HIT or miss: the application of health care information technology to managing uncertainty in clinical decision making.

OBJECTIVE: To discuss the usefulness of health care information technology (HIT) in assisting care providers minimize uncertainty while simultaneously increasing efficiency of the care provided. STUDY DESIGN: An ongoing study of HIT, performance measurement (clinical and production efficiency) and their implications to the payment for care represents the design of this study. Since 2006, all Maryland hospitals have embarked on a multi-faceted study of performance measures and HIT adoption surveys, which will shape the health care payment model in Maryland, the last of the all-payor states, in 2011. METHODS: This paper focuses on the HIT component of the Maryland care payment initiative. While the payment model is still under review and discussion, 'appropriateness' of care has been discussed as an important dimension of measurement. Within this dimension, the 'uncertainty' concept has been identified as associated with variation in care practices. Hence, the methods of this paper define how HIT can assist care providers in addressing the concept of uncertainty, and then provides findings from the first HIT survey in Maryland to infer the readiness of Maryland hospital in addressing uncertainty of care in part through the use of HIT. RESULTS: Maryland hospitals show noteworthy variation in their adoption and use of HIT. While computerized, electronic patient records are not commonly used among and across Maryland hospitals, many of the uses of HIT internally in each hospital could significantly assist in better communication about better practices to minimize uncertainty of care and enhance the efficiency of its production.

[Measurement in public health: what pulmonary tuberculosis management has taught us]. / Evaluación en salud pública: lecciones aprendidas de la gestión de la tuberculosis pulmonar.

Pulmonary tuberculosis rates are increasing worldwide, including in Spain. One of the main challenges when treating this disease is achieving treatment completion, since studies have shown that approximately 30-35% of all patients do not take their medications as intended. The present article explores a continuum of evaluation strategies and performance measures for assessing the effectiveness of community-based programs designed to enhance treatment completion in patients with active pulmonary tuberculosis. Four traditional evaluation strategies (case studies, retrospective and case-control studies, forecasting/modeling, and cost effectiveness analysis) and 2 emerging and promising approaches (quality of life assessment and indicators of the continuum of care) are presented. Several of the evaluation strategies reviewed indicate that treatment programs using directly observed therapy (DOT) that are comprehensive, community-based and patient-centered achieve the highest treatment completion rates. Combinations of these strategies are recommended to create a body of evidence capturing the impact and nuances of community-based public health interventions in improving health outcomes, in this case for patients with pulmonary tuberculosis.

Evaluación en salud pública: lecciones aprendidas de la gestión de la tuberculosis pulmonar / Measurement in Public Health: what pulmonary tuberculosis management has taught us

Las tasas de tuberculosis pulmonar están aumentando entodo el mundo, incluida España. Uno de los retos principales al tratar esta enfermedad es conseguir un buen cumplimiento terapéutico, puesto que alrededor de un 30-35% de los pacientes no sigue la pauta de medicación prescrita. Este artículo revisa un conjunto de estrategias de evaluación y medidas de la práctica para valorar la efectividad de los programas comunitarios orientados a reforzar el cumplimiento terapéutico de los pacientes con tuberculosis pulmonar activa. Se revisan 4 estrategias de evaluación tradicionales (estudio de un caso, estudio retrospectivo y de casos controles,predicción/pronóstico y análisis de coste-efectividad) y 2 enfoques de evaluación emergentes y prometedores (evaluación de calidad de vida e indicadores de continuidad de la asistencia).Varias de las estrategias de evaluación revisadas indican que los programas de tratamiento mediante la terapia de observación directa (directly observed therapy [DOT]), amplios, comunitarios y centrados en el paciente, alcanzan los índices más altos de cumplimiento terapéutico. Se recomienda la utilización conjunta de varias de estas estrategias de evaluación para crear un cuerpo de evidencia que refleje el impacto delos programas de intervención comunitaria en la mejorade los resultados de salud, en este caso concreto para los pacientes con tuberculosis pulmonar

Pulmonary tuberculosis rates are increasing worldwide, including in Spain. One of the main challenges when treating this disease is achieving treatment completion, since studies have shown that approximately 30-35% of all patients do not take their medications as intended.The present article explores a continuum of evaluation strategies and performance measures for assessing the effectiveness of community-based programs designed to enhance treatment completion in patients with active pulmonary tuberculosis. Four traditional evaluation strategies (case studies, retrospective and case-control studies, forecasting/modeling, and cost effectiveness analysis) and 2 emerging and promising approaches (quality of life assessment and indicators ofthe continuum of care) are presented.Several of the evaluation strategies reviewed indicate that treatment programs using directly observed therapy (DOT) that are comprehensive, community-based and patient-centered achieve the highest treatment completion rates. Combinations of these strategies are recommended to create a body of evidencecapturing the impact and nuances of community-basedpublic health interventions in improving health outcomes, in this case for patients with pulmonary tuberculosis (AU)

The World Health Organization Performance Assessment Tool for Quality Improvement in Hospitals (PATH): an analysis of the pilot implementation in 37 hospitals.

OBJECTIVE: To evaluate the pilot implementation of the World Health Organization Performance Assessment Tool for Quality Improvement in hospitals (PATH). DESIGN: Semi-structured interviews with regional/country coordinators and Internet-based survey distributed to hospital coordinators. SETTING: A total of 37 hospitals in six regions/countries (Belgium, Ontario (Canada), Denmark, France, Slovakia, KwaZulu Natal (South Africa)). PARTICIPANTS: Six PATH regional/country coordinators and 37 PATH hospital coordinators. INTERVENTION: Implementation of a hospital performance assessment pilot project. OUTCOME MEASURE: Experience of regional/country coordinators (structured interviews) and experience of hospital coordinators (survey) with the pilot implementation. RESULTS: The main achievement has been the collection and analysis of data on a set of indicators for comprehensive performance assessment in hospitals in regions and countries with different cultures and resource availability. Both regional/country coordinators and hospital coordinators required seed funding and technical support during data collection for implementation. Based on the user evaluation, we identified the following research and development tasks: further standardization and improved validity of indicators, increased use of routine data, more timely feedback with a stronger focus on international benchmarking and further support on interpretation of results. CONCLUSIONS: Key to successful implementation was the embedding of PATH in existing performance measurement initiatives while acknowledging the core objective of the project as a self-improvement tool. The pilot test raised a number of organizational and methodological challenges in the design and implementation of international research on hospital performance assessment. Moreover, the process of evaluating PATH resulted in interesting learning points for other existing and newly emerging quality indicator projects.

Safety is part of quality: a proposal for a continuum in performance measurement.

OBJECTIVES: Safer care is a strategic priority for health care organizations worldwide. Yet, the measurement and evaluation of key processes and outcomes associated with safer care remains challenging, even with existing performance measurement indicators. The multi-national Quality Indicator Project (QI Project) data are analysed to [1] document the patterns of safety indicators used between 1999 and 2006 among hospitals in Asia, Europe and the USA; and [2] to identify trends in using both organization-level and patient-level data in hospital performance improvement. DESIGN AND SETTING: Retrospective data are used to ascertain how the use of safety indicators has changed in comparison to other QI Project indicators. 'Continent' rather than 'hospital' is used as the unit of analysis and P-values of the differences in use percentages across Asia, Europe and the USA are calculated. RESULTS: There was a significant increase in the use of QI Project indicators in Asia between 1999 and 2006. Measured as the mean percentage of usage, the safety versus 'all other' indicators' increase in Asia was 43.7% versus 27% (P < 0.05) and 37.2% versus 24.4% (P < 0.05), respectively, during the study's time period. The European participants used both safety and all other indicators less frequently, 14.7% versus 18% (P < 0.05) and 9.5% versus 19.8% (P < 0.05), respectively. Finally, USA hospitals demonstrated a larger difference in the decrease of QI Project indicator use than European hospitals between the 'safety' and 'all other' indicators, 12.7% decrease for safety indicators and 7.1% for all others (P < 0.05). These findings are consistent with trends reported in a previous study. CONCLUSION: Traditional performance measures continue to assist hospitals in identifying crucial aspects of safety in the delivery of care. Building on the findings of a previous study, there are emerging trends in the type of measures used in hospitals in Asia, Europe and the USA pursuing the improvement of overall performance. The increasing use of patient-level data specifically, in tandem with organizational level indicators, may signal the continuum of measurement strategies, now still predominantly in the USA but anticipated to be adopted both in Europe and Asia.

Does a Cesarean section delivery always cost more than a vaginal delivery?

UNLABELLED: There is evidence that average total charges per episode of child birth depend on maternal plus child length of stay, neonatal intensive care unit (NICU) utilization, maternal race and mode of delivery. In particular, when maternal and child records are linked, this study suggests that when adjusted for maternal characteristics, the cost of vaginal deliveries followed by NICU utilization may be higher than the cost of Cesarean sections and NICU utilization. OBJECTIVE: Cesarean section, one of the most frequently performed surgical procedures on women, is rising globally and in the USA. Much of the current Cesarean section literature focuses on reporting geographic and hospital-specific variations, but little has been published about the clinical and demographic characteristics of the patients, and even less about the economic consequences of a Cesarean section delivery compared with a vaginal delivery [e.g. the total hospital charges and length of neonatal intensive care unit-NICU-stay] of a birth episode. To examine these relationships further, three urban Baltimore hospitals volunteered in 2004 to participate in a retrospective chart review that linked mother and child hospital records. METHODS: 1172 mother-child records were randomly selected and data regarding maternal co-morbidities, age, infant weight along with transfer to neonatal intensive care units, and economic data were extracted from the mother and child charts. CONCLUSION: Average total charges for vaginal deliveries [maternal plus total baby charges that includes NICU utilization (X=$17 624.38)] may be higher than average total charges for Cesarean sections [maternal plus total baby charges that includes NICU utilization (X=$13 805.47)]. Specifically, maternal race--being African American--was indirectly associated with overall charges through its association with mode of delivery and NICU utilization patterns. The presence of maternal co-morbidities--Herpes Simplex Virus, hypertension and diabetes--most probably influenced babies' hospital stay charges as well as NICU charges when transferred to NICU following both vaginal and Cesarean section deliveries. Thus, prenatal care targeting co-morbidities management may reduce the odds of a newborn's transfer to NICU thus avoiding greater lengths of stay, medical care and charges. Recommendations for obstetrical practices as well as health care policy on their charges should not assume that Cesarean section deliveries are always costlier than vaginal deliveries.

A proposed adaptation of the EFQM fundamental concepts of excellence to health care based on the PATH framework.

OBJECTIVE: The use of the European Foundation for Quality Management (EFQM) Model in health care has found that this model is useful in promoting quality improvement, but its use in health care organizations is challenging because being a generic model, it does not cover the clinical aspects or the specifics of this field. For that reason, this article aims to bring the EFQM fundamental concepts of excellence closer to health care, using a specific model as a reference to this field: the Performance Assessment Tool for quality improvement in Hospitals (PATH) conceptual framework, developed by the WHO Regional Office for Europe. METHOD: A content analysis was performed to independently identify the contents that defined the elements of both frameworks. Then, using defined criteria, two independent researchers compared the contents of the elements of both frameworks. The elements from both frameworks that were equivalent were aggregated. Several experts discussed the aspects with discrepancies between the two comparisons. Finally, the EFQM framework is adapted to health care by adding to those aggregated elements the aspects that were exclusive from one of the models. RESULTS: The EFQM framework has many correspondences to a health care-specific framework. The EFQM-health care-adapted framework has eight quality dimensions, two of them (customer focus and safety) being overlapped with the other six (staff, results orientation, responsive governance, leadership and constancy of purpose, clinical effectiveness, and partnership development). This model also has two methodological dimensions (management by processes and facts and continuous learning; improvement and innovation). CONCLUSION: This adapted model seems useful for health care organizations, but it needs to be further used to corroborate this preliminary finding.

Understanding safer practices in health care: a prologue for the role of indicators.

OBJECTIVES: Patient safety and safer practices are central themes to many national strategies for accountability. The multinational Quality Indicator Project (QI Project) database is used to identify patterns of indicator use to measure safety of care in Asia, Europe, and the USA. The second objective is to assess, within the context of an indicator project, the usefulness of indicators to measure errors or mishaps. DESIGN AND SETTING: This descriptive study retrospectively analyses indicator use patterns among hospitals in Asia, Europe, and the USA. The QI Project database is used for the 1999-2002 period. Statistical testing (P-value) of the differences in use percentages across five countries is based on 'country' rather than 'hospital' as the unit of analysis. RESULTS: There was a significant increase in overall QI Project indicator use worldwide between 1999 and 2002. The average change in use was 6.8% for safety indicators and 4.2% for all other indicators. When analysed by country (USA, Austria, Belgium, UK, and Taiwan), the average increases in use percentage were highest in Taiwan and Belgium. When the country-specific differences were tested for significance, Taiwan showed the largest (and statistically significant) increase in safety indicator use between 1999 and 2002 (P<0.0001). In the USA, the rates of safety indicator use have decreased (P=0.0502) during the same time period. CONCLUSION: This paper identifies, perhaps for the first time, how traditional indicators of hospital performance are being used to understand a hospital's performance and associated safety of care. Although the study's time frame is limited to 3 years, the findings seem to suggest that the interest in using these traditional indicators as proxies for safer practice measures is increasing among the QI Project participants worldwide. The challenge of using inherently value-free indicators as indicators of safety (hence de facto labelled as 'error' focused) should be further studied.

A comprehensive grassroots model for statewide safety improvement.

BACKGROUND: The Maryland Patient Safety Center (MPSC) a collaboration of the Maryland Hospital Association and Delmarva Foundation for Medical Care, Inc., was designated by the State of Maryland in June 2004. A voluntary, nonregulatory initiative, the MPSC complements the state's regulatory efforts in mandatory reporting and support for performance improvement. PROGRAMS: The MPSC's mission is to bring health care providers together to understand causes of unsafe practices and to put practical, evidence-based improvements in place. Using a multifaceted approach, the MPSC implements its mission through education and training, safety culture collaboratives, adverse-event and near-miss reporting, research, and special projects. Participation in these initiatives is provided at no cost to Maryland providers. Early results show that health care leaders and front-line workers are embracing the MPSC's vision to make Maryland's health care the safest in the nation. More than 2,500 health care providers have participated in the MPSC's programs in its 15 months. Eighty percent of the state's hospitals are taking part in the intensive care unit (ICU) Safety Culture Collaborative, which has already yielded a 36% decrease in catheter-related blood stream infections and a 20% decrease in ventilator-associated pneumonia. A MODEL FOR OTHER STATES: The MPSC's approach can serve as a model for other states to emulate.

[Local evaluation of quality using generic measurement tools]. / La evaluación local de la calidad mediante instrumentos de medida genéricos.

Performance measurement and accountability are the most frequently encountered concepts across healthcare systems, although the tools used to put these concepts into practice vary. The aim of the present article was to discuss the tools (e.g., indicators) and user expectations (e.g., quality versus performance) of these tools in fulfilling healthcare's accountability mandate. In particular, the developments within the Spanish health system are discussed to illustrate how Spain has addressed, in a stepwise manner, the determinants of a national accountability model. Finally, a multinational project, The Maryland Quality Indicator Project, is presented as a popular framework for measuring performance.

UK Quality Indicator Project (UK QIP) and the UK independent health care sector: a new development.

PURPOSE: To describe implementation of the UK Quality Indicator Project (UK QIP) in the independent health care sector, drawing upon 10 years experience in the UK and approaching 20 years experience in the USA. We describe the history of the project, with an emphasis on recent developments, reflecting upon the critical features of the project and its value for participants. BACKGROUND: The International Quality Indicator Project is the largest international data set of quality indicators. It provides participants with quarterly feedback of comparative indicator data and support for effective use of these data within the participants' own quality improvement programmes. The UK QIP now includes about two-thirds of UK private sector acute hospitals. The UK QIP began as a pilot project in the National Health Service (NHS) public sector in 1991. Implementation of the NHS performance assessment framework, and associated indicator programme, led to a reduction in public sector involvement. In contrast, the private sector, led by the Independent Healthcare Association, sought to identify a provider of key performance indicators to support both internal, within-sector drives for quality improvement and external demands produced by governmental review and the introduction of the National Care Standards Commission. The UK QIP was chosen since it provided a validated, epidemiologically sound system with capacity for support, education and flexibility to meet the changing demands of the sector. The future development of the QIP within the sector, including expansion from acute hospitals to mental health, is described. CONCLUSIONS: Reflection on the process of engagement of the UK independent sector with the QIP emphasizes the generic nature of the project and offers insights into the value of the project. Future challenges, including the issue of public accountability, are discussed in light of the project's underlying philosophy and purpose.

Are performance indicators generic? The international experience of the Quality Indicator Project.

Performance indicators for healthcare organizations represent a strategy for accountability worldwide. A universal approach to either the design for indicators or their applicability to local needs remains a work in progress. The Maryland Hospital Association's Quality Indicator Project (QIP) is the only indicator-based performance measurement system used worldwide. This paper presents, for the first time in QIP's 17 years of existence, data showing why MHA's QIP may qualify as the most accepted generic methodology for healthcare performance measurement and evaluation.

When you hear hoofs, think horses, not zebras: an evidence-based model of health care accountability.

Health care organizations are increasingly asked to show accountability about their performance. This paper proposes that accountability can best be achieved through evaluative methods that are based on evidence regarding the relationship between processes of care and expected outcomes. Root cause analysis (RCA) is used as an illustration of how a generic method of inquiring can be transformed into an ongoing monitoring, evaluation, user education and accountability strategy. The role of performance indicators, as well as patient and community expectations, is discussed.