use of continuous quality improvement methodology to improve nurses' infection control practices at a general hospital in Alexandria

The aim of the present study was to assess the effectiveness of continuous quality improvement [CQI] methodology in improving selected nurses' infection control practices at a general hospital in Alexandria. The study population consisted of important infection control practices performed by nurses. Important practices were defined as high-volume, high-risk, high-cost, and problem-prone activities. Based on these criteria, three practices were selected: [1] handwashing, [2] surgical site dressing, and [3] peripheral intravenous catheterization. The present study used pre-test post-test design to examine nurses' practices before and after implementation of CQI project. It consisted of the following three distinct phases: [1] observation of nurses' practices before intervention, [2] implementation of a quality improvement project, and [3] observation of nurses' practices following implementation of the project. After implementation of CQI interventions, the percentage of times in which indicated handwashing/alcohol hand rubbing was performed increased from 1.7% to 2.8%, and the percentage of times nurses complied with recommended handwashing practices increased for 5 of actual 7 steps. Nurses' practices of surgical site dressing technique showed statistically significant improvement in all 12 steps after implementation of CQI interventions. The proportion of occasions in which nurses complied with recommended procedure for peripheral intravenous catheterization significantly improved after implementation of CQI intervention in 9 of 12 steps

Statistical analysis of referrals by general practitioner at health insurance organization clinics in Alexandria

Referral of patients generates significant economic costs for both physician fees and diagnostic tests. Variation in referral rates between general practices and between individual GPs has long been the focus of attention for policy makers. The present study aimed to analyze the referrals by General Practitioners [GP] at Health Insurance Organization [HIO] clinics in Alexandria. The study was conducted at 18 Health Insurance Organization [HIO] comprehensive clinics in Alexandria, distributed in the 6 districts of Alexandria HIO. Retrospective analysis of records and cross sectional interview to 180 GPs were carried out. Male GPs comprised 82.2% of the sample. On the average, GPs received 6.6 +/- 4.5 patients per working hour. Over the year 2002, 8.4% of consultations were referred to specialists, 5.4% referred to laboratory and only 0.09% were referred to hospital. The highest percent of referrals from GP to specialist were directed to internal medicine followed by orthopedics, general surgery, E.N.T, dermatology, neuropsychiatry, chest then urology clinics. Referral rate from GPs to specialists was found to have a 6.6-fold variation among clinics, and a 54.8-fold variation among individual GPs. Moreover, there was no homogeneity in variations in referral rates of clinics within 3 of the 6 districts. Using multiple regression analysis, the only significant factor was the indirect relation with workload. Comparison of referral rates of GPs with the limits set by HIO [8-17%] revealed that, 48.9% of GPs were within limits, 37.2% were lower and 13.9% were higher than limits. GPs who had diploma or master were average referrers in 51.5%, low referrers in 30.3% and high referrers in 18.2%, compared to 45.6%, 50.6% and only 3.8%, respectively for those with bachelor degree; the difference was statistically significant

Statistical process control for referrals by general practitioner at health insurance organization clinics in Alexandria

Quality control is the application of statistical techniques to a process in an effort to identify and minimize both random and non-random sources of variation. The present study aimed at the application of Statistical Process Control [SPC] to analyze the referrals by General Practitioners [GP] at Health Insurance Organization [HIO] clinics in Alexandria. Retrospective analysis of records and cross sectional interview to 180 GPs were done. Using the control charts [p chart], the present study confirmed the presence of substantial variation in referral rates from GPs to specialists; more than 60% of variation was of the special cause, which revealed that the process of referral in Alexandria [HIO] was completely out of statistical control. Control charts for referrals by GPs classified by different GP characteristics or organizational factors revealed much variation, which suggested that the variation was at the level of individual GPs. Furthermore, the p chart for each GP separately; which yielded a fewer number of points out of control [outliers], with an average of 4 points. For 26 GPs, there was no points out of control, those GPs were slightly older than those having points out of control. Otherwise, there was no significant difference between them. The revised p chart for those 26 GPs together yielded a centerline of 9.7%, upper control limit of 12.0% and lower control limit of 7.4%. Those limits were in good agreement with the limits specified by HIO; they can be suggested to be the new specification limits after some training programs

Measuring physicians' job satisfaction using a combination of methods

The present study attempted to explore the utility of measuring physicians' job satisfaction by a combination of quantitative and qualitative techniques. A nominal Group process, involving 10 physicians, generated 43 job attributes pertaining to 13 job satisfaction dimensions that were regarded as relevant to physicians' overall satisfaction. In addition, a Focus Group Discussion [FGD] was conducted in the hospital together in-depth information about physicians' job satisfaction. Comparison of findings of FGD and the questionnaire survey revealed consistency in identifying job status and relationship with doctors. Pay emerged as the most dissatisfying aspect through the questionnaire and great dissatisfaction was implied indirectly through the FGD. Inconsistencies were most apparent regarding the 3 dimensions of drugs, equipment and administration

Patient satisfaction with hospital services: determinants and level in a hospital in Kuwait

The present study used a well-tested patient satisfaction measuring instrument to identify the determinants of the level of overall satisfaction with hospital services, and to examine the level of satisfaction with attributes of 7 specific dimensions of hospital services. Using multiple regression analysis, it was found that out of 12 patient characteristics, age was the most important determinant of overall satisfaction, followed by gender. Perceived health status, clinical department, and expectations about the quality of services before admission were also significant but less important determinants of overall satisfaction. Marital status, level of education, nationality, and previous hospitalization in the study hospital, in Kuwait, or in a western country hospital, all had no significant effect on overall satisfaction. Concerning the effect of satisfaction with specific dimensions of hospital services on overall satisfaction, it was found that satisfaction with physicians was the most important determinant of overall satisfaction, followed by satisfaction with housekeeping and with nurses. Satisfaction with hospital environment and facilities and with admission process were also significant but less important determinants of overall satisfaction, while satisfaction with food and radiology services did not affect overall satisfaction.The level of overall satisfaction as well as satisfaction with specific dimensions of hospital services were quite high. Physicians, care was the most favorably rated dimension, followed by admission process and housekeeping, while nursing care was the least favorably rated dimension. Among the attributes of physicians and nurses care, technical care and courtesy were the most favorably rated items; while communication, particularly imparting of information, was the least favorably rated aspect. Several attributes of the hospital environment and facilities and of the food services were found to be dissatisfying to patients

Utilization of laboratory services at the health insurance organization hospitals in Alexandria

Review of the medical records of 427 admissions to Gamal Abdel Nasser Hospital and 230 admissions to Karmouz Hospital to investigate the pattern of utilization of laboratory services provided necessary baseline information, in addition to some findings of direct administrative implications. The proportion of patients for whom tests were ordered was 5l.77e at Gamal Hospital and 44.3% at Karmouz Hospital, and the average number of ordered tests per patient was 2.8 and 2.0 respectively, with wide variations being noted among departments within each hospital. Seven tests accounted for two thirds of ordered tests in both hospitals. Abnormal results were recorded for 41.6% of tests performed at Gamal Hospital and 37.0% of those performed at Karmouz Hospital, while repeat tests constituted l6.7% and 8.0% of ordered tests respectively. In both hospitals, reports of one fifth of ordered tests were not found in the patients' medical record. In Gamal Hospital 10.3% of tests were not performed and the re-portsof 6.8% were not attached to the medical record, the respective figures at Karmouz Hospital were 10.3% and 5.7%. Abnormal results of hemoglobin percentage and pus cells in urine were ignored in 25-50% of cases. the proportion of tests performed within one day was 79.6%.at Gamal Hospital and 91.97o at Karmouz Hospital

comparison of deliveries at a hospital versus a maternal and child health centre

The present study compared between 123 women delivered at a maternal and child health centre with 500 women delivered at a maternity hospital. Results revealed some significant differences between the 2 groups, including a higher level of education among the MCHC cases and their husbands, and a higher mean score for the hospital cases on the 6 scales of the Middlesex Hospital questionnaire that identifies 6 different psychoneurotic states. Use of antenatal care was judged as inadequte for the greater proportion of both groups, but the proportion that did not receive any care was much higher among hospital cases. Women tended to use the same setting, and often the same facility for delivery; the majority of those who delivered at the hospital not having utilized the MCHC for antenatal or delivery care. Concerning medical and obstetric differences, based on the Hobel et al.,[1973] scoring system it appeared that the proportion of high risk cases was significantly higher among the hospital group; the number of risk factors identified and their incidence being greater among that group. Regarding obstetric intereferences, it appeared that the process of childbirth was allowed to proceed naturally at the MCHC, whereas different types of interferences were recorded for the low risk group delivered at the hospital. Assessing the performance of the MCHC as a setting for maternity care was approached by examining the process of screening and selection of cases, the outcome of delivery, and the consumers' attitude towards the service. It appeared that the compliance rate with the centre's screening criteria was very high, but based on the Hobel et al., [1973] criteria 14.6% of cases should not have been accepted for delivery. Concerning outcome of care no other complication but one incident of postpartum hemorrhage was recorded for the MCHC cases, denoting the safety of this service. The majority of women who delivered at the MCHC favoured the centre over the hospital when their opinion was sought regarding 4 different aspects of the service

Measuring job satisfaction among hospital nurses: some methodological issues

The present study was undertaken to compare between the various methods that have been used to measure the job satisfaction of nurses. Five different measures were developed: a global measure, an unweighted direct facet-specific measure, an unweighted indirect facet-specific measure, a weighted direct facet-specific measure, and a weighted indirect facet-specific measure. Using the interviewing method, the scaIes constructed to calculate these measures were administered to 91 nurses employed at one of the general hospitals that belong to the Ministry of Public Health in Alexandria. Results indicated that all the ten job facets were rated as very important by the greater proportion of respondents. A statistically significant positive correlation was detected between the total score of all five measures of satisfaction; however the correlation was strong between the weighted and unweighted direct measure, and between the weighted and unweighted indirect measure, but was intermediate between all the remaining measures. Comparison between ratings of satisfaction with ten specific job facets, as measured by the direct and indirect methods, revealed a statistically significant difference for nine facets. Mostly, a more favourable attitude was expressed by the direct method. The accuracy of the available methods of measurement of job satisfaction, and the value of incorporating the degree of importance of job facets in facet-specific measures were questioned. The need for further research in this area was emphasized

study of tonsillectomies at one of the health insurance organisation hospitals

A prospective survey, conducted at El-Nile Health Insurance Organization Hospital in Cairo, showed that out of a total of 71 patients who had a tonsillectomy operation in 1985, only 33 [46.5%] with the criteria for justification of surgery. These criteria were a minimum of 4 attacks of acute tonsillitis, or one attack of peritonsillar abscess during the 12 months prior to surgery. The proportion of cases of unjustified surgery was significantly higher among females and among those who were enrolled in the insurance program for less than one year. A significant strong positive correlation was found between the E.N.T. bed population ratio and the tonsillectomy rate. Inpatient and outpatient records of the study cases were judged as inadequate as sources of information about justification of surgery; the specific number of episodes of illness ot being noted in any of the inpatient records, and only 13.6 of episodes of illness being treated at the polyclinic

Psychiatric admissions to a general hospital II an epidemiological study

During 1982, 1.1/1000 of the health insured population in Alexandria were hospitalized for mental disorders. The rate of hospitalization was significantly higher for males. Schizophrenia was the main diagnosis accounting for 34.3% of cases; collectively psychoses accounted for 50.6% of cases and neurotic disorders for 21.3%. The mean age was highest for cases of organic psychosis [43.7 years] followed by affective psychosis [32.0 years] and epilepsy [32.6 years]. A positive family history for mental disturbances was greatest among psychotics [18.8%] and least among neurotics [7.8%]. Concerning stresses which may be a precipitating cause for psychiatric disturbances, those having personality disorders and addicts complained of work troubles [47.1%] and financial troubles [15.7%] more than other patients, while neurotics complained of family troubles [37.5%] more than others. Drug and alcohol dependence was greatest among those having personality disorders

Preoperative anxiety in surgical patients

The level of preoperative anxiety of 50 surgical patients was compared with that of another 50 patients who received an emotionally supportive preoperative visit by an anesthetist. Anxiety was measured using Taylor scale for manifest anxiety. It was found that the level of preoperative anxiety was significantly lower among those who received the anesthetic visit. It also appeared that both sexes and all age groups were equally affected by preoperative anxiety, and all benefited from the anesthetic visit. The proportion of patients suffering from preoperative sleep disturbance, and that of patients reporting unbearable postoperative anxiety levels. The study also indicated that only a small proportion of males admitted being anxious preoperatively

Assessing the quality of inpatient care: use of explicit versus implicit criteria

Explicit process criteria were developed and used for the assessment of care provided for 50 cases of breast cancer in Gamal Abdel-Nasser Hospital. Based on differential weights for 47 criterion items, the average score obtained was 53.8%. Twenty five of the cases assessed by explicit criteria were submitted to assessment by the implicit review method that had been used in the hospital since 1980. Comparison of the results of these 2 methods indicated that there was slight agreement between judgments on all areas of performance; implicit reviews being less sensitive and more lenient. The present study demonstrated the feasibility of the explicit criteria approach and its value in identifying problem areas that are amenable to corrective action, mainly through education of the medical staff. Development of explicit process criteria for common diagnosis and participation of the medical staff in the process of criteria development was recommended for the purpose of propagating standards of good medical practice. The use of specially designed history and physical examination forms for common conditions, that outline the elements to be entered, was suggested as a means of improving practice and the quality of medical recording which is an important dimension of medical practice

Psychiatric admissions to a general hospital

The present study examined the reasons for admission of psychiatric cases to the neuropsychiatry unit at Gamal Abdel-Naser Hospital in 1982, with the aim of identifying a group of admissions which may be managed as effectively but more efficiently on an ambulatory basis. Results indicated that 2 main reasons accounted for the majority of admissions: admissions to establish a diagnosis [except for fits] and admissions to control excited and /or dangerous cases. The former group was regarded as admissions that may be managed on an ambulatory basis. Such admissions accounted for 279 of the 711 psychiatric admissions [39.2%] and consumed 2473 of the 7323 days [33.7%] provided for psychiatric cases, with an average stay of 8.9 days per admission. The majority of cases admitted to establish a diagnosis [except for fits] [86.4%] were referred to the hospital by psychiatrists in the clinics of the Health Insurance Organization