Continuous quality improvement in measure development: Lessons from building a novel clinical feedback system

Quality of Life Research - While the use of clinical feedback systems has become commonplace in psychological treatment, many of the most common instruments used for this purpose have not changed...     

新型触觉反馈装置的研制

研制一种生物反馈中的新型触觉反馈装置。该装置利用触觉似动现象，使人在进行生物反馈时具备触、视双重加工效能，放松程度高；此外，该装置反馈形式多样，患者喜爱，效果很好。     

Quality assurance of outcome in mental health care: a model for routine use in clinical settings.

A problem-oriented method of quality assurance of clinical outcome was used in 1,384 patients who were assessed and treated over 8 years by 41 nurse therapist trainees. The clinical audit suggested that for most diagnoses patients' improvement after treatment was usually satisfactory. Though the system was developed to monitor the progress of patients with anxiety, sexual and habit disorders having behavioural psychotherapy, it could also be applied to other disorders like depression and to other treatments. The method is simple enough for routine use, and computerisation would put it within the grasp of most clinics and training programs for all mental health care professionals.     

Performance indicators for public mental healthcare: a systematic international inventory

Background

The development and use of performance indicators (PI) in the field of public mental health care (PMHC) has increased rapidly in the last decade. To gain insight in the current state of PI for PMHC in nations and regions around the world, we conducted a structured review of publications in scientific peer-reviewed journals supplemented by a systematic inventory of PI published in policy documents by (non-) governmental organizations.

Methods

Publications on PI for PMHC were identified through database- and internet searches. Final selection was based on review of the full content of the publications. Publications were ordered by nation or region and chronologically. Individual PI were classified by development method, assessment level, care domain, performance dimension, diagnostic focus, and data source. Finally, the evidence on feasibility, data reliability, and content-, criterion-, and construct validity of the PI was evaluated.

Results

A total of 106 publications were included in the sample. The majority of the publications (n = 65) were peer-reviewed journal articles and 66 publications specifically dealt with performance of PMHC in the United States. The objectives of performance measurement vary widely from internal quality improvement to increasing transparency and accountability. The characteristics of 1480 unique PI were assessed. The majority of PI is based on stakeholder opinion, assesses care processes, is not specific to any diagnostic group, and utilizes administrative data sources. The targeted quality dimensions varied widely across and within nations depending on local professional or political definitions and interests. For all PI some evidence for the content validity and feasibility has been established. Data reliability, criterion- and construct validity have rarely been assessed. Only 18 publications on criterion validity were included. These show significant associations in the expected direction on the majority of PI, but mixed results on a noteworthy number of others.

Conclusions

PI have been developed for a broad range of care levels, domains, and quality dimensions of PMHC. To ensure their usefulness for the measurement of PMHC performance and advancement of transparency, accountability and quality improvement in PMHC, future research should focus on assessment of the psychometric properties of PI.     

User satisfaction with a real-time automated feedback system for general practitioners: a quantitative and qualitative study.

OBJECTIVE: The GRIF automated feedback system produces real-time comments on the appropriateness of diagnostic tests ordered by general practitioners (GPs) based on recommendations from accepted national and regional practice guidelines. We investigated the experiences of GPs with this system and, more specifically, with the recommendations produced by the system as well as their views on using this system in daily practice. SETTING: We tested the GRIF system in an experiment in a laboratory setting and in a daily practice trial. STUDY PARTICIPANTS: General practitioners. INTERVENTION: In the laboratory experiment, GPs used the GRIF system to assess the appropriateness of 30 request forms. Each of the GPs was confronted with requests they had submitted to the diagnostic unit of the hospital in the past. In the field trial, the GRIF system was applied during patient consultations for 1 year. MAIN OUTCOME MEASURES: We measured GPs' satisfaction with the system using a questionnaire, and also conducted group discussions (in the laboratory experiment) and in-depth interviews (in the field trial) to elicit GPs' opinions of and experiences with the system. In addition, we explored GPs' reasons for not accepting the comments offered by the GRIF system. RESULTS: The results show that the GPs in the laboratory experiment had more positive attitudes towards the system compared with participants in the field trial. All discussion groups and most of the GPs in the field trial regarded receiving the immediate feedback during the test ordering process as an important advantage. The most frequently mentioned reason to reject the recommendation was disagreement with the content and/or the recommendations in the practice guidelines. CONCLUSION: Apart from securing agreement on guideline content, a prerequisite for using GRIF in daily practice on a large scale is that more attention is paid to promotion of the guidelines and their adoption, and stimulation of a positive attitude towards the practice guidelines among the users.     

The Utrecht Health Project: Optimization of routine healthcare data for research

Background Research on the impact of changes in healthcare policy, developments in community and public health and determinants of health and disease during lifetime may effectively make use of routine healthcare data. These data, however, need to meet minimal criteria for quality and completeness. Research opportunities are further improved when routine data are supplemented with a standardized baseline assessment of the full population. This formed the basis for a new study initiated in a newly developed large residential area in Leidsche Rijn, part of the city of Utrecht, the Netherlands.Methods All new inhabitants are invited by their general practitioner to participate in the Utrecht Health Project (UHP). Informed consent is obtained and an individual health profile (IHP) is made by dedicated research nurses. The IHP is the starting point for the UHP research database as well as for the primary care electronic medical records. Follow-up data are collected through continuous linkage with the computerized medical files recorded by the general practitioners. UHP staff in each practice takes care of quality management of registration as well as data handling.Results Currently, over 60 of invited new residents in the area have given informed consent with participation steadily increasing.Discussion The Utrecht Health Project combines key elements of traditional epidemiologic cohort studies with the current power of routine electronic medical record keeping in primary care. The research approach optimizes routine health care data for use in scientific research.     

Strategic alliances in healthcare: opportunities for the Veterans Affairs healthcare system

Strategic alliances are proving to be effective strategies for responding and adapting to changing environments, and as such they offer the U.S. Department of Veterans Affairs (VA) healthcare system valuable opportunities for accomplishing the goals of its major reorganization effort. This article begins with an examination of basic strategic-alliance structures that are employed across many different types of industries. Next, consideration is given to the ways in which these basic alliance structures may be adapted to the unique organizations and individuals that serve as providers, purchasers, and consumers of health services. Finally, this article explores how models of strategic alliance in healthcare can be tailored to the specific needs and constraints of the VA healthcare system through an examination of existing and potential alliance opportunities.     

Utility of routine data sources for feedback on the quality of cancer care: an assessment based on clinical practice guidelines

Background  

Not all cancer patients receive state-of-the-art care and providing regular feedback to clinicians might reduce this problem. The purpose of this study was to assess the utility of various data sources in providing feedback on the quality of cancer care.     

Development of a diabetes mobile healthcare system and clinical application in China: a narrative review

Journal of Public Health - With the rapid development and spread of information technology, mobile healthcare (M-healthcare) is emerging as a feasible option for improved monitoring and treatment...     

Initial development of the Temporary Utilities Index: a multiattribute system for classifying the functional health impact of diagnostic testing

Purpose  

The effects of testing and screening on quality of life may influence the future behavior of society, but have not been quantified. We derived a health classification and survey items for the morbidities of testing and screening, to be the foundation of a multiattribute utility instrument, the Temporary Utilities Index.     

Redesigning a national healthcare system: the Israeli experience

In 1988 the Government of Israel appointed a Commission of Inquiry (of which the authors were members) to examine the state of its health-care services. Although relating to Israel, some of the problems contributing to the crisis in the health services are shared by other industrialized nations. In 1991 the findings and recommendations of the Commission were adopted by the Government. They related to the major problem areas analysed by the Commission: poor standard of service to the public; health ministry structure and performance; funding and budgeting; poor labour relations in the public health sector; surplus of physicians; mix of public and private health care; shortage of qualified health-care managers. The main recommendations adopted were: legislation for compulsory health insurance (due to be effective on 1 January 1995), establishing a National Health Authority, running of hospitals by autonomous corporations and reform in salary structure.     

Progression of strategies used by a healthcare system preparing for healthcare reform: past and present

Strategies used by CaroMont Health to improve quality, decrease cost, and increase operational efficiency have ultimately aligned our system to address the present and future challenges confronting healthcare. Beginning with To Err is Human (Institute of Medicine 1999) and continuing with the healthcare reform bill of 2010, CaroMont Health has responded to challenges by striving to provide excellent patient care in a cost-effective manner. In this journey, CaroMont has discovered several key success factors essential in navigating this transformation. Our strategies reinforce the fact that improved quality and patient outcomes will ultimately reduce overall healthcare costs. In an ongoing collaboration with the Premier healthcare alliance, CaroMont Health has evolved from focusing on process metrics to delivering value-based care. CaroMont is now positioned to enter the new world of value-based delivery leading to accountability for community health.     

The sustainability of Canada's healthcare system: a framework for advancing the debate

The debate of whether Canada's healthcare system is sustainable is mired in ideology. This paper offers a framework that takes us beyond the ideological standoff with a process to deal ethically with the issue of the sustainability of publicly funded healthcare.     

Assessing the effectiveness of mental health care in routine clinical practice. Characteristics, development, and uses of patient outcomes modules

The health care delivery system faces continually increasing pressure to be accountable for the historically unparalleled amount of resources it utilizes. This article discusses one set of recently developed tools known as outcomes modules that are used to assess how treatment affects outcomes in patients with a given disorder. These tools currently are being used to inform administrative decisions about how to improve the quality of care, and can potentially influence decisions by patients, providers, and payers of care as well. The critical components of outcomes modules, as well as their administration and applications are described, using modules for psychiatric conditions as examples.     

The impact of copayments on mental healthcare utilization: a natural experiment

Empirical evidence suggests that people are fairly sensitive to cost sharing arrangements in ambulatory mental healthcare. However, pure cost sharing effects are typically hard to measure due to the presence of adverse selection effects. In this paper, we examine the impact of cost sharing on mental healthcare utilization in the context of mandatory health insurance where adverse selection is absent. Using a large proprietary dataset of a Dutch private health insurer, we examine to what extent a new copayment scheme for adult mental healthcare changed healthcare utilization. We exploit the fact that non-adults are exempted from copayments. First, we compare changes in utilization among adults and non-adults using t tests and a difference-in-difference analysis. Second, we highlight differential changes in mental healthcare utilization by treatment (duration and type of mental illness) and individual characteristics (gender and socioeconomic status). Third, we evaluate to what extent anticipatory behavior occurred pending the introduction and subsequent repeal of the new copayment scheme. Our results show a strong and significant (p < 0.01) decrease in outpatient secondary mental healthcare utilization among adults following the introduction of copayments, which is absent among non-adults. This decrease is concentrated among treatments for less severe mental illnesses. Furthermore, the utilization patterns suggest the presence of anticipatory behavior.