Motivational drivers for health professionals in a large quality improvement collaborative project in Brazil: a qualitative study.

BACKGROUND: The success of collaborative quality improvement (QI) projects in healthcare depends on the context and engagement of health teams; however, the factors that modulate teams' motivation to participate in these projects are still unclear. The objective of the current study was to explore the barriers to and facilitators of motivation; the perspective was health professionals in a large project aiming to implement evidence-based infection prevention practices in intensive care units of Brazilian hospitals. METHODS: This qualitative study was based on content analysis of semistructured in-depth interviews held with health professionals who participated in a collaborative QI project named "Improving patient safety on a large scale in Brazil". In accordance with the principle of saturation, we selected a final sample of 12 hospitals located throughout the five regions of Brazil that have implemented QI; then, we conducted videoconference interviews with 28 health professionals from those hospitals. We encoded the interview data with NVivo software, and the interrelations among the data were assessed with the COM-B model. RESULTS: The key barriers identified were belief that improvement increases workload, lack of knowledge about quality improvement, resistance to change, minimal involvement of physicians, lack of supplies, lack support from senior managers and work overload. The primary driver of motivation was tangible outcomes, as evidenced by a decrease in infections. Additionally, factors such as the active participation of senior managers, teamwork, learning in practice and understanding the reason for changes played significant roles in fostering motivation. CONCLUSION: The motivation of health professionals to participate in collaborative QI projects is driven by a variety of barriers and facilitators. The interactions between the senior manager, quality improvement teams, and healthcare professionals generate attitudes that modulate motivation. Thus, these aspects should be considered during the implementation of such projects. Future research could explore the cost-effectiveness of motivational approaches.

Hospital care direct costs due to ambulatory care sensitive conditions related to diabetes mellitus in the Mexican public healthcare system.

BACKGROUND: Hospitalizations for ambulatory care sensitive conditions (ACSC) incur substantial costs on the health system that could be partially avoided with adequate outpatient care. Complications of chronic diseases, such as diabetes mellitus (DM), are considered ACSC. Previous studies have shown that hospitalizations due to diabetes have a significant financial burden. In Mexico, DM is a major health concern and a leading cause of death, but there is limited evidence available. This study aimed to estimate the direct costs of hospitalizations by DM-related ACSC in the Mexican public health system. METHODS: We selected three hospitals from each of Mexico's main public institutions: the Mexican Social Security Institute (IMSS), the Ministry of Health (MoH), and the Institute of Social Security and Services for State Workers (ISSSTE). We employed a bottom-up microcosting approach from the healthcare provider perspective to estimate the total direct costs of hospitalizations for DM-related ACSC. Input data regarding length of stay (LoS), consultations, medications, colloid/crystalloid solutions, procedures, and laboratory/medical imaging studies were obtained from clinical records of a random sample of 532 hospitalizations out of a total of 1,803 DM-related ACSC (ICD-10 codes) discharges during 2016. RESULTS: The average cost per DM-related ACSC hospitalization varies among institutions, ranging from $1,427 in the MoH to $1,677 in the IMSS and $1,754 in the ISSSTE. The three institutions' largest expenses are LoS and procedures. Peripheral circulatory and renal complications were the major drivers of hospitalization costs for patients with DM-related ACSC. Direct costs due to hospitalizations for DM-related ACSC in these three institutions represent 1% of the gross domestic product (GDP) dedicated to health and social services and 2% of total hospital care expenses. CONCLUSIONS: The direct costs of hospitalizations for DM-related ACSC vary considerably across institutions. Disparities in such costs for the same ACSC among different institutions suggest potential disparities in care quality across primary and hospital settings (processes and resource utilization), which should be further investigated to ensure optimal supply utilization. Prioritizing preventive measures for peripheral circulatory and renal complications in DM patients could be highly beneficial.

[Comparative analysis of the accreditation of medical facilities in Canada, Chile, the Autonomous Community of Andalusia, Denmark, and MexicoAnálise comparativa da acreditação de estabelecimentos de saúde no Canadá, Chile, Comunidade Autônoma da Andaluzia, Dinamarca e México]. / Análisis comparativo de la acreditación de unidades médicas en Canadá, Chile, la Comunidad Autónoma de Andalucía, Dinamarca y México.

Objective: To compare and contrast the characteristics of the accreditation process for health care facilities in Canada, Chile, the Autonomous Community of Andalusia (Spain), Denmark, and Mexico, in order to identify shared characteristics, differences, and lessons learned that may be useful for other countries and regions. Methods: An observational, analytical, retrospective study using open-access secondary sources on the accreditation and certification of health care facilities in 2019-2021 in these countries and regions. The general characteristics of the accreditation processes are described and comments are made on key aspects of the design of these programs. Additionally, analytical categories were created for degree of implementation and level of complexity, and the positive and negative results reported are summarized. Results: The operational components of the accreditation processes are country-specific, although they share similarities. The Canadian program is the only one that involves some form of responsive evaluation. There is a wide range in the percentage of establishments accredited from country to country (from 1% in Mexico to 34.7% in Denmark). Notable lessons learned include the complexity of application in a mixed public-private system (Chile), the risk of excessive bureaucratization (Denmark), and the need for clear incentives (Mexico). Conclusions: The accreditation programs operate in a unique way in each country and region, achieve varying degrees of implementation, and have an assortment of problems, from which lessons can be learned. Elements that hinder their implementation should be considered and adjustments made for the health systems of each country and region.

Objetivo: Comparar as características do processo de acreditação de estabelecimentos de saúde no Canadá, Chile, Comunidade Autônoma da Andaluzia, Dinamarca e México, a fim de identificar elementos comuns e diferenças, bem como lições aprendidas que podem ser úteis para outros países e regiões. Métodos: Estudo observacional, analítico e retrospectivo usando fontes secundárias de livre acesso sobre acreditação e certificação de estabelecimentos de saúde durante o período 2019-2021 nos países e regiões supracitados. As características gerais do processo de acreditação e suas respostas a pontos-chave no delineamento de tais programas foram descritas. Além disso, foram geradas categorias de análise para o andamento de sua implantação e seu grau de complexidade, e os desfechos favoráveis e desfavoráveis relatados foram resumidos. Resultados: Os componentes operacionais do processo de acreditação são peculiares a cada país, embora compartilhem certas semelhanças. O programa canadense é o único que contempla algum tipo de avaliação responsiva. Houve grande variação entre países no percentual de estabelecimentos acreditados (de 1% no México a 34,7% na Dinamarca). Entre as lições aprendidas, destacam-se a complexidade da aplicação do sistema misto público-privado (Chile), o risco de burocratização excessiva (Dinamarca) e a necessidade de incentivos claros (México). Conclusões: Os programas de acreditação operam de forma peculiar em cada país ou região, têm diferentes escopos e também apresentam diversos problemas a partir dos quais podemos aprender. É preciso considerar os elementos que dificultam a implementação e realizar as adequações necessárias para os sistemas de saúde de cada país ou região.

Acreditación de servicios y calidad de la atención a neonatos en hospitales mexicanos.

OBJETIVO: Comparar la calidad de atención a neonatos con sepsis neonatal, hipoxia intrauterina, prematuridad y asfixia perinatal en hospitales acreditados (HA) y no acreditados (HNA). Material y métodos. Se evaluaron 28 hospi-tales de la Secretaría de Salud en 11 estados de México; la evaluación incluyó infraestructura, equipamiento e insumos, procesos de gestión de calidad e indicadores de calidad clínica. Se utilizó LQAS y se estimó el cumplimiento promedio de criterios e indicadores en HA y HNA. RESULTADOS: Hubo diferencias significativas en favor de HA en equipamiento e insumos y no significativas en existencia y funcionamiento de los comités hospitalarios. No hubo diferencias consistentes ni significativas en cumplimiento de indicadores clínicos entre los HA y HNA. CONCLUSIONES: La acreditación para la atención de neonatos con los diagnósticos seleccionados no se asocia a diferencias en la calidad de la atención.

Disrespect and Abuse in Obstetric Care in Mexico: An Observational Study of Deliveries in Four Hospitals.

INTRODUCTION: To identify and describe the frequency and characteristics of disrespect and abuse practices towards women during facility-based delivery in four hospitals in two Mexican states in 2017, using a mixed method of direct observation and women's reports of health care experiences. METHODS: A cross-sectional study was performed to describe disrespect and abuse practices in obstetric care (interactions or conditions that are experienced as or intended to be humiliating or undignified) committed by healthcare providers. We included all pregnant women admitted for childbirth (vaginal and cesarean). Semi-structured interviews were also conducted with women, prior to discharge, regarding their experience at delivery. RESULTS: 867 deliveries were observed. 18.8% of women (n = 163) experienced at least one disrespect and abuse event, especially at secondary care facilities. There were a total of 493 disrespect and abuse events, which, on average, represents three events per woman (39.4% were verbal abuse, 32% were physical abuse, and 28.6% were discrimination). In the majority of cases (> 50%), women did not give consent to not recommended invasive procedures and were not provided with adequate information to those procedures. CONCLUSIONS FOR PRACTICE: Direct observation and interviews was a useful tool to identify disrespectful and abusive practices during delivery care. Our findings provide new evidence of the frequency and characteristics of disrespect and abuse during delivery care in Mexico, which can be used to inform maternal health programs. Additionally, these results encourage the creation of surveillance policies and committees in order to guarantee violence-free and dignified treatment of women during delivery care.

Barreras y facilitadores en la implementación de guías de práctica clínica en México: perspectiva del personal de salud.

Objetivo. Identificar barreras, facilitadores y propuestas de mejora en la implementación de Guías de Práctica Clínica (GPC) desde la perspectiva de los profesionales de la salud. Material y métodos. Estudio cualitativo a través de 85 entrevistas semiestructuradas a responsables de implementa-ción, difusión y aplicación, y del personal operativo en centros de atención primaria y hospitales en siete estados de México. El contenido fue codificado y analizado con ATLAS.ti 7.0. Resultados. Las principales barreras encontradas fueron la no actualización de las GPC y baja alineación con otras normas, e imposibilidad de implementarlas debido a la sobre-carga de trabajo y los recursos limitados. Conclusiones. El esfuerzo por implementar GPC parece haber sido errático e insuficiente, y la evaluación de su utilización inexistente. Se propone crear estrategias integradas y contextualizadas que resulten ser más efectivas y eficientes para la implementación exitosa de GPC.

Carencias y variabilidad en la calidad de la atención a neonatos hospitalizados en México. Estudio transversal en 28 hospitales públicos.

Objetivo. Evaluar la calidad de la atención a neonatos con indicadores de proceso, en patologías seleccionadas. Ma-terial y métodos. Evaluación multicéntrica, transversal de nueve indicadores en 28 hospitales de 11 entidades de México. Se utilizó Lot Quality Assurance Sampling (LQAS) para estándares de calidad y muestra por hospital. Casos seleccio-nados al azar del Subsistema Automatizado de Egresos Hos-pitalarios. Se clasifican hospitales como "cumplimiento con estándar"/"no cumplimiento" por indicador y, cumplimiento con IC95% exacto binomial, regional y nacional, según mues-treo estratificado no proporcional. Resultados. Ningún indicador cumple el estándar de 75% en hospitales, con 0 a 19 hospitales que cumplen, según indicador. Excepto la iden-tificación oportuna de asfixia perinatal e inicio de antibiótico correcto en sospecha de sepsis temprana, el cumplimiento es <50% en todos los demás indicadores. Conclusiones. La calidad de la atención a neonatos en hospitales es heterogé-nea y deficiente. Se proponen indicadores para monitorizar iniciativas de mejora.

The WHO Safe Childbirth Checklist implementation: impact on the prescription of magnesium sulphate through a one-year longitudinal study.

BACKGROUND: Preeclampsia is a relatively frequent condition during pregnancy and childbirth. The administration of magnesium sulphate as a prophylactic and treatment measure is an evidence-based practice for eclampsia; however, it is not consistently used, compromising the health of pregnant women. This study aimed to assess compliance with recommendations of the International Society for the Study of Hypertension in Pregnancy (ISSHP) for the use of MgSO4 in pregnant women with preeclampsia, before and after the implementation of the World Health Organization Safe Childbirth Checklist (SCC). METHODS: This quasi-experimental study was conducted between July 2015 and July 2016 at a third-level maternity hospital in northeastern Brazil, where the SCC was implemented. Compliance (underuse and overuse of MgSO4) was assessed in biweekly samples of 30 deliveries assessed 6 months before and 6 months after SCC implementation, using indicators based on international guidelines. A total of 720 deliveries were assessed over 1 year using an ad hoc application for reviewing medical records. Aggregated adequate use was estimated for the study period, and the time series measurements were compared to a control chart to assess change. RESULTS: The incidence of preeclampsia was 39.9% (287/720). Among these, 64.8% (186/287) had severe signs or symptoms and needed MgSO4. Underuse (no prescription when needed) of MgSO4 was observed in 74.7% (139/186) of women who needed the drug. Considering all women, non-compliance with the prescription protocol (underuse and overuse) was 20.0% (144/720). After introducing the SCC, the use of MgSO4 in women with preeclampsia with severe features increased from 19.1 to 34.2% (p = 0.025). Longitudinal analysis showed a significant (p < 0.05) ascending curve of adequate use of MgSO4 after the SCC was implemented. CONCLUSIONS: Compliance with recommendations for the use of MgSO4 in preeclampsia was low, but improved after implementation of the SCC. Interventions to improve compliance based on diagnosis and treatment reminders may help in the implementation of this good practice.

Contextual factors favouring success in the accreditation process in Colombian hospitals: a nationwide observational study.

BACKGROUND: To identify context factors associated with and predicting success in the hospital accreditation process, and to contribute to the understanding of the relative relevance of context factors and their organizational level in the success of QI initiatives. METHODS: Analytical study of cases and controls in a sample of hospitals of medium and high complexity in Colombia. Cases (n = 16) are accredited hospitals by the time of preparation of the study (2016) and controls (n = 38) are similar facilities, which have not succeeded to obtain accreditation. Eligibility criteria for both groups included complexity (medium and high), having emergency services, an official quality assurance license, and being in operation for at least 15 years. Besides eligibility criteria, geographical location, and type of ownership (public/private) are used to select controls to match cases. Context measures are assessed using a survey instrument based on the MUSIQ model ("Model for Understanding Success in Quality") adapted and tested in Colombia. Statistical analysis includes descriptive measures for twenty-three context factors, testing for significant statistical differences between accredited and non-accredited hospitals, and assessing the influence and strength of association of context factors on the probability of success in the accreditation process. A multivariate model assesses the predictive probability of achieving accreditation. RESULTS: Eighteen (78.3%) of the twenty-three context factors are significantly different when comparing cases and controls hospitals, particularly at the Microsystem level; all factors are statistically significant in favor of accredited hospitals. Five context factors are strongly associated to the achievement of accreditation but in the logistic multivariable model, only two of them remain with significant OR, one in the Macrosystem, "Availability of economic resources for QI" (OR: 22.1, p: 0,005), and the other in the Microsystem, "Involvement of physicians" (OR: 4.9, p: 0,04). CONCLUSION: This study has applied an instrument, based on the MUSIQ model, which allows assessing the relevance of different context factors and their organizational level in hospitals, to explain success in the accreditation process in Colombia. Internal macrosystem and microsystem seem to be more relevant than external environment factors.

[Approach to the quality of care during pregnancy,delivery and postpartum in women withobstetric risk factors in Mexico]. / Aproximación a la calidad de la atención durante el embarazo, parto y posparto en mujeres con factores de riesgoobstétrico en México.

OBJECTIVE: To assess the quality of care of women with obstetric risk factors during pregnancy, childbirth, and post-partum. MATERIALS AND METHODS: We use data from The National Survey of Health and Nutrition 2018-19. Women were classified by the presence of obstetric risk factors (ORF) in their last pregnancy. The quality of care provided to women was evaluated with indicators of structure and process dur-ing antenatal care (ANC) and, delivery and postpartum care (DPC). RESULTS: Compliance with process indicators in ANC and DPC for women with ORF was 56.9%. In the face of complications during pregnancy or delivery, it decreased in ANC, and in the face of social vulnerability compliance of ANC and DPC indicators decreases. CONCLUSIONS: It is necessary to systematically improve the quality of care during pregnancy, childbirth, and postpartum, regardless the presence of ORF, with special attention to vulnerable groups.

OBJETIVO: Evaluar la calidad de la atención a mujeres con factores de riesgo obstétrico durante el embarazo, parto y posparto. MATERIAL Y MÉTODOS: Con datos de la Encuesta Nacional de Salud y Nutrición 2018-19, se clasificó a las mu-jeres de acuerdo con los factores de riesgo obstétrico (FRO) presentes en su último embarazo y se evaluó la calidad de la atención con indicadores de estructura y proceso en la atención prenatal (APN), y en la atención del parto y posparto (APP). RESULTADOS: El cumplimiento de indicadores de pro-ceso en APN y APP para mujeres con FRO fue de 56.9%. Ante complicaciones durante el embarazo o el parto, disminuyó en la APN, y ante variables socioeconómicas desfavorables, disminuyó en la APN y en la APP. CONCLUSIONES: Es nece-sario mejorar sistemáticamente la calidad de la atención en el embarazo, parto y posparto en mujeres con y sin riesgo obstétrico, principalmente en grupos vulnerables.

[Polypharmacy in Mexico: a challengefor prescription quality]. / Polifarmacia en México: un reto para la calidad en la prescripción.

OBJECTIVE: To analyze the prevalence of polypharmacy, as well as the factors that identify the groups with higher risk, in population study in Mexico. MATERIALS AND METHODS: Descriptive analysis of the Encuesta Nacional de Salud y Nutrición 2018-19 (Ensanut 2018-19), Utilization of services (medicine section) and Household questionnaires, to obtain prevalence of polypharmacy (simultaneous consumption ≥5 medicines). A logistic regression model was used to estimate the association of polypharmacy with sociodemographic and health care factors. RESULTS: Prevalence of polypharmacy: 18 years, 15.5%, and 65 years, 26.5%. Higher prevalence in: nephropathies (61.5%), heart disease (42.2%), chronic ob-structive pulmonary disease (38.5%), diabetes (29.3%) and hypertension (26.4%). Increased possibility in adults 65 years (OR:1.95), low schooling (OR:1.54), social security (OR:1.64), serviced in public services (OR:1.7) and chronic illness (OR:1.84). CONCLUSIONS: Polypharmacy is associated with chronic disease and some sociodemographic factors. Large area of opportunity to improve quality of care, particularly pharmacological prescription to identified population with higher risk.

OBJETIVO: Analizar la prevalencia de polifarmacia, así como los factores que identifican a los grupos con mayor riesgo, en un estudio poblacional en México. MATERIAL Y MÉTODOS: Salud y Nutrición 2018-19 (Ensanut 2018-19), cuestionarios de Utilización de servicios (sección medicamentos) y del Hogar, para obtener la prevalencia de polifarmacia (consu-mo simultáneo ≥5 medicamentos). Se utilizó un modelo de regresión logística para estimar la asociación de polifarmacia con factores sociodemográficos y de atención a la salud. RESULTADOS: Prevalencia de polifarmacia: ≥18 años, 15.5%, y ≥65 años, 26.5%. Prevalencias superiores: nefropatías (61.5%), cardiopatías (42.2%), enfermedad pulmonar obstructiva crónica (38.5%), diabetes (29.3%) e hipertensión (26.4%). Mayor posibilidad en adultos ≥65 años (OR:1.95), con baja escolaridad (OR:1.54), seguridad social (OR:1.64), atendidos en servicios públicos (OR:1.7) y enfermedad crónica (OR:1.84). CONCLUSIONES: La polifarmacia se asocia con tener enfermedad crónica y con factores sociodemográficos. Es una gran área de oportunidad para mejorar calidad de la atención, particularmente la prescripción farmacológica a la población identificada con mayor riesgo.

Indicators for monitoring maternal and neonatal quality care: a systematic review.

BACKGROUND: Research and different organizations have proposed indicators to monitor the quality of maternal and child healthcare, such indicators are used for different purposes. OBJECTIVE: To perform a systematic review of indicators for the central phases of the maternal and child healthcare continuum of care (pregnancy, childbirth, newborn care and postpartum). METHOD: A search conducted using international repositories, national and international indicator sets, scientific articles published between 2012 and 2016, and grey literature. The eligibility criteria was documents in Spanish or English with indicators to monitor aspects of the continuum of care phases of interest. The identified indicators were characterized as follows: formula, justification, evidence level, pilot study, indicator type, phase of the continuum, intended organizational level of application, level of care, and income level of the countries. Selection was based on the characteristics associated with scientific soundness (formula, evidence level, and reliability). RESULTS: We identified 1791 indicators. Three hundred forty-six were duplicated, which resulted in 1445 indicators for analysis. Only 6.7% indicators exhibited all requirements for scientific soundness. The distribution by the classifying variables is clearly uneven, with a predominance of indicators for childbirth, hospital care and facility level. CONCLUSIONS: There is a broad choice of indicators for maternal and child healthcare. However, most indicators lack demonstrated scientific soundness and refer to particular continuum phases and levels within the healthcare system. Additional efforts are needed to identify good indicators for a comprehensive maternal and child healthcare monitoring system.

[Quality of the health information system: A comparative analysis of reported indicators, OECD Mexico 2010-2016.] / Calidad del sistema de información en salud: análisis comparativo de indicadores reportados, México OCDE 2010-2016.

OBJECTIVE: To analyze quantity and quality of the information reported by Mexico to OECD in relation to health indicators. MATERIALS AND METHODS: Analysis of frequency of indicators reporting, data quality, and comparison of reported values in the OECD environment. RESULTS: We analyzed 191 indicators. Mexico reported annually (2010-2016) 52.9% of them. Never reported 45.5%. The highest frequency of not reported (84%) is in the "Quality of care" group. Among the reported, information is of poor quality in 28.7% of them. Comparatively, Mexico holds the worst results in OECD indicators on screening of cancer, child and in-hospital mortality from myocardial infarction, and hospitalization for diabetes, among others. CONCLUSIONS: Mexico has problems of lack and quality of reported information, and frequently unfavorable values among OECD countries. The information system needs improvement, in both quantity and quality of data, and its effective utilization.

OBJETIVO: Analizar cantidad y calidad de la información sobre indicadores de salud reportada por México a la Organización para la Cooperación y el Desarrollo Económicos (OCDE). MATERIAL Y MÉTODOS: Análisis de frecuencia de indicadores reportados, calidad de los datos y comparación de valores reportados en el entorno OCDE. RESULTADOS: Se analizan 191 indicadores. México reportó anualmente (2010-2016) 52.9% de ellos. Nunca reportó 45.5%. La mayor frecuencia de no reportados (84%) es en el grupo "Calidad de la atención". En los reportados, la información es de calidad deficiente en 28.7%. Comparativamente, México ostenta los peores resultados de OCDE en indicadores sobre tamizaje de cáncer, mortalidad infantil e intrahospitalaria por infarto de miocardio y hospitalización por diabetes, entre otros. CONCLUSIONES: México tiene problemas de carencia y calidad de la información reportada y valores frecuentemente desfavorables en el entorno OCDE. Se requiere mejorar el sistema de información incidiendo tanto en cantidad como en calidad de los datos, y su utilización efectiva.

[Quality care indicators for neonates with selected pathologies: pilot study.] / Indicadores de calidad de la atención a neonatos con patologías seleccionadas: estudio piloto.

OBJECTIVE: Develop and pilot indicators of quality of care to neonates with relevant conditions in Mexico (prematurity, neonatal sepsis, perinatal asphyxia, and intrauterine hypoxia). MATERIALS AND METHODS: Own indicators were built based on key recommendations of national clinical practice guidelines and indicators found in international repositories. With previous search, selection and prioritization, the indicators were piloted within two hospitals. The feasibility of measuring, (kappa index) reliability and usefulness was analyzed to detect quality problems. RESULTS: 23 indicators were selected and piloted, 12 are compounds, of the total, nine were feasible and reliable. The quality of the hospital's information was diverse and often poor, limiting both the feasibility and the reliability of the indicators. Improvement opportunities were identified thorough the compliance levels. CONCLUSIONS: A set of nine indicators valid, reliable, feasible and useful indicators is proposed in order to monitor the quality of care of pathological neonates.

OBJETIVO: Desarrollar y pilotar indicadores de calidad de la atención a neonatos con padecimientos relevantes en México (prematuridad, sepsis neonatal, asfixia perinatal e hipoxia intrauterina). MATERIAL Y MÉTODOS: Se construyeron indicadores propios a partir de recomendaciones clave de las guías de práctica clínica nacionales e indicadores encontrados en repositorios internacionales. Previa búsqueda, selección y priorización, los indicadores fueron pilotados en dos hospitales. Se analizó la factibilidad de medición, fiabilidad (índice kappa) y utilidad para detectar problemas de calidad. RESULTADOS: Se seleccionaron y pilotaron 23 indicadores; 12 eran compuestos. Del total, nueve fueron factibles y fiables. La calidad de la información en los hospitales fue diversa y frecuentemente deficiente, limitando tanto la factibilidad como la fiabilidad de los indicadores. Los niveles de cumplimiento identificaron oportunidades de mejora. CONCLUSIONES: Se propone un set de nueve indicadores válidos, factibles, fiables y útiles para la monitorización de la calidad en la atención a neonatos patológicos.

Violations of the International Code of Marketing of Breast-milk Substitutes in Mexico.

This study estimated the prevalence of violations of the International Code of Marketing of Breast-milk Substitutes (BMS) and subsequent resolutions of the World Health Assembly (Code) at health facilities, points of sale (POS), and on BMS labelling and media in Mexico. We carried out a cross-sectional survey among 693 mothers with children aged less than 24 months and 48 health providers at public and private health facilities in two states of Mexico. Observational assessment at 20 POS and the health facilities was conducted as well as an analysis of labels on BMS products for sale. Women attending public and private health facilities reported receiving free BMS samples in the previous 6 months (11.1%), and about 80% reported seeing BMS promotion in the mass media. Health providers reported contact with BMS manufacturer representatives in the previous 6 months (15.5%), and only 41.6% of the health providers had knowledge of the Code. BMS promotions were identified at nearly all POS. Analysis of 190 BMS labels showed that 30% included pictures/text idealizing the use of BMS, and all labels incorporated health and nutrition claims. Violations of the Code are prevalent within the health services, POS, and labelling of BMS products. The high percentage of health providers with no knowledge of the Code calls for action at national level to better disseminate and comply with the Code. A transparent, free from commercial influence, and continual monitoring system for Code compliance is needed, including a follow-up component on sanctions for contraventions of the Code.

Construction and pilot test of a set of indicators to assess the implementation and effectiveness of the who safe childbirth checklist.

BACKGROUND: The World Health Organization (WHO) launched the "Safe Childbirth Checklist (SCC) Collaboration" in 2012. The SCC is designed to contribute to quality care by providing reminders of evidence-based practices for the prevention and management of the leading causes of maternal and neonatal morbidity and mortality. However, indicators to monitor the implementation and effectiveness of the SCC have not been defined. This study aimed to produce and pilot test a set of valid, reliable and feasible indicators to assess the implementation and effectiveness of the SCC, with an emphasis on best practices. METHODS: As part of the WHO Collaboration, the SCC was adapted to the Mexican context, and a set of indicators was developed to assess the SCC use and adherence to SCC-related best practices. The indicators were pilot tested in three hospitals for feasibility and reliability using the prevalence- and bias-adjusted kappa index (PABAK) for multiple independent evaluators (initial sample, n = 47; second sample, n = 30 to re-test reliability). The data sources were clinical records and cognitive tests drawn from questionnaires to mothers and health professionals. RESULTS: We generated 53 indicators, and 38 of the indicators (those related to best practices and outcomes) were pilot tested. Of these, 26 relate to care for the mother (20 were measured based on clinical records and 6 via questionnaire), and 12 relate to newborn care (9 were medical record-based and 3 were from questionnaires). Feasible indicators were generally also reliable (PABAK≥0.6). Routine feasibility is affected by the frequency of assessed events. CONCLUSIONS: The generated indicators allow an assessment of the implementation and effectiveness of the SCC and the monitoring of quality of care during childbirth and the immediate postpartum period.

[Psychometric validation of an instrument to evaluate the context of quality improvement and accreditation of hospitals]. / Validación psicométrica de instrumento para evaluar contexto de mejora de calidad y acreditación de hospitales.

OBJECTIVE: To adapt and validate an instrument to measure the context factors which favor quality improvement initiatives and accreditation of hospitals. MATERIALS AND METHODS: The model and questionnaire Model for Understanding Success in Quality (MUSIQ) is adapted and validated for application in Spanish-speaking countries and its specific use in hospital accreditation projects. The theoretical construct of its dimensions is assessed by confirmatory factor analysis (Bartlett test and Kaiser-Meyer-Olkim index) and internal consistency (Cronbach's a), in a study carried out in a sample of 54 hospitals of medium and high complexity in Colombia. RESULTS: Instrument with four dimensions of context (environment, macrosystem, microsystem, quality team), composed of 23 elements that are measured through 35 variables. Factor analysis showed statistical significance and adequacy of the dimensions, which had also good internal consistency. CONCLUSIONS: Adapted instrument with useful- ness for measurement of context elements that can promote initiatives of improvement and accreditation in hospitals.

OBJETIVO: Adaptar y validar instrumento para medir elementos del contexto que pueden favorecer iniciativas de mejoramiento de la calidad y acreditación de hospitales. MATERIAL Y MÉTODOS: Se adaptó y validó modelo y cuestionario Model for Understanding Success in Quality (MUSIQ) para aplicación en países hispanoparlantes y uso específico para proyectos de acreditación de hospitales. Se realizó un análisis factorial confirmatorio (test de Bartlett e índice Kaiser-Meyer-Olkim) del constructo teórico de sus dimensiones y se comprueba consistencia interna en estudio realizado en muestra de 54 hospitales de mediana y alta complejidad en Colombia. RESULTADOS: Instrumento con cuatro dimensiones de contexto (ambiente, macrosistema, microsistema, equipo de calidad), compuestas por 23 elementos medidos a través de 35 variables. El análisis factorial mostró significancia estadística y adecuación de las dimensiones que tuvieron también buena consistencia interna. CONCLUSIONES: Instrumento adaptado con utilidad para monitorizar elementos del contexto que pueden favorecer iniciativas de mejora y acreditación en hospitales.

Improving the quality of radiological examinations: effectiveness of an internal participatory approach.

QUALITY PROBLEM OR ISSUE: To assess the quality of radiological examinations (REs) and to evaluate the effectiveness of a participatory continuous improvement approach to ensure best practices in a Portuguese hospital imaging department. INITIAL ASSESSMENT: At baseline, we found 232 (10.2%) non-compliances, mostly related to the criteria image centering and framing in chest radiography (CXR), proper use of radiological protection equipment in other conventional RE (CR) and X-ray beam collimation (CXR/CR). CHOICE OF SOLUTION: A baseline and three consecutive evaluations of the RE quality were conducted. Each assessment was followed by participatory focused interventions for improvement. IMPLEMENTATION: For each evaluation, we selected a random sample (n = 60) of cases for four types of examination (total n = 240 for each assessment, and 960 for the whole project). Both the building of quality criteria and the design of interventions for improvement were participatory, involving the radiology technicians. Estimates of criteria compliance were calculated with 95% confidence intervals. The statistical significance of absolute and relative improvements was tested using one-tail z-tests. EVALUATION: After the intervention, non-compliances decreased to 48 (2.1%). Compliance estimates improved in 25 of 38 criteria assessed, with statistical significance for 5 criteria in CXR and 3 in CR and digestive examination. LESSONS LEARNED: The internal participatory approach enabled the identification of existing quality problems and, by focusing on the more frequent quality defects, was effective in improving the quality of RE.

Quality agencies at the global level: characteristics and functions-a narrative review.

PURPOSE: To provide a comparative description of the structure, function and activities of quality agencies around the world and describe the published evidence of their impact on the health system. DATA SOURCES: A narrative review was conducted using the information found on websites, articles, books and gray literature in English and Spanish. STUDY SELECTION: The search process included three complementary approaches: (i) websites of agencies, ministries of health and quality-related official institutions; (ii) evaluations, reports, audits or documents regarding quality agencies; and (iii) scientific articles and gray literature found (key word: quality agency) using Ebsco databases. Information was completed using the 'snowball' technique, tracking internet materials and citing literature of reviewed documents. DATA EXTRACTION: The analytical framework to summarize the information included the agencies' mission, structures, target institutions, activities (following a six-domain model), funding, information management and impact evaluations. RESULTS OF DATA SYNTHESIS: Information was found regarding quality agencies in 62 countries. Those focusing mainly on accreditation were discarded for further analysis. Agencies with a broader focus, according to the six-domain model for quality improvement (QI) strategies, were found in nine countries. Information resulted very heterogeneous in form and substance. However, they share the function of strengthening and advising on 'public goods', through information, knowledge management and development of standards. No impact evaluations of any type were found. CONCLUSION: The characteristics of existing quality agencies are very heterogeneous, being accreditation the main common focus. There is a lack of both a comprehensive approach to QI strategies and a formal assessment of their impact or contribution for improving quality.

[Implementation of quality of care indicators for third-level public hospitals in Mexico]. / Implementación de indicadores de calidad de la atención en hospitales públicos de tercer nivel en México.

OBJECTIVE:: To select, pilot test and implement a set of indicators for tertiary public hospitals. MATERIALS AND METHODS:: Quali-quantitative study in four stages: identification of indicators used internationally; selection and prioritization by utility, feasibility and reliability; exploration of the quality of sources of information in six hospitals; pilot feasibility and reliability, and follow-up measurement. RESULTS:: From 143 indicators, 64 were selected and eight were prioritized. The scan revealed sources of information deficient. In the pilot, three indicators were feasible with reliability limited. Has conducted workshops to improve records and sources of information; nine hospitals reported measurements of a quarter. CONCLUSIONS:: Eight priority indicators could not be measured immediately due to limitations in the data sources for its construction. It is necessary to improve mechanisms of registration and processing of data in this group of hospital.