Article

An Introduction to Quality Assurance in Health Care

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Oxford University Press, 2002 0-19-515809-1; 240 pp; $37.95 Hb, $32.25 Pb It would seem that any discussion about almost any issue in recent times has had to have the word ‘quality’ peppered liberally throughout the exchange. This apparent obsession with a concept that many have argued has no universal language with which to define it has all too often caused confusion and an inability to truly understand what a quality product or service represents. Nowhere is this more apparent than in health care. For some, the acid test of a quality health care service is the survival of the patient, even though this takes no account of the quality of the patient experience during the treatment process. For others it is the successful completion of the procedure, bringing forth the somewhat macabre statement ‘the operation was a success but unfortunately the patient died’. However, Professor Avedis Donabedian brings a refreshing clarity to this important area through a highly readable yet in-depth exploration of the fundamental ingredients that are essential to delivering a quality service within modern health care. He begins by sharing his definition of quality assurance, and in doing so exposes the weakness …

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... According to this approach, it is possible to conceive of quality as the product of two factors: 1) the science and technology of health care and 2) the application of that science and technology in actual practice. With reference to Donabedian (2003), that product of two factors can be characterized by seven attributes that include efficacy, effectiveness, efficiency, optimality, acceptability, legitimacy and equity. These quality dimensions, taken singly or in a variety of combinations, constitute a definition of health care quality. ...
... Donabedian is famous also with the model of " structure-process-outcome" (SPO) that was suggested for assessing the quality of health care. In this model, the structure indicates the settings where the health care is provided, the process indicates how care is technically delivered, and the outcome indicates the effect of care on the health or welfare of the patient (Donabedian, 2003). Donabedian then suggested exploring these three levels in the three dimensions of his definition of quality: technical care (professional perspective), interpersonal relations (patient perspective) and amenities. ...
... To do a right thing requires that physician make the right decisions about care for each patient, and to do it right requires skills, judgment and timeliness of execution. The quality of interaction between physician and patient depends on several elements in their relationship: quality of communication, physician's ability to maintain the patient's trust and to treat the patient with " concern, empathy, honesty, tact and sensivity " (Donabedian, 2003). Still, according to Jun et al. (1998), physicians tend to view themselves more like " scientists " who look to the results, not the personal or human side of their service performance. ...
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Health care service quality is a critical issue for many researchers from different fields of science and practice. Studies of evolution of health care service quality concept allow envisaging that historically health care service quality meant different things for different stakeholders, even if they used the same concept. Physicians traditionally relate service quality with good medical results, expressed in terms of objective measures. The managers of health care organizations tend to evaluate service quality by using some managerial measures. While patients tend to evaluate health care quality as a function of their relationships with health care provider. Trying successfully operating in nowadays fast-changing environment, it is necessary to provide health care service recipients with services that would meet or exceed their needs and expectations. At the same time, it's important to understand the service providers' perspective about high quality service determinants. The complexity of health care services and the importance of the competence of health care providers on health care results enable not to rely only on the consumers' perspective to quality. A number of studies have been conducted to identity the health care quality perception from the patient perspective; there are also many researches done exploring differences between patient and health care provider perceptions of quality. However, a few studies have been conducted trying to reveal the differences of quality perception between the separate groups of health care providers. This paper tries to explore the differences and similarities of health care service quality perception between two groups within health care organization: managers of HCO and health care professionals.
... Immediately after its publication in 1966, Evaluating the Quality of Medical Care, became known as the paramount framework in health services research in which the quality of health care measures were divided into a triad: structure, process and outcome (Perides, 2003). ...
... According to Donabedian, 'continuous improvement' defines quality of care for the demands of health care professionals paired with the expectations of patients are everlasting (Perides, 2003). ...
Article
Reducing readmissions has become a priority for hospitals across the country in an effort to improve care and to avoid financial penalties. The purpose of this pilot study is (a) to evaluate the impact of Project Re-Engineered discharge checklist on hospital readmissions within 30 days of discharge when compared to standard discharge instructions, (b) to evaluate adherence to the initial follow-up appointment with an outpatient provider in the trauma clinic within seven days of hospital discharge for fall patients compared to standard discharge instructions, and (c) to evaluate the impact insurance status, race, education, number of chronic illnesses present on admission, and planned post-discharge living arrangements on adherence to the initial follow-up appointment with an outpatient provider in the trauma clinic within seven days of discharge. Conducted between February 1, 2015 and October 1, 2015, this pilot study used a convenience sample (N = 50) of trauma patients admitted to a level II trauma center located in the Northeast. With respect to results, implementation of the Project Re-Engineered discharge checklist did not reduce readmissions (p = 0.247) or increase adherence to the initial follow-up appointment with an outpatient provider in the trauma clinic (p = 0.248). Demographics variables including age (p = 0.002) and race (p = 0.021) demonstrated statistical significance in reduced 30-day readmissions. Further research is needed to identify which modifications to the Project RED Discharge checklist might provide the greatest benefit to trauma patients in an effort to increase adherence to follow-up care, reduce readmissions and decrease healthcare costs.
... Other more changeable and dynamic properties, such as the organisational processes,10 11 should, therefore, be addressed when attempting to design patient-safe organisations.9 Processes may be defined and operationalised as the care delivered (clinical process measures) or as organisational processes measures that describe the work environemnt.3 12 13 It has been suggested that the impact of safety culture vary with the work environment,14 and several studies have shown that nursing work environments are associated with clinical and nurse-reported quality.5 15 16 17 18 Improvements in nurses’ perceptions of organisational process measures in their work environment are likely to have an impact on nurse-reported quality. ...
... Donabedian's structure–process–outcome model serves as a framework for identifying organisational properties that have an impact on clinical outcomes.1 3 Organisational structures describe the setting of healthcare delivery. Structure measures, such as nurse staffing levels, teaching status and volume are associated with clinical outcomes,4–8 but evidence for impact on clinical outcomes is inconsistent.9 ...
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There is a growing body of evidence for associations between the work environment and patient outcomes. A good work environment may maximise healthcare workers' efforts to avoid failures and to facilitate quality care that is focused on patient safety. Several studies use nurse-reported quality measures, but it is uncertain whether these outcomes are correlated with clinical outcomes. The aim of this study was to determine the correlations between hospital-aggregated, nurse-assessed quality and safety, and estimated probabilities for 30-day survival in and out of hospital. In a multicentre study involving almost all Norwegian hospitals with more than 85 beds (sample size=30, information about nurses' perceptions of organisational characteristics were collected. Subscales from this survey were used to describe properties of the organisations: quality system, patient safety management, nurse-physician relationship, staffing adequacy, quality of nursing and patient safety. The average scores for these organisational characteristics were aggregated to hospital level, and merged with estimated probabilities for 30-day survival in and out of hospital (survival probabilities) from a national database. In this observational, ecological study, the relationships between the organisational characteristics (independent variables) and clinical outcomes (survival probabilities) were examined. Survival probabilities were correlated with nurse-assessed quality of nursing. Furthermore, the subjective perception of staffing adequacy was correlated with overall survival. This study showed that perceived staffing adequacy and nurses' assessments of quality of nursing were correlated with survival probabilities. It is suggested that the way nurses characterise the microsystems they belong to, also reflects the general performance of hospitals.
... Study 1 suggested that these dimensions can be reconciled by considering QOC as an event that occurs when users and providers interact, and that this interaction is embedded within broader social and health systems contexts (Fig. 1). This conceptualisation adopts a dynamic view of Donabedian's structure-process-outcome QA model (53), examining actions and interactions, whilst considering the influence of context. The conceptualisation also adheres to the relativistic model proposed by Chin and Muramatsu (52). ...
... Quality assessment (QA) in healthcare typically focuses on technical and clinical elements of care (50). More recently, conceptualisations of QOC (and QA) have broadened to incorporate interpersonal, organisational, and societal elements of care (51–53). ...
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Estimates suggest that over 350,000 deaths and more than 20 million severe disabilities result from the complications of pregnancy, childbirth or its management each year. Death and disability occur predominately among disadvantaged women in resource-poor settings and are largely preventable with adequate delivery care. This paper presents the substantive findings and policy implications from a programme of PhD research, of which the overarching objective was to assess quality of, and access to, care in obstetric emergencies. Three critical incident audits were conducted in two rural districts on Java, Indonesia: a confidential enquiry, a verbal autopsy survey, and a community-based review. The studies examined cases of maternal mortality and severe morbidity from the perspectives of local service users and health providers. A range of inter-related determining factors was identified. When unexpected delivery complications occurred, women and families were often uninformed, unprepared, found care unavailable, unaffordable, and many relied on traditional providers. Midwives in villages made important contributions by stabilising women and facilitating referrals but were often scarce in remote areas and lacked sufficient clinical competencies and payment incentives to treat the poor. Emergency transport was often unavailable and private transport was unreliable and incurred costs. In facilities, there was a reluctance to admit poorer women and those accepted were often admitted to ill-equipped, under-staffed wards. As a result, referrals between hospitals were also common. Otherwise, social health insurance, designed to reduce financial barriers, was particularly problematic, constraining quality and access within and outside facilities. Health workers and service users provided rich and explicit assessments of care and outcomes. These were used to develop a conceptual model in which quality and access are conceived of as social processes, observable through experience and reflective of the broader relationships between individuals and health systems. According to this model, differential quality and access can become both socially legitimate (imposed by structural arrangements) and socially legitimised (reciprocally maintained through the actions of individuals). This interpretation suggests that in a context of commodified care provision, adverse obstetric outcomes will occur and recur for disadvantaged women. Health system reform should focus on the unintended effects of market-based service provision to exclude those without the ability to pay for delivery care directly.
... and Control); ISO (International Organization for Standardization); BOS (Business Operating System); CI (Continuous Improvement); TQM (Total Quality Management); etc. (Donabedian, 2003; Munro, 2009; Ovretveit, 1992; Ransom et al., 2008 ...
... Many of these approaches are derived and adapted from quality assurance systems in industry, where processes are straightforward and the implementation of such methods is easier. Yet, the medical process represents an intricately interwoven and dynamic process (Donabedian, 2003, Ovretveit, 1992) where many variables are interconnected. For instance, in medical committees, managing authorities, health care medical professionals, technical and administrative personnel, and patients, as well as medical policy, regulations, and goals are all part of medical processes. ...
... The data collection instrument was closed-ended questionnaire. Delivery service satisfaction related questions were adopted from the Donabedian quality assessment framework [8] and presented using a 5- scale likert scale (1-very dissatisfied, 2-dissatisfied, 3-neutral, 4-satisfied, and 5-very satisfied). ...
... Satisfaction is a meaningful output indicator of quality health care [8-10]. Various studies have reported that satisfied service users are more likely to utilize health services, comply with services and follow ups, and continue with the health care [11-14]. ...
Article
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A woman's satisfaction with the delivery service may have immediate and long-term effects on her health and subsequent utilization of the services. Providing satisfying delivery care increases service utilization. The objective of this study is to assess the satisfaction of mothers with referral hospitals' delivery service and identify some possible factors affecting satisfaction in Amhara region of Ethiopia. A hospital-based cross-sectional survey that involved an exit interview was conducted from September to November 2009 in three referral hospitals in Ethiopia. A total of 417 delivering mothers were enrolled in the study. Client satisfaction was measured using a survey instrument adopted from the Donabedian quality assessment framework. We collect data systematically from every other postnatal woman who delivered in the referral hospitals. Multivariate and binary logistic regression was applied to identify the relative effect of each explanatory variable on the outcome (satisfaction). The proportion of mothers who were satisfied with delivery care in this study was 61.9%. Women's satisfaction with delivery care was associated with wanted status of the pregnancy, immediate maternal condition after delivery, waiting time to see the health worker, availability of waiting area, care providers' measure taken to assure privacy during examinations, and amount of cost paid for service. The overall satisfaction of hospital delivery services in this study is found to be suboptimal. The study strongly suggests that more could be done to assure that services provided are more patient centered.
... In basic concept, quality means excellence, expected outcome that is aimed to be achieved [27,28]. Traditionally, quality of care has been termed as providing practically skilled, effectual, risk-free health services which support to the client's well-being [29][30][31][32][33][34]. World Health Organization (WHO) defined quality of care as "the degree to which delivered health care services enhance preferred health outcomes" [35,36]. ...
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Introduction Despite contraceptive behaviors are influenced by multiple and multilevel variables, studies on modern contraceptive use in Indonesia has concentrated on single-level and mostly individual and household variables, and less interest has been devoted to multilevel analysis that accounts for community and SDP characteristics that may affect woman’s decision to use modern FP method. This study aimed to assess the role of structural and process quality of family planning care in modern contraceptive use among women in reproductive ages in Indonesia. Methods This study analyzed data from the 2016 PMA2020 survey of 10,210 women in 372 enumeration areas in Indonesia. The data were analyzed using categorical principal component analysis and multilevel mixed-effects logistic regression. Results The key variables for structural quality were number of contraceptive provided, SDP supports CHWs, available water and electricity, and skilled FP personnel, while the main factors for process quality were privacy of clients and provision of post-abortion service. There were significant differences across communities in how study variables associated with modern FP adoption. The finding shows the evidence of significant roles of structural and process quality FP care in modern contraceptive use. Moreover, women with high autonomy in FP decision, those who had free national/district health insurance, and those living in a community with higher proportion of women visited by CHW, had higher odds of modern contraceptive usage. Yet, women who live in a community with higher mean ideal number of children or greater proportion of women citing personal/husband/religion opposition to FP, had lower odds of modern contraceptive use than their counterparts. Conclusion Study findings suggest improvement in structural and process quality of FP care will yield substantial growths in modern contraceptive use. Moreover, FP workers should also address adverse cultural/traditional customs in community and should target communities where the demand for modern FP was degraded by opposing social beliefs and norms. There was significant variation across communities in how individual, household, community, and SDP factors affect modern FP practice, hence, context should be taken into consideration in the development of FP intervention and promotion programs.
... In this study, we used the conceptual model proposed by Aday [26] to analyze the factors influencing the sustainable management of joint disease. This model explains the effectiveness of prevention and treatment interventions from a clinical perspective [27], and consists of three components: structure, process, and outcome [28]. ...
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Background: Korea's rapidly aging population has led to a rise in the prevalence of knee osteoarthritis (which reached upwards of 21.3% in 2017) in elderly people aged 65 years and over. Most patients with knee osteoarthritis require ongoing management in the community or through primary care. Continuity of care is a desirable attribute of primary care. However, previous studies on the association between continuity of care and health outcomes have focused on specific disease populations, particularly diabetes mellitus and hypertension. The objectives of this study were to determine whether there is an association between continuity of care for outpatients with knee osteoarthritis and health outcomes. Methods: We conducted a cohort study using claims data from 2014. The study population included 131,566 patients. We measured hospital admission and medical costs during the final 3 months and the continuity of care by Most Frequent Provider Continuity (MFPC), Modified Modified Continuity Index (MMCI), and Continuity of Care (COC) index in the 9 preceding months, using multiple logistic regression analyses to determine which index best explains continuity. We evaluated the relationship between COC and hospital admissions, using negative binomial regression analysis due to over-dispersion. Finally, multiple regressions were used to examine the relationship between the COC and medical costs. Results: We selected the COC index to determine the association between hospital admission and cost; the area under the receiver operating characteristic curve (AUC) of the COC was the largest (0.904), while those for the MFPC (0.894) and MMCI (0.893) were similar. The negative binomial regression analysis showed that continuity of care was significantly related to hospitalization, with the relative risk (RR) of hospital admission being low for patients with high continuity of care [RR = 27.17 for those with the reference group COC (0.76-1.00); 95% CI, 3.09-3.51]. Continuity of care was significantly related to medical costs after considering other covariates. A higher COC index was associated with a lower cost. Conclusions: Higher continuity of care for knee osteoarthritis patients might decrease hospital admission and medical costs.
... Quality of family care includes availability of services/supplies, characteristics of health care providers, adherence to the standard of care and client's expectation and perception. [15][16][17] Family planning programs in many developing countries focus efforts on achieving certain demographic goals such as birth rate reduction and slower population growth through increased use and coverage of family planning services. 7,9,19 During past decades, several studies have reported on family planning services quality; most of them were descriptive. ...
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Background: Private sector is providing 40% of the family planning services in Pakistan. The aim of this study was to assess the structural parameters of the quality in private family planning clinics of Khyber Pakhtunkhwa province. Material & Methods: This descriptive study was conducted at private clinics from 2010 to 2014 through standard checklist. Data entered and analyzed in Excel 2007 and percentages computed. Results: All the parameters evaluated through five years and the percentages in the final year i.e. 2014, being discussed. Physical setup showed boards and logos at 60%, IEC material at 80%, flip charts at 96.20%, privacy for the clients was available at 98.9% and cleanliness at 91.5% of health facilities. Record keeping came out to be a weaker component as 33.5%. Procedure room arrangements showed examination tables at 99.7%, proper light source at 98.9%, gloves used at 99.3%, and 66.8% clinics had intrauterine contraceptive device insertion posters prominently displayed. Infection prevention component showed 98% clinics with adequate water supply along with provision of soap, 62.4% were using chlorine solution, boilers present at 98.5%, storage of instruments in high level disinfection containers was at 98%, destru clips were being used in 91% outlets and disposal of the waste by standard method came out to be 40% only which had plastic bags in the waste baskets. 59% clinics were not following standard protocols which came out to be the weaker component. Conclusion: Private clinics are providing quality family planning services in urban areas of Khyber Pakhtun Khwa province.
... We nonetheless chose to base our study on existing general conceptualizations, while attempting to be context-specific. We adapted Donabedian’s [25] structure-process-outcome model based on the object of study, study objectives, methodology and analyses (Figure 1). According to this frame of reference, patient, provider, organizational and system-level characteristics influence the interprofessionnal practices of physiotherapists (viewed as processes), which in turn have effects on patients, providers, organizations and systems. ...
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Background Collaboration and interprofessional practices are highly valued in health systems, because they are thought to improve outcomes of care for persons with complex health problems, such as low back pain. Physiotherapists, like all health providers, are encouraged to take part in interprofessional practices. However, little is known about these practices, especially for private sector physiotherapists. This study aimed to: 1) explore how physiotherapists working in the private sector with adults with low back pain describe their interprofessional practices, 2) identify factors that influence their interprofessional practices, and 3) identify their perceived effects. Methods Participants were 13 physiotherapists, 10 women/3 men, having between 3 and 21 years of professional experience. For this descriptive qualitative study, we used face-to-face semi-structured interviews and conducted content analysis encompassing data coding and thematic regrouping. Results Physiotherapists described interprofessional practices heterogeneously, including numerous processes such as sharing information and referring. Factors that influenced physiotherapists’ interprofessional practices were related to patients, providers, organizations, and wider systems (e.g. professional system). Physiotherapists mostly viewed positive effects of interprofessional practices, including elements such as gaining new knowledge as a provider and being valued in one’s own role, as well as improvements in overall treatment and outcome. Conclusions This qualitative study offers new insights into the interprofessional practices of physiotherapists working with adults with low back pain, as perceived by the physiotherapists’ themselves. Based on the results, the development of strategies aiming to increase interprofessionalism in the management of low back pain would most likely require taking into consideration factors associated with patients, providers, the organizations within which they work, and the wider systems.
... Há ainda fatores facilitadores desse acesso como a distância, barreiras geográficas, o tempo de transporte e o tempo de espera, a disponibilidade de horários. A literatura tem caracterizado esses fatores dentro do conceito de " acessibilidade " , agrupando-o em quatro grupos distintos: acessibilidade geográfica, econômica , cultural e funcional (Donabedian, 2003; Pinheiro e Escosteguy, 2002; Frenk, 1985). No caso particular do setor de saúde suplementar , a análise do acesso e cobertura populacional deve levar em consideração três componentes que, juntos, compõem seu perfil: as ...
... Quality of Care for Pregnancy, Delivery and Postpartum Questionnaire (QCQ), which was an original investigator developed measurement, was employed to measure maternity care quality. The measurement was based on Donabedian’s three variables for evaluating the quality of medical care: setting, process and outcome [36, 37]. In this study, setting was organization or preparation in hospitals and nursing managing system, process was the way of providing care and care attitude of healthcare providers and outcome was women’s behavior and changes in feeling. ...
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Language and cultural differences can negatively impact immigrant women's birth experience. However, little is known about their experiences in Japan's highly homogenous culture. This cross-sectional study used survey data from a purposive sampling of immigrant women from 16 hospitals in several Japanese prefectures. Meeting the criteria and recruited to this study were 804 participants consisting of 236 immigrant women: Chinese (n = 83), Brazilian (n = 62), Filipino (n = 43), South Korean (n = 29) and from variety of English speaking nations (n = 19) and 568 Japanese women. The questionnaire was prepared in six languages: Japanese (kana syllables), Chinese, English, Korean, Portuguese, and Tagalog (Filipino). Associations among quality of maternity care, Japanese literacy level, loneliness and care satisfaction were explored using analysis of variance and multiple linear regression. The valid and reliable instruments used were Quality of Care for Pregnancy, Delivery and Postpartum Questionnaire, Rapid Estimate of Adult Literacy in Medicine Japanese version, the revised UCLA Loneliness Scale-Japanese version and Care satisfaction. Care was evaluated across prenatal, labor and delivery and post-partum periods. Immigrant women scored higher than Japanese women for both positive and negative aspects. When loneliness was strongly felt, care satisfaction was lower. Some competence of Japanese literacy was more likely to obstruct positive communication with healthcare providers, and was associated with loneliness. Immigrant women rated overall care as satisfactory. Japanese literacy decreased communication with healthcare providers, and was associated with loneliness presumably because some literacy unreasonably increased health care providers' expectations of a higher level of communication.
... The approach taken in the present paper was aimed at identifying factors that support the use of ICT in day service provision for adults with learning disabilities by moving beyond personal opinion or self(organisation)defined criteria. Instead, we adopted a normative derivation of appropriate standards and criteria, which Donabedian (2003) defines as: '…either from direct knowledge of the scientific literature and its findings, or from the agreed-upon opinions of experts and leaders, an opinion presumably based on knowledge of the pertinent literature as well as on clinical experience' (p.62). ...
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Information and Communication Technology (ICT) is becoming a part of everyday life for many adults with learning disabilities. However, there is scant information available about which factors are important for using ICT in post-formal educational contexts with adults with learning disabilities. Eight Day Services within one organisation were visited to observe activities and interview staff and service users about ICT, which included use of personal computers, digital cameras and the Internet. Three main levels of ICT use and implementation were identified as well as a number of organisational factors associated with the regular use of ICT resources. Staff beliefs about ICT, the management and organisation of staffing and clear ideas about the purpose of ICT were important factors in addition to the basic requirements of providing resources and training. These factors are useful in guiding practitioners towards implementing and using ICT and highlight the importance of the context within which ICT use takes place. The provision of hardware, software and training are not sufficient by themselves to guarantee good use of ICT and careful attention needs to be paid to wider influential factors. Sharing of ideas about using ICT resources with adults with learning disabilities is timely in relation to the current policy context of social inclusion, but future development depends on the availability of sustained funding to adequately maintain and update equipment; without this the factors supporting regular ICT use described here will remain isolated and largely irrelevant to many people who could otherwise benefit from the use of ICT resources.
... There are a variety of views on its meaning and some debate as to whether quality has to be measurable. Different authors and organizations have proposed varying definitions of the concept [7][8][9][10] such as the World Health Organization (WHO), American Medical Association, Institute of Medicine (IOM) and Agency for Healthcare Research and Quality (AHRQ). Many health services researchers have struggled with defining or modeling quality for healthcare [11,12]. ...
Conference Paper
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Quality is the key to competitive advantage in today's business environment; quality improvement must be at hospital. In this paper, the main goal is building a systematic approach through software package for quality control and assurance of medical equipment performance within the health care quality system and making continuous improvement to the system. The biomedical engineer has the full support from technical manager and division director to provide and arrange high quality calibration and testing for medical devices at the hospital. Measurement is an important requirement of continuous improvement process. It is necessary to establish appropriate metrics for measurement purpose then monitoring will indicate the occurrence of improvement in the system. The objective of quantifying is to be able to measure the quality of a system.
... But it should remain clear that new governance strategies are in accordance with a framework of quality assurance based on the evaluation of structure, process and outcome and should try to reinterpret this perspective in light of the social responsibility of health care organizations. As stated by Avedis Donabedian [8] “Traditionally, in health care, quality assurance has been meant to apply predominantly, or even exclusively, to health care itself as provided directly to patients by legitimate health care practitioners. Removed one level, we include other services that directly affect the ability of practitioners to perform well, meaning such things as radiological, pharmaceutical, and laboratory services. ...
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Changes in modern societies originate the perception that ethical behaviour is essential in organization's practices especially in the way they deal with aspects such as human rights. These issues are usually under the umbrella of the concept of social responsibility. Recently the Report of the International Bioethics Committee of UNESCO on Social Responsibility and Health has addressed this concept of social responsibility in the context of health care delivery suggesting a new paradigm in hospital governance. The objective of this paper is to address the issue of corporate social responsibility in health care, namely in the hospital setting, emphasising the special governance arrangements of such complex organisations and to evaluate if new models of hospital management (entrepreneurism) will need robust mechanisms of corporate governance to fulfil its social responsiveness. The scope of this responsible behaviour requires hospitals to fulfil its social and market objectives, in accordance to the law and general ethical standards. Social responsibility includes aspects like abstention of harm to the environment or the protection of the interests of all the stakeholders enrolled in the deliverance of health care. In conclusion, adequate corporate governance and corporate strategy are the gold standard of social responsibility. In a competitive market hospital governance will be optimised if the organization culture is reframed to meet stakeholders' demands for unequivocal assurances on ethical behaviour. Health care organizations should abide to this new governance approach that is to create organisation value through performance, conformance and responsibility.
... The PIs described in Table 2 are process indicators related to the provision of primary care services that, using the taxonomy of Donabedian [34], capture two dimensions of quality in health care delivery: the ease with which persons can obtain care, i.e. accessibility; and the ability to lower the cost of care without diminishing attainable improvements in health, i.e. efficiency. Efficiency was further decomposed into productivity indicators - on the production per unit of input (for example, consultations per GP) -, and on the costs incurred to produce that amount (for example, total costs for delivering those consultations). ...
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Recent reforms in Portugal aimed at strengthening the role of the primary care system, in order to improve the quality of the health care system. Since 2006 new policies aiming to change the organization, incentive structures and funding of the primary health care sector were designed, promoting the evolution of traditional primary health care centres (PHCCs) into a new type of organizational unit--family health units (FHUs). This study aimed to compare performances of PHCC and FHU organizational models and to assess the potential gains from converting PHCCs into FHUs. Stochastic discrete event simulation models for the two types of organizational models were designed and implemented using Simul8 software. These models were applied to data from nineteen primary care units in three municipalities of the Greater Lisbon area. The conversion of PHCCs into FHUs seems to have the potential to generate substantial improvements in productivity and accessibility, while not having a significant impact on costs. This conversion might entail a 45% reduction in the average number of days required to obtain a medical appointment and a 7% and 9% increase in the average number of medical and nursing consultations, respectively. Reorganization of PHCC into FHUs might increase accessibility of patients to services and efficiency in the provision of primary care services.
... Six-point scales were used, and results greater than or equal to 4 were defined as confirming the presence of an adverse event and its preventability. The assessment of preventable adverse events was based on subjective and implicit criteria, backed by the expertise, practical experience and clinical decision-making of physicians [18]. The assumption was that a preventable adverse event results from poor quality in the process of care or problems in the health system. ...
Article
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Adverse events are considered a major international problem related to the performance of health systems. Evaluating the occurrence of adverse events involves, as any other outcome measure, determining the extent to which the observed differences can be attributed to the patient's risk factors or to variations in the treatment process, and this in turn highlights the importance of measuring differences in the severity of the cases. The current study aims to evaluate the association between deaths and adverse events, adjusted according to patient risk factors. The study is based on a random sample of 1103 patient charts from hospitalizations in the year 2003 in 3 teaching hospitals in the state of Rio de Janeiro, Brazil. The methodology involved a retrospective review of patient charts in two stages - screening phase and evaluation phase. Logistic regression was used to evaluate the relationship between hospital deaths and adverse events. The overall mortality rate was 8.5%, while the rate related to the occurrence of an adverse event was 2.9% (32/1103) and that related to preventable adverse events was 2.3% (25/1103). Among the 94 deaths analyzed, 34% were related to cases involving adverse events, and 26.6% of deaths occurred in cases whose adverse events were considered preventable. The models tested showed good discriminatory capacity. The unadjusted odds ratio (OR 11.43) and the odds ratio adjusted for patient risk factors (OR 8.23) between death and preventable adverse event were high. Despite discussions in the literature regarding the limitations of evaluating preventable adverse events based on peer review, the results presented here emphasize that adverse events are not only prevalent, but are associated with serious harm and even death. These results also highlight the importance of risk adjustment and multivariate models in the study of adverse events.
... This line of research could benefit from integrating concepts such as "shared decision-making" [30], and "patient involvement/participation" [31]. A second possible direction would be to expand the analyses of choice and mobility to explore the impact upon other health related outcomes like quality [32]. ...
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Waiting times for elective care have been considered a serious problem in many health care systems. A topic of particular concern has been how administrative boundaries act as barriers to efficient patient flows. In Norway, a policy combining patient's choice of hospital and removal of restriction on referrals was introduced in 2001, thereby creating a nationwide competitive referral system for elective hospital treatment. The article aims to analyse if patient choice and an increased opportunity for geographical mobility has reduced waiting times for individual elective patients. A survey conducted among Norwegian somatic patients in 2004 gave information about whether the choice of hospital was made by the individual patient or by others. Survey data was then merged with administrative data on which hospital that actually performed the treatment. The administrative data also gave individual waiting time for hospital admission. Demographics, socio-economic position, and medical need were controlled for to determine the effect of choice and mobility upon waiting time. Several statistical models, including one with instrument variables for choice and mobility, were run. Patients who had neither chosen hospital individually nor bypassed the local hospital for other reasons faced the longest waiting times. Next were patients who individually had chosen the local hospital, followed by patients who had not made an individual choice, but had bypassed the local hospital for other reasons. Patients who had made a choice to bypass the local hospitals waited on average 11 weeks less than the first group. The analysis indicates that a policy combining increased opportunity for hospital choice with the removal of rules restricting referrals can reduce waiting times for individual elective patients. Results were robust over different model specifications.
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Hospital reform is a priority in the context of the national health sector strategic plan of Ethiopia. Two of its main goals are to improve the accessibility and quality of health services and to increase the efficiency in health care delivery, considering improvements in both the distribution of resources to priority activities (allocation efficiency) and the management of resources that are allocated (technical efficiency). At each level of the hospital system, the utilization of the hospital capacity and the mix of patients and available services should be appropriate in order to provide quality services to the greatest number of patients at least cost. This paper is based on data routinely collected in 47 hospitals (both governmental and non-governmental) located in 5 regions (Tigray, Amhara, Oromia, SNNP, and Addis Ababa) in EFY 2001. Its objective is to assess the hospital performance in the selected facilities, with a special focus on performance at different levels of the hospital system, highlighting areas of efficiency in service delivery as well as those in need of attention. This evidence is important in the perspective of the implementation of the ongoing hospital reform and the development of the hospital referral system.
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In the first paper of a series exploring quality in primary dental care a definition for quality in dentistry is sought. There is a little agreement in academic literature as to what quality really means in primary dental care and without a true understanding it is difficult to measure and improve quality in a systematic way. 'Quality' of healthcare in dentistry will mean different things to practitioners, policy makers and patients but a framework could be modelled on other definitions within different healthcare sectors, with focus on access, equity and overall healthcare experience.
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Background: To enhance understanding of ethical leadership and the ethical environment and culture (EL/EEC) in the Department of Veterans Affairs (VA) health care system, we mapped selected questions from the VA IntegratedEthics™ Staff Survey (IESS), a national survey of employees’ perceptions of ethical practices, to the Ethical Leadership Compass Points (ELC), a tool to help leaders cultivate an environment and culture that makes it easy for employees to “do the right thing.” The ELC distills insights and principles from organizational and business ethics and provides leaders with specific behaviors that can be incorporated into daily administrative routines. Methods: We analyzed the responses of 88,605 VA employees to the 2010 IESS questions that previously were mapped to the ELC. Descriptive statistics were used to characterize overall distribution of responses to the survey questions, and Pearson's chi-squared tests were performed to assess differences in responses by employee characteristics. Multiple regression analyses examined the association between perceptions of EL/EEC and perceptions of the organizations’ overall ethics quality. Results: Physicians and employees with a higher level of supervisory responsibility were more likely to have the most positive perceptions of EL/EEC and the organization's overall ethics quality. More than three-quarters of the variation in perceptions of overall ethics quality was explained by employee perceptions of EL/EEC. The IESS questions that showed the largest associations with perceptions of overall ethics quality addressed fair allocation of resources across programs and services, avoidance of mixed messages that create ethical uncertainty or conflict, fair treatment of employees, and following up on ethical concerns reported by employees. Conclusions: These results support the important relationships between ethical leadership, an organization's environment and culture, and overall ethics quality. Certain ethical leadership practices may have a larger impact on employees’ perceptions of overall ethics quality than others.
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This manuscript reviews how patient-reported outcomes data can be used to guide efforts to improve patient outcomes. Review Manuscript. The clinical management of chronic, non-cancer pain. Adult patients receiving treatment for chronic, non-cancer pain. While there have been great advances in the science of pain and various therapeutic medications and interventions, patient outcomes are variable. This manuscript reviews how outcomes data can be used to guide efforts to improve patient outcomes. Patient outcomes can be improved with standardization of the process of patient care, as well as through other quality improvement efforts. The cornerstone to any effort to improve patient outcomes starts with the integration of valid outcomes data collection into ongoing patient care. Outcome measurement tools should provide information on several key domains, yet the process of data collection should not pose a significant burden on either the patient or health care team. Efforts to improve patient outcomes are ongoing, and should be a high priority for every health care team.
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Aim: To explore the experiences of adult patients and parents of child patients when their oral healthcare is delegated to dental therapists. Method: Narrative study using semi-structured in-depth interviews of a purposive sample of patients (n = 15) and parents of child patients (n = 3) who have been treated by therapists. Results: Overall, participants reported positive experiences of treatment provided by therapists. Two main themes emerged from the data. The first; perceptions of the nature of dental services appeared related to the second; trust and familiarity in the dental team. Perceptions of the nature of dental services ranged from viewing dentistry as a public service to that of a private service, consistent with a more consumerist stance. Within this theme, three dimensions were identified: rationale for skill-mix; team hierarchy and importance of choice and cost. Consumerist perspectives saw cost reduction, rather than increasing access, as the rationale for skill-mix. Such perspectives tended to focus on hierarchy and a rights-based approach, envisaging dentists as the head of the team and emphasising their right to choose a clinician. Trust in and familiarity with the dental team appeared critical for therapists to be acceptable. Two dimensions were important in developing trust: affective behaviour and communication and continuity of care. Two further dimensions were identified in this theme: experience over qualification and awareness of therapists. Where trust and familiarity existed, participants emphasised the importance of their experiences of care over the qualifications of the providing clinician. Equally, trust in the dentist delegating care appeared to reassure participants, despite awareness of the role of therapists and their training being universally low. Conclusion: Regardless of perspective, views and experiences of treatment provided by therapists were positive. However, trust in and familiarity with the dental team appeared critical. Trust was apparently founded on dental teams' affective behaviour, communication skills and continuity of care. There are implications for skill-mix where staff turnover is high, as this is likely to compromise familiarity, continuity of care and ultimately trust.
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This retrospective study examined the nurse staffing proportion at Martin Army Community Hospital and whether this proportion was a significant predictor of reported negative inpatient outcomes. The proportion of nursing staff to patients was examined to determine if there is a correlation to three specific diagnoses. The specific diagnoses were post operative wound infection, pneumonia, and decubitus ulcers, as captured from the hospital data repository (MHS MART or M2). The information was collected retrospectively for a period of 48 month period from October 2003 to September 2007. This research utilized a regression analysis to predict whether nurse staffing proportion has any effect on three specific diagnoses. This study failed to reject the null hypothesis and therefore, no significant findings were noted from the regression analysis of inpatient bed days, nurse proportion, and the negative diagnoses.
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Purpose: To identify organizational and environmental correlates to rural health clinics' preventive quality of care in the United States. Design: A retrospective observational cohort study design was applied under Donabedian's Structure-Process-Outcome framework. Three structure measures of care (proportion of nonphysicians, absence of physicians, and provider affiliation) and three measures of process (total clinical visits, prevention use for congestive heart failure and diabetes) were used as explanatory variables. Five environmental correlates were included. The Centers for Medicare and Medicaid Services National Medicare Chronic Care Condition Data Warehouse for 2007 was used to obtain clinical data. Preventive quality of care outcomes were measured through Agency for Healthcare Research and Quality prevention quality indicators. The indicators were risk adjusted for age, sex, race, severity, and comorbidity of patients. Methods: Structural equation modeling with maximum likelihood estimation was used. Findings: Provider affiliation (P = .03), absence of physicians (P = .007), and higher proportion of nonphysicians (P = .007) were negatively related to preventive quality of care. Lower cause-specific mortality rate at the county level as compared to the United States average (P = .05) and rural location (P = .001) were positively related to quality of care. Implications: The results of the study showed the need to attract and retain physicians in rural health clinics. The positive relationship between rural location and quality of care reflects more on the limited access to hospitals in remote areas.
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The accuracy of risk adjustment is important in developing surgeon profiles. As surgeon profiles are obtained from observational, nonrandomized data, we hypothesized that selection bias exists in how patients are matched with surgeons and that this bias might influence surgeon profiles. We used the Society of Thoracic Surgeons risk model to calculate observed to expected (O/E) mortality ratios for each of six cardiac surgeons at a single institution. Propensity scores evaluated selection bias that might influence development of risk-adjusted mortality profiles. Six surgeons (four high and two low O/E ratios) performed 2298 coronary artery bypass grafting (CABG) operations over 4 years. Multivariate predictors of operative mortality included preoperative shock, advanced age, and renal dysfunction, but not the surgeon performing CABG. When patients were stratified into quartiles based on the propensity score for operative death, 83% of operative deaths (50 of 60) were in the highest risk quartile. There were significant differences in the number of high-risk patients operated upon by each surgeon. One surgeon had significantly more patients in the highest risk quartile and two surgeons had significantly less patients in the highest risk quartile (p < 0.05 by chi-square). Our results show that high-risk patients are preferentially shunted to certain surgeons, and away from others, for unexplained (and unmeasured) reasons. Subtle unmeasured factors undoubtedly influence how cardiac surgery patients are matched with surgeons. Problems may arise when applying national database benchmarks to local situations because of this unmeasured selection bias.
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The term effectiveness presents a conceptual challenge to both academics and practitioners (Hirsch & Levin 1999). This is no less so in health care provision. Health care provision is a complex issue due to political, organisational, medical, technological, and multi-disciplinary approaches to solving health cases. Additionally, health care in Ireland is a multi-agent provided service, delivered through a variety of modes including market exchanges, networks and hierarchies. These complexities have resulted in multifaceted systems of service delivery and management that give rise to difficulties involved in the management of the health system particularly in terms of coordination which is linked to the construct of process effectiveness that is developed. These difficulties relate to the lack of understanding of process effectiveness within the present system and its determinants. At present we don't know a lot about process effectiveness or what determinants process effectiveness in the Irish health care system. Those responsible for the design of health services are faced with a dearth of information on what determines process effectiveness (Barrington 2003; Department of Health and Children 2001; Koeck 1998; Millar & McKevitt 2000; Page 2003). Health research in Ireland has not focused on service evaluation, which would provide a greater understanding of process effectiveness, and, while there is some annual statistical data available on the use of existing resources, there has been little evaluation of the effectiveness of service programmes (Barrington 2003; Deloitte and Touche 2001; Department of Health and Children 2001; Downey-Ennis & Harrington 2002; Government of Ireland 2003; Hensey 1988; Leahy & Wiley 1998; Millar & McKevitt 2000; O'Sullivan & Butler 2002; Prospectus & Watson Wyatt 2003; Wiley 2000). The lack of evaluation and/or measurement of effectiveness poses a serious challenge to the management of health service delivery. As McKevitt and Keogan (1997:20-21) identify without measurement there can be no clear view on progress towards strategic objectives and there is no meaningful basis for managerial action. This study addresses the concept of effectiveness as it applies to health care service provision and develops a construct of process effectiveness. A model is developed that will assist in the operationalisation of the effectiveness construct that can assist those responsible for health care service delivery to increase its effectiveness. The framework seeks to address the gap in our understanding of what determines process effectiveness at the level of service delivery by applying management and organisational approaches to Irish health care services.
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Background This investigation analyzed the possibility to provide information about the medical qualities of ophthalmologists to make it easier for patients to find the right physician in a Pareto optimal way, i.e. to supply information so that nobody is harmed and at least one derives benefits. Methods Extensive interviews with key deciders in the system for ophthalmological care were carried out and analyzed. Results Pareto optimization is possible. However, implementation is not yet feasible mainly because of legal and economic restrictions and because of difficulties of the measuring system. In order to come to a result, a major medical, economic and legal effort would be required which is unlikely to come into place in the short-term. Conclusion At least in the near future there will be no new Pareto optimal information systems available for patients in order to find the appropriate ophthalmologist. In the mid-term the situation could change if the open questions can be resolved.
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Quality indicators (QIs) are increasingly used in medicine in order to compare and eventually to improve quality of delivered health care. During the last decade, QIs also have been used within intensive care medicine. This paper shortly describes this development and gives an overview of QIs in the intensive care unit (ICU) reported to be in use at national level. Using a search on PubMed and through World Wide Web, QIs documented to be in use at a national level were retrieved. The various sets of QI were compared, and the method to select QIs was found. The search retrieved national indicators from eight countries (United Kingdom, the Netherlands, Spain, Sweden, Germany, Scotland, Austria and India). A total of 63 QIs were in use, and no single indicator was common for all countries. The most frequently used indicator was the standardised mortality rate (in six of eight countries). Measurements of patient/family satisfaction, the presence of an ICU specialist 24/7 and the occurrence of ventilator-associated pneumonia were all used by five countries. All primarily used a physician-driven process to select national QIs. This survey reveals that the concept of QIs is perceived differently throughout countries, also within developed countries in Western Europe. At present, it will be difficult to use national QIs to compare the quality of intensive care between countries.
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To examine the quality of the maternal health system in Eritrea to understand system deficiencies and its relevance to maternal mortality within the context of Millennium Development Goal (MDG) 5. A sample of 118 health facilities was surveyed. Data were collected on 5 dimensions of health system quality: availability; accessibility; management; infrastructure; and process indicators. Data on the causes of hospital admissions for obstetric patients and maternal deaths were extracted from medical records. Eritrea has only 11 comprehensive emergency obstetric care (CEmOC) facilities, all of which are grossly understaffed. There is considerable pressure on the infrastructure and health providers at hospitals. Compliance with clinical care standards and availability of supplies were optimal. As a result, the case fatality rate of 0.65% was low. In total, 45.6% of obstetric admissions and 19.5% of maternal deaths were attributed to abortion complications. In Eritrea, critical gaps in the health system-especially those related to human resources-will impede progress toward MDG 5, and it will not be possible to reduce maternal mortality without addressing the high burden of abortion.
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This study proposes a prototype framework (THEMIS) for estimating algebraically the success (S) of the electronic health collaborative services (e-HCS) and examines two hypotheses: first, that the S estimation of an e-HCS, developed by a third-party vendor, demands a 'shrunk formative model' and second that causal relationships between the involved dimensions (FFP, CO, COSTS) do exist, and their parameters affect the S - from weakly to strongly and vice-versa. A formative model was shrunk to generate three causal dimensions ('Collaborators Objections', 'Costs', 'Fitness for Purpose'). Then, the new framework (THEMIS) was enriched with a causal loop diagram, a prototype scoring method, (termed 'polarisation method') and 42 questions. In order to investigate the feasibility of the THEMIS framework, we estimated the S of 15 e-HCSs and the algebraic outcomes (E(S)) were compared - one by one - with usage categories produced by a commercial software. Our findings supported the initial hypotheses. The S was estimated with accuracy; for the e-HCSs with a weak E(S) the commercial software verified that they remained idle several times during the 11-month evaluation period, whereas the e-HCS with a strong E(S) the commercial software verified that they were used frequently. Frameworks, such as the one proposed, which are based on both qualitative and quantitative methods, may provide significant support on the S estimation field.
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Objective: We used MEDMARX®, the national medication error-reporting program, to compare medication errors reported by critical access hospitals (CAHs) to those reported by non-Federal, general community hospitals.Methods: We used the availability of pharmacist support to represent the structure and process of medication use and within-cluster resampling to account for the correlation of error reports within hospitals.Results: CAHs with 15 or fewer hours of pharmacist support per week were significantly less likely to report “near miss” errors—a characteristic of high-reliability organizations—than general community hospitals with 24-hour pharmacist support. Conclusion: The severity of voluntarily reported medication errors is associated with the structure and process of medication use as indicated by the availability of pharmacist support. MEDMARX is a potential data source for patient safety organizations (PSO). PSOs must consider varying structure and process within reporting organizations and account for the correlation of data within clusters.
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This study was conducted to empirically evaluate specific human, curricular, and material resources that maximize student opportunities for physical activity during physical education (PE) class time. A structure-process-outcome model was proposed to identify the resources that influence the frequency of PE and intensity of physical activity during PE. The proportion of class time devoted to management was evaluated as a potential mediator of the relations between resource availability and student activity levels. Data for this cross-sectional study were collected from interviews conducted with 46 physical educators and the systematic observation of 184 PE sessions in 34 schools. Regression analyses were conducted to test for the main effects of resource availability and the mediating role of class management. Students who attended schools with a low student-to-physical educator ratio had more PE time and engaged in higher levels of physical activity during class time. Access to adequate PE equipment and facilities was positively associated with student activity levels. The availability of a greater number of physical educators per student was found to impact student activity levels by reducing the amount of session time devoted to class management. The identification of structure and process predictors of student activity levels in PE will support the allocation of resources and encourage instructional practices that best support increased student activity levels in the most cost-effective way possible. Implications for PE policies and programs are discussed.
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Disablement theory has been characterized as the sequence of events that occurs after an injury, but little research has been conducted to establish how disablement is experienced and described by physically active persons. To describe the disablement process in physically active persons with musculoskeletal injuries. Concurrent, embedded mixed-methods study. For the qualitative portion, interviews were conducted to create descriptive disablement themes. For the quantitative portion, frequencies analysis was used to identify common terminology. National Collegiate Athletic Association Division I collegiate and club sports, collegiate intramural program, large high school athletics program, and outpatient orthopaedic center. Thirty-one physically active volunteers (15 males, 16 females; mean age  =  21.2 years; range, 14-53 years) with a current injury (18 lower extremity injuries, 13 upper extremity injuries) participated in individual interviews. Six physically active volunteers (3 males, 3 females; mean age  =  22.2 years; range, 16-28 years) participated in the group interview to assess trustworthiness. We analyzed interviews through a constant-comparison method, and data were collected until saturation occurred. Common limitations were transformed into descriptive themes and were confirmed during the group interview. Disablement descriptors were identified with frequencies and fit to the themes. A total of 15 overall descriptive themes emerged within the 4 disablement components, and descriptive terms were identified for each theme. Impairments were marked by 4 complaints: pain, decreased motion, decreased muscle function, and instability. Functional limitations were denoted by problems with skill performance, daily actions, maintaining positions, fitness, and changing directions. Disability consisted of problems with participation in desired activities. Lastly, problems in quality of life encompassed uncertainty and fear, stress and pressure, mood and frustration, overall energy, and altered relationships. A preliminary generic outcomes instrument was generated from the findings. Our results will help clinicians understand how disablement is described by the physically active. The findings also have implications for how disablement outcomes are measured.
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The increasing number of hospitalized elderly persons has greatly challenged decision makers to reorganize services so as to meet the needs of this clientele. Established progressively over the last 30 years, the short-term Geriatric Assessment Unit (GAU) is a specialized care program, now implemented in all the general hospital centres in Quebec. Within the scope of a broader reflection upon the appropriate care delivery for elderly patients in our demographic context, there is a need to revisit the role of GAU within the hospital and the continuum of care. The objective of this project is to describe the range of activities offered by Quebec GAU and the resources available to them. In 2004, 64 managers of 71 GAU answered a mail questionnaire which included 119 items covering their unit's operation and resources in 2002-2003. The clinical and administrative characteristics of the clientele admitted during this period were obtained from the provincial database Med-Echo. The results were presented according to the geographical location of GAU, their size, their university academic affiliation, the composition of their medical staff, and their clinical care profile. Overall, GAU programs admitted 9% of all patients aged 65 years and older in the surveyed year. GAU patients presented one or more geriatric syndromes, including dementia. Based on their clientele, three distinct clinical care profiles of GAU were identified. Only 19% of GAU were focused on geriatric assessment and acute care management; 23% mainly offered rehabilitation care, and the others offered a mix of both types. Thus, there was a significant heterogeneity in GAU's operation. The GAU is at the cutting edge of geriatric services in hospital centres. Given the scarcity of these resources, it would be appropriate to better target the clientele that may benefit from them. Standardizing and promoting GAU's primary role in acute care must be reinforced. In order to meet the needs of the frail elderly not admitted in GAU, alternative care models centered on prevention of functional decline must be applied throughout all hospital wards.
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What drives public health professionals in their daily work? Presumably it is the appeal of working, either locally or globally, to alleviate the suffering caused by (preventable) ill-health. This article explores the political awareness of health professionals, the political implications of their daily activities and suggests an enhanced role for them in the battle against preventable ill-health worldwide. The starting point for this article is the motivating principles behind these professionals as individuals. It challenges established paradigms in health, medicine, development and academia with a focus on health professionals' political, ethical and ideological motivations and awareness plus the implications of their actions in the realm of global health in the future. It further has implications for the everyday practice of health care providers, public health practitioners, epidemiologists and social scientists in academia.
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In the current economy, employers are increasingly aware of the need to employ value-based purchasing strategies. Similar strategies can also be used by health care organization governing boards. Today, more health care providers are accepting positions at the boardroom table than in the past. These providers are well trained in the clinical aspects of health care but not the business of health care delivery. It is not surprising that providers often find themselves unprepared for a board member's role as a decision-maker and steward. It has become clear that education is essential to prepare providers for board positions.
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