Role of users of health care in achieving a quality service

Redesigning Rural Acute Stroke Care: A Person-Centered Approach

Stroke service delivery in rural areas in Australia lacks evidence-based, best practice care protocols as a result of limited resources and opportunity. Healthcare redesign is an approach to improving health services by understanding barriers and enablers to service provision and work with users to develop solutions for improvement. This research aimed to qualitatively evaluate stroke care in rural Tasmania using a person-centered approach, as part of a larger healthcare redesign initiative to improve acute stroke care. Semi-structured interviews, aimed at gaining insight into experiences of healthcare staff and users, were conducted. Thematic analysis revealed three global themes (communication, holistic care, and resourcing) that demonstrated some consistency between healthcare staff and user experience, highlighting that some needs and expectations were not being met. Results of this experiential study provide important perspectives for delivering needs-based improvements in service provision for acute stroke care. Overall, this study showed that systems of stroke care in rural areas could be improved by utilizing a redesign approach including healthcare staff and users in the development of solutions for health service improvement.

Avaliação da qualidade do programa Saúde da Família em municípios do Ceará: uma abordagem multidimensional

Com o intuito de responder às necessidades dos sistemas locais de saúde, este estudo avaliou a qualidade da atenção das equipes do Programa Saúde da Família (PSF) em Municípios do Ceará (Brasil) adotando um modelo de análise multidimensional fundamentado nas elaborações teórico-metodológicas de dois importantes autores conhecidos em nível internacional: Avedis Donadedian e John Øvretveit. Do primeiro autor, foram utilizadas as três abordagens da qualidade, ou seja, a estrutura, o processo e os resultados. Do segundo autor, foram adotadas as três dimensões da qualidade: qualidade percebida pelos pacientes, qualidade técnica definida pelos profissionais e qualidade na perspectiva gerencial. O estudo foi realizado em dez municípios do Estado. Embora com diferentes nuances e ênfase, os informantes entrevistados (médicos e enfermeiros das equipes, coordenadores do PSF, secretários de saúde e usuários) identificaram um conjunto de aspectos referentes à estrutura e ao processo do serviço, que deveria qualificar o PSF. Como resultado final do estudo, os pesquisadores apresentam um conjunto de dimensões e indicadores de qualidade, segundo a perspectiva dos diversos atores envolvidos.

Improving adolescent sexual and reproductive health. A view from Australia: learning from world's best practice

There is increasing awareness worldwide of the importance of sexual and reproductive health in adolescents. Australia's high rates of teenage pregnancy and increasing rates of sexually transmitted infections in young people reflect a failure to prioritise adolescent sexual and reproductive health on the public health agenda. This paper reviews adolescent sexual and reproductive health in Australia in comparison with international data, and examines the systemic, social and cultural factors that influence it. Based on comparisons with international best practice, recommendations are included for improvement in adolescent sexual and reproductive health within the Australian context.

Involving users in low back pain research

OBJECTIVE

To involve users in the design of a research project that aims at describing a 12-month course of low back pain in an adult population sample (epidemiological strand), and to determine how patient and professional perceptions of low back pain and its treatment relate to the use of health-care and to subsequent outcome (qualitative strand).

DESIGN

Three focus groups were organized in the preparatory phase of the project with general practitioners, other health professionals and low back pain sufferers. Issues pertaining to the experience of living with, or treating low back pain were explored and users were asked to identify relevant research questions for consideration within the study.

FINDINGS

The focus groups revealed tensions between involving users as co-researchers for design issues and their role as sufferers and health professionals who want to share their narrative accounts of low back pain. The group discussions produced a wealth of material for analysis, but no explicitly stated research topics. Three key themes and the process of user involvement in the focus groups are discussed.

CONCLUSIONS

The focus group format could be restrictive in that it allows for detailed exchange between participants, but is insufficiently geared towards the production of a research agenda. We draw conclusions as to possible approaches for user involvement in health services research design.

The safety and effectiveness of a nurse-led anticoagulant service

AIM

The aim of this study was to compare the safety and effectiveness of anticoagulant nurses and a consultant haematologist in managing anticoagulant patients in a hospital outpatient setting.

BACKGROUND

Nurses are increasingly developing roles traditionally undertaken by medical staff. As a result nurse-led practice has expanded in many areas including anticoagulant services. Previous studies have attempted to demonstrate the effectiveness of using other professionals to manage anticoagulant clinics over short periods of time. This research evaluates the safety and effectiveness of a consultant-led and a nurse-led service over two sequential 18-month periods.

RESEARCH METHODS

A nonexperimental design was adopted. Data were collected retrospectively, from a random sample of 197 patients, who had been managed by both the consultant-led and nurse-led service. Two main outcome measures were selected: anticoagulant control between professional groups and interval between outpatient clinic appointments.

RESULTS

No statistically significant difference in anticoagulant control was found between professional groups (P=0.137). There was evidence that patients attended anticoagulant clinics on significantly fewer occasions with nurse-led management (P < 0.0005).

CONCLUSION

At the department within which this research was conducted, anticoagulant nurses were found to be at least as safe and effective as the consultant haematologist in managing outpatient anticoagulant patients over the study period. These findings are of importance in both shaping the future provision of anticoagulant care and also contributing to the wider area in evaluating the impact of nurse-led practice within health care.

Choosing and using services for sexual health: a qualitative study of women's views

OBJECTIVE

To explore women's accounts of choosing and using specialist services for sexual health.

METHODS

A qualitative study involving semistructured interviews with 37 women screened for Chlamydia trachomatis attending genitourinary medicine and family planning clinics in an East Midlands health authority.

RESULTS

In making the decision to seek help, women act on a range of specific prompts, including lay ideas about the significance of symptoms; their own behaviour; their partner's symptoms or behaviour; contact tracing; and health promotion. Some women do not seek help specifically in relation to sexual health but are identified as being at risk of sexually transmitted infections (STIs) during routine consultations. Important influences on women's choice of services include the lay referral system, "insider" knowledge of health services, referral by health professionals, and need to have alternatives to general practice care. Women's willingness to access services is mediated by psychosocial factors such as embarrassment. They may use smear tests as a legitimate opportunity to raise questions about sexual health. Women's priorities for services are that their feelings of stigma and embarrassment are managed appropriately; that staff communicate well and are sensitive to their emotions and comfort during tests and procedures; that they are "in control" when obtaining test results; and that confidentiality is preserved.

CONCLUSIONS

A detailed understanding of both lay people's response to symptoms or behaviour that indicates risk of an STI and their needs when using services should inform interventions aimed at encouraging secondary prevention of STIs.

Patients' perspective of quality of care in a high-dependency unit

This study was designed to identify and explore the patients' perspective of the concept quality of care within the context of a high-dependency unit (HDU). Data were collected in two phases. In phase one, 55 patients were interviewed to clarify the concept quality of care. In phase two, 77 patients were interviewed to explore this concept in further detail. This study has clarified the patients' concept of quality of care into the principal constructs of the environment, meeting individual needs, staff attitudes and manners, organization of care, communication, staff skills and family and friends. It has been successful in providing patients with a voice to comment upon an aspect of service provision. A well-known concept has been clarified and applied to a high-dependency environment. This has identified the need for future evaluation of HDUs to go beyond traditional physiological measures, to incorporate the service experience itself and the impact it has upon the patients.

Patient satisfaction with HIV service provision in NPMS hospitals: the development of a standard satisfaction questionnaire. NPMS Steering Group

A self-completion satisfaction questionnaire evaluating the standard of care of HIV outpatient services was developed as part of the National Prospective Monitoring System on the Use, Cost and Outcome of HIV Service Provision in English Hospitals (NPMS). The questionnaire was designed in conjunction with service users and health care professionals, and piloted in three London and three non-London HIV clinics. In addition to testing alternative methods of administering the questionnaire, the pilot provided satisfaction scores on a variety of aspects of service provision for participating clinics. The questionnaire was completed by 548 respondents and was most effectively collected using a sealed box in the clinic waiting area. Mean satisfaction scores for the attitude and skills of staff members was 4.7 (95% CI 4.6-4.7) but satisfaction scores were significantly lower for the clinic environment with a mean of 4.1 (95% CI 4.1-4.2). Satisfaction scores did not differ significantly by gender, age, sexual orientation, ethnic group, employment status or severity of symptoms. London respondents were more satisfied with the clinic environment and seeing preferred members of staff than their non-London counterparts, however there were no other differences between clinics. The questionnaire functioned well in practice and provided meaningful and useful information for individual clinics as well as at aggregate level.

Mammography: influence of departmental practice and women's characteristics on patient satisfaction: comparison of six departments in Norway

OBJECTIVE

To investigate how departmental practice and women's characteristics are related to low patient satisfaction with mammography.

DESIGN

Survey of patients by means of self administered questionnaires before and after mammography.

PATIENTS

488 women (89% of those invited), aged 23-86 years, at six departments.

MAIN OUTCOME MEASURES

Low level of satisfaction measured on psychometric scales of physical pain, psychological distress, staff punctuality and technical skills, information provided, and physical surroundings.

RESULTS

Satisfaction varied by department on the scales for pain, punctuality, information, and surroundings. After adjustment for women's characteristics an attributable risk of negative outcome by department was identified on the scales for pain, distress, punctuality, information, and surroundings. Adjusted odds ratio (ORs) ranged from 0.3 (95% confidence interval (95% CI) 1.2 to 6.0) on the pain scale, to 6.0 (2.9 to 12.3) on the punctuality scale. After adjustment for confounding variables, higher risk of dissatisfaction was associated with age < 50, nervousness about mammography, expected pain, lack of knowledge about mammography, and distrust in mammography (adjusted OR (95% CI) ranged from 1.6 (1.0 to 2.7) to 3.7 (2.0 to 7.3)).

CONCLUSION

Departmental practices differed for breast compression, information, punctuality, and facilities and were associated with a low level of satisfaction irrespective of patient characteristics. Women's lack of knowledge about mammography and distrust in the procedure were confirmed as risk factors for dissatisfaction. All these factors might be helped by training the staff, improving facilities, and informing the women.

Respect for autonomy: issues in neurological rehabilitation

OBJECTIVE

To examine the ethical principle of respect for autonomy within the context of neurological rehabilitation.

DISCUSSION

The nature of the principle of respect for autonomy is examined, and specific difficulties to which it may give rise in this area of practice are identified. These concern difficulties of communication with neurologically impaired patients, issues of competence related to patient decision-making, problems of consensus between patient and professional, and the role of the patient's family in the rehabilitation process.

CONCLUSION

A number of strategies, based on a client-centred model of practice, are suggested which may counteract these difficulties and assist in respecting the patient's autonomy to the appropriate degree, while seeking to attain high-quality clinical outcomes.

Incorporating patients' voices in the audit process

Obtaining patients' views about their experiences of care should be an integral part of clinical audit. The importance of listening to patients as an aspect of quality can be attributed, in part, to the growth of consumerism in health care, and this in turn has led to the widespread use of satisfaction surveys to obtain patients' views. This paper raises some doubts about current methods for assessing patient satisfaction, and recommends the use of qualitative methods to capture patients' voices in audit.

Can different patient satisfaction survey methods yield consistent results? Comparison of three surveys

OBJECTIVE

To examine the consistency of survey estimates of patient satisfaction with interpersonal aspects of hospital experience.

DESIGN

Interview and postal surveys, evidence from three independent population surveys being compared.

SETTING

Scotland and Lothian.

SUBJECTS

Randomly selected members of the general adult population who had received hospital care in the past 12 months.

MAIN OUTCOME MEASURES

Percentages of respondents dissatisfied with aspects of patient care.

RESULTS

For items covering respect for privacy, treatment with dignity, sensitivity to feelings, treatment as an individual, and clear explanation of care there was good agreement among the surveys despite differences in wording. But for items to do with being encouraged and given time to ask questions and being listened to by doctors there was substantial disagreement.

CONCLUSIONS

Evidence regarding levels of patient dissatisfaction from national or local surveys should be calibrated against evidence from other surveys to improve reliability. Some important aspects of patient satisfaction seem to have been reliably estimated by surveys of all Scottish NHS users commissioned by the management executive, but certain questions may have underestimated the extent of dissatisfaction, possibly as a result of choice of wording.