Quality/risk management system in radiotherapy: Changes afoot.

The French sanitary and regulatory context in which radiotherapy centres are comprised is evolving. Risk and quality management systems are currently adapting to these evolutions. The French nuclear safety agency (ASN) decision of July 1st 2008 on quality assurance obligations in radiotherapy has reached 10 years of age, and the French high authority of health (HAS) certification system 20 years now. Mandatory tools needed for the improvement of quality and safety in healthcare are now well known. From now on, the focus of healthcare policies is oriented towards evaluation of efficiency of these new organisations designed following ASN and HAS nationwide guidelines.

The Affordable Care Act at 10 Years: Evaluating the Evidence and Navigating an Uncertain Future.

The year 2020 marks the 10th anniversary of the signing of the Affordable Care Act (ACA). Perhaps the greatest overhaul of the US health care system in the past 50 y, the ACA sought to expand access to care, improve quality, and reduce health care costs. Over the past decade, there have been a number of challenges and changes to the law, which remains in evolution. While the ACA's policies were not intended to specifically target surgical care, surgical patients, surgeons, and the health systems within which they function have all been greatly affected. This article aims to provide a brief overview of the impact of the ACA on surgical patients in reference to its tripartite aim of improving access, improving quality, and reducing costs.

Strategies for Success in Regulatory Readiness.

This article describes the formation of a Regulatory Advisory Council to address regulatory preparedness. The council used quality improvement methods to address data and findings from previous mock surveys and created 2 categories of work, an environment of care and clinical standards group, with checklists and work streams to improve organizational success with regulatory readiness.

Advancing the Culture of Patient Safety and Quality Improvement.

The American health care system has many great successes, but there continue to be opportunities for improving quality, access, and cost. The fee-for-service health care paradigm is shifting toward value-based care and will require accountability around quality assurance and cost reduction. As a result, many health care entities are rallying health care providers, administrators, regulators, and patients around a national imperative to create a culture of safety and develop systems of care to improve health care quality. However, the culture of patient safety and quality requires rigorous assessment of outcomes, and while numerous data collection and decision support tools are available to assist in quality assessment and performance improvement, the public reporting of this data can be confusing to patients and physicians alike and result in unintended negative consequences. This review explores the aims of health care reform, the national efforts to create a culture of quality and safety, the principles of quality improvement, and how these principles can be applied to patient care and medical practice.

Health Literacy-How Do We Improve the Conversation at the Heart of Healthcare when We Know so Many People are Struggling with It?

The Scottish Government published "Making it Easy - A Health Literacy Action Plan for Scotland" in 2014, and in 2017 the next steps were set out in "Making it Easier - A Health Literacy Action Plan for Scotland 2017-2025." This article discusses what health literacy is, outlining the key points from these national action plans. The importance of understanding and addressing health literacy in relation to renal services, and dialysis in particular, is highlighted by use of an example of a Scottish renal unit's practice to outline the principles being used in a service.

Improved access to health care in Massachusetts after 2006 Massachusetts Healthcare Reform Law is associated with a significant decrease in mortality among vascular surgery patients.

BACKGROUND: Access to medical care, by adequate insurance coverage, has a direct impact on outcomes for patients undergoing vascular procedures. We evaluated in-hospital mortality for patients undergoing index vascular procedures before and after the Massachusetts Healthcare Reform Law (MHRL) in 2006, which mandated insurance for all Massachusetts residents, both in Massachusetts and throughout the United States. METHODS: The National Inpatient Sample was queried to identify patients undergoing interventions for peripheral arterial disease, carotid artery stenosis, and abdominal aortic aneurysms based on International Classification of Diseases, Ninth Revision, Clinical Modification procedural and diagnostic codes. The cohort was then divided into patients treated within Massachusetts (MA) and non-Massachusetts (NMA) hospitals. Two time intervals were examined: before (2003-2006, P1) and after the MHRL (2007-2011, P2). The primary outcome of interest included in-hospital mortality. Patients in MA and NMA hospitals were described in terms of demographics and presentation by time interval (P2 vs P1) compared using χ2 and t-tests. Weighted logistic regression with term modeling change in the odds ratio (OR) for P2 was performed to test and to estimate trends in mortality. Time (year of procedure) and region interactions were investigated by inclusion of time-region interactions in our analyses. Subgroup analysis was performed for P2 vs P1 among nonwhite, nonelderly, and low-income patients. RESULTS: We identified 306,438 patients who underwent repair of abdominal aortic aneurysm, lower extremity bypass, or carotid endarterectomy in MA and NMA hospitals. MA hospital patients had an increase in both Medicaid and private insurance status after the MHRL (P1 = 2.6% and 21% vs P2 = 3.3% and 21.7%, respectively; P = .034). In-hospital mortality trended down for all groups across the entire study. In comparing P2 vs P1 trends, MA hospital odds of mortality per year was lowered by 26% (OR, 0.74; 95% confidence interval [CI], 0.56-0.99; P = .042) not seen in NMA hospitals (OR, 1.03; 95% CI, 0.97-1.09; P = .405). Time and region interaction terms indicated significant time trend difference in both unadjusted (P = .031) and adjusted (P = .033) analysis in MA hospitals not observed in NMA hospitals. This pattern continued when the samples were stratified by procedure. Patients undergoing vascular procedures in MA hospitals had a significantly lowered OR of mortality, with fewer patients presenting at late disease stages in P2 vs P1. Nonelderly patients in Massachusetts, who benefit from the Medicaid expansion provided by the MHRL, had a profound 92% drop in odds of mortality in P2 vs P1 (OR, 0.08; 95% CI, 0.010-0.641; P = .017) compared with the 14% drop in NMA (OR, 0.86; 95% CI, 0.709-1.032; P = .103). CONCLUSIONS: The 2006 MHRL is associated with a decrease in mortality for patients undergoing index vascular surgery procedures in MA compared with NMA hospitals. This study suggests that governmental policy may play a key role in positively affecting the outcomes for patients.

Operationalizing Multidisciplinary Assessment and Treatment as a Quality Metric for Interventional Pain Practices.

Objective: Quality improvement (QI) is an underutilized approach among pain medicine specialists to improve comprehensive pain assessment and the delivery of multimodal pain care. We report the results of a QI program that utilized peer review and financial incentives to improve these processes in interventional pain clinics. Design: Retrospective chart review. Setting: Eight academic and community-based practices that included separate hospital-based and non-hospital-based interventional pain clinics. Subjects: Results of chart audits by nine academic pain medicine physicians. Methods: An audit of a random sample of each pain physician's charts was periodically examined for mention and discussion of specific components of multidisciplinary pain care. A portion of the physician's incentive payment was withheld if less than 70% of charts were compliant. The rates of compliance after the intervention for the group were compared. Results: Before this program was instituted, an audit of 10 patient charts from each of the nine pain medicine physicians revealed only a 13% baseline rate of compliance. After the audit system was implemented, 90% of all patient charts were compliant during the first 12-month period (P < 0.01 for the change in rate of compliance). Conclusions: The results of this QI project suggest that pain clinics can make this value-based transition and offer high-quality multidisciplinary assessment and treatment, with good compliance among a group of physicians in primarily intervention-based practices.

Strategies for Increasing the Role of Family Medicine in Mexican Health Care Reform.

There is little or no role for primary care and family medicine in current health reforms in Mexico. However, robust evidence shows that primary care helps prevent morbidity and mortality and increases health equity. Mexico has participated in several international meetings sponsored by the World Organization of National Colleges, Academies and Academic Associations and the North American Primary Care Research Group that are aimed at increased understanding of national health systems and the need to strengthen primary care for improved health outcomes. From 1 of these meetings the Cancún Manifesto emerged, with a strategic plan to increase the stature and impact of the Mexican College of Family Physicians (COLMEXAC) in strengthening primary care in Mexico. We aim to describe this strategic plan and discuss its early implementation, and for this account to serve as a possible formula for other countries. The 5 specific strategies discussed are 1) the need for consensus on the leading role of the Mexican family physician in the national health system; 2) health ecology research; 3) to improve the perception of patients about the benefits of primary care and family medicine; 4) to organize meetings of health providers, users, and other stakeholders; and 5) to promote the professionalization of COLMEXAC as a legal entity.

Emergency Department Involvement in Accountable Care Organizations in Massachusetts: A Survey Study.

STUDY OBJECTIVE: We assess Massachusetts emergency department (ED) involvement and internal ED constructs within accountable care organization contracts. METHODS: An online survey was distributed to 70 Massachusetts ED directors. Questions attempted to assess involvement of EDs in accountable care organizations and the structures in place in EDs-from departmental resources to physician incentives-to help achieve accountable care organization goals of decreasing spending and improving quality. RESULTS: Of responding ED directors, 79% reported alignment between the ED and an accountable care organization. Almost all ED groups (88%) reported bearing no financial risk as a result of the accountable care organization contracts in which their organizations participated. Major obstacles to meeting accountable care organization objectives included care coordination challenges (62%) and lack of familiarity with accountable care organization goals (58%). The most common cost-reduction strategies included ED case management (85%) and information technology (61%). Limitations of this study include that information was self-reported by ED directors, a focus limited to Massachusetts, and a survey response rate of 47%. CONCLUSION: The ED directors perceived that the majority of physicians were not familiar with accountable care organization goals, many challenges remain in coordinating care for patients in the ED, and most EDs have no financial incentives tied to accountable care organizations. EDs in Massachusetts have begun to implement strategies aimed at reducing admissions, utilization, and overall cost, but these strategies are not widespread apart from case management, even in a state with heavy accountable care organization penetration. Our results suggest that Massachusetts EDs still lack clear directives and direct involvement in meeting accountable care organization goals.

Improving Mental Health Services Through Physician Assistants: Legislation in Several Southern States.

A national effort to provide more expansive mental health care in the United States has been an increasing priority during the last decade. States have enacted laws that allow for the delegation of psychiatric services to physician assistants in an effort to address the shortage and geographic maldistribution of mental health services and to more efficiently use the skills of psychiatrists. This statutory scheme recognizing physician assistants has been effective in broadening access to mental health care in various southern states. It also has, however, imposed certain risks and responsibilities upon psychiatrists who choose to supervise physician assistants. Understanding the regulatory responsibilities imposed upon supervising psychiatrists and anticipating the risks associated with supervising a physician assistant are important in avoiding grave financial consequences and the difficulties associated with litigation. Here, we review the statutory responsibilities imposed upon the psychiatrists supervising physician assistants across various southern states and to discuss the risk of vicarious liability of the psychiatrists for the actions of the physician assistants.

PERSPECTIVES: Accountability for Mental Health: The Australian Experience.

BACKGROUND: Australia was one of the first countries to develop a national policy for mental health. A persistent characteristic of all these policies has been their reference to the importance of accountability. What does this mean exactly and have we achieved it? Can Australia tell if anybody is getting better? AIMS OF THE STUDY: To review accountability for mental health in Australia and question whether two decades of Australian rhetoric around accountability for mental health has been fulfilled. METHODS: This paper first considers the concept of accountability and its application to mental health. We then draw on existing literature, reports, and empirical data from national and state governments to illustrate historical and current approaches to accountability for mental health. We provide a content analysis of the most current set of national indicators. The paper also briefly considers some relevant international processes to compare Australia's progress in establishing accountability for mental health. RESULTS: Australia's federated system of government permits competing approaches to accountability, with multiple and overlapping data sets. A clear national approach to accountability for mental health has failed to emerge. Existing data focuses on administrative and health service indicators, failing to reflect broader social factors which reveal quality of life. In spite of twenty years of investment and effort Australia has been described as outcome blind, unable to demonstrate the merit of USD 8bn spent on mental health annually. DISCUSSION AND LIMITATIONS: While it may be prolific, existing administrative data provide little outcomes information against which Australia can genuinely assess the health and welfare of people with a mental illness. International efforts are evolving slowly. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Even in high income countries such as Australia, resources for mental health services are constrained. Countries cannot afford to continue to invest in services or programs that fail to demonstrate good outcomes for people with a mental illness or are not value for money. IMPLICATIONS FOR HEALTH POLICIES: New approaches are needed which ensure that chosen accountability indicators reflect national health and social priorities. Such priorities must be meaningful to a range of stakeholders and the community about the state of mental health. They must drive an agenda of continuous improvement relevant to those most affected by mental disorders. These approaches should be operable in emerging international contexts. IMPLICATIONS FOR FURTHER RESEARCH: Australia must further develop its approach to health accountability in relation to mental health. A limited set of new preferred national mental health indicators should be agreed. These should be tested, both domestically and internationally, for their capacity to inform and drive quality improvement processes in mental health. CONCLUSION: Existing systems of accountability are not fit for purpose, incapable of firing necessary quality improvement processes. Supported by adequate resources, realistic targets and a culture of openness, new accountability could drive real quality improvement processes for mental health, facilitate jurisdictional comparisons in Australia, and contribute to new efforts to benchmark mental health internationally.

[Assessing user satisfaction, an objective for quality of care]. / L'évaluation de la satisfaction des usagers, un enjeu pour la qualité des soins.

The assessment of user satisfaction constitutes a key indicator of the quality of care. It can be envisaged either as part of an internal strategy which favours the improvement of practices, an external strategy whose focus is more commercial and/or an exploratory strategy to develop care models. User satisfaction is expressed in particular through complaint letters and discharge questionnaires. These regulated schemes enable quality to be approached on an individual and collective level.