Measuring hospital outcomes: don't make perfect the enemy of good!

Teamwork during resuscitation

Effective resuscitation requires the integration of several cognitive, technical, and behavioral skills. Because resuscitation is performed by teams of health care professionals, these individuals must be able to work together in a coordinated and efficient manner, making teamwork a critical skill for care of patients in distress. Despite the importance of teamwork in health care, little consensus exists as to what it is, how it can most effectively be learned, and how it should be assessed. This article reviews current knowledge on the measurement, training, and importance of teamwork in pediatric resuscitation.

OECD Health Care Quality Indicator Project. The expert panel on primary care prevention and health promotion

PURPOSE

This article describes a project undertaken as part of the Organization for Economic Co-operation and Development (OECD)'s Healthcare Quality Indicator (HCQI) Project, which aimed to develop a set of quality indicators representing the domains of primary care, prevention and health promotion, and which could be used to assess the performance of primary care systems.

METHODS

Existing quality indicators from around the world were mapped to an organizing framework which related primary care, prevention, and health promotion. The indicators were judged against the US Institute of Medicine's assessment criteria of importance and scientific soundness, and only those which met these criteria and were likely to be feasible were included. An initial large set of indicators was reduced by the primary care expert panel using a modified Delphi process.

RESULTS

A set of 27 indicators was produced. Six of them were related to health promotion, covering health-related behaviours that are typically targeted by health education and outreach campaigns, 13 to preventive care with a focus on prenatal care and immunizations and eight to primary clinical care mainly addressing activities related to risk reduction. The indicators selected placed a strong emphasis on the public health aspects of primary care.

CONCLUSIONS

This project represents an important but preliminary step towards a set of measures to evaluate and compare primary care quality. Further work is required to assess the operational feasibility of the indicators and the validity of any benchmarking data drawn from international comparisons. A conceptual framework needs to be developed that comprehensively captures the complex construct of primary care as a basis for the selection of additional indicators.

Toward a new paradigm in hospital-based pediatric education: the development of an onsite simulator program

OBJECTIVE

The low incidence of crises in pediatrics, coupled with logistic issues and restricted work hours for trainees, hinders opportunities for frequent practice of crisis management and teamwork skills. We hypothesized that a dedicated simulator suite contiguous to the intensive care unit (ICU) would enhance the frequency and breadth of critical-incident training for a range of clinicians.

DESIGN

Descriptive study.

SETTING

A tertiary-care pediatric teaching hospital.

MEASUREMENTS AND MAIN RESULTS

A realistic pediatric simulator suite was constructed 100 feet from the ICU, at a total base cost of $290,000. The simulation room is an exact replica of an ICU bed space, incorporating high-fidelity mannequin simulators. To capture an even wider audience, a portable unit was also created. Leaders from seven departments-critical care, cardiac intensive care, emergency medicine, transport medicine, anesthesia, respiratory care, and general pediatrics-completed instructor training to ensure effective debriefing techniques. Pediatric staff, including 100% of critical care fellows, 86% of nurses, 90% of respiratory therapists, and 74% of pediatric house staff, participated in >1500 learning encounters per year. All individuals were trained during their normal workday in the hospital. Courses in crisis resource management, skills acquisition, annual review, orientation, and trauma management (1,116, 98, 90, 60, and 60 encounters per year, respectively) were all designed by a multidisciplinary committee to ensure goal-directed education to a range of audiences. Annual costs were on par with those at other centers (approximately 44 dollars per trainee encounter).

CONCLUSIONS

An onsite and comprehensive simulation program can significantly increase the opportunities for clinicians from multiple disciplines, in the course of their daily routines, to repetitively practice responses to pediatric medical crises. After an initial capital investment, the training appears to be cost-effective. Hospital-based simulator suites may point the way forward as a new paradigm for the effective education of today's busy clinicians.

Improving care of the critically ill: institutional and health-care system approaches

Institutional and health-care system approaches complement bedside strategies to improve care of the critically ill. Focusing on the USA and the UK, we discuss seven approaches: education (especially of non-clinical managers, policy-makers, and the public), organisational guidelines, performance reporting, financial and sociobehavioural incentives to health-care professionals and institutions, regulation, legal requirements, and health-care system reorganisation. No single action is likely to have sustained effect and we recommend a combination of approaches. Several recent initiatives that hold promise tie performance reporting to financial incentives. Though performance reporting has been hampered by concerns over cost and accuracy, it remains an essential component and we recommend continued effort in this area. We also recommend more public education and use of organisational guidelines, such as admission criteria and staffing levels in intensive care units. Even if these endeavours are successful, with rising demand for services and continuing pressure to control costs, optimum care of the critically ill will not be realised without a fundamental reorganisation of services. In both the USA and UK, we recommend exploration of regionalised care, akin to US state trauma systems, and greater use of physician-extenders, such as nurse practitioners, to provide enhanced access to specialist care for critical illness.