Methodology employed in measuring and evaluating the level of quality in organized health care is the basic theme addressed by several of the authors whose work is reported here. Duncan Neuhauser and Lloyd Provost kick off the discussion by going back a few decades to reexamine the seminal contributions Pearson and Gossett made in the interest of reducing guesswork in evaluation.
Patients' reviews of providers' performance have become an online staple. Farrokh Alemi and his coauthors point to the need for providers to conduct speedy, efficient, and reliable analysis of the underlying meanings of patients' responses to satisfaction questionnaires. They present the process of sentiment analysis of patients' comments, involving pattern recognition, as an effective way to reveal and assess the respondent's reaction to his or her medical encounter. They submit that the use of sentiment analysis, based on the recognition and analysis of language and vocabulary patterns in patients' satisfaction survey responses, can significantly shorten the time needed to process and analyze the results of surveys, facilitating the analysis of increasingly larger samples.
The objective of the quality improvement project on which Ranjit Chima and his colleagues report was to reduce the incidence of hypoglycemia in critically ill, nondiabetic children with hypoglycemia through the use of a guideline for the management of symptomatic hypoglycemia in this population. The authors found that implementation of the protocol for the management of critical illness hypoglycemia in nondiabetic, critically ill children was not only associated with a reduction in hypoglycemic events, but also associated with an increase in adherence to glucose checks. The authors acknowledge that, while timely adherence to a guideline and glucose checks may help to avoid hypoglycemia in critically ill children, their results may not be universally generalizable, because not all hospitals use electronic medical records or use "trigger tool" methods to identify adverse events.
It is commonly recognized that long waits in the emergency department (ER) or other entry locations before inpatient admission for definitive treatment are often the result of inpatient bed shortages that may, in turn, be related to the community's lack of continuing care facilities. Stephen Duckett and Cheri Nijsen-Jordan state that the Province of Alberta, Canada, had seen a steady decline in hospital timeliness in dealing with emergency patients over an 8-year period. Several factors were at work here, and developing a lasting solution would involve a system-wide structural reorganization. Designing and implementing a plan for facilitating inpatient admission where it is clinically indicated involved 2 measures of hospital performance: the waiting times of patients who would be discharged home and those who would be admitted as inpatients. Targets for the length of time spent in the ER were established for both groups, and compliance levels were set. A major factor in extending waiting times was the sluggish flow of patients requiring inpatient admission from ER beds to ward beds. This condition, in turn, was in large part related to the community's and province's relative lack of extended care facilities, limiting the hospital's ability to move patients whose treatment had been completed out of the hospital's ward beds and into continuing care facilities. The authors summarize the strategies that are in process to facilitate needed systemic change.
Another take on managing and controlling the time spent by patients awaiting treatment in a hospital is reported by Johan Hansson and his colleagues. The base for their qualitative case study, employing the Pettigrew and Whipp model, was a Swedish teaching hospital. The authors point to factors that may dilute the quality of much of the research on improving wait management, such as the observational nature of many of the studies reported in the literature and the paucity of objective data in some countries. They found that commitment of the top-down management to the objective and assigning high priority to the production aspects of the improvement effort were among the factors contributing to change.
A significant volume of nonemergency medical care is moving out of physician-staffed medical office clinics into retail walk-in clinics staffed by nurse practitioners. At the same time, the rate of early return visits for the same diagnosis is often tracked as an important factor in measuring the quality of the patient care outcome. With a study sample of pediatric patients diagnosed with otitis media, Rohrer, Garrison, and Angstman present a comparison of the rates of 2-week return visits to retail walk-in clinics and standard office facilities. They found that patients seen in the standard office setting had a higher 2-week return rate than the patients seen in the retail model clinics. The authors acknowledge that their study involved retail clinics and standard offices that belong to the same health care system, sharing an electronic medical record system. They point out that while this circumstance makes comparisons fairly easy, it is not commonly found.
A qualitative research design was employed by Airica Steed in her exploration of the leadership qualities that are necessary to facilitate and support the use of the Toyota Production System (TPS) lean strategies in health care organizations. The author found that the literature addressing the application of lean tools to health care organizations provides little analysis of the leadership characteristics that are evident in successful implementations. In the course of her research, she finds a combination of leadership attributes and strategies that could serve health care leaders in their application of lean methodology.
To me, one of the most interesting passages reported by Karolina Peltomaa in her interview of James Reason is his discussion of the practice he calls "working around." "Working around" describes the adjustments, compensations, and improvisations carried out by workers to overcome the obstacles presented by the system within which they must function. As he comments, nurses in particular like to work around system-dictated features that are perceived as interfering with clinical patient care. In the nonmedical world, we have all seen the experienced skilled worker who enjoys a professional challenge and uses his or her ingenuity to circumvent what he or she sees as an inconveniently rigid system in order to attain a satisfactory outcome. If the ad hoc solution works, and supervisors find no fault, over time the improvisation supplants the prescribed procedure. Reason suggests the undesired consequences that may follow that development.
-Jean Gayton Carroll, PhD
Editor