Referral of patients to an anticoagulant clinic: implications for better management.
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The quality of anticoagulant treatment of ambulatory patients is affected by the content of referral letters and administrative processes. To assess these influences a method was developed to audit against the hospital standard the referral of patients to one hospital anticoagulant clinic in a prospective study of all (80) new patients referred to the clinic over eight months. Administrative information was provided by the clinic coordinator, and the referral letters were audited by the researchers. Referral letters were not received by the clinic for 10% (8/80) of patients. Among the 72 referral letters received, indication for anticoagulation and anticipated duration of treatment were specified in most (99%, 71 and 81%, 58 respectively), but only 3% (two) to 46% (33) reported other important clinical information (objective investigations, date of starting anticoagulation, current anticoagulant dose, date and result of latest international normalised ratio, whether it should be the anticoagulant clinic that was eventually to stop anticoagulation, patients' other medical problems and concurrent treatment. Twenty two per cent (16/80) of new attenders were unexpected at the anticoagulant clinic. Most patients' case notes were obtained for the appointment (61%, 47/77 beforehand and 30% 23/77 on the day), but case notes were not obtained for 9% (7/77). The authors conclude that health professionals should better appreciate the administrative and organisational influences that affect team work and quality of care. Compliance with a well documented protocol remained below the acceptable standard. The quality of the referral process may be improved by using a more comprehensive and helpful referral form, which has been drawn up, and by educating referring doctors. Measures to increase the efficiency of the administrative process include telephoning the clinic coordinator directly, direct referrals through a computerised referral system, and telephone reminders by haematology office staff to ward staff to ensure availability of the hospital notes. The effect of these changes will be assessed in a repeat audit. (+info)
Evaluation of patients' knowledge about anticoagulant treatment.
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OBJECTIVE: To develop a questionnaire to evaluate patients' knowledge of anticoagulation. DESIGN: Anonymous self completed questionnaire study based on hospital anticoagulant guidelines. SETTING: Anticoagulant clinic in a 580 bed district general hospital in London. SUBJECTS: 70 consecutive patients newly referred to the anticoagulant clinic over six months. MAIN MEASURES: Information received by patients on six items of anticoagulation counselling (mode of action of warfarin, adverse effects of over or under anticoagulation, drugs to avoid, action if bleeding or bruising occurs, and alcohol consumption), the source of such information, and patients' knowledge about anticoagulation. RESULTS: Of the recruits, 36 (51%) were male; 38(54%) were aged below 46 years, 22(31%) 46-60, and 10(14%) over 75. 50 (71%) questionnaires were returned. In all, 40 respondents spoke English at home and six another language. Most patients reported being clearly advised on five of the six items, but knowledge about anticoagulation was poor. Few patients could correctly identify adverse conditions associated with poor control of anticoagulation: bleeding was identified by only 30(60%), bruising by 23(56%), and thrombosis by 18(36%). Only 26(52%) patients could identify an excessive level of alcohol consumption, and only seven (14%) could identify three or more self prescribed agents which may interfere with warfarin. CONCLUSION: The questionnaire provided a simple method of determining patients' knowledge of anticoagulation, and its results indicated that this requires improvement. IMPLICATIONS: Patients' responses suggested that advice was not always given by medical staff, and use of counselling checklists is recommended. Reinforcement of advice by non-medical counsellors and with educational guides such as posters or leaflets should be considered. Such initiatives are currently being evaluated in a repeat survey. (+info)
Using a multidisciplinary automated discharge summary process to improve information management across the system.
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We developed and implemented an automated discharge summary process in a regional integrated managed health system. This multidisciplinary effort was initiated to correct deficits in patients' medical record documentation involving discharge instructions, follow-up care, discharge medications, and patient education. The results of our team effort included an automated summary that compiles data entered via computer pathways during a patient's hospitalization. All information regarding admission medications, patient education, follow-up care, referral at discharge activities, diagnosis, and other pertinent medical events are formulated into the discharge summary, discharge orders, patient discharge instructions, and transfer information as applicable. This communication process has tremendously enhanced information management across the system and helps us maintain complete and thorough documentation in patient records. (+info)
Trauma emergency unit: long-term evaluation of a quality assurance programme.
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OBJECTIVE: Long-term evaluation of a quality assurance programme (after an assessment in 1993). DESIGN: Review of medical records. SETTING: Emergency area of an orthopaedic, trauma, and plastic surgery unit in a French teaching hospital (Besancon). SUBJECTS: 1187 consecutive ambulatory patients' records, from July 1995. MAIN MEASURES: Occurrence of near adverse events (at risk events causing situations which could lead to the occurrence of an adverse event). RESULTS: 71 near adverse events were identified (5.9% of the ambulatory visits). There was a significant decrease in the rate of near adverse events between 1993 (9.9% (2056 ambulatory visits, 204 near adverse events)), and 1995 (5.9% (1187 ambulatory visits, 71 near adverse events)), and significant change in the proportion of each category of adverse event (decrease in departures from prevention protocols). CONCLUSIONS: Despite their limitations, the effectiveness and efficiency of quality assurance programmes seem to be real and valuable. Maintaining quality improvement requires conditions which include some of the basic principles of total quality management (leadership, participatory management, openness, continuous feed back). The organisation of this unit as a specialised trauma centre was also a determining factor in the feasibility of a quality assurance programme (specialisation and small size, high activity volume, management of the complete care process). Quality assurance is an important initial step towards quality improvement, that should precede consideration of a total quality management programme. (+info)
Description of local adaptation of national guidelines and of active feedback for rationalising preoperative screening in patients at low risk from anaesthetics in a French university hospital.
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OBJECTIVE: To describe the effect of local adaptation of national guidelines combined with active feedback and organisational analysis on the ordering of preoperative investigations for patients at low risk from anaesthetics. DESIGN: Assessment of preoperative tests ordered over one month, before and after local adaptation of guidelines and feedback of results, combined with an organisational analysis. SETTING: Motivated anaesthetists in 15 surgical wards of Bordeaux University Hospital, Region Aquitain, France. SUBJECTS: 42 anaesthetists, 60 surgeons, and their teams. MAIN OUTCOME MEASURES: Number and type of preoperative tests ordered in June 1993 and 1994, and the estimated savings. RESULTS: Of 536 patients at low risk from anaesthetics studied in 1993 before the intervention 80% had at least one preoperative test. Most (70%) tests were ordered by anaesthetists. Twice the number of preoperative tests were ordered than recommended by national guidelines. Organisational analysis indicated lack of organised consultations and communication within teams. Changes implemented included scheduling of anaesthetic consultations; regular formal multidisciplinary meetings for all staff; preoperative ordering decision charts. Of 516 low risk patients studied in 1994 after the intervention only 48% had one or more preoperative tests ordered (p < 0.05). Estimated mean (SD) saving for one year if changes were applied to all patients at low risk from anaesthesia in the hospital 3.04 (1.23) mFF. CONCLUSIONS: A sharp decrease in tests ordered in low risk patients was found. The likely cause was the package of changes that included local adaptation of national guidelines, feedback, and organisational change. (+info)
Physicians' views on capitated payment for medical care: does familiarity foster acceptance?
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Physicians' attitudes toward capitated payment have not been quantified. We sought to assess physicians' views on capitated payment and to compare the views of those who did and did not participate in such payment. A written survey was given to 200 physicians with admitting privileges at a 600-bed Ohio hospital; 82 (41%) responded and were included in this study. Among respondents, 21 (26%) were primary care physicians, 18 (22%) were medical subspecialists, and 18 (22%) were surgeons. Fifty-eight (71%) were providers for managed care plans, and 35 (43%) participated in capitated payment arrangements. Among physicians who did not participate in capitated care, 100% believed that there was a conflict of interest in capitated payment, and 77% (23 physicians) believed that participation in plans that reduce physician income in proportion to medical expenditures is not acceptable. Among those who did participate in capitated payment contracts, 95% (41 physicians) believed these plans posed a conflict of interest, and 72% (31 physicians) said this was not acceptable (P = 0.4 and 0.66 for each comparison). There was no trend toward the opinion that capitated payment arrangements are acceptable with greater levels of experience in capitated care (P = 0.5 by Spearman test). There were trends suggesting that compared with those who were not receiving capitated payments, those who received capitated payment were 50% more likely to have never discussed capitated payment with any patient (63% versus 42%, P = 0.08), were 70% more likely to very strongly oppose the use of capitation to pay their own family's physicians (49% versus 29%, P = 0.07), and were 30% more likely to believe that it is impossible to stay in the practice of medicine without participating in capitated payment plans (84% versus 65%, P = 0.06). None of the respondents reported that they had a contractual "gag clause," but 34% (27 physicians) said they would not speak publicly about any perceived risks of capitated payments anyway. Among this sample of physicians, those who participated in existing capitated payment managed care plans had views that were as negative, or more negative, on the acceptability of capitated payment as did those of nonparticipating physicians. Many were participating in capitated payment plans in spite of these negative views because they feared that to do otherwise would force them out of medical practice. The hypotheses generated by this study must be tested in larger, national studies. (+info)
Observations on centrifugation: application to centrifuge development.
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This report outlines the background to the development of an automated, serial, discrete centrifuge, reporting on the criteria considered essential in such an instrument. We established the criteria by examining the detailed logistics of centrifuge operation in a hospital laboratory. The mean sample load per run, using six centrifuges, was 13.6 samples, and the user-selectable cycle time ranged from 00:01:10 to 00:12:33 (hours:minutes:seconds) with a fixed g value of 1050. During the laboratory working window, (0900-1700), only 50% of the centrifuge capacity was utilized and more than one-third of the sample workload was delayed for >5 min because the centrifuges were not emptied promptly. In addition, 35% of the sample workload was centrifuged for less than the time prescribed in the operational specifications. Based on these findings, we designed a new continuous, serial centrifuge to overcome some of the deficiencies noted in the logistics study. The centrifuge operates continuously, nominally treating 150 samples/h, with a cycle time of 5 min at 1,000 g. The cycle time and g value are variable between limits, and their selection governs the throughput rate. Each sample is centrifuged separately in individual rotors mounted in a sturdy carousel with a periphery that traverses a load/unload station. There is no sample delay because of operator absence, and the capacity is fully utilized. The centrifuge can operate in a stand-alone capacity or has the capability of being integrated into a sample preparation system or as a direct front end for high-throughput analyzers. (+info)
A quasi-experimental study on a quality circle program in a Taiwanese hospital.
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OBJECTIVE: To explore the impact of quality circles on job satisfaction, absenteeism, and turnover among hospital nurses in Taiwan. DESIGN: A quasi-experimental research design. SETTING: In November 1995, a study was initiated to establish quality circles in a 500-bed community hospital in Taiwan. After the administrative process and a pilot study, three of the experimental units began implementing the quality circle program in January 1997. For the comparison group, three non-quality circle medical-surgical units were selected from another building. STUDY PARTICIPANTS: All registered nurses on the three selected units who met the criteria of having worked full-time on those units for > or = 6 months were included in the study. There were 53 full-time registered nurses (49 female, four male) who met the criteria and 100% participated. There were no significant differences between the quality circle group and the non-quality circle group in terms of sex, age, and number of years of working experience, education or marital status. INTERVENTIONS: After obtaining administrative approval and support, the pilot study began with 3-month quality circle courses and 3-month quality circle process training for the experimental group nurses. Each circle has been meeting for 1 hour each week to identify problems, barriers, and solutions for effective implementation since 1997. MAIN OUTCOME MEASURES: (i) Demographic data questionnaire; (ii) Stamps and Piedmont's Index of Work Satisfaction; (iii) hospital records for absenteeism and turnover data. RESULTS: The data reveal that nurses of the three quality circle units felt more satisfied (P < 0.01) than did nurses from the three non-participating units. In the non-participating group, 36% had considered leaving the units, compared to 10% of nurses from the quality circle group. The turnover rate was significantly higher for the non-participating group (40%) than for the quality circle group (13%). CONCLUSION: This quality circle program in a Taiwanese hospital significantly improved satisfaction, reduced absenteeism, and lowered turnover of nurses. The findings support other studies reported in the literature. (+info)