Implementing TQM in a military hospital in Saudi Arabia.

BACKGROUND: Health care services in the Kingdom of Saudi Arabia are unique not only in the varied patient population served and multinational staff recruited to provide services, but also because they are not driven by financial or medicolegal constraints. As part of a five-year plan (carried out in four phases) to improve the quality of health care provided in the Kingdom, the North West Armed Forces Hospitals (NWAFH) in Tabuk became the first health care facility in the Kingdom to implement total quality management (TQM). This was not an implementation de novo, but a well-coordinated transition from quality assurance (QA) to TQM. The hospital leadership believe that TQM is best implemented when there is a strong foundation of QA to provide a pre-existing process for data collection and performance measurement. METHODS: Using the eight-step model for implementing TQM adapted from Joint Commission standards and The Health Care Manager's Guide to Continuous Quality Improvement, the QA staff identified the customers of the QA department, their needs, and professional requirements; implemented changes to meet these needs; identified internal monitors to evaluate the effectiveness of the operational changes and monitor performance; reported results and identified opportunities for improvement; and problem solved with FOCUS-PDCA. RESULTS: These efforts yielded a customer satisfaction survey in the form of a report card. In addition, three case studies launched by the QA department to address abstract data accuracy and completion, nosocomial infection rates in cesarean-section patients, and receipt of hospital laboratory reports by peripheral clinics are described in detail. CONCLUSION: The NWAFH Program leadership believes that TQM is a pancultural concept and that these first successful efforts can provide a model for the expansion of TQM not only in Saudi Arabia but throughout the rest of the Middle East.

From retrospective to concurrent monitoring in a university student health center: a report on the transition.

From 1984, when the quality assurance (QA) program at the Student Health Center of the New Mexico State University, Las Cruces, was initiated, to 1990, QA activities moved from purely retrospective chart reviews to concurrent monitoring. The QA plan divides center services into six units (physician medical, certified nurse practitioner [CNP] medical, nursing, clerical, laboratory, and pharmacy), for which indicators are selected by the QA committee to be evaluated each semester. Concurrent monitoring has led to improvement in areas such as laboratory specimen labeling, patient chart documentation, and patient satisfaction.

A quality assurance program for a state university student health center.

The New Mexico State University Student Health Center redesigned its quality assurance program to follow the Joint Commission's ten-step process for monitoring and evaluation. This article outlines the scopes of care in the Health Center's different units and provides case-study examples, including important aspects of care and indicators, to illustrate the monitoring and evaluation process as it is used for both retrospective studies and concurrent monitoring.

The vasoactivity of the fetal lamb ductus arteriosus studied in utero.

The ductus arteriosus of the undisturbed fetal lamb was studied chronically by techniques that allowed direct serial measurements of the calibre of the fetal channel. When the direct actions were studied of vasoactive agents on the ductus arteriosus, prostaglandins did not dilate the vessel beyond its resting dimensions. The cyclooxygenase inhibitor, indomethacin, was a potent vasoconstrictor with a plateau of the dose-effect relationship occurring at 0.2 mg/kg. Fetuses of 95--98 days gestational age were equally sensitive to indomethacin when compared to animals near term. Although the prostaglandins, PGE1, PGE2 PGF2 alpha, PGH2, PGI2 and PGG2, had no direct effect on the ductus arteriosus, PGE1, PGE2, PGH2 and PGI2 reversed the vasoconstrictor action of indomethacin. Autonomic nervous system mediators and blockers, i.e., acetylcholine, atropine, norepinephrine, propranolol, phentolamine and methoxamine, had neither direct effects on the ductus arteriosus nor any influence of indomethacin-induced vasoconstriction. The same was true of angiotensin 1, angiotensin 2, blockade of conversion of angiotensin 1 to 2, serotonin, methysergide, aminophylline, adenosine, and dibutyryl cyclic AMP. Imidazole, a blocker of thromboxane synthase, had no direct effect on the ductus arteriosus, but reduced significantly the magnitude of the indomethacin constrictor action. The major finding of this investigation was the exquisite sensitivity of the ductus arteriosus to manipulations of the prostaglandin environment. The results suggest that both locally generated prostaglandins, as well as prostanoids in the circulation, may be involved in ductal patency and closure. A high degree of control is likely of the circulation of the ductus arteriosus and constriction of the fetal channel is probably the result of an active process.

The influence of inhibition of prostaglandin synthesis on hippurate extraction in conscious, newborn lambs.

The influence of indomethacin (INDO) on the renal extraction of hippurate (EH) was studied in 12 conscious, newborn lambs divided into two groups based upon age. EH was measured before and after INDO (7.5 mg/kg i.v.) by collecting blood samples from both the abdominal aorta (opposite the renal artery) and renal vein (under fluoroscopy). In the youngest group (0--4 days, n = 5), control EH was 18 +/- 8% (mean +/- SE) and increased to 29 +/- 6% following INDO (p = NS). In the older animals (2--3 weeks, n = 7) control EH was 66 +/- 5% (p less than 0.001), compared to the 0--4-day-olds) and decreased to 57 +/- 4% following INDO (p less than 0.02). The results suggest that EH increases during the first weeks of life and that prostaglandins may play a role in regulating the tubular transport of hippurate.

The efficacy of practolol-induced beta1 adrenergic blockade in the canine heart.

The efficacy of adrenergic blockade with practolol was assessed by subjecting 6 adult mongrel dogs in a closed-chest procedure to bolus injections of isoproterenol (0.5 mcg/kg, i.v.) before and after practolol (2.0 mg/kg, i.v.). Following practolol both heart rate and pulse pressure responses were significantly reduced. It is suggested that significant beta1 receptor adrenergic blockade is achieved by practolol.

Vagal stabilization of the ischemic canine ventricle.

To determine whether vagal activity during myocardial ischemia functions to stabilize the heart, the left anterior descending coronary artery in dogs was occluded for periods of 3 1/2 minutes with and without concurrent vagal stimulation. Bipolar electrograms were measured from the surface of the canine left ventricle within and outside the regions of intended ischemia. Ischemia in the absence of vagal stimulation depressed both the electrogram amplitude and the upstroke velocity of the electrogram signal. Vagal stimulation significantly decreased the absolute magnitude of the ischemia-induced decrease of the electrogram signal, which indicates that it tended to stabilize the insulted heart. This stabilizing influence however, was seen only in the presence of adrenergic blockade with practolol. The vagal response was only partially blocked by atropine, whereas it was abolished by lidocaine. These results suggest that a vagally mediated stabilization of the ischemic canine ventricle can occur and is unmasked only in the absence of sympathetic neural activity.