In his essay, Irwin Press addresses the issues that may impede patient satisfaction with care in academic medical centers. He points to organization and plant size and complexity-the sometimes off-putting aura of expertise as well as a "heroic" attitude among practitioners, the research and teaching rather than direct care and bent, and the possibility that treatment may be administered at times by inexperienced staff. On the other hand, the author proceeds to outline what patients want. He offers some practical solutions for reconciling these 2 sets of attitudes and desires. He develops a "mandate" designed for the accomplishment of this goal.

Alemi and his coauthors search for a way to conduct patient satisfaction surveys in a more efficient and cost-effective manner and have developed and tested a 1-minute, 2-item postcard survey format. Their experience suggests a response rate between 34% and 77%, presumably resulting in reducing the need for and expense of mailing or telephoning follow-up reminders. They append the survey script, containing 1 closed-end item and 1 open-end item.

David Grembowski and his coauthors point out that the Institute of Medicine (IOM) has not presented models or methods for improving what it described as poorly designed health care delivery systems. Of particular interest to Health Maintenance Organizations is the fact that, although the IOM recommendations include new care processes, better information technology, and the alignment of provider payment with quality improvement, the IOM offered no methodological recommendations, and relatively little information is found in the literature about how these process changes would work in combination with one another. Group Health Cooperative's Access Initiative involves a set of 7 patient-centered reforms, designed for consistency with the IOM recommendations, in an integrated delivery system. Using time series study designs, the authors present an evaluation of the impact of Group Health Cooperative's Access Initiative.

Heibatollah Baghi explores the limitations imposed by relying solely on statistical probability and null-hypothesis testing in quality management research, and suggests the greater use of power analysis in the early stages of a study's design. She argues that using a combined approach, employing power analysis as a step in hypothesis testing, along with probability values, would be useful in designing quality assessment and improvement studies. She demonstrates the concept with a hypothetical proposed study design. She recommends that, in estimating experimental effects, not only the P value but also the [eta]² value be used to assess the significance of the findings.

Mediators may influence the suggested relationship between nurse staffing levels and patient outcomes. Maureen Anthony used a retrospective, correlational research design to analyze the role of nurse adherence to practice guidelines at the shift level in mediating outcomes in a sample of hypoglycemic inpatients in 2 hospitals-one an urban teaching institution and the other a nonteaching hospital. She points out that the data were collected from medical records, a problematic source of reliable information about the quality of care. What the author found was that, in this study, nurse staffing was not found to be related to adherence by professional nurses to practice guidelines in the treatment of hypoglycemia.

Timely access to needed care is a vital aspect of the quality of care and a reliable determinant of both patient and physician satisfaction levels. Maria T. Britto and her coauthors conducted a penetrating study involving 4 subspecialty clinics at a large tertiary care pediatric hospital in a midwestern city in the United States. The project's goal was to make new patient visit appointments within 7 days of the request or referral. The basic plan is an analytical study of supply, demand, and productivity. In phase 1 of the project, the teams studied the demand for initial appointments. Although the 4 clinics implemented the strategies designed to reduce waiting times and backlogs for the initial appointment, phase 1 results were disappointing. In phase 2 of the project, a study of availability of physicians supplying services (the "supply" component of the project), the teams studied clinic productivity. The principal conclusion in this phase was that the supply of physicians was inadequate. The authors conclude that the strategies shown to be effective in the area of primary care were not effective in an academic pediatric setting.

Increasingly, patients are using the Internet to acquire information (of varying levels of validity). Karen Homa, Karen E. Schifferdecker, and Virginia A. Reed undertook a study of the impact of specific Internet training on the behavior of health care providers and personnel. Their objective was to determine the extent to which staff and personnel who had attended an Internet health care resource training program transferred knowledge and skills to others in their respective practices. They report that certain elements of the Web training intervention may have created a spread of knowledge and skill, increasing opportunities for patient education. However, they conclude that expectations for the spread of skills in specific medical decision-making were not realized.

Hospital quality improvement departments have come a long way from the days when a single employee in the risk management department, which in itself often was a corner of the general counsel's office, was responsible for ensuring that "patient care audits" were performed in accordance with The Joint Commission standards. As Judith Perry-Ewald points out, the role and the scope of responsibilities have expanded almost exponentially. At the same time, hospitals complain of shortages of professionally qualified quality management staff. However, the author finds that few studies and reports have addressed the issues of workload and staffing in this vital part of the hospital organizational structure. In the course of reviewing quality management department staffing levels in her hospital system, Perry-Ewald conducted a series of informal surveys during 2004, 2006, and 2007, exploring staffing, workload, recruiting challenges, and the nature of responsibility levels in academic/tertiary care hospitals, community hospitals, and rural hospitals. Although the samples are small, the data collected provide a highly informative snapshot. The responses to the open-ended questions cast light on sources of discontent among the members of quality management departments. As Perry-Ewald notes, "[horizontal ellipsis] this was not a formal research project. However, this work, while informally conducted, raises some important issues for our profession about staffing standards and department operations" (Judith Perry-Ewald, personal communication, April 3, 2008).

In his article on monitoring time to the next medication error, James G. Miller responds to the tutorial by Cynthia Hovor and Cathy Walsh in the Fall 2007 issue of Quality Management in Health Care.1 Miller reevaluates the data used by Hovor and Walsh. He focuses on the incidents reported by Hovor and Walsh (written communication), showing how the analysis can be carried out with the use of a standard control chart for nonconforming items. He finds that the incidents reported by Hovor and Walsh are approximately Poisson distributed, whereas the time intervals between incidents are approximately exponentially distributed.

Jean Gayton Carroll, PhD

Editor

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