Pierre Lombrail

The World Health Organization Performance Assessment Tool for Quality Improvement in Hospitals (PATH): An Analysis of the Pilot Implementation in 37 Hospitals

OBJECTIVE To evaluate the pilot implementation of the World Health Organization Performance Assessment Tool for Quality Improvement in hospitals (PATH). DESIGN Semi-structured interviews with regional/country coordinators and Internet-based survey distributed to hospital coordinators. SETTING A total of 37 hospitals in six regions/countries (Belgium, Ontario (Canada), Denmark, France, Slovakia, KwaZulu Natal (South Africa)). PARTICIPANTS Six PATH regional/country coordinators and 37 PATH hospital coordinators. INTERVENTION Implementation of a hospital performance assessment pilot project. OUTCOME MEASURE Experience of regional/country coordinators (structured interviews) and experience of hospital coordinators (survey) with the pilot implementation. RESULTS The main achievement has been the collection and analysis of data on a set of indicators for comprehensive performance assessment in hospitals in regions and countries with different cultures and resource availability. Both regional/country coordinators and hospital coordinators required seed funding and technical support during data collection for implementation. Based on the user evaluation, we identified the following research and development tasks: further standardization and improved validity of indicators, increased use of routine data, more timely feedback with a stronger focus on international benchmarking and further support on interpretation of results. CONCLUSIONS Key to successful implementation was the embedding of PATH in existing performance measurement initiatives while acknowledging the core objective of the project as a self-improvement tool. The pilot test raised a number of organizational and methodological challenges in the design and implementation of international research on hospital performance assessment. Moreover, the process of evaluating PATH resulted in interesting learning points for other existing and newly emerging quality indicator projects.

Rôles et missions de la personne de confiance à l’hôpital : insuffisamment connus par les malades: Enquête semi-directive chez 95 patients du CHU de Nantes

INTRODUCTION The law of March 4th, 2002 allows the patient hospitalized to appoint a reliable person who can support him, help him and represent him throughout his disease. This possibility must be necessarily proposed by hospitals. The roles and the missions entrusted to this reliable person do not stop becoming more marked since. OBJECTIVE A study was realized to know if the hospitalized patients knew that is a reliable person and if yes how had they learnt him? The study tried to know who is or would then be appointed and who are or would be and would be the roles and missions which appear to him important? METHOD By one question semi-directive distributed to the patients hospitalized in units of pointed care, following care and the long-term care of Nantes (France), these estimated the roles and the missions awarded to the reliable person by the legal texts. RESULTS A meadow of a patient on two does not know who is a reliable person. A direct relative (parent children, spouse and not the regular doctor) is or would be indicated. The reliable person is a help considered very important by the patients. More than 8 patients on 10 estimate him very precious audience in the accompaniment during the hospitalization and in the respect for their last wills more than in the direct support. The patients of more than 65 years old and retired know less well this reliable person. The information delivered to the reliable person has to be the object for the patient of a real partnership with the teams of care. DISCUSSION The information and the knowledge by the patients and the nursing of the roles and the missions of the reliable person are clearly insufficient. Establishments in other did not take all the measure of this obligation to propose his name. An initial and continuous training nursing on its subject would be necessary. CONCLUSION The patients grant a big importance for this reliable person and this study shows that the patients would tune him a lot of importance if hospital departments answered their obligations.

L’antibiothérapie aux urgences, évaluation par une approche qualitative et quantitative

INTRODUCTION Most antibiotic therapies are initiated in the emergency unit (EU). To better understand the antibiotic consumption survey in this unit, we compared our results to two neighbor hospitals. This quantitative data was then compared to a quality assessment of antibiotic prescription (audit). METHODS The quantitative measure of antibiotic consumption (three markers: ceftriaxone, amoxicillin-clavulanate, and fluoroquinolones) based on the ratio DDD:1000 patient admitted in the EU was compared between one teaching hospital and the two neighbor hospitals. Qualitative measure: a retrospective clinical targeted audit of antibiotic prescriptions was performed. The compliance to guidelines for infection diagnosis and antibiotic treatment were assessed. RESULTS Antibiotic consumption: the survey showed a higher consumption of the three antibiotics in the teaching hospital, especially for amoxicillin-clavulanate (3.7-5.5 higher). Audit: 93 files of EU patients were reviewed; their mean age was 71 years (18-96). Diagnosis was conform to the expert opinion in 70% of cases. No antibiotic was really necessary in 20% of cases, and delay between hospitalization and antibiotic prescription was relevant only for 56% of patients. The most frequently prescribed antibiotics were betalactams (penicillins 43%, third generation cephalosporin 21%, and fluoroquinolones 22%). The choice was conform to local and national guidelines in 78% of justified prescribed antibiotherapy. CONCLUSION The qualitative assessment cannot explain the higher antibiotic consumption trend. The number of unjustified antibiotic prescriptions does not explain the variable antibiotic consumption.

Validation of a tool assessing appropriateness of hospital days in rehabilitation centres

OBJECTIVE To develop and validate a list of objective criteria to assess the appropriateness of hospital days for patients admitted to rehabilitation centres and sub-acute care units. DESIGN Sixteen appropriateness criteria were defined by a multidisciplinary panel of 33 experts using a formalized consensus method. A single ticked criterion classifies the hospital day as appropriate. Reliability was studied by measuring concordance between two independent and simultaneous ratings using the instrument. External validity was tested by comparing conclusions derived from the instrument with the individual judgements of one, two or three experts on the same random sample of hospital days. PARTICIPANTS The assessment on these criteria was performed on a randomized sample of 406 hospital days from 17 French wards. MAIN OUTCOME MEASURES Inter-rater reliability and external validity were evaluated using the kappa statistic and prevalence-adjusted and bias-adjusted kappa (PABAK). RESULTS The inter-rater reliability test showed a kappa-value of 0.71 [95% confidence interval (95% CI) 0.63-0.78] and a PABAK of 0.77 (95% CI 0.70-0.83). There was a good agreement between the conclusions reached using the instrument and the individual judgements of experts with a kappa coefficient of 0.42 (95% CI 0.35-0.50) and a PABAK of 0.60 (95% CI 0.52-0.67). CONCLUSIONS The instrument is reliable and valid for assessing appropriateness of hospital days in rehabilitation centres and sub-acute care units. The next step in this study is the development of a tool for the analysis of causes of inappropriateness.

Does comparison of performance lead to better care? A pilot observational study in patients admitted for hip fracture in three French public hospitals.

OBJECTIVE To assess whether comparison of quality of hip fracture care among three teams located in different hospitals is associated with improvement in process and outcomes. DESIGN A baseline assessment was performed using quality indicators selected by professionals. RESULTS were discussed among the three teams followed by a post-comparison assessment of the same indicators. SETTING Three hospitals in North Western France. PARTICIPANTS Professionals caring for patients operated on for a low-impact hip fracture. INTERVENTION Review and discussion of comparative performance results by three teams followed by implementation of quality improvement as deemed necessary by each team. MAIN OUTCOME MEASURES Fifteen quality indicators of health care during orthopedic and rehabilitation stay, mobility, dependence and place of residence before hip fracture and 3 months after discharge, 3 month post-surgery mortality and readmission rates. RESULTS Major differences were observed among hospitals throughout the care process during baseline period. Comparison of performance and discussion among the three teams were followed by corrective action in 11 areas. After comparison, a significant improvement was observed in 10 areas, seven of which corresponded to quality improvement areas chosen for improvement action by professionals. A significant decrease in readmission rate (6.7% vs. 15.7%, P < 0.001) was observed but there was no change in mortality, functional outcome or length of stay. CONCLUSIONS Comparison of performance among voluntary teams, on fields selected by health-care professionals, was associated with improvement in the care process and with improvement of some related outcomes.

Causes of inappropriate hospital days: development and validation of a French assessment tool for rehabilitation centres

OBJECTIVE To develop and validate a list of criteria to assess the causes of inappropriate hospital days for patients admitted to rehabilitation centres and sub-acute care units. DESIGN The tool was developed by a multidisciplinary panel of 33 experts, using a formalized consensus method. It collects both the needs of patients (distinguishing healthcare needs (9 criteria) and accommodation needs (9 criteria)) and the reasons for inappropriateness (19 criteria). Inappropriate days were identified using the tool to assess appropriateness of hospital days validated previously. Reliability was studied by measuring agreement between two independent simultaneous ratings. SETTING The validation study was performed on a randomized sample of 576 hospital days from 22 wards in France. MAIN OUTCOME MEASURES Inter-rater reliability was evaluated using the κ-statistic and prevalence-adjusted and bias-adjusted kappa (PABAK). RESULTS For patient accommodation needs, the inter-rater reliability was estimated by a κ-value of 0.80 (95% confidence interval (95% CI) 0.66-0.92) and a PABAK of 0.80 (95% CI 0.63-0.91). There was good agreement on the reasons for inappropriateness, with κ-values from 0.30 to 0.60 and PABAK from 0.46 to 0.69. The κ-coefficient varied from 0.33 to 0.49 for the assessment of patient healthcare needs, with PABAK ranging from 0.49 to 0.72. CONCLUSIONS The instrument is suitable and valid to assess the causes of inappropriate hospital days in rehabilitation centres and sub-acute care units. The study showed that the tool can be easily used by healthcare workers, which makes it useful for quality improvement.

Rôles et missions de la personne de confiance à l’hôpital : insuffisamment connus par les malades

INTRODUCTION The law of March 4th, 2002 allows the patient hospitalized to appoint a reliable person who can support him, help him and represent him throughout his disease. This possibility must be necessarily proposed by hospitals. The roles and the missions entrusted to this reliable person do not stop becoming more marked since. OBJECTIVE A study was realized to know if the hospitalized patients knew that is a reliable person and if yes how had they learnt him? The study tried to know who is or would then be appointed and who are or would be and would be the roles and missions which appear to him important? METHOD By one question semi-directive distributed to the patients hospitalized in units of pointed care, following care and the long-term care of Nantes (France), these estimated the roles and the missions awarded to the reliable person by the legal texts. RESULTS A meadow of a patient on two does not know who is a reliable person. A direct relative (parent children, spouse and not the regular doctor) is or would be indicated. The reliable person is a help considered very important by the patients. More than 8 patients on 10 estimate him very precious audience in the accompaniment during the hospitalization and in the respect for their last wills more than in the direct support. The patients of more than 65 years old and retired know less well this reliable person. The information delivered to the reliable person has to be the object for the patient of a real partnership with the teams of care. DISCUSSION The information and the knowledge by the patients and the nursing of the roles and the missions of the reliable person are clearly insufficient. Establishments in other did not take all the measure of this obligation to propose his name. An initial and continuous training nursing on its subject would be necessary. CONCLUSION The patients grant a big importance for this reliable person and this study shows that the patients would tune him a lot of importance if hospital departments answered their obligations.

Impact of Home-Based Management of malaria combined with other community-based interventions: what do we learn from Rwanda?

Introduction This study aimed to evaluate the impact of home-based management of malaria (HBM) strategy on time to treatment and reported presumed malaria morbidity in children aged less than 5 years in Rwanda. Methods The study was carried out in two malaria-endemic rural districts, one where HBM was applied and the other serving as control. In each district, a sample of mothers was surveyed by questionnaire before (2004) and after (2007) implementation of HBM. Results After implementation, we observed: i) an increase (P < 0.001) in the number of febrile children treated within 24 hours of symptom onset in the experimental district (53.7% in 2007 vs 5% in 2004) compared with the control district (28% vs 7.7%); ii) a decrease in the reported number of febrile children in the experimental district (28.7% vs 44.9%, P < 0.01) compared with the control district (45.7% vs 56.5%, P < 0.05). Conclusion HBM contributed to decrease time to treatment and reported presumed malaria morbidity.

[Roles and missions of the reliable person at the hospital: Insufficiently known by the patients].

INTRODUCTION The law of March 4th, 2002 allows the patient hospitalized to appoint a reliable person who can support him, help him and represent him throughout his disease. This possibility must be necessarily proposed by hospitals. The roles and the missions entrusted to this reliable person do not stop becoming more marked since. OBJECTIVE A study was realized to know if the hospitalized patients knew that is a reliable person and if yes how had they learnt him? The study tried to know who is or would then be appointed and who are or would be and would be the roles and missions which appear to him important? METHOD By one question semi-directive distributed to the patients hospitalized in units of pointed care, following care and the long-term care of Nantes (France), these estimated the roles and the missions awarded to the reliable person by the legal texts. RESULTS A meadow of a patient on two does not know who is a reliable person. A direct relative (parent children, spouse and not the regular doctor) is or would be indicated. The reliable person is a help considered very important by the patients. More than 8 patients on 10 estimate him very precious audience in the accompaniment during the hospitalization and in the respect for their last wills more than in the direct support. The patients of more than 65 years old and retired know less well this reliable person. The information delivered to the reliable person has to be the object for the patient of a real partnership with the teams of care. DISCUSSION The information and the knowledge by the patients and the nursing of the roles and the missions of the reliable person are clearly insufficient. Establishments in other did not take all the measure of this obligation to propose his name. An initial and continuous training nursing on its subject would be necessary. CONCLUSION The patients grant a big importance for this reliable person and this study shows that the patients would tune him a lot of importance if hospital departments answered their obligations.

Les réadmissions évitables des « pneumopathies communautaires » : utilité et fiabilité d’un indicateur de la qualité du parcours de soins du patient

UNLABELLED Unlike Anglo-Saxon countries, the rate of preventable readmissions is not a national quality indicator in France. In the context of the European research project Performance Assessment Tool for quality improvement in Hospitals (PATH), this pilot study provides a tool for health professionals to more easily identify preventable readmissions in order to analyze their causes. The objective of this work was to show the reliability of this tool. METHODS We compared the rate of preventable readmissions occurring within 30 days, for a given disease, collected by analyzing medical reports (the gold standard rate of this study) to the rates of preventable readmissions occurring within 30 days, measured from algorithms using data from the French Programme of Medicalization of Information Systems (PMSI). The data were derived from PMSI data of the Lariboisiere-Fernand-Widal Hospital, a university hospital in Paris. RESULTS The community-acquired pneumonia gold standard rate of preventable readmissions occurring within 30 days was 6.3 %. Five algorithmic tools were used and measured rates between 2.9 % and 7.9 %. The positive likelihood ratios of these tools range from 8 to 308. CONCLUSION This work presents a tool aimed at the health professionals that takes into account the diversity and complexity of the causes of avoidable readmissions, resulting from the quality of medical practice, the variability of the organization of hospital pathways and the links with ambulatory care.