To explore the association between implicit rationing of nursing care and selected patient outcomes in Swiss hospitals, adjusting for major organizational variables, including the quality of the nurse practice environment and the level of nurse staffing. Rationing was measured using the newly developed Basel Extent of Rationing of Nursing Care (BERNCA) instrument. Additional data were collected using an adapted version of the International Hospital Outcomes Study questionnaire.
Multi-hospital cross-sectional surveys of patients and nurses.
Eight Swiss acute care hospitals
Nurses (1338) and patients (779) on 118 medical, surgical and gynecological units.
Patient satisfaction, nurse-reported medication errors, patient falls, nosocomial infections, pressure ulcers and critical incidents involving patients over the previous year.
Generally, nurses reported rarely having omitted any of the 20 nursing tasks listed in the BERNCA over their last 7 working days. However, despite relatively low levels, implicit rationing of nursing care was a significant predictor of all six patient outcomes studied. Although the adequacy of nursing resources was a significant predictor for most of the patient outcomes in unadjusted models, it was not an independent predictor in the adjusted models. Low nursing resource adequacy ratings were a significant predictor for five of the six patient outcomes in the unadjusted models, but not in the adjusted ones.
As a system factor in acute general hospitals, implicit rationing of nursing care is an important new predictor of patient outcomes and merits further study.
To implement a prescribing-error reporting system in primary care offices and analyze the reports.
Descriptive analysis of a voluntary prescribing-error-reporting system
Seven primary care offices in Vermont, USA.
One hundred and three prescribers, managers, nurses and office staff.
Nurses and office staff were asked to report all communications with community pharmacists regarding prescription problems.
All reports were classified by severity category, setting, error mode, prescription domain and error-producing conditions.
All practices submitted reports, although reporting decreased by 3.6 reports per month (95% CI, –2.7 to –4.4, P < 0.001, by linear regression analysis). Two hundred and sixteen reports were submitted. Nearly 90% (142/165) of errors were severity Category B (errors that did not reach the patient) according to the National Coordinating Council for Medication Error Reporting and Prevention Index for Categorizing Medication Errors. Nineteen errors reached the patient without causing harm (Category C); and 4 errors caused temporary harm requiring intervention (Category E). Errors involving strength were found in 30% of reports, including 23 prescriptions written for strengths not commercially available. Antidepressants, narcotics and antihypertensives were the most frequent drug classes reported. Participants completed an exit survey with a response rate of 84.5% (87/103). Nearly 90% (77/87) of respondents were willing to continue reporting after the study ended, however none of the participants currently submit reports.
Nurses and office staff are a valuable resource for reporting prescribing errors. However, without ongoing reminders, the reporting system is not sustainable.
To compare the prevalence of pressure ulcers and prevention before and after a quality improvement program; determine whether patient characteristics differed for those who did and did not develop pressure ulcers; identify pressure ulcer prevention implemented at admission and whether prevention and risk factors varied by pressure ulcer severity.
Descriptive comparative study based on two cross-sectional pressure ulcer surveys conducted in 2002 and 2006, complemented with a retrospective audit of the electronic health record and administrative system for patients identified with pressure ulcers.
1100-bed Swedish university hospital.
612 hospitalized patients in 2002 and 632 in 2006.
Prevalence of pressure ulcers and prevention (pressure-reducing mattresses; planned repositioning; chair, heel and 30° lateral positioning cushions).
Pressure ulcer prevalence was 23.9% in 2002 and 22.9% in 2006. When non-blanchable erythema was excluded, the prevalence was 8.0 and 12.0%, respectively. The use of pressure-reducing mattresses increased while planned repositioning decreased. Those who developed ulcers were older, at-risk for ulcers, incontinent and had longer length of stay. Little prevention was documented at admission. Some prevention strategies and risk factors were related to severity of ulcers.
Pressure ulcer prevalence did not decrease, despite a comprehensive quality improvement program. Special attention is needed to provide prevention to older patients with acute admission. Skin and risk assessment, as well as prevention, should start early in the hospitalization. Identifying those persons with community-acquired versus hospital-acquired ulcers will strengthen pressure ulcers as an accurate marker of quality of care for hospitalized patients. If possible, data should be reported by ward level for comparison over time.
To assess the effect of a Crew Resource Management (CRM) intervention specifically designed to improve teamwork and communication skills in a multidisciplinary obstetrical setting.
Design-A before-and-after cross-sectional study designed to assess participants' satisfaction, learning and change in behaviour, according to Kirkpatrick's evaluation framework for training programmes. Setting-Labour and delivery units of a large university-affiliated hospital. Participants-Two hundred and thirty nine midwives, nurses, physicians and technicians from the department of anaesthesia, obstetrics and paediatrics. Intervention-All participants took part in a CRM-based training programme specifically designed to improve teamwork and communication skills. Principal measures of outcome-We assessed participants' satisfaction by means of a 10-item standardized questionnaire. A 36-item survey was administered before and after the course to assess participants' learning. Behavioural change was assessed by a 57-item safety attitude questionnaire measuring staff's change in attitude to safety over 1 year of programme implementation.
Most participants valued the experience highly and 63–90% rated their level of satisfaction as being very high. Except for seven items, the 36-item survey testing participants' learning demonstrated a significant change (P < 0.05) towards better knowledge of teamwork and shared decision making after the training programme. Over the year of observation, there was a positive change in the team and safety climate in the hospital [odds ratio (OR) 2.9, 95% confidence interval (CI) (1.3–6.3) to OR 4.7, 95% CI (1.2–17.2)]. **There was also improved stress recognition [OR 2.4, 95% CI (1.2–4.8) to OR 3.0, 95% CI (1.0–8.8)].
The implementation of a training programme based on CRM in a multidisciplinary obstetrical setting is well accepted and contributes to a significant improvement in interprofessional teamwork.
Many patients do not receive guideline-recommended care for diabetes and other chronic conditions. Automated speech-recognition telephone outreach to supplement in-person physician–patient communication may enhance patient care for chronic illness. We conducted this study to inform the development of an automated telephone outreach intervention for improving diabetes care among members of a large, not-for-profit health plan.
In-depth telephone interviews with qualitative analysis.
Individuals with diabetes (n = 36) enrolled in a large regional health plan in the USA.
Patients' opinions about automated speech-recognition telephone technology.
Patients who were recently diagnosed with diabetes and some with diabetes for a decade or more expressed basic informational needs. While most would prefer to speak with a live person rather than a computer-recorded voice, many felt that the automated system could successfully supplement the information they receive from their physicians and could serve as an integral part of their care. Patients suggested that such a system could provide specific dietary advice, information about diabetes and its self-care, a call-in menu of information topics, reminders about laboratory test results and appointments, tracking of personal laboratory results and feedback about their self-monitoring.
While some patients expressed negative attitudes toward automated speech recognition telephone systems generally, most felt that a variety of functions of such a system could be beneficial to their diabetes care. In-depth interviews resulted in substantive input from health plan members for the design of an automated telephone outreach system to supplement in-person physician–patient communication in this population.
To investigate which aspects of treatment satisfaction are the best predictors of improved health, improved mental health and achievement of abstinence in drug misuse treatment services.
Data were collected as part of the Drug Outcome Research in Scotland study, a prospective cohort study designed to evaluate drug misuse treatment provided in Scotland. Data were collected using a structured interview. Participants were recruited between 1 October 2001 and 30 June 2002. Follow-up interviews were carried out ~8 months later. Logistic regression analysis is used to explore client satisfaction with treatment on outcomes, using the Treatment Perceptions Questionnaire (discussed in Marsden et al., Assessing client satisfaction with treatment for substance use problems and the development of the Treatment Perceptions Questionnaire (TPQ). Addict Res 2000;8:455–70).
Prison, residential and community facilities.
A total of 841 drug users starting a new episode of drug treatment in Scotland in 2000–01.
Methadone, substitute drugs other than methadone, residential rehabilitation, residential detoxification and non-clinical.
Reported improvements in physical health, mental health and abstinence.
Client satisfaction predicted positive outcomes, independent of treatment setting. Predicting abstinence and improved physical and mental health were the items: ‘I have received the help that I was looking for’ and ‘The staff have helped to motivate me to sort out my problems’.
Feeling that treatment is appropriate, finding staff motivating, and having enough time to sort out problems are important aspects of satisfaction with treatment among users of drug treatment services who achieved positive treatment outcomes. Services should seek to provide more individualized services based on understanding of individual client needs. This may require longer treatment periods and greater client involvement.
The aim of the study was to determine how the time factor affected the patients' perception of the acceptability of the primary health care system and to assess their satisfaction with family physician care.
A series of cross-sectional studies was conducted in 1998, 2002 and 2006, using face-to-face interviews with structured questionnaires.
The study was performed in Gizycko, Poland, where family physician services were introduced in 1995.
Three surveys were conducted, each involving 1000 subjects. Every time, random sample was taken, after selecting a subgroup of patients using medical service within the previous week.
Acceptability of the primary health care system (accessibility, the patient–practitioner relationship, the amenities of care, patient's preferences), perception of the changes in primary care and overall satisfaction with family physician care.
Between 1998 and 2002, an improvement was noted, lasting till 2006, in such accessibility components as the possibility of making an appointment by phone or at a definite hour. Some aspects of the patient–doctor relationship indicate that family physician care is directed at illness rather than health-oriented. The level of patient satisfaction was high.
Generally, patients are satisfied with primary care reform and implementation of the family physician system. However, it is easier to improve accessibility of services than physician's personal qualities and the patient–practitioner relationship. Expressive functions of a physician (listening and reassuring) and activities regarding health promotion require special attention in the process of education of family physicians.
Despite good contraceptive coverage rates, recent studies in Iran have shown an alarmingly high incidence of unplanned pregnancy.
To determine factors affecting quality of family planning services, a cross-sectional study was performed from June to August 2006 on women visiting urban Primary Health Care clinics in a provincial capital in western Iran. The primary focus of the study was on provider–client interaction.
We used a slightly edited version of a UNICEF checklist and a convenient sampling method to assess quality of care in 396 visits to the family planning sections at 25 delivery points.
Poor performance was observed notably in Counselling and Choice of method sections. In logistic regression analysis, the following factors were found to be associated with higher quality of care: provider experience [OR (odds ratio) = 1.9, CI0.95 (confidence interval) = 1.2–3.0], low provider education (OR = 6.7, CI0.95 = 4.0–10.8), smaller workload at the clinic (OR = 3.7, CI0.95 = 2.0–6.7), and ‘new client’ status (OR = 4.2, CI0.95 = 2.6–6.7).
This study identified the issues of counselling and information exchange as the quality domains in serious need of improvement; these areas are expected to be the focus of future training programmes for care providers. Also, priority should be given to devising effective supervision mechanisms and on-the-job training of senior nursing and midwifery graduates to make them more competent in delivering basic family planning services.
To translate and adapt the Critical Care Family Satisfaction Survey (CCFSS), and test its validity and reliability for use in Saudi Arabia.
Seven hundred-bed tertiary care hospital in Saudi Arabia.
Seventy-six adult relatives of patients who had been cared for in an intensive care unit for 24 hrs or more.
The CCFSS, a battery of 20 items divided into five subscales, was translated into Arabic. After transfer of patients to regular inpatient units, interviewers administered the survey to their next-of-kin. Respondents ranked their satisfaction with each item on a 5-point Likert scale.
Subscale scores were calculated as the average of the individual item scores. The total scale score was the sum of the subscale scores.
The total scale and ‘Information’, ‘Support’, ‘Comfort’ and ‘Assurance’ subscales showed acceptable internal consistency (Spearman's correlation coefficient of the total score with each of the subscale scores = 0.52–0.81, P < 0.01; Cronbach's alpha = 0.67–0.88). But the ‘Proximity’ subscale performed poorly (r = 0.48, P < 0.01; Cronbach's alpha = 0.36). Discriminant validity was tested with a Spearman's rank correlation matrix of the subscales, and ranged from weak between ‘Support’ and both ‘Assurance’ and ‘Information’ (r = 0.80) to substantial between ‘Information’ and ‘Proximity’ (r = 0.54) (P < 0.01).
This Arabic translation and adaptation of the CCFSS is a valid, reliable and feasible tool to evaluate family satisfaction in Saudi Arabian intensive care units.
One of the prime goals of any health system is to deliver good and competent quality of healthcare. Through World Bank-assisted Maharashtra Health Systems Development Project, Government of Maharashtra in India developed and implemented clinical indicators to improve quality.
During this, clinical areas eligible for monitoring quality of care and roles of health staff working at various levels were identified.
Brainstorming discussion sessions were conducted to refine list of potential clinical indicators and to identify implementation problems.
It was implemented in four stages. (a) Self-explanatory tool of record, standard operating procedures and training manual were prepared during tools preparation stage. (b) Pilot implementation was done to monitor the usefulness of indicators, document the experiences and standardize the system accordingly. (c) The final selection of indicators was done taking into consideration points like data reliability, indicator usefulness etc. For final implementation, 15 indicators for district and 6 indicators for rural hospitals were selected. (d) Transfer of skills was done through training of various hospital functionaries.
Selection and prioritization of clinical indicators is the most crucial part. Active participation of local employees is essential for sustainability of the scheme. It is also important to ensure that data recorded/reported is both reliable and valid, to conduct monthly review of the scheme at various levels and to link it with the quality improvement programme.