Evaluation Health Care Quality - Science topic

Let me approach this question from a different perspective.

Clinical Practice Guidelines, Protocols, and Policies and Procedures are generally in the category of the so-called soft laws or norms. Soft norm refers to some quasi-legal instruments, rules or guidelines of behaviour that are neither strictly binding in nature nor completely lacking legal significance such as non-binding resolutions, declarations, and guidelines created by governments and private organizations.

Those various kinds of quasi-legal instruments, within the context of the healthcare sector, may include guidelines, policy declarations, or codes of conduct that set standards of conduct couched in the normative moods. Soft norms are usually not directly binding or enforceable in accordance with formal techniques of international law but are capable of exerting a powerful influence over the behaviour of the parties to which it applies. Soft norm is not an alternative to the ‘traditional’ lawmaking, but rather, a complement to it. It is fast becoming a major ‘legalisation form’ of the norm-like activities of private and public-private crossbreed authorities where the new type of informal soft norm has come to be primarily relied on by such authorities owing to its flexible and context-dependent nature.

Soft norms are preferred for a variety of reasons. For instance, it is preferred to solve straightforward situations in which the existence of a focal point is enough to generate compliance, or loss avoidance theory, where a non-compliance with a hard law could attract higher sanctions to deter more violations. Soft-law instruments cope better with diversity and provide greater flexibility to cope with uncertainty and allow for adjustments over time. Therefore, soft-norm instruments are easier to negotiate, less costly, and allow parties to be more ambitious and engage in “deeper” cooperation than they would if they had to worry about enforcement.

Conversely, hard law refers generally to legal obligations that are legally binding on, and therefore, enforceable by the parties involved before a court. Generally, hard-law instruments allow parties to commit themselves more credibly to agreements, to avoid the increased cost of reneging due to sanctions. Hard-law instruments have direct legal effects and create mechanisms for the interpretation of the legal commitments, and for enforcement of commitments through either courts or alternative dispute-settlement bodies.

It may seem to be a good question to ask, why adopting a “soft norm” while we already have the hard law. Critics of hard law have raised a number of significant issues. For instance, hard law tends to be set of fixed rules, for universal application, presupposes a prior knowledge, and is difficult to change. While on the other hand, soft norms allow for flexibility, diversity, experimentation and adjustments, and internalization of the hard laws themselves in order to ease in enforcement and to achieve an optimal outcome.

In the contemporary situation that needs flexible compliance with, and enforcement of the laws to achieve maximum results, the application of a hybrid of soft and hard law would seem imperative. Soft norms, by their design, encourage adherence to the standards and allows for substantial flexibility in methods to reach sustainability that fit with their institutional needs and peculiarities, supplementing the hard law that includes a set of fixed rules that define what constitutes a wrongful act and provides sanctions for noncompliance with these rules serving as deterrents.

Coming back to your question as to which one of Clinical Practice Guidelines, Protocols, or Policies and Procedures is preferred, I would say that they all the same in terms of legal weight. Although under some jurisdiction they do not form a legal weight, it is still used as a base fr establishing the legal duty of care, and the standard of care before finally deciding if the health professional is liable in negligence. For instance, see Bolam v Friern Hospital Management Committee [1957] 1 WLR 583 under the UK jurisdiction. Under some other jurisdictions, non-compliance with Clinical Practice Guidelines, Protocols, or Policies and Procedures could carry legal liability (See Article 31 of the Saudi Law on Practicing Healthcare Professions). It is an offence to violate relevant codes of practice or acts contrary to professional conduct or ethics, which could attract disciplinary action that includes a warning, fine (up to 10,000 riyals or revocation of licence Article 33).

While I did not specifically answer your question, I thought it is an opportunity to give a different perspective o the question.

Hi All,

I'm also looking for APACHE IV score calculation with coefficients in any kind of programming language.

Good question. Related with my work. So following....

Thanks

There are a number of reasons that I can highlight:

1. Community organisations are directly in touch with grassroots communities, which make it easier for researchers to recruit research participants while statutory health organisations function within the rigid delivery systems of government;

2. Sometimes funding for research in contexts where government is less trusted is channelled directly to communities with the support of NGO structures. This enables researchers and donors to quickly achieve results and avoid red tape in statutory organisations. 

3. Communities are sometimes unaware of their rights as research subjects vs statutory organisations. While this may sound exploitative and extractionist, researchers find it easy to gather through communities and community organisations rather than restrictive conditions sometimes imposed statutory organisations. 

4. Research in statutory is usually conducted in a manner where standard operational tools (data collection instruments) are the ones used within standard care systems which makes it difficult to design studies outside the statutory organisations framework. This is usually done to ensure that the collected data fits within government analysis frameworks. Therefore to avoid this, community organisations provide an option for researchers to use own research tools adapted to the community context. 

5. First, there is increased trend of evidence based interventions and a push to build in research in NGOs and CBOs so that their work contributes to knowledge generation. Second, implementation research has been recently identified as an important way of conducting research, which means the day to day work of CBOs in communities provide this research space. 

Repeated time to event analysis with censoring would seem to me be a possible option. 

What a wonderful line of questioning. There's much published on the topic, such as perceptions of nursing care quality from different perspectives- patients, nurses' and institutions.  More recently, I've seen social identity and patients perception's of nursing care quality discussed. What peaks your curiosity in this area?

Dear Vikal, are you a social scientist or a medical scientist. If the former, are you interested in marketing or production these can help better in conceptualizing and tool choice for your research.  For example marketing research for customer satisfaction is benchmarked against customer expectations( itself multifactorially decided in physical, social, technology state and economic terms) of returns on sum total cost monetary and non monetary, physical, social and even mental or psychological cost of seeking care.  In this model it is not difficult to get a low expectant satisfied customer even when medical care is less than desirable.  So define more precisely your interest and the tool will be clearer

Hi Pricivel,

Thanks a lot for your answer. I will look at these resources as well.

Kind regards,

Ahmet,

Hello Claus

   I am not aware of any such studies but I work at a retail pharmacy in a medical building and we have a diabetes center in the building staffed by nurses and dietitians that are certified diabetes educators. Both pharmacists on staff are certified in diabetes management.. Patients can only be seen at the diabetes center with an appointment but we can see them at the pharmacy whenever is convenient for them by appointment or as walk-ins. We have not done any studies comparing participant satisfaction levels between on demand services and standard appointment based services.

Dear Bounmy, I agree with the previous answers. It is possible, but needs some carefully consideration of possible implications for measurement and data analysis.As Dean already mentioned, a lot of social and health-related behavior is rather a behavioral category than a single behavior (e.g. "exercising"). You can aggregate your constructs (1)-(3) in a single behavior labelled "providing care to patients by a health care professional". In my opinion it is of prevailing importance to clearly define the behavioral category in terms of your intended constructs. You need to ensure that all study participants have the same understanding of the behavior under investigation. 

However, I recommend to study Fishbein & Ajzen's recent book: Predicting and Changing Behavior (2010). The authors discuss the role of "behavioral categories" in detail.

Hi Aleef,

Good to see you after a long time. The mobilization of patients with EVD is very limited. In my practice setting as soon as the ICP is controlled the neurosurgeon allows us to clamp the EVD so we can start mobilizing the patient.  As long as the EVD is not clamped the mobilization of patient is limited to ROM only. Please email me at arshal.thomas@stmarysofmichigan.org.

Thank you,

Arshal Thomas.

This article may help

Hibbard JH, Collins PA, Mahoney E, Baker LH. The development and testing of a measure assessing clinician beliefs about patient self-management. Health Expect. 2009;13:65–72.

The difference is Theoretical, if you assume that your construct is reflective it cant be formative. Is important not to rely only on statistics, but in the theoretical assumptions underlying the construct.

Hello Jean 

I wish if this can help with kind regards.

Nurse Level of Education, Quality of Care and Patient Safety in the Medical and Surgical Wards in Malaysian Private Hospitals: A Cross-sectional Study.

Global journal of health science 04/2015; 7(6):331-337. DOI: 10.5539/gjhs.v7n6p331.

Mr Kumorotomo good morning,

I believe you could find the attached file helpful.  Good luck in your struggle.

Thank you everyone for responding to my question. All your comments are gratefully appreciated. Muhd Abdullah, I will be attending ISQua in Doha in Oct. I have attended all the ISQua conferences since 2005. I am an ISQua surveyor and have done 5 organizational surveys around the world in the past 3 years and will be doing my 6th in June. Mike, thank you for introducing me to Kieran Walshe (I bought the book) and your very thoughtful response, which I am still digesting. Ariel, you seem to be suggesting a conceptual framework for accreditation. Ibrahim, thank you for recommending Pomey. I have read several of her articles but not that one. Mariana, I have looked at TQM and the transition of accreditation to CQI. I want to peel the onion further. I had the pleasure of visiting Brazil twice last year - in June to survey one of Brazil’s national accreditation agencies and in October to attend the ISQua conference in Rio. Smitha, thank you for your suggestion to look at KPIs and PDCA/PDSA. I live in Jordan and visit the UAE quite often. Again, thanks to everyone.

Thank you all for your input this has help lead me in the correct direction of rewording and addressing PAs in the field of healthcare, until i started doing more research i was unaware that there is only 30,402 PA's in primary care that is 43% and this number has only rose from 1975 when there was only 200 practicing PA's nationwide, i am looking at linking them to the state of Indiana state run healthcare program.

A graduate student of mine and I analyzed ambulance log data and hospital ER statistics to determine the effect of ER capacity on ambulance crew and patient waiting times. Some  variables of interest were: 1) waiting time from arrival to admission to ER bed; 2) ambulance diversions due to ER capacity limitations; and 3) ER capacity measures. Ambulance log data should be available from the emergency transportation provider and hospital ER measures are usually avialable form the ERs.

The U.S. agency AHRQ developed HCAHPS. It is a blend of experience of care, satisfaction, and quality of care indicators. The instrument is in the public domain and it has been in use long enough to have comparative information also available. 

Unfortunately, NICE guidelines are related to "definite drug in a particular condition" and are therefore very often incomplete, as they expect the manufacturer of the product to prove that there are 'better' outcomes leading to approval of that particular drug's availability in the NHS schema. It is more of equitable treatment of the common man!

Hi Mary, 

No doubt your work sounds interesting. May I point out something simple regarding it suggest a few materials for you, i.e. if you do not have them already. My feeling is that, your work fits into the general urban-rural migration opus. Thus I suggest a few recent materials in the area to help you ground your work in the extant studies.

*Stockdale, A., & Catney, G. (2014). A life course perspective on urban–rural migration: the importance of the local context. Population, Space and Place, 20(1), 83-98.

Rérat, P. (2014). Highly qualified rural youth: why do young graduates return to their home region?. Children's Geographies, 12(1), 70-86.

Ango, A. K., Ibrahim, S. A., & AA, Y. (2014). Impact of youth rural-urban migration on household economy and crop production: A case study of Sokoto metropolitan areas, Sokoto State, North-Western Nigeria. Journal of Agricultural Extension and Rural Development, 6(4).

Gray, D., Chau, S., Huerta, T., & Frankish, J. (2011). Urban-Rural Migration and Health and Quality of Life in Homeless People. Journal of Social Distress and the Homeless, 20(1-2), 75-93.

All the best.

Hi Jomma,

There's an amount of varying level evidence on NIV and nursing in general (I've listed some, below) but the first ones relate to nursing perceptions:

Practical wisdom: a qualitative study of the care and management of non-invasive ventilation patients by experienced intensive care nurses.

Non-invasive ventilation outside the Intensive Care Unit for acute respiratory failure: the perspective of the general ward nurses.

Nurse-patient collaboration: a grounded theory study of patients with chronic obstructive pulmonary disease on non-invasive ventilation.

Check also "related citations" or "cited by" for these papers.

Best of luck,

Anne

Noninvasive positive pressure ventilation: an ABC approach for advanced nursing in emergency departments and acute care settings. : http://www.ncbi.nlm.nih.gov/pubmed/19855200

Delivering non-invasive respiratory support to patients in hospital.

The utility and futility of non-invasive ventilation in non-designated areas: can critical care outreach nurses influence practice?: http://www.ncbi.nlm.nih.gov/pubmed/21665473

The implementation of a nurse-provided, ward-based bilevel non-invasive ventilation service: http://www.ncbi.nlm.nih.gov/pubmed/15869065

[The critical role of the nurse in successful non-invasive ventilation in acute respiratory failure]. (article in French): http://www.ncbi.nlm.nih.gov/pubmed/22372113

Emergency nurse responsibilities for mechanical ventilation: a national survey.

Non-invasive BiPAP--implementation of a new service. http://www.ncbi.nlm.nih.gov/pubmed/12526869

Introducing non-invasive positive pressure ventilation. http://www.ncbi.nlm.nih.gov/pubmed/12216238

Using non-invasive ventilation in acute wards: Part 1.  http://www.ncbi.nlm.nih.gov/pubmed/14533250

Using non-invasive ventilation in acute wards: Part 2.  http://www.ncbi.nlm.nih.gov/pubmed/14596218

Using non-invasive ventilation on acute wards: how to provide an effective service.

The impact of different nursing skill mix models on patient outcomes in a respiratory care center. http://www.ncbi.nlm.nih.gov/pubmed/22489996

The benefits of non-invasive ventilation and CPAP therapy.

Cochrane: Non-invasive ventilation for cystic fibrosis.  http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002769.pub4/abstract

Acute exacerbation of COPD: nursing application of evidence-based guidelines.

Non-invasive ventilation in COPD. 2: Starting and monitoring NIV.

General protocols: Protocols for and training on noninvasive positive pressure ventilation in emergency departments.

In a very, very basic search across Medline, Embase and PsycInfo, I did a search with precede adjacent to proceed and survey.  Attached is a Word file with 32 citations that might help.  Duplicates have been removed.

I hope this helps.

ALS meets these criteria, but there are opportunity costs for the time and physical effort entailed in data collection. Patients and caregivers would rightly ask what's in it for them. High-burden diseases for which we lack even moderately efficacious therapy, unlike the two above, will all fall into this category, because things haven't gone far enough to warrant PROs as endpoints.  

I give this negative answer only to point out the huge gap between much QoL research and the real sufferer world, and encourage those of you doing QoL to earn impact at the point of care. 

Dear Shaikh, sorry, I didn't mean to offend you, but are you really serious about this question? You must be not be surprised if you get no answer to such a question. The first step would be to search on Google or Wikipedia. This search brings you the first clues and hints for further research. Kind regards.

Not-for-profit organisations such as public hospitals are distinguished from profit maximising organisations by two characteristics:

1) Public health organisations do not have external shareholders providing risk capital for the business. They do not distribute dividends, so any profit (or surplus) that is generated is retained by the business as a further source of capital.

2) Such organisations usually include a socially responsible (and welfare) dimension, which would not be readily provided efficiently through the workings of the market system.

In a nutshell, a public health organisation should ideally provide value for money service for tax payers. A successful performance is based on the 3Es: Economy; Efficiency and Effectiveness.

This is SO true. I also suspect some of their "recommendations" are market driven, not patient, and CERTAINLY NOT cost containment oriented..

Technically, the difference is that reflective maesures are expected to have high inter-correlations. This is what one usually tests with exploratory or confirmatory factor analysis. Also, the very common Cronbach's alpha measures unidimensionality of a scale by inter-correlations. The measure scan literally be said to "reflect" the latent variable. Most personality scales are constructed as reflective.

Formative measures are not expected to correlate. They can be thought of having "formed" the latent property in the past. As a purely fictional example: development of mathematical skills depends on the analytical thinking and reading abilities. But, the two preconditions are not causally related, such that we would not expect a strong correlation between the two.

To my knowledge, the concepts are most common in path modelling using the partial least square approach. For a real example see [1].

[1] Christophersen, T. and Konradt, U. Development and validation of a formative and a reflective measure for the assessment of online store usability. Behaviour & Information Technology 31, 9 (2012), 839–857.

Hi Mohammad. Very interesting question and great discussion. In Germany regulatory bodies are discussing the inclusion of preference studies in healthcare decision making. The discussion started with the introduction of the efficiency frontier to make pricing decisions for pharmaceuticals. The problem was, that multiple clinical endpoints (decision criteria) might be used to make these decisions. Multiple decision criteria might lead to contradicting decision. Therefore the question arose how to identify patient relevant endpoints, how to weight the identified endpoints and how to aggregate multiple decision criteria into a single metric (describing patients benefit). Two pilot studies have been conducted. One study used AHP and the other study used Discrete-choice analysis in order to support this approach by eliciting patient preferences. If it comes to public or patient participation in healthcare decision making, the Discrete-choice experiment seems to be an appropriate quantitative method to analyze public or patients preferences.