PubMed · 10236835
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1975. CPHA developing emergency department information system.. https://pubmed.ncbi.nlm.nih.gov/10236835/
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Visitations (audits) are considered an instrument of external quality assurance by which the structural and organizational set-up of health facilities can be assessed on site by external experts. The Deutsche Rentenversicherung Bund (including the former Bundesversicherungsanstalt für Angestellte, BfA, the statutory pension insurance agency for white collar employees) is the largest body responsible for rehabilitation in Germany, and it regularly carries out visitations in the approximately 650 rehab centres it sends its patients to. The project presented in this article aimed at developing a manual with detailed descriptions of the procedures and criteria of the assessment, as well as at checking the inter-rater-reliability of the assessment. The manual was developed in cooperation with experts of the Deutsche Rentenversicherung Bund. It contains a description of the areas to be assessed during a visitation as well as leading questions and criteria for the evaluation of single features. The manual was examined in "test visitations" in 10 centres, each of which was visited by three visitation teams (1 medical and 1 administrative expert) simultaneously. When the resulting 30 assessments were compared, the criterion "overall quality of the centre" (which was assessed on a 10-point scale) showed precise agreement in 47 %, and a deviation by 1 point in 33 % of the cases. Single features assessed on a three-point scale (no improvement needed/improvement recommended/immediate improvement obligatory) resulted in precise agreement in between 80 % ("medical and therapeutic processes") and 86 % ("structural features") of the cases. Two-point scales (condition fulfilled or not fulfilled) showed an agreement between 89 % ("internal quality management") and 97 % ("single structural features"). In order to maintain and further develop this good inter-rater-reliability, the visitors of Deutsche Rentenversicherung Bund are continually trained in applying the visitation manual. In addition to transferring knowledge, these internal training courses are aimed at exchanging views and experience in order to enhance consensus among the visitors. This approach of Deutsche Rentenversicherung Bund could be regarded as "internal quality assurance" of its visitation procedure.
Clinical governance has been acknowledged as the driving force behind National Health Service (NHS) reform since the government white paper outlined a new style of NHS in the UK in 1997. The framework of clinical governance ensures that NHS organizations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will develop. A major component of a clinical governance framework requires utilizing audit procedures, which assess the effectiveness of current systems and ultimately direct continual quality improvement. This paper describes the audit component of a local clinical governance framework designed for a unit based within an NHS trust, which has utilized a multidisciplinary approach to assess the effectiveness of a newly commissioned service and its impact on the residents and staff. The unit is a 12-bedded, low-secure-intensive rehabilitation unit for clients with severe and enduring mental illness. Using recognized and standardized psychometric outcome measures, information was collected on clinical symptoms, social functioning, social behaviour, quality of life, relationship quality with named nurses and medication side-effects. Additionally, confidential staff measures were included to assess levels of burnout, identify expressed emotion and assess staff perception of models of illness. The paper includes a comprehensive account of how managerial commitment, teaching processes and application of technology ensured prompt data collection and maintained the momentum through the audit timescale. Data analysis and presentation of data in both clinical reviews and in senior management meetings within the unit are discussed. Findings highlight the full integration of the audit system into the processes of the unit. Clinically, the paper highlights the enhancement of the knowledge base of the client group and the influence on clinical decision-making processes and care delivery as a result of the audit. Brief clinical examples are given. In conclusion, the impact of the audit on unit strategy and organizational efficiency are discussed to highlight the importance of closing the audit loop and completing the cycle of clinical governance. The audit system has positive implications for replication in other services.
Advances in prostate specific antigen (PSA) diagnosis are accompanied by deficits in realization. The justification of claims by affected patients against their doctors are reviewed by commissions of experts and mediation by medical councils out of court, impartial and free of charge. The objectivity of the review is ensured by the independence of the commission and its members as well as the determination of facts and their assessment. Criteria are professional standards and required care. Since 1995, 21 requests by affected patients have been reviewed. In 15 cases (71.4%), treatment errors were ascertained. This involved either a delayed or an insufficient diagnosis (prostatic biopsy). In ten of the patients, a mostly early prostate cancer would have be diagnosed and treated at the time of the first finding of PSA values between 3.3 and 10.4 ng/ml. In ten of 13 patients, the tumor was diagnosed late, having PSA values between 6.8 and 1251 ng/ml with no chance of curative therapy. As in other life threatening diseases, time of recognition is most important for the diagnosis and treatment of patients with prostate cancer. Particularly for early recognition, PSA is much more sensitive then digital rectal examination, and in cases without a digital finding is the only parameter for early diagnoses. In men with suspicious PSA values (>4.0 ng/ml) suitable a diagnostic test (prostate biopsy) is required early, until cancer is detected or excluded.