Improving health care, Part 4: Concepts for improving any clinical process

The Hawthorne Effect: Quality and Outcomes in Neurosurgery

Measure something, and it gets better-this is what is called as the Hawthorne effect (also known as the observer effect). The Hawthorne factory experiments in 1920s were remarkable industrial data collection and analysis exercises that lead to Edwards Deming's quality revolution. The Harvard Medical Practice Study (1991), Leape's "Error in Medicine" (1994), and the Bristol pediatric cardiac report (2001) are among many documents that have revealed the huge gap between best practices and actual medical practice. Alarmed by the poor standards of quality at the most respected institutions, the medical fraternity therefore began visiting facilities in different fields and observing their quality assessment processes. The next leap for neurosurgery is to realize that it is unacceptable to treat patients with no regard for the standard of clinical outcomes. The traditional neurosurgery residency training has long ignored the most important issues of self-assessment, reappraisal, relearning, and measurement of skill and surgical outcomes. However, the experience taken from disparate fields, especially cardiac surgery, may encourage research and progress in measurement and improvement of quality in neurosurgery. Like cardiac surgeons, neurosurgeons must examine and analyze the results of their interventions. The concept of quality measurement is the most important single advance we can make in neurosurgery practice. Meticulous and precise measurement of outcomes will allow future progress of our specialty.

Reinventing CME: the role of the care pilot in the medical group practice

This article recommends that the content of traditional continuing medical education be changed significantly to include the concepts and skills necessary to enable practice teams to feedback information into the practice, which would result in the creation of a learning organization with the ability to plan for and anticipate future activities. The primary role in this new organization would be called a care pilot who would have as a primary responsibility, the successful navigation and improvement of the 6 aims as spelled out in the Institute of Medicine report Crossing the Quality Chasm.

Preadmission Testing in a Children's Facility

NURSES IN A SAME DAY SURGERY (SDS) UNIT used their hospital's quality model to identify a long-term problem, establish a project, analyze the problem, and make recommendations for changes to improve patient care. THE PROCESS included conducting a review of the literature, collecting data about procedure delays and cancellations, making a site visit to another children's hospital, and presenting pertinent findings to the OR committee. THE NURSES initiated a pilot program to bring surgical patients into the SDS area for a preadmission testing visit. DELAYS AND CANCELLATIONS decreased, and satisfaction among nurses working in the SDS unit increased as a result of this program.

Interdisciplinary education and teamwork: a long and winding road

PURPOSE

This article examines literature on interdisciplinary education and teamwork in health care, to discover the major issues and best practices.

METHODS

A literature review of mainly North American articles using search terms such as interdisciplinary, interprofessional, multidisciplinary with medical education.

MAIN FINDINGS

Two issues are emerging in health care as clinicians face the complexities of current patient care: the need for specialized health professionals, and the need for these professionals to collaborate. Interdisciplinary health care teams with members from many professions answer the call by working together, collaborating and communicating closely to optimize patient care. Education on how to function within a team is essential if the endeavour is to succeed. Two main categories of issues emerged: those related to the medical education system and those related to the content of the education.

CONCLUSIONS

Much of the literature pertained to programme evaluations of academic activities, and did not compare interdisciplinary education with traditional methods. Many questions about when to educate, who to educate and how to educate remain unanswered and open to future research.

Quality improvement interventions: what works?

Quality improvement efforts in healthcare focus on the use of interventions and tools to change identified processes. What interventions and tools are effective? A survey of the literature yields information on interventions and tools that have been used to successfully create quality improvement. Effective methods for changing clinical practice include face-to-face education outreach visits, involvement of local opinion leaders, reminder systems, repeated feedback from the senior medical staff, patient-mediated interventions, and a combination of interventions deployed simultaneously. Participation in an organized continuous quality improvement process is beneficial in conjunction with additional interventions.

Improving clinical performance: a "how to" for procedures review

As part of comprehensive performance improvement for accredited hospitals, the Joint Commission on Accreditation of Healthcare Organizations requires that institutional data collection include a review of "operative, other invasive, and noninvasive procedures that place patients at risk" (JCAHO, 1998b, p. 125). To meet the standard for comprehensive procedures review, the University Hospitals and Clinics at the University of Mississippi Medical Center developed an innovative methodology to ensure Joint Commission compliance. This article describes the processes used and the outcomes realized by the performance improvement team responsible for procedures review.

Improving the repeat prescribing process in a busy general practice. A study using continuous quality improvement methodology

PROBLEM

A need to improve service to patients by reducing the time wasted by reception staff so that the 48 hour target for processing repeat prescription requests for patient collection could be achieved.

DESIGN

An interprofessional team was established within the practice to tackle the area of repeat prescribing which had been identified as a priority by practice reception staff. The team met four times in three months and used continuous quality improvement (CQI) methodology (including the Plan-Do-Study-Act cycle) with the assistance of an external facilitator.

BACKGROUND AND SETTING

A seven partner practice serving the 14,000 patients on the northern outskirts of Bournemouth including a large council estate and a substantial student population from Bournemouth University. The repeat prescribing process is computerised.

KEY MEASURES FOR IMPROVEMENT

Reducing turn around times for repeat prescription requests. Reducing numbers of requests which need medical records to be checked to issue the script. Feedback to staff about the working of the process.

STRATEGIES FOR CHANGE

Using a Plan-Do-Study-Act cycle for guidance, the team decided to (a) coincide repeat medications and to record on the computer drugs prescribed during visits; (b) give signing of prescriptions a higher priority and bring them to doctors' desks at an agreed time; and (c) move the site for printing prescriptions to the reception desk so as to facilitate face to face queries.

EFFECTS OF CHANGE

Prescription turnaround within 48 hours increased from 95% to 99% with reduced variability case to case and at a reduced cost. The number of prescriptions needing records to be looked at was reduced from 18% to 8.6%. This saved at least one working day of receptionist time each month. Feedback from all staff within the practice indicated greatly increased satisfaction with the newly designed process.

LESSONS LEARNT

The team's experience suggests that a combination of audit and improvement methodology offers a powerful way to learn about, and improve, practice. The interventions used by the team not only produced measurable and sustainable improvements but also helped the team to learn about the cost of achieving the results and provided them with tools to accomplish the aims. The importance of feedback to all staff about CQI measures was also recognised.