According to W. Edwards Deming, American companies require nothing less than a transformation of management style and of governmental relations with industry. In Out of the Crisis, originally published in 1982, Deming offers a theory of management based on his famous 14 Points for Management. Management's failure to plan for the future, he claims, brings about loss of market, which brings about loss of jobs. Management must be judged not only by the quarterly dividend, but by innovative plans to stay in business, protect investment, ensure future dividends, and provide more jobs through improved product and service. In simple, direct language, he explains the principles of management transformation and how to apply them.

Out of the Crisis

http://gavecelt.it/nuovo/sites/default/files/uploads/epic_guidelines_2013.pdf

epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England

Evaluating the quality of medical care.

America's health care system has become too complex and costly to continue business as usual. Best Care at Lower Cost explains that inefficiencies, an overwhelming amount of data, and other economic and quality barriers hinder progress in improving health and threaten the nation's economic stability and global competitiveness. According to this report, the knowledge and tools exist to put the health system on the right course to achieve continuous improvement and better quality care at a lower cost.The costs of the system's current inefficiency underscore the urgent need for a systemwide transformation. About 30 percent of health spending in 2009--roughly $750 billion--was wasted on unnecessary services, excessive administrative costs, fraud, and other problems. Moreover, inefficiencies cause needless suffering. By one estimate, roughly 75,000 deaths might have been averted in 2005 if every state had delivered care at the quality level of the best performing state. This report states that the way health care providers currently train, practice, and learn new information cannot keep pace with the flood of research discoveries and technological advances.About 75 million Americans have more than one chronic condition, requiring coordination among multiple specialists and therapies, which can increase the potential for miscommunication, misdiagnosis, potentially conflicting interventions, and dangerous drug interactions. Best Care at Lower Cost emphasizes that a better use of data is a critical element of a continuously improving health system, such as mobile technologies and electronic health records that offer significant potential to capture and share health data better. In order for this to occur, the National Coordinator for Health Information Technology, IT developers, and standard-setting organizations should ensure that these systems are robust and interoperable. Clinicians and care organizations should fully adopt these technologies, and patients should be encouraged to use tools, such as personal health information portals, to actively engage in their care.This book is a call to action that will guide health care providers; administrators; caregivers; policy makers; health professionals; federal, state, and local government agencies; private and public health organizations; and educational institutions.

Best Care at Lower Cost: The Path to Continuously Learning Health Care in America

Frailty defined by deficit accumulation and geriatric medicine defined by frailty.

The checklist--a tool for error management and performance improvement.

Background. Checklists are used in both medical and non-medical industries as cognitive aids to guide users through accurate task completion. Their development requires a systematic and comprehensive approach, particularly when implemented in high intensity fields such as medicine. Objective. A narrative review of the literature was conducted to outline the methodology to designing and implementing clear and effective medical checklists. Methods. We systematically searched for relevant English-language medical and non-medical literature both to describe where checklists have been demonstrated to improve delivery of care and also, how to develop valid checklists. Results. The MEDLINE search yielded 8303 citations of which 1042 abstracts were reviewed. On the basis of criteria for inclusion and subsequent full-manuscript review, 178 sources, including 17 non-medical publications, were included in the narrative review. This information was further supplemented by expert opinion in the area of checklist development and implementation. A small number of strategies for designing effective checklists were referenced in the literature, including utilization of pre-published guidelines, formation of expert panels and repeat pilot-testing of preliminary checklists. Conclusion. Despite currently available evidence, a highly effective, standardized methodology for the development and design of medical-specific checklists has not previously been developed and validated, which has likely contributed to their inconsistent use in several key fields of medicine, despite evidence of their fundamental role in error management.

Development of medical checklists for improved quality of patient care

Context Evidence-based practices improve intensive care unit (ICU) outcomes, but eligible patients may not receive them. Community hospitals treat most critically ill patients but may have few resources dedicated to quality improvement. Objective To determine the effectiveness of a multicenter quality improvement program to increase delivery of 6 evidence-based ICU practices. Design, Setting, and Participants Pragmatic cluster-randomized trial among 15 community hospital ICUs in Ontario, Canada. A total of 9269 admissions occurred during the trial (November 2005 to October 2006) and 7141 admissions during a decay-monitoring period (December 2006 to August 2007). Intervention We implemented a videoconference-based forum including audit and feedback, expert-led educational sessions, and dissemination of algorithms to sequentially improve delivery of 6 practices. We randomized ICUs into 2 groups. Each group received this intervention, targeting a new practice every 4 months, while acting as control for the other group, in which a different practice was targeted in the same period. Main Measure Outcomes The primary outcome was the summary ratio of odds ratios (ORs) for improvement in adoption (determined by daily data collection) of all 6 practices during the trial in intervention vs control ICUs. Results Overall, adoption of the targeted practices was greater in intervention ICUs than in controls (summary ratio of ORs, 2.79; 95% confidence interval [CI], 1.00-7.74). Improved delivery in intervention ICUs was greatest for semirecumbent positioning to prevent ventilator-associated pneumonia (90.0% of patient-days in last month vs 50.0% in first month; OR, 6.35; 95% CI, 1.85-21.79) and precautions to prevent catheter-related bloodstream infection (70.0% of patients receiving central lines vs 10.6%; OR, 30.06; 95% CI, 11.00-82.17). Adoption of other practices, many with high baseline adherence, changed little. Conclusion In a collaborative network of community ICUs, a multifaceted quality improvement intervention improved adoption of care practices. Trial Registration clinicaltrials.gov Identifier: NCT00332982

https://jamanetwork.com/journals/jama/articlepdf/645231/jce05012_363_372.pdf

A multifaceted intervention for quality improvement in a network of intensive care units: a cluster randomized trial.

Background 
Little data exists addressing satisfaction with end-of-life care among hospitalized patients, as they and their family members are systematically excluded from routine satisfaction surveys. It is imperative that we closely examine patient and institution factors associated with quality end-of-life care and determine high-priority target areas for quality improvement.


Methods 
Between September 1, 2010 and January 1, 2012 the Canadian Health care Evaluation Project (CANHELP) Bereavement Questionnaire was mailed to the next-of-kin of recently deceased inpatients to seek factors associated with satisfaction with end-of-life care. The primary outcome was the global rating of satisfaction. Secondary outcomes included rates of actual versus preferred location of death, associations between demographic factors and global satisfaction, and identification of targets for quality improvement.


Results 
Response rate was 33% among 275 valid addresses. Overall, 67.4% of respondents were very or completely satisfied with the overall quality of care their relative received. However, 71.4% of respondents who thought their relative did not die in their preferred location favoured an out-of-hospital location of death. A common location of death was the intensive care unit (45.7%); however, this was not the preferred location of death for 47.6% of such patients. Multivariate Poisson regression analysis showed respondents who believed their relative died in their preferred location were 1.7 times more likely to be satisfied with the end-of-life care that was provided (p = 0.001). Items identified as high-priority targets for improvement included: relationships with, and characteristics of health care professionals; illness management; communication; and end-of-life decision-making.


Interpretation 
Nearly three-quarters of recently deceased inpatients would have preferred an out-of-hospital death. Intensive care units were a common, but not preferred, location of in-hospital deaths. Family satisfaction with end-of-life care was strongly associated with their relative dying in their preferred location. Improved communication regarding end-of-life care preferences should be a high-priority quality improvement target.

/pdf/factors-affecting-family-satisfaction-with-inpatient-end-of-s38ush0sge.pdf

Factors affecting family satisfaction with inpatient end-of-life care.

Background:Psoriasis impacts many different areas of a patient's life, including work productivity. There is no information regarding lost productivity owing to psoriasis in a Canadian population.Objective:The objective of this study was to determine the lost productivity of Canadian patients with moderate to severe psoriasis.Methods:Seventy-nine consecutive Canadian dermatology patients were interviewed and completed the Work Productivity and Activity Impairment Questionnaire (WPAIQ).Results:On average, 2.2 hours (± 5.6 hours) were lost from work per week owing to psoriasis-related events. Absence from work may result in lost mean patient wages of C$2,270.84 per person per year. Total lost wages owing to moderate to severe psoriasis may cost up to approximately $749 million for all moderate to severe psoriasis patients in Canada.Conclusion:The results from our study indicate that moderate to severe psoriasis may have a substantial impact on the work productivity of patients with this disease.

Brigette Hales

Papers

The checklist--a tool for error management and performance improvement.

Development of medical checklists for improved quality of patient care

A multifaceted intervention for quality improvement in a network of intensive care units: a cluster randomized trial.

Factors affecting family satisfaction with inpatient end-of-life care.

Work-related lost productivity and its economic impact on Canadian patients with moderate to severe psoriasis.