Quality circles in ambulatory care: state of development and future perspective in Germany.
OBJECTIVE: To survey the quantitative development of quality circles (peer review groups; QC) and their moderators in ambulatory care in Germany, to describe approaches to documentation and evaluation, to establish what types of facilities and support is available and to assess opinions on the future importance of QC. DESIGN: Cross-sectional survey using a standardized questionnaire and supplementary telephone interviews. SETTING: All 23 German regional Associations of Statutory Health Insurance Physicians (ASHIP) were surveyed. RESULTS: The total number of QC in ambulatory care in Germany increased rapidly from 16 in 1993 to 1633 in June 1996, with about 17% (range 1.0-52.1%) of all practicing physicians (112 158) currently involved. Throughout Germany, 2403 moderators were trained in 168 training courses by the qualifying date. Follow-up meetings were held or being planned in 20 ASHIP, with approximately 39% (23-95%) of the moderators participating. Systematic documentation of QC work was undertaken or planned in all 23 ASHIIP, and 10 ASHIP carried out comparative evaluation, with at least five others planning to start it. The ASHIP promoted the work of QC by providing organizational (22) or financial (20) support, materials (20) or mediation of resource persons (16). Eleven ASHIP received grants from drug companies. ASHIP rated the future importance of QC as increasing (18) or stable (four), but in no case as decreasing. CONCLUSIONS AND RECOMMENDATIONS: The quantitative growth of QC in Germany is encouraging, but the extent of support and evaluation appears insufficient. Increased methodological support and facilitation, follow-up meetings on a more regular basis, improved documentation and evaluation of individual QC, and problem oriented evaluation of their impact on health care are essential for further successful development. Principles, problems and solutions discussed may be relevant for similar QI activities in other countries. (+info)
Clinical complaints and their handling: a time for change?
OBJECTIVES: To assess the performance of the hospital complaints procedure for complaints proceeding to peer review and the quality of responses to complainants. DESIGN: Retrospective study of data on clinical complaints proceeding to peer review during 1986-91 from clinical records, correspondence, reports of the complaints investigations, and expert review of written responses to complainants. SETTING: Northern Regional Health Authority, covering three million people. SUBJECTS: All 71 clinical complaints investigated to the third stage of the hospital complaints procedure and a sample of 65 written responses to complainants. MAIN MEASURES: Characteristics, duration, and outcome of complaints; findings of peer review; and quality of written responses at various stages in the procedure as evaluated by an expert panel against eight agreed criteria. RESULTS: The median duration of a complaint investigated through all stages of the procedure was 381 days. The longest median stages were those involving attempted resolution locally (131 days) and in which peer review was being arranged (113 days). More complaints alleging failure of communication were upheld by peer review (46/59, 78%) than those alleging misapplication of clinical skills (20/98, 20%) or failure to initiate appropriate investigations or treatment (8/32, 25%). Written responses commonly fell below the standards agreed by the expert panel. CONCLUSIONS: The hospital complaints procedure takes too long and its final peer review stage may not demonstrate sufficient impartiality. The written responses suggest that criticism is not welcomed as a way of improving service. IMPLICATION: The clinical complaints procedure needs to be reformed to ensure true accountability to patients. (+info)
An appraisal of the Peer Assessment Rating (PAR) Index and a suggested new weighting system.
The PAR Index was developed to measure treatment outcome in orthodontics. Validity was improved by weighting the scores of some components to reflect their relative importance. However, the index still has limitations, principally due to the high weight assigned to overjet. Difficulties also arise from the application of one weighting system to all malocclusions, since occlusal features vary in importance in different classes of malocclusion. The present study examined PAR Index validity using orthodontic consultant assessments as the 'Gold standard' and clinical ranking of occlusal features and statistical modelling to derive a new weighting system, separate for each malocclusion class. Discriminant and regression analyses were used to derive new criteria for measuring treatment outcome. As a result a new and more sensitive method of assessment is suggested which utilizes a combination of point and percentage reductions in PAR scores. This was found to have better correlations with the 'Gold standard' than the PAR nomogram. (+info)
Assessment of clinical case presentations for the Membership in Orthodontics, Royal College of Surgeons of England 1995, 1996.
The cases presented and treated at successive examinations by the candidates for the Membership Examination in Orthodontics in 1995 and 1996 at The Royal College of Surgeons of England, were of a very high standard and demonstrated a wide range of treatment modalities. All cases had fixed appliances, predominantly with pre-adjusted Edgewise appliances. IOTN confirmed that most cases were in great need of treatment, with PAR scores showing them to be treated to a high standard. (+info)
Assessment of physician performance in Alberta: the physician achievement review.
The College of Physicians and Surgeons of Alberta, in collaboration with the Universities of Calgary and Alberta, has developed a program to routinely assess the performance of physicians, intended primarily for quality improvement in medical practice. The Physician Achievement Review (PAR) provides a multidimensional view of performance through structured feedback to physicians. The program will also provide a new mechanism for identifying physicians for whom more detailed assessment of practice performance or medical competence may be needed. Questionnaires were created to assess an array of performance attributes, and then appropriate assessors were designated--the physician himself or herself (self-evaluation), patients, medical peers, consultants and referring physicians, and non-physician coworkers. A pilot study with 308 physician volunteers was used to evaluate the psychometric and statistical properties of the questionnaires and to develop operating policies. The pilot surveys showed good statistical validity and technical reliability of the PAR questionnaires. For only 28 (9.1%) of the physicians were the PAR results more than one standard deviation from the peer group means for 3 or more of the 5 major domains of assessment (self, patients, peers, consultants and coworkers). In post-survey feedback, two-thirds of the physicians indicated that they were considering or had implemented changes to their medical practice on the basis of their PAR data. The estimated operating cost of the PAR program is approximately $200 per physician. In February 1999, on the basis of the operating experience and the results of the pilot survey, the College of Physicians and Surgeons of Alberta implemented this innovative program, in which all Alberta physicians will be required to participate every 5 years. (+info)
A model of efficient and continuous quality improvement in a clinical setting.
OBJECTIVE: To establish a system of Continuous Quality Improvement (CQI) which does not require substantial resources in a clinical setting. SETTING: A busy department of obstetrics and gynaecology. METHODS: The system is based on seven elements: (i) comprehensive accumulation of data; (ii) involvement of all faculty members and the majority of residents; (iii) continuous monitoring of processes within the organization; (iv) application of clinical indicators; (v) file review system; (vi) task force approach for evaluation of processes within the organization; and (vii) intervention measures. MAIN OUTCOME MEASURES: Quality of contents of files and documentation, satisfaction of customers (patients, family members), trends of clinical indicators, effect of task force work, incidence of complaints. RESULTS: Inadequate documentation was noted in 14.6% before, and 4% 1 year after the initiation of the CQI program. Task force work in a variety of projects led to a substantial improvement in measured outcome. The absolute and relative numbers of complaints against the department decreased from 44 in 1993, to 27 in 1994, 20 in 1995 and 16 in 1996. In terms of the percentage of complaints directed against the hospital these figures represent 12.4, 9.6, 6.9 and 5.4% for 1993, 1994, 1995 and 1996 respectively. CONCLUSION: Our proposed CQI system has proved to be highly efficient and requires only minimal additional resources. (+info)
A pilot study of peer review in residency training.
OBJECTIVE: To explore the utility of peer review (review by fellow interns or residents in the firm) as an additional method of evaluation in a university categorical internal medicine residency program. DESIGN/PARTICIPANTS: Senior residents and interns were asked to complete evaluations of interns at the end-of-month ward rotations. MAIN RESULTS: Response rates for senior residents evaluating 16 interns were 70%; for interns evaluating interns, 35%. Analysis of 177 instruments for 16 interns showed high internal consistency in the evaluations. Factor analysis supported a two-dimensional view of clinical competence. Correlations between faculty, senior resident, and intern assessments of interns were good, although varied by domain. CONCLUSIONS: An end-of-year attitude survey found that residents gave high ratings to the value of feedback from peers. (+info)
Development of review criteria for assessing the quality of management of stable angina, adult asthma, and non-insulin dependent diabetes mellitus in general practice.
OBJECTIVE: To develop review criteria to assess the quality of care for three major chronic diseases: adult asthma, stable angina, and non-insulin dependent diabetes mellitus. SUBJECTS AND METHODS: Modified panel process based upon the RAND/UCLA (University College of Los Angeles) appropriateness method. Three multiprofessional panels made up of general practitioners, hospital specialists, and practice nurses. RESULTS: The RAND/UCLA appropriateness method of augmenting evidence with expert opinion was used to develop criteria for the care of the three conditions. Of those aspects of care which were rated as necessary by the panels, only 26% (16% asthma, 10% non-insulin dependent diabetes, 40% angina) were subsequently rated by the panels as being based on strong scientific evidence. CONCLUSION: The results show the importance of a systematic approach to combining evidence with expert opinion to develop review criteria for assessing the quality of three chronic diseases in general practice. The evidence base for the criteria was often incomplete, and explicit methods need to be used to combine evidence with expert opinion where evidence is not available. (+info)