[Measurement of Quality with Routine Data]. / Qualitätsmessung aus Routinedaten.

There is a growing interest in quality measurement in the healthcare sector. Hospitals in Germany are obligated to participate in measures for external quality assurance and they must establish an internal quality management system. In addition to the legal requirements, measurement of quality is also possible with routine data. Suitable sources are the ICD system or unstandardized information from treatment documentation. The selection of suitable quality indicators is necessary to interpret the data. Complications or achievement of surgical objectives can be suitable quality indicators. Analysis of procedures or the assessment of waiting time are also possible indicators. Our first data concerning waiting time show that with increasing use of an electronic patient guidance system, the waiting time decreased in our outpatient department. Assessment of quality indicators from routine data enables a continuous measurement of quality over a long period. Measures to increase quality can easily be checked. Routine data also provide the possibility to participate in a public reporting of quality indicators.

The future for peer review. Florida's constitutional amendment chills quality community.

A new amendment to its state constitution has opened up Florida's peer review meeting notes to the public, with chilling effects on the entire peer review process.

On the coding and reporting of race and ethnicity in New Hampshire for purposes of cancer reporting.

BACKGROUND: The objective was to investigate how data on race and ethnicity are collected by hospitals reporting to the New Hampshire State Cancer Registry (NHSCR). METHOD: NHSCR surveyed hospitals asking how information on race and ethnicity were collected. A review of relevant legal mandates and national guidelines was undertaken. RESULTS: Many hospitals lack policies on collection, computer systems fail to support national guidelines, and staff rely on visual inspection. CONCLUSIONS: Hospital staffs are not now culturally equipped to collect race and ethnicity in a meaningful way. The numerator in cancer incidence rates is most likely not accurate and for some smaller populations very biased. A new framework is needed that takes into account the needs of the democracy.

[Clinical performance measurement in surgery and orthopedics -- new aspects in 2004]. / Externe Qualitätssicherung Chirurgie und Orthopädie -- Was ändert sich im Jahr 2004?

In 2004, principles and practice of clinical performance measurement (CPM) in German hospitals were changed according to new legislative and administrative regulations. In many respects, focus and methods of clinical performance measurement were improved in favour of hospitals. Starting from January 1, 2004, the new Gemeinsamer Bundesausschuss (Joint Federal Board) has competence for decisions on future focus and scope of CPM. Former agreements on implementation of CPM in 2004 will be effective as long as Gemeinsamer Bundesausschuss passes new resolutions. Methods to identify relevant cases for CPM particularly changed in 2004. Until end of 2003, obligations to report case data were based on special types of hospital reimbursement. In 2004, obligations for reporting no longer derive from financial criteria, but from medical criteria such as diagnoses and procedures. In 2003, reporting for CPM covered more than 30 subjects in medicine and nursing. For 2004, the scope of CPM has been reduced by 13 subjects which need to be reconsidered in order to secure unified quality goals for out-patients as well as in-patients and to allow long-term follow-up of outcome data. For their CPM expenditure, hospitals receive an additional fee of euro 0.58 per case reimbursed by DRG. Financial sanctions will be effective for hospitals with overall CPM reporting rates below 80 %. Starting from 2005, hospitals are obliged to publish CPM reporting rates for each CPM subject in annual hospital quality reports.

[Compliance with regulations for medical records in 15 Aquitaine public health facilities. Aquitaine DIM Physician's Group]. / Conformité à la réglementation des dossiers de soins dans 15 établissements publics de santé en Aquitaine. Groupe des médecins des DIM d'Aquitaine.

OBJECTIVE: Record keeping contributes to the quality of health care in addition to fulfilling medicolegal and accreditation regulations. We conducted an audit of patient files in 15 public hospitals in Aquitaine to determine their compliance with national laws. METHODS: One hundred patient files were randomly selected in each hospital. Their compliance with 18 criteria established in 1992 by the ANDEM was studied. These 18 criteria were updated in accordance with the latest decrees from the health ministry and precisely defined in order to achieve good reproducibility of the measurements. RESULTS: Ten percent of the files fulfilled all 18 criteria. Each component of the record was correctly identified and the name of the general practitioner, admission documents, and delivery, anesthesia and transfusion records were almost always present. Surgery reports were found in 65 to 89% of the files. Low compliance with three criteria was observed: authorization to give health care to a minor (39 to 80% of the files), identification of the physician who prescribed the drugs during hospitalization (6 to 32%) and discharge prescription (42 to 95%). We also pinpointed problems concerning archiving and retrieval, especially concerning the results of complementary exams which were not necessarily stored with the patient files. CONCLUSION: This audit allowed us to define the first steps of a quality improvement project for patient records. We were able to deduct recommendations for analyzing compliance with legal requirements and suggest that the 1992 ANDEM criteria be updated to allow for valid comparisons between health care establishment.

When patient care is shared, who is the most responsible physician?

Ottawa lawyer Karen Capen examines the case of five Ontario physicians who faced charges of professional misconduct after a patient they cared for died in 1988. The investigation, which focused on the concept of "most responsible physician," serves as a cautionary tale for all doctors who share the care of a patient with colleagues.

Unusual problems for the physician in managing a hospital patient who received a malicious insulin overdose.

A patient recovering normally from a biopsy and subtotal removal of a malignant brain tumor became severely hypoglycemic on the ward and died. The differential diagnosis eliminated disease as a possible cause, and medication error on the floor was also ruled out. Deliberate administration of a massive dose of insulin intravenously seemed to be the only alternative. A careful investigation supported the likelihood of a criminal act. The patient's wife came under suspicion and was subsequently arrested, charged with murder, and convicted. This sequence of events created three problems that fell outside of our normal professional training and experience as physicians. First, we were slow to suspect foul play in our search for an unusual cause. Second, the steps taken to protect the patient against further risk without denying reasonable rights to family or arousing the suspect's suspicions needed strengthening. Third, even though the occurrence of these events in a hospital allowed an unusual degree of evidence documenting the allegations to be accumulated, key parts of the evidence could not be used. The routine hospital handling of laboratory tests critical to support of the accusations was not sufficient to meet the demands of the legal system, which has its own criteria. We discuss the issues in managing these problems.

Reporting the case of Baby Jane Doe.

KIE: Kathleen Kerr of the Long Island newspaper Newsday describes her paper's coverage of the Baby Jane Doe case for which she as the lead reporter received a Pulitzer Prize. Kerr traces her and Newsday's involvement from the first request for a court hearing to compel surgery against parental wishes to the broader issues of the ethical, legal, and public policy aspects of treatment decisions for handicapped newborns.^ieng