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The residents and relatives committee is an area for exchange and expression concerning the running of the facility or unit caring for a resident. It is an important body which places the user at its centre but which can however reveal disparities in the way it operates.

Nursing performance measures are an integral part of quality initiatives in acute care; however, organizations face numerous challenges in developing infrastructures to support quality improvement processes and timely dissemination of outcomes data. At the Hospital of the University of Pennsylvania, a Magnet-designated organization, extensive work has been conducted to incorporate nursing-related outcomes in the organization's quality plan and to integrate roles for clinical nurses into the Department of Nursing and organization's core performance-based programs. Content and strategies that promote active involvement of nurses and prepare them to be competent and confident stakeholders in quality initiatives are presented. Engaging clinical nurses in the work of quality and performance improvement is essential to achieving excellence in clinical care. It is important to have structures and processes in place to bring meaningful data to the bedside; however, it is equally important to incorporate outcomes into practice. When nurses are educated about performance and quality measures, are engaged in identifying outcomes and collecting meaningful data, are active participants in disseminating quality reports, and are able to recognize the value of these activities, data become one with practice.

In the U.S. today, the pathologists, both hospital-based and forensic, are regularly involved in quality assurance (QA) programs, the evaluation of patient safety at all levels of medical care, including treatments in walk-in clinics and medical offices. In the United States, official death investigations are conducted by the Medical Examiner's Office. The Medical Examiner's Office is aided in its work by a network of coordinating agencies to provide complete, comprehensive reporting and investigation of deaths placed under its jurisdiction. Those agencies are the Health Department, the Registrar of Vital Statistics on Births and Deaths, Division of Health Facilities, the Hospital Office of Decedent Affairs and the State medical licensing agencies, as well as the various law enforcement and regulatory agencies and the prosecuting attorney's office. Forensic pathologists are witnesses to the fatal results of often avoidable untoward events. They need to use their experiences to address and emphasize overall prevention programs to improve the quality of life in the community, to publicize the avoidable actions which can lead to untoward results. In the current growing atmosphere of threatening chemical, biological and radiation terrorist attacks, the health care system, especially hospitals, including emergency services, are mobilizing to develop plans to meet possible anticipated need for disaster preparedness.

Objectives: To describe how well the problems detected by a quality improvement plan (QIP) for a health care team (HCT) were solved; and to analyse the identification methods, the quality causes and dimensions affected by the problems detected, and the participation of professionals., Design: Descriptive study. Evaluation of the situation in December 2004 of the problems identified since 1989., Setting: Urban HCT, with 58 professionals caring for a population of 18,897 inhabitants in the La Mina District, Barcelona, Spain., Participants: Five-hundred and thirty problems identified., Main Measurements: Number and kind of detections and problems; identification methods; quality dimensions; causes; degree of solution, by method and cause; degree of solution of the QIP (of "internal" problems, excluding the problems caused externally or by patients); professional participation., Results: In 312 meetings, there were 963 detections (annual average, 60.1; SD, 18.8), corresponding to 530 problems (annual average, 33.1; SD, 12.4). Of these 530 problems, 411 improved (77.5%). Of the 258 "internal" problems, 225 improved. The degree of solution of the QIP was 87.2%. The identification method that detected most problems (53.02% of the total) was the active listening of the quality improvement group. The quality dimensions most affected by the problems were effectiveness (31.7%) and accessibility (20.4%). The most frequent cause of problems and, at the same time, the category with the highest improvement rate (81.6%) was internal organization; 83.9% of professionals took part in the QIP., Conclusions: Having a QIP at our centre facilitated the management of the quality of care delivery.

Blood transfusion is still an important procedure in modern medical practice despite efforts to avoid it. This is due to it's association with infections especially HIV. It is therefore necessary to have proper quality control of its production, storage and usage [1]. A way of controlling usage is to do regular clinical audit. To effect this, there has to be an agreed standard for appropriate use of blood. The aim of this paper is to briefly highlight the importance of audit, audit procedures and tools i.e. required records, development of audit criteria and audit parameters. Every hospital/blood transfusion center is expected to develop a system of audit that is appropriate to its needs. The suggestions are mainly based on the experience at the Lagos University Teaching Hospital and the Lagos State Blood Transfusion Service.

Problem: When patient safety programs were mandated for Japanese health care institutions, a safety culture, a tool for collecting incident reports, an organizational arrangement for multidisciplinary collaboration, and interventional methods for improvement had to be established., Design: Observational study of effects of new patient safety programs., Setting: Osaka University Hospital, a large government-run teaching hospital., Strategy for Change: A voluntary and anonymous web-based incident reporting system was introduced. For the new organizational structure a clinical risk management committee, a department of clinical quality management, and area clinical risk managers were established with their respective roles clearly defined to advance the plan-do-study-act cycle and to integrate efforts. For preventive action, alert procedures, staff education, ward rounds by peers, a system oriented approach for reducing errors, and various feedback channels were introduced., Effects of Change: Continuous incident reporting by all hospital staff has been observed since the introduction of the new system. Several error inducing situations have been improved: wrong choice of drug in computer prescribing, maladministration of drugs due to a look-alike appearance or confusion about the manipulation of a medical device, and poor after hours service of the blood transfusion unit. Staff participation in educational seminars has been dramatically improved. Ward rounds have detected problematic procedures which needed to be dealt with., Lessons Learnt: Patient safety programs based on a web-based incident reporting system, responsible persons, staff education, and a variety of feedback procedures can help promote a safety culture, multidisciplinary collaboration, and strong managerial leadership resulting in system oriented improvement.

This article describes the implementation of an online, document-tracking system for policies and procedures. The process of converting from a "binder system" to an online, paperless system is described in detail. The advantages of real-time computer access to staff are identified as well as the necessary steps needed to move an entire hospital into the future and use emerging technology.

Objectives: To determine the existing infrastructure for monitoring blood transfusion practices in New South Wales hospitals., Design: A questionnaire survey conducted in August 1998., Participants: All healthcare facilities known to have used blood products from the Australian Red Cross Blood Service--New South Wales in the 12 months before the survey., Main Outcome Measures: Existence of a transfusion committee and policies and procedures to ensure appropriate use and issue of blood products; monitoring expiry rates of red blood cells, platelets and fresh frozen plasma; using a maximum blood ordering schedule (MBOS); and measuring the crossmatch to transfusion ratio (CT ratio)., Results: 224 hospitals were surveyed and 144 responses were received (64%). Twenty-five hospitals (17%) had a transfusion committee; 60 (42%) monitored expiry rates of red cells, and 39 (27%) and 42 (29%), respectively, monitored these rates for platelets and fresh frozen plasma. Thirty-three hospitals (23%) used an MBOS and 43 (30%) measured the CT ratio. However, over 70% of the larger hospitals (> 200 beds) had all these aspects of transfusion infrastructure in place, and 35% had transfusion committees., Conclusions: Our survey showed that, overall, there was a lack of transfusion infrastructure in NSW hospitals. However, most of the hospitals with more than 200 beds had infrastructure in place to monitor transfusion practices, but only a minority had established transfusion committees.

Incident reporting has emerged as a cornerstone of sound quality improvement programs. Sentinel events, "a serious and undesirable occurrence involving the loss of life, limb, or function of an individual served" (Joint Commission on Accreditation of Healthcare Organizations, 1996), is a mandated indicator for Joint Commission standards of accreditation for audited healthcare facilities. Properly investigated and documented individual incidents can lead to systemic improvements, which may enhance the quality of client care and the integrity of the healthcare facility. This article proposes a systemic approach to the incident review (IR) process in long-term healthcare facilities. This comprehensive approach incorporates identification, investigation, and management of the IR process from the inception of a problem to the continued follow-up to ensure that improvement plans are effectively implemented.

I have presented a variety of methods of helping practitioners evaluate products. It does not appear that the frustrating challenge of product evaluation will become less complex. Practitioners should use all of the concepts enumerated in this article to aid in their selection of products and be thankful that we have the freedom to select the products that we believe, after due consideration, are best for our patients.

An urban community hospital redesigned the quality assurance (QA) procedures of its medical staff to increase the effectiveness of QA. The best features of the plans of several leading hospitals were presented to departments and committees. These redesigned their QA efforts into a hospital-wide plan. Leadership commitment to redesign, increased process objectivity, and more horizontal structure resulted in the identification of adverse events and the assignment of numerical assessments to them. The rate of adverse event detection was equal to the rate achieved by the literature's benchmark study.

That nurses should base their practice on the best available knowledge is generally accepted by the profession. However, the operationalisation of this ideal if difficult for hard pressed clinicians. We believe that responsibility for assimilating current knowledge in a practical format belongs to all nurses working in an organisation. This paper describes a project where clinicians, administrators and academics have collaborated to rewrite standards of practice in a format that includes up to date evidence and practical measures for appraising outcomes. This work is a practical example of quality assurance activities serving to create opportunities for collaboration between nurses who have chosen to practice, teach, manage and/or research nursing.

This article summarizes the successful development and implementation of an IABP program. Administrative, fiscal, and educational considerations are described. It is important for nursing leaders to maintain a patient focus in an environment that currently reacts to both internal and external pressures.

Medical staff organizations and their leaders are frequently confronted with concerns about physician knowledge, performance, or behavior. Dealing with these concerns is a serious and time-consuming task. Poorly handled issues may result in serious legal consequences. In highly structured organizations, authority for responsibilities, income, and employment rests with individuals who must manage these problems, but medical staff structures do not always lend themselves to dealing with these issues. Introduction of quality improvement processes into medicine has been received as a panacea for physician problems. Certainly the majority of physicians understand quality improvement and work toward common goals to improve patient care. Unfortunately, a small minority remain problem physicians. Steps that can be taken to deal with problem physicians, particularly for issues of quality management, are described in this article.

Many people have an interest in the quality of medical education. Students have the right to as good an education as possible, and the public has the right to well-educated and well-trained general physicians and specialists. Therefore, a medical school or faculty must ensure its quality and is accountable for the quality of the training it provides. This paper emphasizes that the best way to ensure quality is by continuous attention to it. Quality depends not on measurement instruments and tools but rather on the spread of quality awareness among faculty, staff, and students. A tool for safeguarding quality is the design of a well-functioning quality assessment system, based on two pillars: a system of internal quality control and external assessment by peers. The connection between the internal and external assessments is the self-evaluation by the school. On the one side, this self-evaluation is a critical self-analysis and an agenda for improvement. On the other side, it contains information for the external reviewers. The peer review also provides input for the process of improvement.

Home infusion therapy began in response to the medical needs of the patients. In the traditional model, products and services were delivered in the home on a physician's prescription. Limitations related to medical quality management and cost were recognized in this model. Because of these limitations, the changes that continue to occur in health care delivery and the increase in number and acuity of patients requiring non-hospital services, a managed care model was conceived and implemented at the University of Minnesota Medical School and Hospital. This model emphasizes physician-based case management, total quality management, a point of contact medical information system, outcomes assessment and management, and research and education activities designed to evaluate and improve home infusion therapies. The model was implemented through a public-private partnership. This application of managed care to home infusion therapies is described in this communication.

A successful quality assessment program simultaneously creates, sustains and documents excellence in patient care. As clinical practices evolve, it helps to assure their continuing improvement. The program strives to eliminate unnecessary transfusions as the cornerstone of transfusion safety. It should be conducted in a professional, nonadversarial, and educational manner.

Successful examples of teams and drug use evaluations explore communication strategies to enhance quality improvement of medication use. Topics highlighted include establishing contacts within key departments, creating committee connections, fostering physician and nurse participation, and increasing visibility and maintaining awareness. Multidisciplinary collaboration and linkage between the hospital and the managed care pharmacy are also reviewed. Medication use can be improved by integrating these communication tactics.

Sixteen hospitals from the Northeastern New York Hospital Council tested the theory that clinical pathways are an essential component of the integrated quality assessment process. Clinical pathways served as a transition to the holistic, process-oriented approach of quality improvement. The clinical pathways that they developed included preadmission, hospitalization, and postdischarge care needs. Respect and trust established among the hospitals in the consortium were evidenced by the cooperation and collaboration of the participating hospitals. This regional approach to care resulted in increased patient and staff satisfaction, positive patient outcomes, and a decrease in length of stay.

Background: During the months of July, August, and September 1993, we implemented a respiratory care assessment-treatment pilot study on the orthopedic surgery floor in our hospital. The purpose of the study was to determine feasibility and establish cost-effective treatment plans with quality patient outcomes, while maintaining appropriate communications with physicians and nursing staff., Study Development & Implementation: The study's Task Force developed protocols for oxygen therapy, aerosolized medication therapy, volume expansion therapy, and bronchial hygiene therapy using the American Association for Respiratory Care's Clinical Practice Guidelines as supporting documents. Meetings were held with the orthopedic surgeons and nursing staff to inform them of the key components of the pilot program. Ten patient evaluators were trained to assess patients and implement treatment plans., Evaluation Methods: A reference book was established that contained the protocols and support material. Patient outcomes were evaluated using previously established quality assurance plans. The length of stay, procedural volume, and cost data were collected., Evaluation Results: More than 50% of the orders received during the pilot program were for "Respiratory Care Protocol." This allowed the patient care evaluator the flexibility to initiate one of the approved protocols if indicated. No changes in patient outcomes were noted and average length of stay remained unchanged during the pilot study compared to the base period. Treatment volumes decreased, resulting in identified cost savings of $5,318 during the study. Nurses and physicians supported protocol implementation, and increased communication among caregivers was documented. We believe that professionalism of the RCPs was enhanced without compromising the ultimate decision-making responsibilities of the physician., Conclusions: The use of respiratory care protocols is an acceptable method of developing clinically effective and fiscally responsible care plans. RCPs at our hospital were able to implement care plans that resulted in cost savings without a measured change in patient outcomes. Approval has been extended from the Executive Committee of the medical staff to expand hospital-wide.

Objective: To evaluate the effect of establishing a new quality assurance program in obstetrics at a large teaching hospital., Methods: Seven obstetric clinical indicators were selected. After the computerized data base identified the patients as outliers from these indicators, the medical record of each patient was reviewed. Each case was presented to the nine-member committee, which made recommendations or actions for changes or improvement in patient care. The number of patients coming to review and the number of clinical indicators from the year before the program were compared to the results of the second year of the program., Results: The new program significantly reduced the number of patient records reviewed and the clinical indicators. Of the clinical indicators, prolonged hospitalization after both vaginal and cesarean births was decreased. Recommendations to the department included the need for better chart documentation, specific educational presentations as grand rounds, and a protocol for antibiotic use for postpartum endomyometritis., Conclusion: A quality assurance program in obstetrics may decrease the number of clinical indicators after only 1 year. This decreasing trend and better documentation may be considered as measures of improvement in obstetric care.

A continuous quality improvement program can provide the means through which medical organizations can guide their activities. This article illustrates how a pediatrics department in an urban medical center incorporated continuous quality improvement into the management of health services. Key elements of the Quality Assurance program included the organization and facilities in the department of pediatrics, important processes related to patient care, and outcome measures. If a structure is established that allows participation in decision-making and mutual adjustment, trained professionals can perform up to their standards and those standards of their peers. Involvement of physicians in the design of quality management programs and other administrative strategies offer an opportunity to develop a working formula for ongoing success.

During the past several years, the continuous quality improvement (CQI) process has gradually been adapted to the healthcare setting to improve quality without increasing costs. In traditional quality assurance models, quality is measured by the number of accidents or errors occurring. No provision is made for improving the conditions under which the errors occurred. However, continuous quality improvement focuses on the processes used to achieve a goal. These processes may be clinical, financial, or operational issues. Each step in the process is analyzed; then a plan for improvement is tested and refined. The concepts of quality improvement that have been applied in the industrial setting are now being applied in the healthcare arena. Case management and CQI are linked in philosophy and process. The steps of the CQI process can be applied to managed care plans from both a clinical and financial perspective.

Optimal outcomes for the AMI patient can be achieved by national and local healthcare organizations working together for quality care (see Figure). The JCAHO has provided hospitals with the 10-step process to guide quality improvement through a multidisciplinary, collaborative approach for planning and evaluating care. The ACC and AHA have established national standards for AMI care that can be used as guidelines for writing individual hospital AMI standards. The National AMI Registry Report provides current care statistics to participating hospitals. Hospitals can use the CQI dynamics to process the statistics to ensure that standards are met, ultimately facilitating clinical excellence along with cost-effective healthcare for patients with AMI. When caregivers take action to improve patient care based on these statistics, the time spent on data collection and evaluation will finally be worthwhile.

Pressure area care is often thought to be only 'skin deep' but this does not fulfil the philosophy of holistic patient care. Nurses, as the pivot of the multidisciplinary team, must fully assess each patient's needs and implement care based on this assessment, thereby creating the optimum environment for pressure area care.

The use of Phaneuf's Nursing Audit in an action research project that is investigating quality assessment and peer review is discussed. A brief description of the project is given followed by an analysis of the audit tool. This analysis suggests that the tool has more disadvantages than advantages. The paper concludes with a discussion about why the tool may be of use despite the disadvantages identified.

Hospitals that have successfully integrated the risk-management function with other hospital departments say that the process requires both education and teamwork. Among the major challenges: overcoming physician reluctance to participate in risk-management activities, and linking risk management to quality assurance.

At the time of writing, January 1992, we are in the very early stages of setting up a standard setting group, and as such this article reflects our current thinking on why it is desirable, perhaps even necessary to do this and how we envisage assuring quality care for our patients in the recovery room.

What does it take for a hospital to achieve excellence in the area of customer service? How can customer service be improved within a large and complex healthcare facility? Many hospitals are currently seeking answers to these questions.

A hospital's commitment to quality has tremendous impact on all levels of the organization. In this article, the phases of total quality management implementation at Sutter General Hospital are presented. The theme of quality improvement through effective team work has reached to all departments including the medical record department.

Quality assurance has an important contribution to make in the judicious use of scarce resources. Auckland Hospital has established a transfusion committee because there was an escalating usage of blood and blood products which are expensive prescription medicines. A pilot audit of red cell transfusions indicated that 29% of red cell transfusions may have been unnecessary. A wide range of initiatives at Auckland Hospital has reduced blood product usage. Inappropriate use of blood carries an opportunity cost and may subject patients to unnecessary risk of reactions, including potential disease transmission. Strategies which need to be employed by transfusion committees include the introduction of clinical audit, physician education, restrictions on availability, and clinical budgeting. It is recommended that transfusion committees be set up in all major hospitals.

An increase in elderly patients and severity of illness rates means greater use of nasogastric feeding tubes for both high-risk acutely ill and chronically ill patients. When the QA screening process at Booth Memorial Medical Center revealed a certain percentage of complications with small bore, weight-tipped feeding tubes inserted through the nares, a multidisciplinary peer review committee (MPRC) was formed to review the enteral nutrition program. After a literature review to determine possible complications, the MPRC identified lung perforations due to tube misplacement, tube feeding aspiration into the lungs leading to possible aspiration pneumonia, and an internal tip separation from the tube product failure. Unconscious incubated patients on ventilators were shown as at high risk for feeding tube misplacement in an initial MPRC patient study. A second study evaluated several different feeding tube products in the medical, respiratory and surgical ICU. The MPRC established a credentialing process for physician assistants, interns and residents in feeding tube placement. The MPRC proceedings were presented to the hospital-wide QA committee for review, endorsement and recommendations on all policy and procedure changes. The conclusions were that a more concerted effort must be made to improve medical management and encourage ongoing education in the administration of enteral feedings to high-risk patients.