The Joint Commission journal on quality improvement
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Jt Comm J Qual Improv · Jun 1998
The "door-to-needle blitz" in acute myocardial infarction: the impact of a CQI project.
A continuous quality improvement (CQI) project was conducted at Soroka Medical Center in Beer-Sheva, Israel, in an effort to identify and address causes of delays in thrombolytic therapy in patients arriving at a high-volume (160,000 patients per year) emergency department with acute myocardial infarction and thereby reduce the "door-to-needle time" (DTNT). The study had four phases: preintervention survey, peri-intervention process redesign, postintervention evaluation, and follow-up evaluation. CQI TEAM: The CQI team followed a seven-step protocol: problem definition, present-state screening, factors analysis, solution development, outcome evaluation, standardization, and conclusions. ⋯ Results suggest that the 30-minute DTNT suggested by the American College of Cardiology/American Heart Association is appropriate for patients with a clear diagnosis and no contraindications for thrombolysis, but when the risk-benefit ratio of thrombolytic therapy raises concerns, a 45- to 60-minute DTNT may still be acceptable. Further CQI projects should address technical triage of simple cases and clinical estimation of risk-benefit ratio in complicated patients.
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Jt Comm J Qual Improv · May 1998
ReviewQuality management in medical specialties: the use of channels and dikes in improving health care in The Netherlands.
In 1989 a Dutch national policy was instituted to ensure that quality management is the responsibility of both health care professionals and management, with input from insurers and patients. In turn, quality management of medical specialists remained to a large extent self-regulatory, with accountability toward third-party payers and patients. Three programs for quality management-peer review, guidelines, and visitation-have sufficiently persuaded patient organizations and care insurers about medical specialists' ability to ensure the quality of the care they provide. ⋯ Profession-driven peer review, practice guidelines, and visitation programs have been effective support tools for quality management in The Netherlands. Future challenges involve creating more synergy among these programs and between the profession-based quality management approaches and recently introduced hospital-based quality systems and maintaining the trust between third-party payers and patients.
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Jt Comm J Qual Improv · Nov 1997
ReviewUsing continuous quality improvement to improve diabetes care in populations: the IDEAL model. Improving care for Diabetics through Empowerment Active collaboration and Leadership.
The care of patients with chronic diseases, especially those with diabetes mellitus, has been less than ideal. However, despite clear national guidelines, various examples of better care models, and multiple attempts to improve care, an effective process for facilitating and replicating diabetes care improvements in typical primary care practices has been elusive. ⋯ The IDEAL model holds promise for substantial improvements in care, not only for diabetes but for all chronic diseases and for other settings.
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Jt Comm J Qual Improv · May 1997
Measuring and averting underuse of necessary cardiac procedures: a summary of results and future directions.
Attempting to explain the marked variation in utilization of medical procedures has vexed health policy analysts for nearly three decades. Most health services research to date has been directed at identifying and reducing excessive utilization. Little attention has been given to underuse of care. THE LOS ANGELES CARDIAC UNDERUSE PROJECT OVERVIEW: A research group at the University of California, Los Angeles (UCLA), performed two separate, published studies seeking to measure underuse of coronary angiography and coronary artery revascu-larization (bypass surgery and angioplasty), two critical links in the chain of care leading from initial diagnosis of coronary artery disease to definitive treatment. In each study, the necessity criteria developed by the panel were used to identify patients needing an invasive procedure. ⋯ Despite limitations of the method, detection of underuse is feasible, valid, and affordable in the context of overall health care expenditures. Moreover, the case for implementing "underuse prevention" systems is increasingly compelling. Measuring and disseminating data on underuse of expensive but highly beneficial procedures would provide health care consumers (patients and employers) with useful information and enable health care providers to develop quality improvement strategies aimed at rational use of health care resources.
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Reengineering, involving the radical redesign of business processes, has been used successfully in a variety of health care settings. In 1994 New York University (NYU) Medical Center (MC) launched its first reengineering team, whose purpose was to redesign the entire process of caring for patients-from referral to discharge-on the cardiovascular (CV) surgery service. REENIGINEERING TEAM: The multidisciplinary CV Surgery Reengineering Team was charged with two goals: improving customer (patient, family, and referring physician) satisfaction and improving profitability. The methodology to be used was based on a reengineering philosophy-discarding basic assumptions and designing the patient care process from the ground up. THE TRANSFER-IN INITIATIVE: A survey of NYU cardiologists, distributed in April 1994, suggested that the organization was considered a difficult place to transfer patients. The team's recommendations led to a new, streamlined transfer-in policy. The average waiting time from when a referring physician requested a patient transfer and the time when an NYUMC physician accepted the transfer decreased from an average of 9 hours under the old system to immediate acceptance. ⋯ For the first time at NYUMC, a multidisciplinary team was given the mandate to achieve major changes in an entire patient care process. Similar projects are now underway.