Assessing the implementation of a comprehensive quality management system for cross-sectoral psycho-oncology in Germany

INTRODUCTION

Quality management in healthcare is essential for safe, effective, and patient-centered services. Quality management systems (QMS) monitor and improve healthcare quality. Integrating QMS is crucial for optimal quality of care, but previous studies show gaps in integration. This study aims to assess program adherence to a QMS in cross-sectoral psycho-oncological care and to develop strategies for better integration, ultimately improving healthcare quality.

MATERIALS AND METHODS

The study used a utility analysis to assess the program adherence of a cross-sectoral psycho-oncology care program using a 5-point scale. The evaluation process involved breaking down the program into distinct areas, and used key figures and developed indicators to assess adherence. Descriptive statistics were used.

RESULTS

The study conducted a comprehensive assessment of program adherence in a complex care program, analysing 4460 evaluation cases based on 128 quality indicators. The results showed a score of 4.2 out of 5 points (84%), indicating a highly effective implementation of the QMS. Notably, the study observed successful implementation of top-down elements, while encountering more challenges in integrating bottom-up aspects.

CONCLUSION

The study demonstrates effective implementation of a comprehensive QMS. Successful integration was observed in areas such as care concept, care management, quality assurance, and IT-based documentation, while challenges remain in quality development and indicators. Active leadership involvement, staff training, data collection, and a learning culture are essential for successful implementation. Future research should assess the impact and cost-effectiveness of QMSs and develop tailored approaches to sustain healthcare professionals' motivation in quality improvement efforts.

Factor VIII assay mimicking in vivo coagulation conditions

Under certain circumstances, the determination of coagulation factor VIII (FVIII) is hampered by assay discrepancies between clotting and chromogenic approaches. These are observed in certain patients' plasma as well as in certain concentrates. We intended to develop a novel assay for the quantification of coagulation FVIII which reflects the physiological situation better than the established assays. It is based on plasma without chelation of divalent cations and simultaneously minimizes the generation of activated factors which could function as uncontrolled triggers of coagulation. FVIII deficient plasma is prepared with the aid of biotinylated antibodies against FVIII from normal plasma in presence of inhibitors of contact activation. To start the assay only tiny amounts of activated FIX serve as trigger. The FVIII determination is performed in a kinetic experiment and is based on the cleavage of a fluorogenic substrate for activated FX. FVIII concentrations between 0.01 and 1 IU mL(-1) are easily determined. Plasma-derived and recombinant FVIII concentrates were compared. All plasma-derived concentrates were found to contain FVIII activities within the specification of the manufacturer. Recombinant concentrates yielded only 35-50% of the claimed potency. The novel in vivo-like assay avoids the undue advantage or disadvantage of certain product characteristics by eliminating unphysiological assay conditions. Its usefulness could turn out in future experiments with plasma from haemophilia A patients.

[Psychological interventions for acute pain in childhood]

BACKGROUND

Pain sensation depends on individual anxiety and situational circumstances. It is attributed a psychological and social basis. In children, the sensation of pain generally exceeds its perception.

ACUTE PAIN IN CHILDHOOD

Facing acute pain in childhood - especially during medical procedures -, interventions derived from behavioural medicine may help minimize the sensation of fear and pain as well as maximize the experience of internal control. But, it is impossible to totally eliminate acute pain that way. Although it is undisputed that children benefit from psychological intervention, in clinical practice its potential is largely underestimated. Factors with impact on the sensation of acute pain and resulting behavioural and coping strategies are presented. The psychological preparation for a painful medical procedure is demonstrated in detail as an example of a behavioural medicine derived procedure.

Structuring psychosocial care in pediatric oncology

The requirements for high quality psychosocial care for children with cancer and their families are steadily increasing. As an additional supplement to medical and nursing care, psychosocial work has to consider both the requirements of the medical treatment and the associated stress factors. It is essential to structure the different possibilities of intervention in a way which guarantees the practice of psychosocial care within the ongoing medical care. This requires a standardized psychosocial care manual. In July 1994, a 'Manual for Psychological Care in Pediatric Oncology' was put into practice and has been continually improved in the Department of Pediatric Hematology/Oncology of the University of Bonn. It contains special indications for different standards of psychosocial care, is oriented according to the phases and situations of medical treatment, and consists of a health education program as well as special care measurements. The latter are related to both the stressors primarily caused by the requirements of familial adherence to medical and nursing care and the stressors primarily caused by factors of the individual or the familial life circumstances. The theoretical basis of this manual and concrete information for its use are described in this paper.

High sensitivity detection of activated factor IX: application to the analysis of different therapeutical factor IX concentrates and prothrombin complexes

A very sensitive and highly reliable test system for the detection of activated coagulation factor IX (FIXa) has been established. This assay system is based on the cleavage of a fluorogenic substrate by activated factor X (FXa) which is generated by FIXa. This assay can be used to process a large number of samples at a time and, being based on the convenient microtiter plate format, can easily be adapted to automated processing for routine screening of large sample numbers. With this assay at hand we determined the FIXa content of different commercially available therapeutic FIX sources, such as high purity FIX (HPFIX) and prothrombin complex concentrates (PCC). Here we demonstrate that PCC from several suppliers do not contain significantly higher levels of FIXa as compared to HPFIX from the same supplier. In fact, there is a tendency for HPFIX to contain more FIXa than PCC. Moreover, HPFIX from certain manufacturers who do not produce PCC are characterized by an exceptionally high content of FIXa. Therefore, the higher thrombogenic potential of PCC which is well documented clinically cannot be explained solely -- if at all -- by an increased content of FIXa. Rather, it will be necessary to identify other components responsible for this phenomenon.

[Psychology of patient management: evaluation and quality assurance of psychosocial management in pediatric oncology]

Since the introduction of health-care reform in Germany, quality assurance of inpatient care is required. In paediatric oncology this also includes quality assurance measures of psycho-social care. Care Psychology deals with the development, testing and continual improvement of high-quality psycho-social care. Based on clinical experience, scientific knowledge and ascertained requirements a handbook and manual of service delivery of psycho-social care is formulated and tested in everyday practice. Service performance analyses are carried out, and verified improvements are re-tested in practice. This, as well as additional attempts, should lead to total quality management (TQM) of psycho-social care in paediatric oncology according to the criteria of the European Foundation of Quality Management (EFQM).

[Differences in current state and at the beginning of cancer therapy and possible sequelae: a pilot study in pediatric oncology]

The psycho-social and medical care of families with a cancer sick child can be more effective if the team can identify those parents who need help most desperately from the very beginning. In a retrospective study of 20 patients and their families two groups of parents with different levels of stress could be seperated. Highly stressed parents demonstrated already at the time of diagnosis unfavorable coping strategies with the possibility of a cancer disease. They experience a high degree of guilt feelings and believe that they might be responsible for the occurrence of the disease. However they refuse more often than the other parents psycho-social help offered by the professionals. The results suggest to implement special kind of help for the more stressed families already in the early phase of diagnosis and treatment.

[Inpatient psychological management in pediatric oncology: the concept of liaison management]

Concepts for counseling and long term support have been the major interest in the psychosocial care of pediatric oncology patients and their families. Similar methods for psychosocial care on the ward are still rare. This paper presents the psychological care of the oncology patients during their stay on the ward, complimentary to the medical treatment. The concept is based on the process of coping with the phases and specific situations (L.P.; B.M.A.; diagnosis; medication ect.) of the cancer therapy. This process contains on the part of the patients and their parents the need for information, active involvement in treatment regimes and relaxation (before, during and after the stressful situation). The concepts of informed consent, adherence and recovery-counseling are related to the coping methods of the patients and their parents. The aims of our concept are to create and utilize diagnostic tests and psychological methods to enable the families to help themselves. To reach this goal, the technique of semantic and pragmatic information is very important because this kind of social communication helps us to make the medical implications of the treatment understandable and suitable for the patients and families.

[The psychosocial questionnaire for pediatric oncology]

A concept based on empirical data is needed for psychological support of children with cancer and their families. A number of concepts are already available, but a psychological assessment is needed, which controls the feasibility of these concepts. The psychosocial questionnaire is such an assessment, which transforms individual data into the practical psychosocial work during the entire course of cancer treatment. The diagnostical procedure includes aspects of coping with cancer, such as stress, protective and risk factors and health behavior. Data are collected before, during and after the intensive cancer treatment and in a follow-up after 6 or 12 months respectively. The questionnaire has four parts. Each contains a "handbook for parents", which informs the parent in detail on each part. Thus, we enforce the potential of each parent to help him-/herself.

Mutations in the par genes of Caenorhabditis elegans affect cytoplasmic reorganization during the first cell cycle

A dramatic reorganization of cytoplasm occurs during the first cell cycle in embryos of the nematode, Caenorhabditis elegans. We present here the results of a quantitative study of some of the events during this reorganization in wild-type embryos and in par mutant embryos. The par mutations define a set of genes required for cytoplasmic localization in early embryos. We show that par mutations lead to defects in several events of the reorganization. Mutations in all four of the par genes we studied lead to defects in pseudocleavage and asymmetric redistribution of cortical microfilaments. In addition, some of the par mutations affect streaming of cytoplasm, migration of the pronuclei, and asymmetric shortening of the embryo. We propose that the major function of the par genes might be to orchestrate this initial reorganization of cytoplasm.

[Social interaction with autistic children: an approach to disorder-specific, therapy-oriented diagnosis]

Assessment and intervention is a great challenge in working with autistic children. The problems of assessment can be described as a function of the autism-specific developmental problem of decontextualization. The problems of psychological intervention as a related problem of generalization. To control both problems in the social interaction with autistic children one is called to create and videotape situations of social interaction. One can create units of observation on the basis of development psychology studies. Those units are derived from the three main aspects of social interaction, the interactional situation, the interactional style and the interaction behavior. The audio-visuell taping and videoanalysis of many such interactions-sequences at the beginning, in the course and at the end of the intervention process make it possible to control the problems of intervention planning, finetuning and effectiveness.

Maternal-effect lethal mutations on linkage group II of Caenorhabditis elegans

We have analyzed a set of linkage group (LG) II maternal-effect lethal mutations in Caenorhabditis elegans isolated by a new screening procedure. Screens of 12,455 F1 progeny from mutagenized adults resulted in the recovery of 54 maternal-effect lethal mutations identifying 29 genes. Of the 54 mutations, 39 are strict maternal-effect mutations defining 17 genes. These 17 genes fall into two classes distinguished by frequency of mutation to strict maternal-effect lethality. The smaller class, comprised of four genes, mutated to strict maternal-effect lethality at a frequency close to 5 X 10(-4), a rate typical of essential genes in C. elegans. Two of these genes are expressed during oogenesis and required exclusively for embryogenesis (pure maternal genes), one appears to be required specifically for meiosis, and the fourth has a more complex pattern of expression. The other 13 genes were represented by only one or two strict maternal alleles each. Two of these are identical genes previously identified by nonmaternal embryonic lethal mutations. We interpret our results to mean that although many C. elegans genes can mutate to strict maternal-effect lethality, most genes mutate to that phenotype rarely. Pure maternal genes, however, are among a smaller class of genes that mutate to maternal-effect lethality at typical rates. If our interpretation is correct, we are near saturation for pure maternal genes in the region of LG II balanced by mnC1. We conclude that the number of pure maternal genes in C. elegans is small, being probably not much higher than 12.

Genetic studies of unusual loci that affect body shape of the nematode Caenorhabditis elegans and may code for cuticle structural proteins

In Caenorhabditis elegans, four loci (sqt-1, sqt-2, sqt-3 and rol-8) in which mutations affect body shape and cuticle morphology have unusual genetic properties. Mutant alleles of sqt-1 can interact to produce animals with a variety of mutant phenotypes: left roller, right roller, dumpy and long. At least three mutant phenotypes are specified by mutations in the sqt-3 locus. Most alleles at these loci are either dominant or cryptic dominant (i.e., are dominant only in certain genetic backgrounds). Most alleles of these loci exhibit codominance. Two putative null alleles of the sqt-1 locus produce a wild-type phenotype. Many alleles of these genes demonstrate unusual intergenic interactions that are not the result of simple epistasis: animals doubly heterozygous for mutations at two loci often display unexpected and unpredictable phenotypes. We suggest that these genetic properties might be expected of genes, such as the collagen genes, the products of which interact to form the animal's cuticle, and which are member genes of a gene family.

Cuticle of Caenorhabditis elegans: its isolation and partial characterization

The adult cuticle of the soil nematode, Caenorhabditis elegans, is a proteinaceous extracellular structure elaborated by the underlying layer of hypodermal cells during the final molt in the animal's life cycle. The cuticle is composed of an outer cortical layer connected by regularly arranged struts to an inner basal layer. The cuticle can be isolated largely intact and free of all cellular material by sonication and treatment with 1% sodium dodecyl sulfate (SDS). Purified cuticles exhibit a negative material in the basal cuticle layer. The cuticle layers differ in their solubility in sulfhydryl reducing agents, susceptibility to various proteolytic enzymes and amino acid composition. The struts, basal layer, and internal cortical layer are composed of collagen proteins that are extensively cross-linked by disulfide bonds. The external cortical layer appears to contain primarily noncollagen proteins that are extensively cross-linked by nonreducible covalent bonds. The collagen proteins extracted from the cuticle with a reducing agent can be separated by SDS-polyacrylamide gel electrophoresis into eight major species differing in apparent molecular weight.

GENETIC AND PHENOTYPIC CHARACTERIZATION OF ROLLER MUTANTS OF CAENORHABDITIS ELEGANS

Eighty-eight mutants of C. elegans that display a roller phenotype (a helically twisted body) have been isolated and characterized genetically and phenotypically. The mutations are located in 14 different genes. Most genes contain a number of alleles. Their distribution among the chromosomes appears nonrandom, with seven of the genes being located on linkage group 11, some very closely linked. The phenotypes of the mutants suggest that there are five different classes of genes, each class representing a set of similar phenotypic effects: Left Roller (four genes), Right Roller (one gene), Left Squat (one gene), Right Squat (two genes) and Left Dumpy Roller (six genes). The classes of mutants differ with respect to a number of characteristics that include the developmental stages affected and the types of aberrations observed in cuticle structure. A variety of gene interactions were found, arguing that these genes are involved in a common developmental process. The presence of alterations in cuticle morphology strongly suggests that these genes are active in the formation of the nematode cuticle.

Binding of aldosterone to cytoplasmic and nuclear receptors of the urinary bladder epithelium of Bufo marinus

Binding of aldosterone to cytoplasmic and nuclear sites in urinary bladder epithelia of Bufo marinus (Dominican variant) is saturable and dependent upon steroid concentration. Scatchard analysis of specific cytoplasmic binding yielded a maximal binding capacity (N) of 14.5 X 10(-14) mol/mg protein and an apparent equilibrium dissociation constant (Kd) of 1.4 X 10(-8) M. Since Scatchard analysis of specific nuclear binding was complex, this binding was resolved by a computer-generated cirve-fitting technique which analyzed total aldosterone bound. Nuclear binding was resolved into three sites: a nonsaturable site that was linearly dependent upon aldosterone concentration, and two saturable sites (types I and II). Type I sites had relatively low capacity for aldosterone (N = 31 +/- 1 X 10(-14) mol/mg DNA) and high affinity (Kd = 2.5 +/- 0.5 X 10(-9 M); tffininty (Kd = 8.6 +/- 1.7 X 10(-7) M). Competition for [3H]aldosterone binding by dexamethasone, corticosterone, cortisol, progesterone, testosterone, and 17 beta-estradiol demonstrated that type I nuclear sites have higher affinity for aldosterone than for other steroids. The findings are consistent with the inference that the type I site is the mineralocorticoid receptor.

Aldosterone receptor occupancy and sodium transport in the urinary bladder of Bufo marinus

The concentration dependence of binding of [3H]aldosterone to cytoplasmic and nuclear receptors was evaluated in urinary bladder epithelial cells of Colombian toads. One class of specific sites (sensitive to displacement by excess aldosterone) was detected in the cytosol. However, two classes of specific nuclear [3H]aldosterone binding sites were evident. In the nucleus, high-affinity (Kd = 2.7 X 10(-9) M), low-capacity (N = 15 X 10(-14) mol/mg DNA) sites (type I) were completely saturated at approximately 4 X 10(-8) M aldosterone, a concentration which gave a maximal increase in short-circuit current (SCC). Occupancy of low-affinity (Kd = 4.6 X 10(-7) M), high-capacity sites (N = 150 X 10(-14) mol/mg DNA) (type II) occurred at higher steroid concentrations and did not correlate with further increase in SCC. Binding parameters of Colombian and Dominican variants of Bufo marinus were compared. In both variants, the SCC increase elicited by aldosterone correlated with accumulation of type I complexes in the nucleus, but the relationship was markedly nonlinear. Various alternatives were considered as the basis for a curvilinear dependence of the increment in Na+ transport on abundance of nuclear type I complexes.