Following up on their previous work on the use of control charts in the evaluation of clinical performance, Marilyn K. Hart, James W. Robertson, Robert F. Hart, and Stephen Schmaltz now address the use of Shewhart Xbar and s charts with risk-adjusted variables data to compare length of stay data from several health care organizations.1 Their methodology involved using the same control chart method on the data both before and after risk adjustment, permitting the impact of risk adjustment to be readily determined. They demonstrate the usefulness of the s chart in determining whether the differences between processes in their within-process variation might be attributed to common-cause variation.
Seema S. Sonnad and Karl Matuszewski argue that the observance of medical practice guidelines can effectively contain costs while simultaneously serving as guides to ensure that practitioners provide the necessary and appropriate patient care. Implementing such a plan can become an issue in a complex organization such as a large hospital. In their study they focus on mechanisms that facilitate guideline implementation. They studied the application of a single guideline in a study sample of 61 hospitals. They offer several strategies for implementing selective use guidelines in hospitals and conclude that a suitable decision process to facilitate implementation will be a valuable tool. They identify 4 processes for guideline implementation.
Developing a recommended list of performance indicators from routinely collected emergency department data was the objective of Australian researchers David Sibbritt, Geoffrey K. Isbister, and Rhonda Walker. They collected their performance data from emergency department patient records. The group studied a series of 7 performance indicators reflecting waiting time, triage processes, management, length of stay in the emergency department, disposition, and readmission, as these relate to the categorization system of the Australian Council of Healthcare Standards.
Nir Menachemi, Robert G. Brooks, Art Clawson, Curtis Stine, and Les Beitsch address the impact of rising professional liability insurance expense on the number and nature of medical services provided by family physicians in Florida, and thus on access to medical care. They point out that access to care is one component of the quality of care. Although their investigation focused on family physicians in rural areas, they found that the responses of a comparison group of urban physicians concerning insurance premiums and changes in service did not differ materially from those of rural physicians. The authors suggest that the current documented trend in the direction of continuing decline in services, when coupled with the ongoing rise in professional liability insurance costs, is an issue that should be examined by policy makers.
Surmising that many practitioners and provider organizations in Taiwan do not fully apply the clinical pathway concept in patient care, Chun-Lang Chang, Bor-Wen Cheng, and Chih-Min Luo set about to determine the level of understanding and application of this model that exist in members of selected provider groups. To gather data, they employed the Delphi process with in-depth interviews rather than questionnaire surveys, feeling that the results of earlier survey questionnaires had generated a misunderstanding of clinical pathway analysis. They report that interviews at 8 teaching hospitals revealed that the knowledge-based clinical pathway approach was being implemented effectively in only 1 of the 8 hospitals.
Theodora Zachariadou, Loukia Makri, Henri E. J. H. Stoffers, Anastasios Philalithis, and Christos Lionis performed an audit of the care received by 296 patients with type 2 diabetes who were being treated at 4 primary health care centers in Nicosia, Cyprus. They report that theirs is the first study in which the care of type 2 diabetes patients in Cyprus' primary health care system has been formally evaluated. Citing their findings concerning patient encounters, testing, and medication regimens, they conclude that the primary health care system has a good deal of room for improvement. Not the least of the problems they report is that poor documentation in many of the records means that the results must be interpreted with caution.
Jean Gayton Carroll, PhD, Editor
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