; fear of penalties. Administration and managers should support nurses who report their own errors.</p> </sec>


Vital signs monitoring on general wards: clinical staff perceptions of current practices and the planned introduction of continuous monitoring technology
<sec id="mzw062s1"><st>Objective</st> <p>Early detection of patient deterioration and prevention of adverse events are key challenges to patient safety. This study investigated clinical staff perceptions of current monitoring practices and the planned introduction of continuous monitoring devices on general wards.</p> </sec> <sec id="mzw062s2"><st>Design</st> <p>Multi-method study comprising structured surveys, in-depth interviews and device trial with log book feedback.</p> </sec> <sec id="mzw062s3"><st>Setting</st> <p>Two general wards in a large urban teaching hospital in Sydney, Australia.</p> </sec> <sec id="mzw062s4"><st>Participants</st> <p>Respiratory and neurosurgery nursing staff and two doctors.</p> </sec> <sec id="mzw062s5"><st>Results</st> <p>Nurses were confident about their abilities to identify patients at risk of deterioration, using a combination of vital signs and visual assessment. There were concerns about the accuracy of current vital signs monitoring equipment and frequency of intermittent observation. Both the nurses and the doctors were enthusiastic about the prospect of continuous monitoring and perceived it would allow earlier identification of patient deterioration; provide reassurance to patients; and support interdisciplinary communication. There were also reservations about continuous monitoring, including potential decrease in bedside nurse&ndash;patient interactions; increase in inappropriate escalations of patient care; and discomfort to patients.</p> </sec> <sec id="mzw062s6"><st>Conclusions</st> <p>While continuous monitoring devices were seen as a potentially positive tool to support the identification of patient deterioration, drawbacks, such as the potential for reduced patient contact, revealed key areas that will require close surveillance following the implementation of devices. Training and improved interdisciplinary communication were identified as key requisites for successful implementation.</p> </sec>


Patient perspectives of care and process and outcome quality measures for heart failure admissions in US hospitals: how are they related in the era of public reporting?
<sec id="mzw063s1"><st>Importance</st> <p>Process quality measure performance has improved significantly with public reporting, requiring reevaluation of process&ndash;outcome relationships and the emerging role of patient perspectives on care.</p> </sec> <sec id="mzw063s2"><st>Objective</st> <p>To evaluate associations between heart failure patient perspectives of care and publicly reported processes and outcomes.</p> </sec> <sec id="mzw063s3"><st>Design</st> <p>Cross-sectional study, July 2008&ndash;June 2011.</p> </sec> <sec id="mzw063s4"><st>Setting</st> <p>US hospitals in the Press Ganey database.</p> </sec> <sec id="mzw063s5"><st>Participants</st> <p>Heart failure inpatients.</p> </sec> <sec id="mzw063s6"><st>Measures</st> <p>Outcomes were Hospital Compare hospital-level risk-adjusted 30-day heart failure mortality and readmissions. Predictors included Hospital Compare heart failure processes of care, a weighted process composite and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) domains for heart failure. Hospital characteristics included volume of heart failure patients and race, health status and education.</p> </sec> <sec id="mzw063s7"><st>Results</st> <p>Among 895 included hospitals, performance on process measures was high (median by hospital for composite, 95.6%); the median HCAHPS overall rating was 86.9. Median mortality was 11.3% and readmissions was 24.8%. No process measures were statistically significantly associated with lower mortality or readmissions in adjusted analyses. Higher ratings on HCAHPS patient perspectives of care were significantly correlated with lower readmissions in adjusted analyses, particularly those publicly reported domains conceptually related to readmissions. The magnitude was small (1.8 points higher on a 100-point scale between the highest and lowest quartiles of hospital readmissions).</p> </sec> <sec id="mzw063s8"><st>Conclusions</st> <p>Publicly reported process quality measures were no longer associated with outcomes, but higher patient perspectives of care were associated with lower heart failure readmissions. These associations support continued reevaluation of these measures and increased emphasis on patient experience and outcomes, as planned for Value-Based Purchasing.</p> </sec>


Interface transition checklists in spinal surgery
<sec id="mzw061s1"><st>Issue</st> <p>Recently, quality tools have been promoted to improve patient safety and&nbsp;process efficiency in healthcare. While surgeons primarily focused on surgical issues, like infection rates or implant design, we introduced&nbsp;pre-admission and preoperative checklists in the early 2000s.</p> </sec> <sec id="mzw061s2"><st>Initial assessment</st> <p>To assess the efficiency of these tools in a neurosurgical department, we performed a survey of all spinal instrumentation patients operated in 2011 (<I>n</I>&nbsp;=&nbsp;147). The results revealed several problems.</p> </sec> <sec id="mzw061s3"><st>Choice of solution</st> <p>We consequently redesigned the checklists accompanied by flanking measures, such as written&nbsp; and online accessible standards. Furthermore, the staff was trained to use the updated quality tools.</p> </sec> <sec id="mzw061s4"><st>Implementation</st> <p>The measures were implemented in 2012.</p> </sec> <sec id="mzw061s5"><st>Evaluation</st> <p>Results were re-evaluated in a second survey in 2013 (<I>n&nbsp;</I>=&nbsp;162). We found that the use of pre-admission checklists significantly increased from 47 to 96%, while the use of preoperative checklists significantly decreased from 86 to 75%. Within the same period, the quality and completeness of the checklists did, however, increase, so that in 2013, 43% of the patients had a completely processed preoperative checklist, compared to 29% in 2011.</p> </sec> <sec id="mzw061s6"><st>Lessons learned</st> <p>The introduction of checklists alone did not in itself guarantee an improved workflow. The introduction must be accompanied by other measures, like written standards and regular training of employees. Otherwise, the positive effect wears off quickly. Nevertheless, we could show that the stringent application of quality tools can induce a sustainable change. Our data further suggest that the clear and traceable delegation of responsibilities is of high importance.</p> </sec>


Collaboration, capacity building and co-creation as a new mantra in global health


Abstracts en este numero


Resumos neste numero


&#x4E2D;&#x6587;&#x6458;&#x8981; (Simplified Chinese Abstracts)


&#x4E2D;&#x6587;&#x6458;&#x8981;(Traditional Chinese Abstracts)


&#x65E5;&#x672C;&#x8A9E;&#x6284;&#x9332; (Japanese Abstracts)


French Abstracts


Advantages of involving patients in the guidelines development


RAPADAPTE for rapid guideline development: high-quality clinical guidelines can be rapidly developed with limited resources
<p>Guideline development is challenging, expensive and labor-intensive. A high-quality guideline with 90 recommendations for breast cancer treatment was developed within 6 months with limited resources in Costa Rica. We describe the experience and propose a process others can use and adapt.</p> <p>The ADAPTE method (using existing guidelines to minimize repeating work that has been done) was used but existing guidelines were not current. The method was extended to use databases that systematically identify, appraise and synthesize evidence for clinical application (DynaMed, EBM Guidelines) to provide current evidence searches and critical appraisal of evidence. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence and the strength of recommendations. Draft recommendations with supporting evidence were provided to panel members for facilitated voting to target panel discussion to areas necessary for reaching consensus.</p> <p>Training panelists in guideline development methodology facilitated rapid consensus development. Extending &lsquo;guideline adaptation&rsquo; to &lsquo;evidence database adaptation&rsquo; was highly effective and efficient. Methods were created to simplify mapping DynaMed evidence ratings to GRADE ratings. Twelve steps are presented to facilitate rapid guideline development and enable further adaptation by others.</p> <p>This is a case report and the RAPADAPTE method was retrospectively derived. Prospective replication and validation will support advances for the guideline development community. If guideline development can be accelerated without compromising validity and relevance of the resulting recommendations this would greatly improve our ability to impact clinical care.</p>


The patient satisfaction questionnaire of EUprimecare project: measurement properties
<sec><st>Objective</st> <p>The measurement of patient satisfaction is considered an essential outcome indicator to evaluate health care quality. Patient satisfaction is considered a multi-dimensional construct, which would include a variety of domains. Although a large number of studies have proposed scales to measure patient satisfaction, there is a lack of psychometric information on them. This study aims to describe the psychometric properties of the Primary Care Satisfaction Scale (PCSS) of the EUprimecare project.</p> </sec> <sec><st>Design</st> <p>A cross-sectional survey of patient satisfaction with primary care was carried out by telephone interview.</p> </sec> <sec><st>Setting</st> <p>Primary care services of Estonia, Finland, Germany, Hungary, Lithuania, Italy and Spain.</p> </sec> <sec><st>Participants</st> <p>A total of 3020 adult patients aged 18&ndash;65 years old attending primary care services.</p> </sec> <sec><st>Method</st> <p>Classic psychometric properties were analysed and Rasch analysis was used to assess the following measurement properties: fit to the Rasch model; uni-dimensionality; reliability; differential item functioning (DIF) by gender, age, civil status, area of residency and country; local independency; adequacy of response scale; and scale targeting.</p> </sec> <sec><st>Results</st> <p>To achieve good fit to the Rasch model, the original response scales of three items (1, 2 and 6) were rescored and Item 3 (waiting time in the room) was removed. The scale was uni-dimensional and Person Separation Index was 0.79, indicating a good reliability. All items were free from bias. PCSS linear measure displayed satisfactory convergent validity with overall satisfaction with primary care.</p> </sec> <sec><st>Conclusions</st> <p>PCSS, as a reliable and valid scale, could be used to measure patient satisfaction in primary care in Europe.</p> </sec>


Association between accessibility to emergency cardiovascular centers and cardiovascular mortality in Japan
<sec><st>Objective</st> <p>The aim of this study was to examine the association between accessibility to cardiovascular emergency centers and cardiovascular mortality in Japan.</p> </sec> <sec><st>Design</st> <p>A semi-ecological study.</p> </sec> <sec><st>Setting</st> <p>Three databases were generated: accessibility to emergency cardiovascular centers, population records and death records.</p> </sec> <sec><st>Main Outcome Measures</st> <p>The standardized mortality ratio (SMR) for cardiovascular disease was adjusted by age and sex. Accessibility was represented by transfer time, number of cardiovascular emergency hospitals, and the proportion of habitable areas. Combinations of the three were divided into Categories 1&ndash;8 from the worst to the best, and the association with SMR was analyzed.</p> </sec> <sec><st>Results</st> <p>There were 1998 cardiovascular emergency hospitals. The median of crude mortality was 0.16%. The median SMR of the reference Category 8 (transfer time &lt;30 min and habitable area &ge;50% with cardiovascular emergency hospitals) was 0.96, but that of the low accessibility Category 1 (transfer time &ge;30 min and habitable area &lt;50% without cardiovascular emergency hospitals) was 1.10. The SMR of accessibility Category 1 : Category 8 was 1.18 (95% confidence interval: 1.14&ndash;1.21).</p> </sec> <sec><st>Conclusions</st> <p>Decreased accessibility to cardiovascular emergency hospitals was associated with increased SMR. Areas with less accessibility and higher cardiovascular mortality were characterized by geographical variability in Japan.</p> </sec>


Cohort study for evaluation of dose omission without justification in a teaching general hospital in Bahia, Brazil
<sec><st>Objective</st> <p>To evaluate the incidence of medication errors due to dose omissions and the reasons for non-administration of medications.</p> </sec> <sec><st>Design</st> <p>A cohort study blinded to the nursing staff was conducted for 5 consecutive days to evaluate administration of prescribed medications to selected inpatients.</p> </sec> <sec><st>Setting</st> <p>A major academic teaching hospital in Brazil.</p> </sec> <sec><st>Participants</st> <p>Dispensed doses to patients in medical and surgical wards.</p> </sec> <sec><st>Main Outcome Measures</st> <p>Doses returned to pharmacy were evaluated to identify the rate of dose omission without a justification for omission.</p> </sec> <sec><st>Results</st> <p>Information was collected from 117 patients in 11 wards and 1119 doses of prescribed medications were monitored. Overall, 238/1119 (21%) dispensed doses were not administered to the patients. Among these 238 doses, 138 (58%) had no justification for not being administered. Failure in the administration of at least 1 dose occurred for 58/117 (49.6%) patients. Surgical wards had significantly more missed doses than that in medical wards (<I>P</I> = 0.048). The daily presence of a pharmacist in the wards was significantly correlated with lower frequency of omission errors (<I>P</I> = 0.019). Nervous system medications were missed more significantly than other medications (<I>P</I> &lt; 0.001). No difference was noted in the omission doses in terms of route of administration.</p> </sec> <sec><st>Conclusions</st> <p>High incidence of omission errors occurs in our institution. Factors such as the deficit of nursing staff and clinical pharmacists and a weak medication dispensing system, probably contributed to incidence detected. Blinding nursing staff was essential to improve the sensibility of the method for detecting omission errors.</p> </sec>


Performance results for a workstation-integrated radiology peer review quality assurance program
<sec><st>Objective</st> <p>To assess review completion rates, RADPEER score distribution, and sources of disagreement when using a workstation-integrated radiology peer review program, and to evaluate radiologist perceptions of the program.</p> </sec> <sec><st>Design</st> <p>Retrospective review of prospectively collected data.</p> </sec> <sec><st>Setting</st> <p>Large private outpatient radiology practice.</p> </sec> <sec><st>Participants</st> <p>Radiologists (<I>n</I> = 66) with a mean of 16.0 (standard deviation, 9.2) years of experience.</p> </sec> <sec><st>Interventions</st> <p>Prior studies and reports of cases being actively reported were randomly selected for peer review using the RADPEER scoring system (a 4-point scale, with a score of 1 indicating agreement and scores of 2&ndash;4 indicating increasing levels of disagreement).</p> </sec> <sec><st>Main Outcome Measures</st> <p>Assigned peer review completion rates, review scores, sources of disagreement and radiologist survey responses.</p> </sec> <sec><st>Results</st> <p>Of 31 293 assigned cases, 29 044 (92.8%; 95% CI 92.5&ndash;93.1%) were reviewed. Discrepant scores (score = 2, 3 or 4) were given in 0.69% (95% CI 0.60&ndash;0.79%) of cases and clinically significant discrepancy (score = 3 or 4) was assigned in 0.42% (95% CI 0.35&ndash;0.50%). The most common cause of disagreement was missed diagnosis (75.2%; 95% CI 66.8&ndash;82.1%). By anonymous survey, 94% of radiologists felt that peer review was worthwhile, 90% reported that the scores they received were appropriate and 78% felt that the received feedback was valuable.</p> </sec> <sec><st>Conclusion</st> <p>Workstation-based peer review can increase completion rates and levels of radiologist acceptance while producing RADPEER scores similar to those previously reported. This approach may be one way to increase radiologist engagement in peer review quality assurance.</p> </sec>


Added value of involving patients in the first step of multidisciplinary guideline development: a qualitative interview study among infertile patients
<sec><st>Background</st> <p>Patient involvement in scoping the guideline is emphasized, but published initiatives actively involving patients are generally limited to the writing and reviewing phase.</p> </sec> <sec><st>Objective</st> <p>To assess patients' added value to the scoping phase of a multidisciplinary guideline on infertility.</p> </sec> <sec><st>Design</st> <p>Qualitative interview study.</p> </sec> <sec><st>Setting and participants</st> <p>We conducted interviews among 12 infertile couples and 17 professionals.</p> </sec> <sec><st>Intervention</st> <p>We listed and compared the couples' and professionals' key clinical issues (=care aspects that need improvement) to be addressed in the guideline according to four domains: current guidelines, professionals, patients and organization of care.</p> </sec> <sec><st>Main Outcome Measures</st> <p>Main key clinical issues suggested by more than three quarters of the infertile couples and/or at least two professionals were identified and compared.</p> </sec> <sec><st>Results</st> <p>Overall, we identified 32 key clinical issues among infertile couples and 23 among professionals. Of the defined main key clinical issues, infertile couples mentioned eight issues that were not mentioned by the professionals. These main key clinical issues mainly concerned patient-centred (e.g. poor information provision and poor alignment of care) aspects of care on the professional and organizational domain. Both groups mentioned two main key clinical issues collectively that were interpreted differently: the lack of emotional support and respect for patients' values.</p> </sec> <sec><st>Conclusions</st> <p>Including patients from the first phase of the guideline development process leads to valuable additional main key clinical issues for the next step of a multidisciplinary guideline development process and broadens the scope of the guideline, particularly regarding patient-centredness and organizational issues from a patients' perspective.</p> </sec>


Influence of patient-assessed quality of chronic illness care and patient activation on health-related quality of life
<sec><st>Objective</st> <p>To examine the association of the Patient Assessment of Chronic Illness Care (PACIC) with health-related quality of life (HRQoL) and the modulating effect of patient activation on this association.</p> </sec> <sec><st>Design and participants</st> <p>A population-based prospective cohort study of people with Type 2 diabetes in Queensland, Australia, using data from self-report questionnaires, collected annually from 2008 (<I>n</I> = 3761) to 2010 (<I>n</I> = 3040).</p> </sec> <sec><st>Main Outcome Measures</st> <p>Predictors were the 20-item PACIC (dichotomized at the score of 3), and the 13-item Patient Activation Measure (PAM), dichotomized into activation Levels 1 and 2 versus Levels 3 and 4. Analyses were restricted to participants whose PACIC and PAM categories did not change over 2 years of follow-up. Outcome variables were EQ-5D index and EQ VAS dichotomized at the uppermost quartile, and EQ-5D index also dichotomized at the median.</p> </sec> <sec><st>Statistical analyses</st> <p>An inverse probability weighted Poisson regression with a log-link function and a binary response variable for each outcome was used to obtain risk ratios (RRs), and the interaction between PACIC and PAM was statistically modelled, taking into consideration patient characteristics and the respective baseline outcome variable.</p> </sec> <sec><st>Results</st> <p>The positive association between the PACIC and EQ VAS was seen only in participants with low activation (adjusted RR: 3.91; 95% CI: 1.40&ndash;10.95; <I>P</I> = 0.009), and not in those with high activation, indicating the non-synergistic interaction effect of the PACIC and PAM. This association was not found with EQ-5D index.</p> </sec> <sec><st>Conclusions</st> <p>Chronic care received consistently over time can positively affect health status, and benefit patients with low activation.</p> </sec>


SIMulation of Medication Error induced by Clinical Trial drug labeling: the SIMME-CT study
<sec><st>Objective</st> <p>To assess the impact of investigational drug labels on the risk of medication error in drug dispensing.</p> </sec> <sec><st>Design</st> <p>A simulation-based learning program focusing on investigational drug dispensing was conducted.</p> </sec> <sec><st>Setting</st> <p>The study was undertaken in an Investigational Drugs Dispensing Unit of a University Hospital of Lyon, France.</p> </sec> <sec><st>Participants</st> <p>Sixty-three pharmacy workers (pharmacists, residents, technicians or students) were enrolled<b>.</b> </p> </sec> <sec><st>Intervention</st> <p>Ten risk factors were selected concerning label information or the risk of confusion with another clinical trial. Each risk factor was scored independently out of 5: the higher the score, the greater the risk of error. From 400 labels analyzed, two groups were selected for the dispensing simulation: 27 labels with high risk (score &ge;3) and 27 with low risk (score &le;2). Each question in the learning program was displayed as a simulated clinical trial prescription.</p> </sec> <sec><st>Main Outcome Measure</st> <p>Medication error was defined as at least one erroneous answer (i.e. error in drug dispensing). For each question, response times were collected.</p> </sec> <sec><st>Results</st> <p>High-risk investigational drug labels correlated with medication error and slower response time. Error rates were significantly 5.5-fold higher for high-risk series. Error frequency was not significantly affected by occupational category or experience in clinical trials.</p> </sec> <sec><st>Conclusions</st> <p>SIMME-CT is the first simulation-based learning tool to focus on investigational drug labels as a risk factor for medication error. SIMME-CT was also used as a training tool for staff involved in clinical research, to develop medication error risk awareness and to validate competence in continuing medical education.</p> </sec>


Virtual obesity collaborative with and without decision-support technology
<sec><st>Objective</st> <p>The purpose of this study was to evaluate school-based health center (SHBC) provider adherence to guidelines for identification and assessment of childhood obesity after participation in a virtual Health Disparities Learning Collaborative with and without HeartSmartKids&trade;, decision-support technology with tailored patient education.</p> </sec> <sec><st>Design and Setting</st> <p>A cluster randomized comparative effectiveness trial was conducted with 24 SBHCs from six states.</p> </sec> <sec><st>Participants</st> <p>The sample consisted of 33 SBHC providers and review of medical charts at three time points. Chart data were collected at baseline (<I>n</I> = 850), after training (<I>n</I> = 691) and 6 months after training (<I>n</I> = 612).</p> </sec> <sec><st>Main Outcome Measures</st> <p>Charts from a random sample of youth 5&ndash;12 years making well-child visits were examined for the documentation of: BMI percentile, accurate weight diagnosis based upon BMI percentile, blood pressure percentile, and ordering appropriate laboratory assessment of obese youth &ge;10 years old.</p> </sec> <sec><st>Results</st> <p>Percentage of overweight/obese children in this study was 40.4&ndash;47.2%. For both the HeartSmartKids&trade; and non-HeartSmartKids&trade; groups, provider adherence significantly improved after training for BMI percentile and blood pressure percentile documentation, as well as correct diagnosis for overweight and obese. Implementation of the HeartSmartKids&trade; was variable at the technology sites and differences in identification and assessment were not found between groups.</p> </sec> <sec><st>Conclusion</st> <p>The virtual collaborative approach to quality improvement resulted in improved adherence to guidelines for identification and assessment of overweight/obese children. The impact of the training with and without HeartSmartKids&trade; on patient outcomes needs to be evaluated. Coaching on implementation of technology needs to be included in future work.</p> </sec>


Off-hours admission and quality of hip fracture care: a nationwide cohort study of performance measures and 30-day mortality
<sec><st>Objective</st> <p>Higher risks of adverse outcomes have been reported for patients admitted acutely during off-hours. However, in relation to hip fracture, the evidence is inconsistent. We examined whether time of admission influenced compliance with performance measures, surgical delay and 30-day mortality in patients with hip fracture.</p> </sec> <sec><st>Design</st> <p>Cohort study.</p> </sec> <sec><st>Setting</st> <p>Data from The Danish Multidisciplinary Hip Fracture Registry linked with data from Danish National Registries.</p> </sec> <sec><st>Participants</st> <p>Danish patients undergoing hip fracture surgery, aged &gt;65 years, admitted 1 March 2010 to 30 November 2013 (<I>N</I> = 25 305).</p> </sec> <sec><st>Exposure</st> <p>Off-hours: weekday evenings and nights, and weekends.</p> </sec> <sec><st>Main Outcome Measures</st> <p>Meeting specific performance measures, surgical delay and mortality.</p> </sec> <sec><st>Results</st> <p>No differences were found in patient characteristics or in meeting performance measures (RRs from 0.99 [95% CI: 0.98&ndash;1.01] to 1.01 [95% CI: 0.99&ndash;1.02]. When comparing admission on weekdays (evenings and nights vs. days), off-hours admission was associated with a lower risk of surgical delay (adjusted OR 0.75 [95% CI: 0.66&ndash;0.85]) while no differences in 30-day mortality was found (adjusted OR 0.91 [95% CI: 0.80&ndash;1.04]. When comparing admission during weekends with admission during weekdays, off-hours admission was associated with a higher risk of surgical delay (adjusted OR 1.19 [95% CI: 1.05&ndash;1.37]) and a higher 30-day mortality risk (adjusted OR 1.13 [95% CI: 1.04&ndash;1.23]. The risk of surgical delay appeared not to explain the excess 30-day mortality.</p> </sec> <sec><st>Conclusions</st> <p>Patients admitted off-hours and on-hours received similar quality of care. The risk of surgical delay and 30 days mortality was higher among patients admitted during weekends; explanations need to be clarified.</p> </sec>


Development and testing of the cancer multidisciplinary team meeting observational tool (MDT-MOT)
<sec><st>Objective</st> <p>To develop a tool for independent observational assessment of cancer multidisciplinary team meetings (MDMs), and test criterion validity, inter-rater reliability/agreement and describe performance.</p> </sec> <sec><st>Design</st> <p>Clinicians and experts in teamwork used a mixed-methods approach to develop and refine the tool. Study 1 observers rated pre-determined optimal/sub-optimal MDM film excerpts and Study 2 observers independently rated video-recordings of 10 MDMs.</p> </sec> <sec><st>Setting</st> <p>Study 2 included 10 cancer MDMs in England.</p> </sec> <sec><st>Participants</st> <p>Testing was undertaken by 13 health service staff and a clinical and non-clinical observer.</p> </sec> <sec><st>Intervention</st> <p>None.</p> </sec> <sec><st>Main Outcome Measures</st> <p>Tool development, validity, reliability/agreement and variability in MDT performance.</p> </sec> <sec><st>Results</st> <p>Study 1: Observers were able to discriminate between optimal and sub-optimal MDM performance (<I>P</I> &le; 0.05). Study 2: Inter-rater reliability was good for 3/10 domains. Percentage of absolute agreement was high (&ge;80%) for 4/10 domains and percentage agreement within 1 point was high for 9/10 domains. Four MDTs performed well (scored 3+ in at least 8/10 domains), 5 MDTs performed well in 6&ndash;7 domains and 1 MDT performed well in only 4 domains. Leadership and chairing of the meeting, the organization and administration of the meeting, and clinical decision-making processes all varied significantly between MDMs (<I>P</I> &le; 0.01).</p> </sec> <sec><st>Conclusions</st> <p>MDT-MOT demonstrated good criterion validity. Agreement between clinical and non-clinical observers (within one point on the scale) was high but this was inconsistent with reliability coefficients and warrants further investigation. If further validated MDT-MOT might provide a useful mechanism for the routine assessment of MDMs by the local workforce to drive improvements in MDT performance.</p> </sec>


A mixed-methods study of the causes and impact of poor teamwork between junior doctors and nurses
<sec><st>Objectives</st> <p>This study aimed to collect and analyse examples of poor teamwork between junior doctors and nurses; identify the teamwork failures contributing to poor team function; and ascertain if particular teamwork failures are associated with higher levels of risk to patients.</p> </sec> <sec><st>Design</st> <p>Critical Incident Technique interviews were carried out with junior doctors and nurses.</p> </sec> <sec><st>Setting</st> <p>Two teaching hospitals in the Republic of Ireland.</p> </sec> <sec><st>Participants</st> <p>Junior doctors (<I>n</I> = 28) and nurses (<I>n</I> = 8) provided descriptions of scenarios of poor teamwork. The interviews were coded against a theoretical framework of healthcare team function by three psychologists and were also rated for risk to patients by four doctors and three nurses.</p> </sec> <sec><st>Results</st> <p>A total of 33 of the scenarios met the inclusion criteria for analysis. A total of 63.6% (21/33) of the scenarios were attributed to &lsquo;poor quality of collaboration&rsquo;, 42.4% (14/33) to &lsquo;poor leadership&rsquo; and 48.5% (16/33) to a &lsquo;lack of coordination&rsquo;. A total of 16 scenarios were classified as high risk and 17 scenarios were classified as medium risk. Significantly more of the high-risk scenarios were associated with a &lsquo;lack of a shared mental model&rsquo; (62.5%, 10/16) and &lsquo;poor communication&rsquo; (50.0%, 8/16) than the medium-risk scenarios (17.6%, 3/17 and 11.8%, 2/17, respectively).</p> </sec> <sec><st>Conclusion</st> <p>Poor teamwork between junior doctors and nurses is common and places patients at considerable risk. Addressing this problem requires a well-designed complex intervention to develop the team skills of doctors and nurses and foster a clinical environment in which teamwork is supported.</p> </sec>


Patient satisfaction between primary care providers and hospitals: a cross-sectional survey in Jilin province, China
<sec><st>Objective</st> <p>To assess patient satisfaction with outpatient and inpatient care between primary care providers and secondary/tertiary hospitals, and to examine its association with socio-demographic characteristics and type of institution, based on self-reported survey data.</p> </sec> <sec><st>Design</st> <p>Cross-sectional survey.</p> </sec> <sec><st>Setting</st> <p>Healthcare facilities within Jilin province, China.</p> </sec> <sec><st>Participants</st> <p>In total, 993 outpatients and 925 inpatients aged &ge;15 years old were recruited.</p> </sec> <sec><st>Main Outcome Measures</st> <p>Patient satisfaction with the care experience.</p> </sec> <sec><st>Results</st> <p>Patient satisfaction with outpatient and inpatient care was significantly associated with type of healthcare delivery setting in Jilin, China. Seeking outpatient care from community health centers (CHCs) was significantly associated with a higher ratio of patient satisfaction. Patients of county and tertiary hospitals complained about long-waiting times, bad attitudes of health workers, high expense of treatment, and their overall satisfaction towards outpatient care was lower. In the terms of inpatient care, patients were more satisfied with treatment expense in CHCs compared with county hospitals.</p> </sec> <sec><st>Conclusions</st> <p>CHCs and hospitals face different challenges regarding patient satisfaction. Further healthcare reform in China need to adopt more measures (e.g. increasing quality of primary care, setting up a referral medical system etc.) to improve patient satisfaction.</p> </sec>


Qualitative analysis of US Department of veterans affairs mental health clinician perspectives on patient-centered care
<sec><st>Objective</st> <p>Enhanced patient involvement in care has the potential to improve patient experiences and health outcomes. As such, large national and global healthcare systems and organizations, including the US Department of Veterans Affairs (VA), have made patient-centered care a primary goal. Little is known about mental health clinician perspectives on, and experiences with, providing patient-centered care. Our main objective was to better understand VA mental health clinicians' perceptions of patient-centered care, and ascertain possible facilitators and barriers to patient-centered practices in mental health settings.</p> </sec> <sec><st>Design</st> <p>Qualitative study of six focus groups conducted in late 2013.</p> </sec> <sec><st>Setting and participants</st> <p>Thirty-five mental health clinicians and staff from a large VA Medical Center.</p> </sec> <sec><st>Outcomes</st> <p>Transcripts were analyzed using an inductive and deductive thematic analysis approach.</p> </sec> <sec><st>Results</st> <p>Participants described patient-centered care ideally as a process of shared discovery, and expressed general enthusiasm for patient-centered care. Participants described several ongoing patient-centered care practices but conveyed concerns about the practicalities of its full implementation. Participants expressed a strong desire to change the current biomedical culture and policies of the institution that may hinder clinicians' flexibility and clinician&ndash;clinician collaboration when serving patients. In particular, clinicians worried about being held responsible for addressing all of the needs or goals that a patient may identify.</p> </sec> <sec><st>Conclusions</st> <p>If patient-centered care is to be practiced fully in mental health settings, healthcare institutions need to develop multimodal strategies to enhance clinician&ndash;clinician and clinician&ndash;patient collaborations to promote and support a focus on discovery and shared accountability for outcomes.</p> </sec>


Development, implementation and evaluation of a patient handoff tool to improve safety in orthopaedic surgery
<sec><st>Objective</st> <p>To develop, implement and test the effect of a handoff tool for orthopaedic trauma residents that reduces adverse events associated with the omission of critical information and the transfer of erroneous information.</p> </sec> <sec><st>Design</st> <p>Components of this project included a literature review, resident surveys and observations, checklist development and refinement, implementation and evaluation of impact on adverse events through a chart review of a prospective cohort compared with a historical control group.</p> </sec> <sec><st>Setting</st> <p>Large teaching hospital.</p> </sec> <sec><st>Participants</st> <p>Findings of a literature review were presented to orthopaedic residents, epidemiologists, orthopaedic surgeons and patient safety experts in face-to-face meetings, during which we developed and refined the contents of a resident handoff tool. The tool was tested in an orthopaedic trauma service and its impact on adverse events was evaluated through a chart review. The handoff tool was developed and refined during the face-to-face meetings and a pilot implementation. Adverse event data were collected on 127 patients (<I>n</I> = 67 baseline period; <I>n</I> = 60 test period).</p> </sec> <sec><st>Intervention</st> <p>A handoff tool for use by orthopaedic residents.</p> </sec> <sec><st>Main Outcome Measurements</st> <p>Adverse events in patients handed off by orthopaedic trauma residents.</p> </sec> <sec><st>Results</st> <p>After controlling for age, gender and comorbidities, testing resulted in fewer events per person (25&ndash;27% reduction; <I>P</I> &lt; 0.10).</p> </sec> <sec><st>Conclusions</st> <p>Preliminary evidence suggests that our resident handoff tool may contribute to a decrease in adverse events in orthopaedic patients.</p> </sec>


A PICU patient safety checklist: rate of utilization and impact on patient care
<sec><st>Objective</st> <p>In healthcare, checklists help to ensure patients receive evidence-based, safe care. Since 2007, we have used a bedside checklist in our PICU to facilitate daily discussion of care-related questions at each bedside. The primary objective of this study was to assess compliance with checklist use and to assess how often individual checklist elements affected patient management. A secondary objective was to determine whether patient and unit factors (severity of illness, unit census, weekday vs. weekend, admitting diagnosis group) influenced checklist use.</p> </sec> <sec><st>Design</st> <p>This was a prospective observational study. A research assistant attended daily bedside rounds to collect data at each eligible patient encounter.</p> </sec> <sec><st>Setting</st> <p>The study was conducted in the Children's Hospital of Eastern Ontario (CHEO) PICU, a 12-bed cardiac and medical-surgical unit.</p> </sec> <sec><st>Participants</st> <p>Included all patients admitted to the PICU prior to 6 am and who were not being discharged that day.</p> </sec> <sec><st>Intervention</st> <p>A bedside rounds checklist.</p> </sec> <sec><st>Main Outcome Measures</st> <p>Included compliance and whether the checklist affected the patient's management plan.</p> </sec> <sec><st>Results</st> <p>A total of 148 encounters were collected on 28 days between September 2013 and February 2014. Compliance with the checklist was 89.2% (132/148; 95% CI 83.2&ndash;93.2%) and was not influenced by admitting diagnosis group, patient census, severity of patient's conditions or weekday/weekend status. The checklist affected the patient management plan 52.6% of the time (69/132; 95% CI 44.2&ndash;61%).</p> </sec> <sec><st>Conclusions</st> <p>Our study found high rates of compliance with an established checklist that has been in use in the PICU since 2007. Checklist use frequently resulted in a change in the patient management plan.</p> </sec>


Do integrated care structures foster processes of integration? A quasi-experimental study in frail elderly care from the professional perspective
<sec><st>Objective</st> <p>This study explores the processes of integration that are assumed to underlie integrated care delivery.</p> </sec> <sec><st>Design</st> <p>A quasi-experimental design with a control group was used; a new instrument was developed to measure integration from the professional perspective.</p> </sec> <sec><st>Setting and participants</st> <p>Professionals from primary care practices and home-care organizations delivering care to the frail elderly in the Walcheren region of the Netherlands.</p> </sec> <sec><st>Intervention</st> <p>An integrated care intervention specifically targeting frail elderly patients was implemented.</p> </sec> <sec><st>Main Outcome Measures</st> <p>Structural, cultural, social and strategic integration and satisfaction with integration.</p> </sec> <sec><st>Results</st> <p>The intervention significantly improved structural, cultural and social integration, agreement on goals, interests, power and resources and satisfaction with integration.</p> </sec> <sec><st>Conclusions</st> <p>This study confirms that integrated care structures foster processes of integration among professionals.</p> </sec> <sec><st>Trial registration</st> <p>Current Controlled Trials ISRCTN05748494.</p> </sec>


Improving handoff communication from hospital to home: the development, implementation and evaluation of a personalized patient discharge letter
<sec><st>Objective</st> <p>To develop, implement and evaluate a personalized patient discharge letter (PPDL) to improve the quality of handoff communication from hospital to home.</p> </sec> <sec><st>Design</st> <p>From the end of 2006&ndash;09 we conducted a quality improvement project; consisting of a before&ndash;after evaluation design, and a process evaluation.</p> </sec> <sec><st>Setting</st> <p>Four general internal medicine wards, in a 1024-bed teaching hospital in Amsterdam, the Netherlands.</p> </sec> <sec><st>Participants</st> <p>All consecutive patients of 18 years and older, admitted for at least 48 h.</p> </sec> <sec><st>Interventions</st> <p>A PPDL, a plain language handoff communication tool provided to the patient at hospital discharge.</p> </sec> <sec><st>Main Outcome Measures</st> <p>Verbal and written information provision at discharge, feasibility of integrating the PPDL into daily practice, pass rates of PPDLs provided at discharge.</p> </sec> <sec><st>Results</st> <p>A total of 141 patients participated in the before&ndash;after evaluation study. The results from the first phase of quality improvement showed that providing patient with a PPDL increased the number of patients receiving verbal and written information at discharge. Patient satisfaction with the PPDL was 7.3. The level of implementation was low (30%). In the second phase, the level of implementation improved because of incorporating the PPDL into the electronic patient record (EPR) and professional education. An average of 57% of the discharged patients received the PPDL upon discharge. The number of discharge conversations also increased.</p> </sec> <sec><st>Conclusion</st> <p>Patients and professionals rated the PPDL positively. Key success factors for implementation were: education of interns, residents and staff, standardization of the content of the PPDL, integrating the PPDL into the electronic medical record and hospital-wide policy.</p> </sec>


Consumer perspectives of medication-related problems following discharge from hospital in Australia: a quantitative study
<sec><st>Objective</st> <p>The aim of this study was to investigate the consumer's perspectives and experiences regarding medication related problems (MRPs) following discharge from hospital.</p> </sec> <sec><st>Design</st> <p>A cross-sectional study was conducted using an online 80-question survey.</p> </sec> <sec><st>Setting</st> <p>Survey participants were recruited through an online market research company.</p> </sec> <sec><st>Participants</st> <p>Five hundred and six participants completed the survey. Participants were included if they were aged 50 years or older, taking 5 or more prescription medicines, had been admitted to hospital with a minimum stay of 24 h, admitted to hospital within the last 4 months and discharged from hospital within the last 1 month.</p> </sec> <sec><st>Main Outcome Measures</st> <p>The survey comprised questions measuring: health literacy, health status, medication safety (measured by reported MRPs), missed dose(s), role of health professionals, health services and cost, and socio-demographic status. Descriptive and univariate statistics and logistic regression analysis was performed to examine the predictors of experiencing MRPs.</p> </sec> <sec><st>Results</st> <p>Four main risk factors of MRPs emerged as significant: health literacy (<I>P</I> &lt; 0.05), health status (<I>P</I> &lt; 0.05), consumer engagement (<I>P</I> &lt; 0.05) and cost of medicines (<I>P</I> = 0.001). Participants reporting a lack of perceived control over their medicines (OR 6.3; 95% CI: 3.4&ndash;11.8) or those who played less of a role in follow-up discussions with their healthcare professionals (OR 7.6; 95% CI: 1.3&ndash;45.7) were more likely to experience a self-reported MRP.</p> </sec> <sec><st>Conclusions</st> <p>This study provides insight into consumers' experiences and perceptions of self-reported MRPs following hospital discharge. Results highlight novel findings demonstrating the importance of consumer engagement in developing processes to ensure medication safety on patient discharge.</p> </sec>


Reporting and use of the OECD Health Care Quality Indicators at national and regional level in 15 countries
<sec><st>Quality problem or issue</st> <p>OECD member states are involved since 2003 in a project coordinated by the OECD on Health Care Quality Indicators (HCQI). All OECD countries are biennially requested by the OECD to deliver national data on the quality indicators for international benchmarking purposes.</p> </sec> <sec><st>Initial assessment</st> <p>Currently, there is no knowledge whether the OECD HCQI information is used by the countries themselves for healthcare system accountability and improvement purposes.</p> </sec> <sec><st>Choice of solution</st> <p>The objective of the study is to explore the reporting and use of OECD HCQI in OECD member-states.</p> </sec> <sec><st>Implementation</st> <p>Data were collected through a questionnaire sent to all OECD member-states containing factual questions on the reporting on all OECD HCQ-indicators. Responses were received between June and December 2014. In this timeframe, two reminders were sent to the participants. The work progress was presented during HCQI Meetings in November 2014 and May 2015.</p> </sec> <sec><st>Evaluation</st> <p>Fifteen countries reported to have a total of 163 reports in which one or more HCQIs were reported. One hundred and sixteen were national and 47 were regional reports. Forty-nine reports had a general system focus, 80 were disease specific, 10 referred to a specific type of care setting, 22 were thematic and 2 were a combination of two (disease specific for a particular type of care and thematic for a specific type of care). Most reports were from Canada: 49. All 15 countries use one or more OECD indicators.</p> </sec> <sec><st>Lessons learned</st> <p>The OECD quality indicators have acquired a clear place in national and regional monitoring activities. Some indicators are reported more often than others. These differences partly reflect differences between healthcare systems. Whereas some indicators have become very common, such as cancer care indicators, others, such as mental healthcare and patient experience indicators are relatively new and require some more time to be adopted more widely.</p> </sec>


New approaches to infection prevention and control: implementing a risk-based model regionally
<sec><st>Quality issue</st> <p>Infectious disease outbreaks result in substantial inconvenience to patients and disruption of clinical activity.</p> </sec> <sec><st>Initial assessment</st> <p>Between 1 April 2008 and 31 March 2009, the Vancouver Island Health Authority (Island Health) declared 16 outbreaks of Vancomycin Resistant <I>Enterococci</I> and <I>Clostridium difficile</I> in acute care facilities. As a result, infection prevention and control became one of Island Health's highest priorities.</p> </sec> <sec><st>Choice of solution</st> <p>Quality improvement methodology, which promotes a culture of co-production between front-line staff, physicians and Infection Control Practitioners, was used to develop and test a bundle of changes in practices.</p> </sec> <sec><st>Implementation</st> <p>A series of rapid Plan-Do-Study-Act cycles, specific to decreasing hospital-acquired infections, were undertaken by a community hospital, selected for its size, clinical specialty representation, and enthusiasm amongst staff and physicians for innovation and change. Positive results were incorporated into practice at the test site, and then introduced throughout the rest of the Health Authority.</p> </sec> <sec><st>Evaluation</st> <p>The changes implemented as a result of this study have enabled better control of antibiotic resistant organisms and have minimized disruption to routine activity, as well as saving an estimated $6.5 million per annum. When outbreaks do occur, they are now controlled much more promptly, even in existing older facilities.</p> </sec> <sec><st>Lessons learned</st> <p>Through this process, we have changed our approach in Infection Prevention and Control (IPAC) from a rules-based approach to one that is risk-based, focusing attention on identifying and managing high-risk situations.</p> </sec>


Preparing national health systems to cope with the impending tsunami of ageing and its associated complexities: Towards more sustainable health care
<p>Healthcare systems across the world are experiencing increased financial, organizational and social pressures attributable to a range of critical issues including the challenge of ageing populations. Health systems need to adapt, in order to sustainably provide quality care to the widest range of patients, particularly those with chronic and complex diseases, and especially those in vulnerable and low-income groups. We report on a workshop designed to tackle such issues under the auspices of ISQua, with representatives from Argentina, Australia, Canada, Columbia, Denmark, Emirates, France, Ireland, Jordan, Qatar, Malaysia, Norway, Oman, UK, South Africa and Switzerland. We discuss some of the challenges facing healthcare systems in countries ageing rapidly, to those less so, and touch on current and future reform options.</p>


eHealth and quality in health care: implementation time
<p>The use of information and communication technologies in health and health care could improve healthcare quality in many ways. Today's evidence base demonstrates the (cost-)effectiveness of online education, self-management support and tele-monitoring in several domains of health and care. While new results gradually provide more evidence for eHealth's impact on quality issues, now is the time to come to grips with implementation issues. Documented drawbacks such as low acceptance, low adoption or low adherence need our attention today to make the most of eHealth' potential. Improvement science is beginning to deliver the tools to address these persistent behavioural and cultural issues. The ceHRes Roadmap, for instance, is a plural and pragmatic approach that includes users' needs. It is now imperative to improve our implementation strategies in order to scale up eHealth technologies. This will accelerate the much needed transformation of our healthcare systems and sustain access, affordability and quality for all in the near future.</p>


How do we learn about improving health care: a call for a new epistemological paradigm
<sec><st>Purpose</st> <p>The field of improving health care has been achieving more significant results in outcomes at scale in recent years. This has raised legitimate questions regarding the rigor, attribution, generalizability and replicability of the results. This paper describes the issue and outlines questions to be addressed in order to develop an epistemological paradigm that responds to these questions.</p> </sec> <sec><st>Questions</st> <p>We need to consider the following questions: (i) Did the improvements work? (ii) Why did they work? (iii) How do we know that the results can be attributed to the changes made? (iv) How can we replicate them? (Note, the goal is not to copy what was done, but to affect factors that can yield similar results in a different context.)</p> </sec> <sec><st>Next steps</st> <p>Answers to these questions will help improvers find ways to increase the rigor of their improvements, attribute the results to the changes made and better understand what is context specific and what is generalizable about the improvement.</p> </sec>


Abstracts en este numero


Resumos neste numero


&#x4E2D;&#x6587;&#x6458;&#x8981; (Simplified Chinese Abstracts)


&#x4E2D;&#x6587;&#x6458;&#x8981; (Traditional Chinese Abstracts)


&#x65E5;&#x672C;&#x8A9E;&#x6284;&#x9332; (Japanese Abstracts)


French Abstracts


Work environment and quality improvement in healthcare


Lean interventions in healthcare: do they actually work? A systematic literature review
<sec><st>Purpose</st> <p>Lean is a widely used quality improvement methodology initially developed and used in the automotive and manufacturing industries but recently expanded to the healthcare sector. This systematic literature review seeks to independently assess the effect of Lean or Lean interventions on worker and patient satisfaction, health and process outcomes, and financial costs.</p> </sec> <sec><st>Data sources</st> <p>We conducted a systematic literature review of Medline, PubMed, Cochrane Library, CINAHL, Web of Science, ABI/Inform, ERIC, EMBASE and SCOPUS.</p> </sec> <sec><st>Study selection</st> <p>Peer reviewed articles were included if they examined a Lean intervention and included quantitative data. Methodological quality was assessed using validated critical appraisal checklists. Publically available data collected by the Saskatchewan Health Quality Council and the Saskatchewan Union of Nurses were also analysed and reported separately.</p> </sec> <sec><st>Data extraction</st> <p>Data on design, methods, interventions and key outcomes were extracted and collated.</p> </sec> <sec><st>Results of data synthesis</st> <p>Our electronic search identified 22 articles that passed methodological quality review. Among the accepted studies, 4 were exclusively concerned with health outcomes, 3 included both health and process outcomes and 15 included process outcomes. Our study found that Lean interventions have: (i) no statistically significant association with patient satisfaction and health outcomes; (ii) a negative association with financial costs and worker satisfaction and (iii) potential, yet inconsistent, benefits on process outcomes like patient flow and safety.</p> </sec> <sec><st>Conclusion</st> <p>While some may strongly believe that Lean interventions lead to quality improvements in healthcare, the evidence to date simply does not support this claim. More rigorous, higher quality and better conducted scientific research is required to definitively ascertain the impact and effectiveness of Lean in healthcare settings.</p> </sec>


Applying the WHO conceptual framework for the International Classification for Patient Safety to a surgical population
<sec><st>Objective</st> <p>Efforts to improve patient safety are challenged by the lack of universally agreed upon terms. The International Classification for Patient Safety (ICPS) was developed by the World Health Organization for this purpose. This study aimed to test the applicability of the ICPS to a surgical population.</p> </sec> <sec><st>Design</st> <p>A web-based safety debriefing was sent to clinicians involved in surgical care of abdominal organ transplant patients. A multidisciplinary team of patient safety experts, surgeons and researchers used the data to develop a system of classification based on the ICPS. Disagreements were reconciled via consensus, and a codebook was developed for future use by researchers.</p> </sec> <sec><st>Results</st> <p>A total of 320 debriefing responses were used for the initial review and codebook development. In total, the 320 debriefing responses contained 227 patient safety incidents (range: 0&ndash;7 per debriefing) and 156 contributing factors/hazards (0&ndash;5 per response). The most common severity classification was &lsquo;reportable circumstance,&rsquo; followed by &lsquo;near miss.&rsquo; The most common incident types were &lsquo;resources/organizational management,&rsquo; followed by &lsquo;medical device/equipment.&rsquo; Several aspects of surgical care were encompassed by more than one classification, including operating room scheduling, delays in care, trainee-related incidents, interruptions and handoffs.</p> </sec> <sec><st>Conclusions</st> <p>This study demonstrates that a framework for patient safety can be applied to facilitate the organization and analysis of surgical safety data. Several unique aspects of surgical care require consideration, and by using a standardized framework for describing concepts, research findings can be compared and disseminated across surgical specialties. The codebook is intended for use as a framework for other specialties and institutions.</p> </sec>


Development and evaluation of an automated fall risk assessment system
<sec><st>Background and objective</st> <p>Fall risk assessment is the first step toward prevention, and a risk assessment tool with high validity should be used. This study aimed to develop and validate an automated fall risk assessment system (Auto-FallRAS) to assess fall risks based on electronic medical records (EMRs) without additional data collected or entered by nurses.</p> </sec> <sec><st>Methods</st> <p>This study was conducted in a 1335-bed university hospital in Seoul, South Korea. The Auto-FallRAS was developed using 4211 fall-related clinical data extracted from EMRs. Participants included fall patients and non-fall patients (868 and 3472 for the development study; 752 and 3008 for the validation study; and 58 and 232 for validation after clinical application, respectively). The system was evaluated for predictive validity and concurrent validity.</p> </sec> <sec><st>Results</st> <p>The final 10 predictors were included in the logistic regression model for the risk-scoring algorithm. The results of the Auto-FallRAS were shown as high/moderate/low risk on the EMR screen. The predictive validity analyzed after clinical application of the Auto-FallRAS was as follows: sensitivity = 0.95, NPV = 0.97 and Youden index = 0.44. The validity of the Morse Fall Scale assessed by nurses was as follows: sensitivity = 0.68, NPV = 0.88 and Youden index = 0.28.</p> </sec> <sec><st>Conclusion</st> <p>This study found that the Auto-FallRAS results were better than were the nurses' predictions. The advantage of the Auto-FallRAS is that it automatically analyzes information and shows patients' fall risk assessment results without requiring additional time from nurses.</p> </sec>


Patient assessment of diabetes care in a pay-for-performance program
<sec><st>Objective</st> <p>Few studies address quality of care in pay-for-performance (P4P) programs from the perspective of patients' perceptions. This study aimed to examine and compare the patient assessment of diabetes chronic care as perceived by diabetic patients enrolled and not enrolled in a P4P program from the patients' self-reported perspectives.</p> </sec> <sec><st>Design</st> <p>A cross-sectional study with case and comparison group design.</p> </sec> <sec><st>Setting</st> <p>A large-scale survey was conducted from February to November 2013 in 18 healthcare institutions in Taiwan.</p> </sec> <sec><st>Participants</st> <p>A total of 1458 P4P (<I>n</I> = 1037) and non-P4P (<I>n</I> = 421) diabetic patients participated in this large survey. The Chinese version of the Patient Assessment of Chronic Illness Care (PACIC) instrument was used and patients' clinical outcome data (e.g. HbA1c, LDL) were collected.</p> </sec> <sec><st>Intervention</st> <p>None.</p> </sec> <sec><st>Main Outcome Measures</st> <p>Five subscales from the PACIC were measured, including patient activation, delivery system design/system support, goal setting/tailoring, problem solving/contextual and follow-up/coordination. Patient clinical outcomes were also measured. Multiple linear regression and logistic regression models were used and controlled for patient demographic and health institution characteristics statistically.</p> </sec> <sec><st>Results</st> <p>After adjusting for covariates, P4P patients had higher overall scores on the PACIC and five subscales than non-P4P patients. P4P patients also had better clinical processes of care (e.g. HbA1c test) and intermediate outcomes.</p> </sec> <sec><st>Conclusions</st> <p>Patients who participated in the program likely received better patient-centered care given the original Chronic Care Model. Better perceptions of diabetic care assessment also better clinical outcomes. The PACIC instrument can be used for the patient assessment of chronic care in a P4P program.</p> </sec>


Development and psychometric characteristics of the pediatric inpatient experience survey (PIES)
<sec><st>Objective</st> <p>To study the psychometric properties of the Pediatric Inpatient Experience Survey (PIES), a mail and phone survey for parent reporting of family-centered aspects of inpatient care experiences.</p> </sec> <sec><st>Design</st> <p>Two waves of cross-sectional survey data were collected by mail and phone in 2009 to design a measurement instrument with good psychometric characteristics. Additional cross-sectional data from a mail administration in 2011 confirmed the measurement domains.</p> </sec> <sec><st>Setting</st> <p>Free-standing pediatric hospital in the northeastern USA.</p> </sec> <sec><st>Participants</st> <p>A convenience sample of English-speaking parents of hospitalized children, stratified by patient type (medical versus surgical) and previous stays at this hospital (yes versus no), constituted the instrument design phase. Four hundred and seventy-nine (63%) of those approached agreed to participate and were randomly assigned to mail or phone survey administration. Four hundred and one of these respondents completed the first wave of the survey and 354 respondents completed the second wave. A shortened instrument was mailed to parents randomly selected from patient discharge records. Data from 929 parents (response rate: 36.2%) were used for confirmatory analysis of the created measurement domains.</p> </sec> <sec><st>Main outcome measures</st> <p>The main outcome measures of this psychometric validation study were individual item performance, test&ndash;retest reliability, internal consistency, and construct validity.</p> </sec> <sec><st>Results</st> <p>The resulting survey includes 61 items with 35 rating items with satisfactory test&ndash;retest reliability loading on eight domains. The factor structure was supported by Cronbach's alpha and confirmatory factor analysis. The survey supported construct validity in distinguishing between medical versus surgical and first time versus previous hospital stay groups known to differ with regard to satisfaction. Comparing mail and phone administrations, differences in scores were exacerbated in domain scores and showed the need for mode adjustment.</p> </sec> <sec><st>Conclusion</st> <p>PIES shows satisfactory test&ndash;retest reliability, internal consistency, and construct validity. A new domain measuring emotional connectedness to staff and the hospital is highly correlated with overall satisfaction.</p> </sec>


Patients' informational needs while undergoing brachytherapy for cervical cancer
<sec><st>Objective</st> <p>To identify informational needs of South African women receiving intracavitary brachytherapy for locally advanced cervical cancer as part of a process to develop guidelines for quality patient-centred care.</p> </sec> <sec><st>Design</st> <p>A prospective, qualitative study with a phenomenological approach.</p> </sec> <sec><st>Setting</st> <p>Brachytherapy Unit, Department Oncology, Universitas Hospital, Bloemfontein, South Africa.</p> </sec> <sec><st>Participants</st> <p>Purposive sampling was utilized to recruit patients undergoing brachytherapy for cervical cancer from July to December 2012.</p> </sec> <sec><st>Main Outcome Measures</st> <p>Semi-structured, one-to-one interviews were conducted, guided by a theme list. Audio-recorded interviews were conducted in Sesotho, Afrikaans and English by an unaffiliated, multilingual interviewer. The interviews were transcribed, translated and thematic analysis performed.</p> </sec> <sec><st>Results</st> <p>Data saturation was achieved having interviewed 28 participants, aged 30&ndash;73 years. Four themes with sub-themes were identified: (i) informational needs, (ii) patient disposition towards treatment, (iii) psychological experience and (iv) physical experience. Findings on patients' informational needs were the overarching theme and form the focus of this article. These informational needs included: providing patients with disease- and treatment-related information in their home language; adequate information concerning possible side-effects, sexual intercourse and pre-treatment preparation; and providing patients with informative material as standard procedure.</p> </sec> <sec><st>Conclusion</st> <p>The article has identified women's informational needs providing a focus for patient-centred care. Providing patients with sufficient and understandable information could lessen feelings of fear and anxiety towards treatment delivery. Guidelines with a patient-centred approach could thus be developed to be used as a tool to assist members of multidisciplinary teams in providing quality care to this group of women.</p> </sec>


Observations on quality senior health business: success patterns and policy implications
<sec><st>Objective</st> <p>Population ageing is a global issue that affects almost every country. Most ageing researches focused on demand side and studies related to supply side were relatively scarce. This study selected quality enterprises focus on ageing health and analysed their patterns on providing quality services successfully.</p> </sec> <sec><st>Design</st> <p>Our study selected quality senior health enterprises and explored their success patterns through face-to-face semi-structured in-depth interviews with CEO of each enterprise in 2013.</p> </sec> <sec><st>Setting</st> <p>Thirty-three quality senior health enterprises in Taiwan.</p> </sec> <sec><st>Participants</st> <p>Thirty-three CEO's of enterprises were interviewed individually.</p> </sec> <sec><st>Intervention</st> <p>None.</p> </sec> <sec><st>Main Outcome Measures</st> <p>Core values and vision, historical development, organization structure, services/products provided, delivering channels, customer relationships and further development strategies.</p> </sec> <sec><st>Results</st> <p>Our results indicated success patterns for senior enterprises that there were meeting diversified lifestyles and substitutive needs for the elderly and their caregivers, providing a total solution for actual/virtual integration and flexible one-stop shopping services. We classified these enterprises by used degree of clicks-and-mortar of services and residing situation of the elderly. Industry characteristics and policy implications were summarized.</p> </sec> <sec><st>Conclusions</st> <p>Our observations will serve as a primary evidenced base for enterprises developing their senior market, and also for opening dialogue between customers and enterprises to facilitate valuable opportunities for co-creation between the supply and demand sides.</p> </sec>


Types and patterns of safety concerns in home care: client and family caregiver perspectives
<sec><st>Objective</st> <p>Drawing on interviews with home care clients and their family caregivers, we sought to understand how these individuals conceptualize safety in the provision and receipt of home care, how they promote safety in the home space and how their safety concerns differ from those of home support workers.</p> </sec> <sec><st>Design</st> <p>In-depth, semi-structured interviews were conducted with clients and family caregivers. The analysis included topic and analytical coding of participants' verbatim accounts.</p> </sec> <sec><st>Setting</st> <p>Interviews were completed in British Columbia, Canada.</p> </sec> <sec><st>Participants</st> <p>Totally 82 clients and 55 caregivers participated.</p> </sec> <sec><st>Results</st> <p>Clients and family caregivers identified three types of safety concerns: physical, spatial and interpersonal. These concerns are largely multi-dimensional and intersectional. We present a conceptual model of client and caregiver safety concerns. We also examine the factors that intensify and mitigate safety concerns in the home.</p> </sec> <sec><st>Conclusions</st> <p>In spite of safety concerns, clients and family caregivers overwhelmingly prefer to receive care in the home setting. Spatial and physical concerns are the most salient. The financial burden of creating a safe care space should not be the client's alone to bear. The conceptualization and promotion of safety in home care must recognize the roles, responsibilities and perspectives of all of the actors involved, including workers, clients and their caregivers.</p> </sec>


Does the patient's inherent rating tendency influence reported satisfaction scores and affect division ranking?
<sec><st>Objective</st> <p>To determine the impact of adjusting for rating tendency (RT) on patient satisfaction scores in a large teaching hospital and to assess the impact of adjustment on the ranking of divisions.</p> </sec> <sec><st>Design</st> <p>Cross-sectional survey.</p> </sec> <sec><st>Setting</st> <p>Large 2200-bed university teaching hospital.</p> </sec> <sec><st>Participants</st> <p>All adult patients hospitalized during a 1-month period in one of 20 medical divisions.</p> </sec> <sec><st>Intervention</st> <p>None.</p> </sec> <sec><st>Main Outcome Measures</st> <p>Patient experience of care measured by the Picker Patient Experience questionnaire and RT scores.</p> </sec> <sec><st>Results</st> <p>Problem scores were weakly but significantly associated with RT. Division ranking was slightly modified in RT adjusted models. Division ranking changed substantially in case-mix adjusted models.</p> </sec> <sec><st>Conclusions</st> <p>Adjusting patient self-reported problem scores for RT did impact ranking of divisions, although marginally. Further studies are needed to determine the impact of RT when comparing different institutions, particularly across inter-cultural settings, where the difference in RT may be more substantial.</p> </sec>


A randomized, controlled trial of team-based competition to increase learner participation in quality-improvement education
<sec><st>Objective</st> <p>Several barriers challenge resident engagement in learning quality improvement (QI). We investigated whether the incorporation of team-based game mechanics into an evidence-based online learning platform could increase resident participation in a QI curriculum.</p> </sec> <sec><st>Design</st> <p>Randomized, controlled trial.</p> </sec> <sec><st>Setting</st> <p>Tertiary-care medical center residency training programs.</p> </sec> <sec><st>Participants</st> <p>Resident physicians (<I>n</I> = 422) from nine training programs (anesthesia, emergency medicine, family medicine, internal medicine, ophthalmology, orthopedics, pediatrics, psychiatry and general surgery) randomly allocated to a team competition environment (<I>n</I> = 200) or the control group (<I>n</I> = 222).</p> </sec> <sec><st>Intervention</st> <p>Specialty-based team assignment with leaderboards to foster competition, and alias assignment to de-identify individual participants.</p> </sec> <sec><st>Main Outcome Measures</st> <p>Participation in online learning, as measured by percentage of questions attempted (primary outcome) and additional secondary measures of engagement (i.e. response time). Changes in participation measures over time between groups were assessed with a repeated measures ANOVA framework.</p> </sec> <sec><st>Results</st> <p>Residents in the intervention arm demonstrated greater participation than the control group. The percentage of questions attempted at least once was greater in the competition group (79% [SD &plusmn; 32] versus control, 68% [SD &plusmn; 37], <I>P</I>= 0.03). Median response time was faster in the competition group (<I>P</I>= 0.006). Differences in participation continued to increase over the duration of the intervention, as measured by average response time and cumulative percent of questions attempted (each <I>P</I>&lt; 0.001).</p> </sec> <sec><st>Conclusions</st> <p>Team competition increases resident participation in an online course delivering QI content. Medical educators should consider game mechanics to optimize participation when designing learning experiences.</p> </sec>


Using mixed methods to evaluate perceived quality of care in southern Tanzania
<sec><st>Objective</st> <p>To compare perceived quality of maternal and newborn care using quantitative and qualitative methods.</p> </sec> <sec><st>Design</st> <p>A continuous household survey (April 2011 to November 2013) and in-depth interviews and birth narratives.</p> </sec> <sec><st>Setting</st> <p>Tandahimba district, Tanzania.</p> </sec> <sec><st>Participants</st> <p>Women aged 13&ndash;49 years who had a birth in the previous 2 years were interviewed in a household survey. Recently delivered mothers and their partners participated in in-depth interviews and birth narratives.</p> </sec> <sec><st>Intervention</st> <p>None.</p> </sec> <sec><st>Main Outcome Measures</st> <p>Perceived quality of care.</p> </sec> <sec><st>Results</st> <p>Quantitative: 1138 women were surveyed and 93% were confident in staff availability and 61% felt that required drugs and equipment would be available. Drinking water was easily accessed by only 60% of respondents using hospitals. Measures of interaction with staff were very positive, but only 51% reported being given time to ask questions. Unexpected out-of-pocket payments were higher in hospitals (49%) and health centres (53%) than in dispensaries (31%). Qualitative data echoed the lack of confidence in facility readiness, out-of-pocket payments and difficulty accessing water, but was divergent in responses about interactions with health staff. More than half described staff interactions that were disrespectful, not polite, or not helpful.</p> </sec> <sec><st>Conclusion</st> <p>Both methods produced broadly aligned results on perceived readiness, but divergent results on perceptions about client&ndash;staff interactions. Benefits and limitations to both quantitative and qualitative approaches were observed. Using mixed methodologies may prove particularly valuable in capturing the user experience of maternal and newborn health services, where they appear to be little used together.</p> </sec>


Patient complaints about hospital services: applying a complaint taxonomy to analyse and respond to complaints
<sec><st>Objective</st> <p>To explore the applicability of a patient complaint taxonomy to data on serious complaint cases.</p> </sec> <sec><st>Design</st> <p>Qualitative descriptive study.</p> </sec> <sec><st>Setting</st> <p>Complaints made to the New South Wales (NSW) Health Care Complaints Commission, Australia between 2005 and 2010.</p> </sec> <sec><st>Participants</st> <p>All 138 cases of serious complaints by patients about public hospitals and other health facilities investigated in the 5-year period.</p> </sec> <sec><st>Main Outcome Measure</st> <p>A thematic analysis of the complaints was conducted to identify particular complaint issues and the Reader <I>et al.</I> (Patient complaints in healthcare systems: a systematic review and coding taxonomy. BMJ Qual Saf 2014;23:678&ndash;89.) patient complaint taxonomy was then used to classify these issues into categories and sub-categories.</p> </sec> <sec><st>Results</st> <p>The 138 investigated cases revealed 223 complaint issues. Complaint issues were distributed into the three domains of the patient complaint taxonomy: clinical, management and relationships. Complaint issue most commonly related to delayed diagnosis, misdiagnosis, medication errors, inadequate examinations, inadequate/nil treatment and quality of care including nursing care.</p> </sec> <sec><st>Conclusions</st> <p>The types of complaints from patients about their healthcare investigated by the NSW Commission were similar to those received by other patient complaint entities in Australia and worldwide. The application of a standard taxonomy to large numbers of complaints cases from different sources would enable the creation of aggregated data. Such data would have better statistical capacity to identify common safety and quality healthcare problems and so point to important areas for improvement. Some conceptual challenges in devising and using a taxonomy must be addressed, such as inherent problems in ensuring coding consistency, and giving greater weight to patient concerns about their treatment.</p> </sec>


Incidence and impact of proxy response in measuring patient experience: secondary analysis of a large postal survey using propensity score matching
<sec><st>Objective</st> <p>To determine whether use of proxy respondents in a patient experience survey was related to patient characteristics, and to compare patient and proxy responses.</p> </sec> <sec><st>Design</st> <p>Secondary analysis, using propensity score matching, of the NHS adult inpatient survey, a large cross-sectional survey.</p> </sec> <sec><st>Setting</st> <p>Hospitals (<I>n</I> = 161) providing inpatient services in England in 2011.</p> </sec> <sec><st>Participants</st> <p>The survey received 70 863 responses: 10 661 (15.6%) involved proxy respondents in some way.</p> </sec> <sec><st>Intervention</st> <p>None.</p> </sec> <sec><st>Main Outcome Measures</st> <p>Prevalence of proxy response was explored by patient demographic characteristics. Responses were compared using seven composite domains and one overall rating. Cases involving proxy responses were matched to similar independent responses via propensity score matching and mean scores compared using <I>t</I>-tests.</p> </sec> <sec><st>Results</st> <p>Use of proxy respondents was common, with 15.7% of responses involving a proxy in some way: higher than in other similar collections internationally. Proxy response was more common for some patient groups, such as older people and those from black and minority ethnic groups. Reports made by or with the assistance of proxy respondents were markedly less positive than those from patients completing the survey unaided. This pattern was consistent across all tested variables, although the biggest differences were observed for a subjective &lsquo;overall rating&rsquo; question.</p> </sec> <sec><st>Conclusions</st> <p>The prevalence of proxy response varied according to patient characteristics, but proxies were consistently less positive than patients responding unaided. Possible explanations include genuine differences in care, differential health outcomes or differences in perceptions. Patient experience surveys should collect information on use of proxy respondents to enable more refined analysis.</p> </sec>


Nurse staffing and the work environment linked to readmissions among older adults following elective total hip and knee replacement
<sec><st>Objective</st> <p>To examine the effect of nurse staffing and the work environment on 10- and 30-day unplanned readmissions for US Medicare patients following elective total hip and knee replacement.</p> </sec> <sec><st>Design</st> <p>A cross-sectional analysis of secondary data.</p> </sec> <sec><st>Setting</st> <p>Acute care hospitals in California, Florida, New Jersey and Pennsylvania, during 2006.</p> </sec> <sec><st>Participants</st> <p>Medicare patients (<I>n</I> = 112 017) admitted to an acute care hospital for an elective total hip or knee replacement.</p> </sec> <sec><st>Main Outcome Measures</st> <p>The adjusted odds ratio (OR) of experiencing an unplanned readmission within 10 and 30 days of discharge following an elective total hip or knee replacement.</p> </sec> <sec><st>Results</st> <p>Our sample included 112 017 Medicare patients in 495 hospitals. Nearly 6% of the patients were readmitted within 30 days; more than half of whom were rehospitalized within 10 days. Adjusted for patient and hospital characteristics, patients had 8% higher odds of 30-day readmission and 12% higher odds of 10-day readmission, for each additional patient per nurse. Patients cared for in the best work environments had 12% lower odds of 30-day readmission.</p> </sec> <sec><st>Conclusions</st> <p>Readmission outcomes following major joint replacement are associated with hospital nursing care. Attention to nurse work conditions may be central to improving readmissions in this postoperative Medicare population.</p> </sec>


Should quality goals be defined for multicenter laboratory testing? Lessons learned from a pilot survey on a national surveillance program for diabetes
<sec><st>Quality problem</st> <p>Robust laboratory protocols and stringent quality control (QC) procedures are essential for meaningful collection of data from multiple sites in large-scale population-based studies. Failure to design and implement an effective QC program not only adversely affects the scientific outcome, but also affects public confidence in the acceptability of the data.</p> </sec> <sec><st>Initial assessment</st> <p>A pilot survey was conducted to assess the analytical performance of multicenter plasma glucose measurements in a national surveillance program for diabetes in China.</p> </sec> <sec><st>Choice of solution</st> <p>Quality goals of the imprecision in terms of coefficient of variation (CV) and total analytical error (TEa) were defined based on the Clinical Laboratory Improvement Amendments (CLIA) criteria for acceptable performance of proficiency testing (PT) for plasma glucose using commercial QC preparations.</p> </sec> <sec><st>Implementation</st> <p>A web-based internal QC (IQC) program was established to monitor the analytical performance of the 302 centers participating in the survey.</p> </sec> <sec><st>Evaluation</st> <p>The participation rate was 96% (289/302). Statistical analysis showed that the percentage of centers meeting the acceptable specifications of CV &le;5.0% and TEa &le;10% using the CLIA PT criteria was 91.7% while 76.4% of laboratories achieved the goals for desirable performance of CV &le;2.9% and TEa &le;6.9%, as proposed by the Laboratory Medicine Practice Guidelines for the management of diabetes mellitus based on biological criteria.</p> </sec> <sec><st>Lessons learned</st> <p>Communications and training are important in ensuring the data integrity of multicenter population-based studies. Performance verification and IQC programs should be implemented to help identify centers that can fulfill the eligibility criteria to perform laboratory analyses.</p> </sec>


Re: A systematic review of patients' experiences of adverse events in health care


Author's response