In the "medical home" adult primary care setting, practitioners are seeing an increasing emphasis on patient involvement in setting the goals of care. Nicole Rocco, Katherine Scher, Barebara Basberg, Swaytha Yalamanchi, and Kimberly Baker-Genaw point out that the patient's involvement in health care decision making strongly influences his or her compliance and adherence to the plan of care. The authors report on a study of the effects of patients' involvement in planning and goal setting on their clinical outcomes. The research team employed a new plan of care tool incorporated in an organized patient-centered team care program to implement the plan. Although other investigators have explored many aspects of patient involvement, at the time of writing, the authors' literature search had revealed no other studies of specific tools that measured the clinical outcomes of patients who had participated in goal-setting discussions with their physicians.
Jeffrey Borckardt and his colleagues set out to analyze the factors underlying an observed association between nonpsychiatric hospitalization frequency, duration, and costs and the patient's history of outpatient psychiatric treatment. Although the existence of an association in this study population was confirmed, the reasons for the association are not definitively identified. A number of possible combinations of clinical approaches and utilization practices that might account for the association are discussed by the authors. They recommend further study of the criteria used to determine the need for a psychiatric consultation, along with the timing of the consultation requests.
As V. Susan Carroll and Michelle Freitag point out, the patient's safety and well-being depend in large part on the way in which his or her information is transmitted from one set of caregivers to another during transitions in care, such as a shift change, a transfer, or discharge (the "handoff"). Every handoff is an opportunity for error. The transmission of information is hampered when the structure of the online information system makes no provision for interactive communication of questions and answers. In the hospital that is the scene of the case study reported here, a failure mode and effects analysis (FMEA) of the handoff process was carried out, beginning with the Telemetry Unit. In discussing the findings, the authors point to the opportunity for patient participation in the handoff process, and the observed effect of such participation in improving patient satisfaction scores.
The role to be played by the hospital patient's subjective evaluation of his or her care in calculating pay for performance is explored by Francis Fullam and Irwin Press. The authors state that there are only 2 ways to derive a measure of the quality of care: quantifying outcomes and judging processes. They argue that patient satisfaction falls into the broad process category. However, they also point out that only the clinical processes and their results are documented in the medical record, whereas measures of patient satisfaction are not. In their analysis of the issues involved, the authors discuss the results and implications of evidence found in a collaborative study carried out by institutional members of the University Healthsystem Consortium.
A leading academic medical center has been conducting a 4-year initiative to improve hand hygiene practices of hospital health care workers. Although gratifying overall improvement in hand hygiene compliance rates have occurred over the project's term, significant differences in compliance were seen among the 16 groups of 2 types of workers and the 8 hospital areas that were involved. Karen Homa describes the organization's use of an analysis of means (AOM) study, the results of which can be used to identify the groups on which to focus future hand hygiene improvement efforts
In response to a request for proposal and the offer of a grant, 183 health care agencies in Sweden's Kalmar County Council's oversight region submitted proposals for ways to improve the quality of the care they were providing. The proposals focused on organizational process, evidence and quality, competency development, process technology, and proactive patient work. To generalize application of these 5 categories beyond the current program and to validate the typology, Ann-Christine Andersson, Mattias Elg, Ewa Idvall, and Kent-Inge Perseius applied the typology to all articles addressing quality improvement projects published in Quality Management in Health Care during the preceding 2 years. They found that each of those articles fit into at least 1 of the 5 proposal categories. In the present article, which is intended to provide a foundation for further investigation in connection with the Kalmar County Council's health care improvement program, the authors discuss the significance of these preliminary findings for future research and program development.
A clinical medical laboratory is the site of a study involving the use of the Delphi process in conducting a FMEA. Peter B. Southard, Sameer Kumar, and Cheryl Southard report on the use of the Delphi approach. The authors point to the Joint Commission's tacit support of the define, measure, analyze, improve, and control (DMAIC) strategy as part of the efforts to improve organizational performance. Although the laboratory successfully employed the FMEA approach, the authors suggest that the DMAIC tool itself may need some improvement.
One size does not fit all. So say Gerard C. Niemeijer, Ronald J. M. M. Does, Jeron de Mast, Albert Trip, and Jaap van den Heuvel. The authors assert that process improvement projects should be conducted throughout the entire organization and should be led by professionals who are involved in the relevant processes, rather than by investigators who are not involved. However, they point to the fact that it can be difficult to define such a project in terms of the steps to be taken. In their retrospective analysis of process improvement projects in hospitals, they focus on the necessity for defining the improvement project, producing templates or models of structured plans for improving the safety and efficacy of health service delivery. The authors refer to their present study and report as a case-based approach to help practitioners in effectively defining their improvement projects.
Jean Gayton Carroll, PhD
Editor