Racial, ethnic, and economic disparities in the quality of hospital care in the United States continue to be a focus of national media and political attention. Clinicians are joining teams of social scientists representing various disciplines ranging from economics and demography to behavioral science and cultural anthropology to study the causes and effects of the uneven distribution of high-quality health care services. Reliable quantitative measurement tools remain elusive, often making experts' conclusions subject to questioning, and thereby contributing to political controversy and public confusion. Bruce Siegel, Deborah Bear, Ellie Andres, and Holly Mead have set out to create an index that could serve as a tool to facilitate more precise quantitative analysis of health care disparities. Their testing was conducted in hospitals, and the authors acknowledge its limitations in terms of its application to larger study samples such as community populations. Nonetheless, such an index is a potentially useful tool worthy of further testing.
Improving the efficiency of syndrome surveillance computer programs used in community health surveys is the subject of an important study reported by David C. Pattie, Martin J. Atherton, and Kenneth L. Cox. As an example of excessive "noise" in a community surveillance system, they point to the deceptively high volume of false-positive diagnoses that can result from complete reliance on clinical data that identify only the individual ICD-9 codes reflecting patients' symptoms. Instead, the authors propose developing Boolean algorithms to predict the laboratory-positive confirmation of a diagnosis while simultaneously ruling out the negative indicators of a diagnosis. For purposes of their study, they applied the Boolean approach to the Department of Defense electronic surveillance system for the early notification of community-based epidemics (ESSENCE), using a sample of patient records with DOD's influenza-like illness diagnostic classification. Their findings point toward a potentially useful way to enhance efficiency in a broadly applicable diagnostic system.
Robert J. Bepko, John R. Moore, and John R. Coleman report that 30% of all medication errors in hospitals occur during the administration phase of the medication distribution process. The introduction of robotics into the medication administration process is one of the strategies designed to ensure medication safety in the hospital. The authors argue for combining pharmacy robotics with digital practitioner order entry and bedside medication bar coding in the interest of reducing medication errors and were instrumental in setting up a plan for implementing such a system in a Connecticut hospital. They describe the steps involved in implementing their new medication management process from obtaining governing body support and administration approval to the bedside administration of bar-coded medications.
A fresh and provocative look at potential determinants of the quality of health care services is provided by Thomas R. Campion Jr and Cynthia S. Gadd. Using intensive insulin therapy (IIT) as an example, they present the sociological theory of institutional isomorphism as an explanation for the widespread adoption of any specific therapeutic approach in the absence of concrete evidence of its effectiveness. The theory suggests that, under pressure from regulatory agencies and in attempts to emulate successful peer organizations, an organization will strive to enhance its position by adopting what it perceives to be the norms and practices of the group to which it aspires to belong. In this case, that group would consist of the elite band of health care organizations that have adopted IIT. Campion and Gadd examine the adoption of IIT, despite the related high costs and unproven efficacy, as a possible manifestation of institutional isomorphism. They would warn health care organizations against falling into this dynamic.
In the light of decreases in hospital mortality during 2006 as reported by the Agency for Healthcare Research and Quality, Thomas K. Ross reexamines the achievements of the "100,000 Lives Campaign" initiated by the Institute for Healthcare Improvement. While he fully supports the campaign and points to its indisputable successes, he points out that analysis of the reported statistics raises some questions. The author argues that inability to verify the numbers of lives saved as a result of campaign-driven strategies points to ways in which future quality improvement efforts should be improved.
Product or service branding is not a topic we might expect to find in a journal devoted to studying and improving the determinants of quality in health care delivery systems. However, Roman Snihurowych, Felix Cornelius, and Volker Eric Amelung, in a fairly unusual take on health care quality, hold that health care service delivery can be improved through the application of certain branding strategies. The authors argue that patient-oriented branding measures may result in more transparent and efficient consumer choices, reduced costs, improved patient retention, better patient communication, and more appropriate services.
While health self-rating scales and reports are common, James E. Rohrer and Robert J. Stroebel point out that there have been relatively few studies of any relationship between levels of physical activity and self-rated general health. One problem has been the absence of an efficient way to measure the relationship between regular exercise and overall self-rated health in primary care patients. Using a sample of 939 patients, the authors studied the relationships among hard exercise; moderate exercise; several behavioral, lifestyle, demographic, and physical variables; and self-rated overall health. The conclusion was that exercise is related to better subjective health. In addition, the findings suggest that the total number of minutes of exercise per week may be more relevant than the number of exercise episodes per week.
An insight into quality management policies and procedures as implemented in an Israeli governmental hospital is provided by Yafa Haron. Haron reports on the related organizational restructuring and the development of a culture of quality. The hospital in question is certified by the International Standards Organization and is the first general hospital in Israel to have adopted the departmental model sponsored by the European Foundation for Quality Management. In the European Foundation for Quality Management model, each department and unit is autonomously responsible for its own quality. The author has provided an illuminating description of a working quality management system that shows similarities to and differences from that to which most American hospital personnel are accustomed.
Jean Gayton Carroll, PhD
Editor