Do performance indicators predict regulator ratings of healthcare providers? Cross-sectional study of acute hospitals in England.

OBJECTIVE: To determine whether a large set of care performance indicators ('Intelligent Monitoring (IM)') can be used to predict the Care Quality Commission's (CQC) acute hospital trust provider ratings. DESIGN: The IM dataset and first-inspection ratings were used to build linear and ordered logistic regression models for the whole dataset (all trusts). This was repeated for subsets of the trusts, with these models then applied to predict the inspection ratings of the remaining trusts. SETTING: The United Kingdom Department of Health and Social Care's Care Quality Commission is the regulator for all health and social care services in England. We consider their first-inspection cycle of acute hospital trusts (2013-2016). PARTICIPANTS: All 156 English NHS acute hospital trusts. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Percentage of correct predictions and weighted kappa. RESULTS: Only 24% of the predicted overall ratings for the test sample were correct and the weighted kappa of 0.01 indicates very poor agreement between predicted and actual ratings. This lack of predictive power is also found for each of the rating domains. CONCLUSION: While hospital inspections draw on a much wider set of information, the poor power of performance indicators to predict subsequent inspection ratings may call into question the validity of indicators, ratings or both. We conclude that a number of changes to the way performance indicators are collected and used could improve their predictive value, and suggest that assessing predictive power should be undertaken prospectively when the sets of indicators are being designed and selected by regulators.

Differences in Acute Ischemic Stroke Quality of Care and Outcomes by Primary Stroke Center Certification Organization.

BACKGROUND AND PURPOSE: Primary stroke center (PSC) certification was established to identify hospitals providing evidence-based care for stroke patients. The numbers of PSCs certified by Joint Commission (JC), Healthcare Facilities Accreditation Program, Det Norske Veritas, and State-based agencies have significantly increased in the past decade. This study aimed to evaluate whether PSCs certified by different organizations have similar quality of care and in-hospital outcomes. METHODS: The study population consisted of acute ischemic stroke patients who were admitted to PSCs participating in Get With The Guidelines-Stroke between January 1, 2010, and December 31, 2012. Measures of care quality and outcomes were compared among the 4 different PSC certifications. RESULTS: A total of 477 297 acute ischemic stroke admissions were identified from 977 certified PSCs (73.8% JC, 3.7% Det Norske Veritas, 1.2% Healthcare Facilities Accreditation Program, and 21.3% State-based). Composite care quality was generally similar among the 4 groups of hospitals, although State-based PSCs underperformed JC PSCs in a few key measures, including intravenous tissue-type plasminogen activator use. The rates of tissue-type plasminogen activator use were higher in JC and Det Norske Veritas (9.0% and 9.8%) and lower in State and Healthcare Facilities Accreditation Program certified hospitals (7.1% and 5.9%) (P<0.0001). Door-to-needle times were significantly longer in Healthcare Facilities Accreditation Program hospitals. State PSCs had higher in-hospital risk-adjusted mortality (odds ratio 1.23, 95% confidence intervals 1.07-1.41) compared with JC PSCs. CONCLUSIONS: Among Get With The Guidelines-Stroke hospitals with PSC certification, acute ischemic stroke quality of care and outcomes may differ according to which organization provided certification. These findings may have important implications for further improving systems of care.

Causality analysis on health care evaluation criteria for state-operated mental hospitals in Korea using Malcolm Baldrige National Quality Award model.

Hospitals today are pressured to move away from the conventional health services management techniques and provide higher-quality health care to survive in intense competition. In our study, we aimed to develop health care evaluation criteria for the mental health care sector based on the existing Malcolm Baldrige National Quality Award model, and verify the causality of the evaluation model to lay groundwork for future research on the outcomes of national quality awards for mental health care. We focused on comparison groups comprising five state-operated mental hospitals in Korea using 92 survey questions derived from the MBNQA criteria for health care through structural equation modeling techniques. We verified that Leadership drives Foundation and Direction, which affect System that creates Results with 15 hypotheses supported out of 18 hypotheses established. We believe our findings will provide valuable implications to the top management of mental hospitals for self-examining quality management and promoting competitiveness.

[Assessment of targeted clinical audit in suicide attempt]. / Prise en charge des suicidants. Quel apport d'une démarche d'audit clinique ciblé?

BACKGROUND: Suicide attempt is a serious condition that is frequent in France. Picardie ranks fifth in France for suicide (418 deaths in 2005 for 1,890,000 inhabitants). Suicide attempt is one of the priorities of the regional public health program. The National Agency for Accreditation and Evaluation in Health (Anaes) has designed targeted clinical audits (TCA) on various conditions to promote this method as the basic tool for quality improvement. AIM: We investigated the contribution of TCA for improving the quality of care of suicide attempt within a regional framework in Picardie. METHODS: TCA were conducted in 12 state hospitals (eight Surgical Medicine and Obstetrics, three specialized in psychiatry, one local) between 2004 and 2006. The standards from the Anaes had 16 criteria in three fields: care on admission (n=10); assessment of family and social environment (n=2); management for after hospital care (n=4). A project manager and a MD certified in health care quality supported the medical (MD certified in acute care and in psychiatry) and nursing staff of the emergency wards. All the wards analyzed 30 patients' files for the first cycle, set up and implemented improvement actions and then performed the second cycle of data collection. RESULTS: All wards fully satisfied the protocol with 30 patients' files per cycle and two cycles. In all wards the teams consisted of physicians (both certified for emergency or psychiatry) and others care providers (nurses, psychologists, social workers, secretary). For the first cycle, three criteria (patient assessment, somatic examination and coordination) met the 100% target for more than half of the wards while three criteria (sociofamily and environmental evaluation, management for after hospital care, monitoring of follow-up) did not conform by more than 50% in more than half of the wards. All wards implemented changes after the first cycle with a total of 29 interventions, each one specifically devoted to improving a particular criterion. Intervention included better coordination and communication, protocol design and reminders, and information tools. The second cycle showed modest and mixed changes. After the interventions only one criteria reached the 100% target in one ward; the degree of conformity decreased in nine cases (with a mean of -23%) and increased in 16 cases (+19%). Globally, three criteria improved by less than 10% while three slightly decreased. DISCUSSION: G. Shaw introduced clinical audits in 1989 to boost a poorly performing system within the "clinical governance" framework, a condition quite different from the French healthcare system in 2005. Therefore, the validation of clinical audit in a different context appeared necessary. Anaes has not yet published the evaluation of this method in a peer reviewed journal. Observed changes are modest and mixed. Moreover, the true impact on care delivery appears limited and one cannot rule out that the observed improvements are in fact related to an improvement in traceability or due to Hawthorne's effect. Quality improvement methods must be evaluated and validated by scientific methods such as for new treatments with clinical research. CONCLUSION: The feasibility of the method was excellent, due to the methodological and technical support, however the method did not significantly improve the quality of care.

Descriptive survey of women's childbirth experiences in two state hospitals in KwaZulu-Natal.

BACKGROUND: Giving birth is one of the most important events in a woman's life and is a highly individualistic and unique experience. OBJECTIVES: The study aimed to describe women's childbirth experiences in two state hospitals in KwaZulu-Natal. METHOD: A non-experimental, quantitative, descriptive survey of low-risk mothers was conducted in two state hospitals by using the Childbirth Experience Questionnaire (CEQ). RESULTS: With a response rate of 96%, 201 questionnaires were completed and returned. The highest mean score of the four dimensions of the CEQ was for the dimension of Professional Support (3.1). The results of the individual dimension items scoring the highest positive response were: I felt that I handled the situation well (147; 74%) (Own Capacity); I felt very well cared for by my midwife (165; 82%) (Professional Support); 151 respondents (76%) scored the item My impression of the team's medical skill made me feel secure as the highest positive experience (Perceived Safety); and I felt I could have a say in the choice of pain relief (105; 52%) (Participation). The relationship between demographic variables (age, level of education, parity, antenatal clinic attendance, induction of labour, augmentation and duration of labour) and respondents' scores of the CEQ dimensions was calculated, and only the dimension of Perceived Safety and duration of labour (≥ 12 hours) were found to be significant (p = 0.026). CONCLUSION: From the women perspectives, the study results described childbirth experience as multi-dimensional experience and subjective. Both positive and negative experiences coexisted in all dimensions of the CEQ, with the dimension of Professional Support scoring the highest positive response. To maintain a positive birth experience, the study suggests that women should be involved and equipped with knowledge on the process of childbirth.

Achieving quality in a government hospital: departmental responsibility.

Quality improvement in health care organizations requires structural reorganization and system reform and the development of an appropriate organizational "culture." In 2007, the Division of Quality and Excellence in Civil Service in Israel developed a concept to improve quality management in governmental institutions throughout the country. To put this strategy into practice, Western Galilee Hospital, a governmental hospital, in northern Israel, developed a plan to advance the quality management system where each department and unit is autonomously responsible for its own quality and excellence. Since the hospital has been certificated by ISO 9001 for more than 10 years (the only hospital in Israel to have this certificate), the main challenge now is to improve the quality and excellence system in every department. The aim of this article is to describe the implementation of a comprehensive program designed to raise the ability of managers and workers in Western Galilee Hospital in addressing all of the government's requirements for quality and excellence in service in Israel.

Getting It Right First Time: the national survey of surgical site infection rates in NHS trusts in England.

INTRODUCTION: Surgical site infections are associated with increased morbidity and mortality in patients. The Getting It Right First Time surgical site infection programme set up a national survey to review surgical site infection rates in surgical units in England. The objectives were for frontline clinicians to assess the rates of infection following selected procedures, to examine the risk of significant complications and to review current practice in the prevention of surgical site infection. METHODS: A national survey was launched in April 2017 to assess surgical site infections within 13 specialties: breast surgery, cardiothoracic surgery, cranial neurosurgery, ear, nose and throat surgery, general surgery, obstetrics and gynaecology, ophthalmology, oral and maxillofacial surgery, orthopaedic surgery, paediatric surgery, spinal surgery, urology and vascular surgery. All participating trusts prospectively identified and collected supporting information on surgical site infections diagnosed within the six-month study period. RESULTS: Data were received from 95 NHS trusts. A total of 1807 surgical site infection cases were reported. There were variations in rates reported by trusts across specialties and procedures. Reoperations were reported in 36.2% of all identified cases, and surgical site infections are associated with a delayed discharge rate of 34.1% in our survey. CONCLUSION: The Getting It Right First Time surgical site infection programme has introduced a different approach to infection surveillance in England. Results of the survey has demonstrated variation in surgical site infection rates among surgical units, raised the importance in addressing these issues for better patient outcomes and to reduce the financial burden on the NHS. Much work remains to be done to improve surgical site infection surveillance across surgical units and trusts in England.

[Patient safety culture in three Brazilian hospitals with different types of management]. / Cultura de segurança do paciente em três hospitais brasileiros com diferentes tipos de gestão.

The scope of the study was to evaluate patient safety culture and associated factors in Brazilian hospitals with different types of management, namely federal, state and private hospitals. The design was cross-sectional and observational. A survey of 1576 professionals at three hospitals of Rio Grande do Norte state was performed using the Hospital Survey on Patient Safety Culture adapted for Brazil, which measures 12 dimensions of safety culture. Perceptions are described by attributing a general result (Range 0-10) and the percentage of positive responses to estimate their strengths and weaknesses. The response rate was 13.6% (n= 215). The patient safety coefficient was between 7 and 10 for 78.1% of the respondents, whereby the highest average grade was attributed to the private hospital (8.32). It has been estimated that the type of hospital management, unit service, position and number of adverse event notifications are associated with the overall patient safety grade (p <0.001). Only the private hospital had strengths in the dimensions analyzed, while the weaknesses appeared in all the hospitals.

O objetivo do estudo foi avaliar a cultura de segurança do paciente e fatores associados em hospitais brasileiros com diferentes tipos de gestão: federal, estadual e privado. O desenho foi observacional transversal. Enviaram-se 1576 questionários aos profissionais de três hospitais do estado do Rio Grande do Norte, utilizando o Hospital Survey on Patient Safety Culture, adaptado para o Brasil, que mede 12 dimensões da cultura de segurança. As percepções são descritas através de uma nota geral (0 a 10) e dos percentuais de respostas positivas para estimar fortalezas e fragilidades em cada dimensão. A taxa de resposta foi de13,6% (n = 215). A segurança do paciente teve nota entre 7 e 10, para 78,1% dos respondentes, sendo a maior média das notas apresentada pelo hospital privado (8,32). O tipo de gestão hospitalar, unidade de serviço, cargo e quantidade de notificação de eventos adversos estiveram associados à nota geral da segurança do paciente (p < 0,001). Apenas o hospital privado apresentou fortalezas nas dimensões analisadas, enquanto que as fragilidades apareceram em todos os hospitais.

epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England.

National evidence-based guidelines for preventing healthcare-associated infections (HCAI) in National Health Service (NHS) hospitals in England were commissioned by the Department of Health (DH) and developed during 1998-2000 by a nurse-led multi-professional team of researchers and specialist clinicians. Following extensive consultation, they were published in January 2001. These guidelines describe the precautions healthcare workers should take in three areas: standard principles for preventing HCAI, which include hospital environmental hygiene, hand hygiene, the use of personal protective equipment, and the safe use and disposal of sharps; preventing infections associated with the use of short-term indwelling urethral catheters; and preventing infections associated with central venous catheters. The evidence for these guidelines was identified by multiple systematic reviews of experimental and non-experimental research and expert opinion as reflected in systematically identified professional, national and international guidelines, which were formally assessed by a validated appraisal process. In 2003, we developed complementary national guidelines for preventing HCAI in primary and community care on behalf of the National Collaborating Centre for Nursing and Supportive Care (National Institute for Healthand Clinical Excellence). A cardinal feature of evidence-based guidelines is that they are subject to timely review in order that new research evidence and technological advances can be identified, appraised and, if shown to be effective in preventing HCAI, incorporated into amended guidelines. Periodically updating the evidence base and guideline recommendations is essential in order to maintain their validity and authority. Consequently, the DH commissioned a review of new evidence published following the last systematic reviews. We have now updated the evidence base for making infection prevention and control recommendations. A critical assessment of the updated evidence indicated that the original epic guidelines published in 2001 remain robust, relevant and appropriate but that adjustments need to be made to some guideline recommendations following a synopsis of the evidence underpinning the guidelines. These updated national guidelines (epic2) provide comprehensive recommendations for preventing HCAI in hospitals and other acute care settings based on the best currently available evidence. Because this is not always the best possible evidence, we have included a suggested agenda for further research in each section of the guidelines. National evidence-based guidelines are broad principles of best practice which need to be integrated into local practice guidelines. To monitor implementation, we have suggested key audit criteria for each section of recommendations. Clinically effective infection prevention and control practice is an essential feature of protecting patients. By incorporating these guidelines into routine daily clinical practice, patient safety can be enhanced and the risk of patients acquiring an infection during episodes of healthcare in NHS hospitals in England can be minimised.

Providing medical care in state psychiatric hospitals.

BACKGROUND: Dorothea Dix State Psychiatric Hospital (DDH) was cited by regulatory agencies in 1999-2001 for serious deficiencies in providing medical care to psychiatric patients. This resulted in a change in the discipline responsible for providing medical care. We report here how clinical staff and regulatory agencies evaluated the change. In addition, we sought to determine how medical care is currently provided at other state hospital across the nation. METHODS: A transition occurred whereby the responsibility for medical care (direct care and supervision of physician extenders) was changed from psychiatrists to internists. We surveyed psychiatrists and nurses about their impressions of the change and calculated the number of citations from regulators pre-and post-changeover. In addition, a survey was sent to all 212 state psychiatric hospitals. RESULTS: Response rates were: 100% for DDH psychiatrists, 42% for DDH nurses, and 67% for state hospitals. At DDH, clinicians favorably viewed the changeover with 23 (96%) of the 24 psychiatrists reporting a preference for internists having overall responsibility for medical care. There was also a marked reduction in deficiencies cited by regulatory agencies, with 10 prior to the change and only one after the change. Responses to the State Psychiatric Hospital survey revealed that psychiatrists currently provide or are responsible for at least some portion of the medical care at 690% ofall facilities. LIMITATIONS: DDH staffevaluated a change from a system that had not been in place for 3 years. Quality of care measures were not available. How these data generalize to other state hospitals is unknown. CONCLUSIONS: Having internists responsible for medical care was well received by staff and regulatory agencies. Currently, state psychiatric facilities use different approaches to provide medical care. Further research is needed on how quality of care, and ultimately patient safety, may be impacted by these different service delivery models.

Implementación de un código de trauma en un servicio de emergencias de un hospital nacional / Implementation of a trauma code

Resumen Objetivo: Desarrollar una propuesta accesible a la realidad local de un hospital general terciario (Hospital Calderón Guardia) para la implementación de un código de trauma, basada en la mejor evidencia médico científica disponible. Métodos: Se realizó una revisión de la bibliografía; se buscaron los trabajos de investigación publicados a nivel nacional e internacional sobre la conformación y criterios relativos al código de trauma, su implementación, sus desafíos, y sus limitaciones; mediante 3 buscadores: Scielo, Pubmed y Ovid. Se incluyeron estudios con diversa metodología, disponibles en inglés o español. Resultados: Treinta artículos publicados en revistas indexadas fueron seleccionados y la información se agrupó en las siguientes categorías: Conformación del equipo de trauma en la activación de los códigos para cada hospital, criterios de activación, niveles de activación, experiencia local y limitaciones. Dicha información permitió identificar dos elementos principales para conseguir un beneficio: la conformación de un equipo multidisciplinario de primera respuesta para los pacientes más graves y la estandarización de criterios específicos para la activación de dicho equipo; entonces, se procedió a elaborar y proponer un modelo viable y concordante con las características del servicio hospitalario. Conclusión: La implementación hospitalaria de un modelo de código de trauma supone un impacto positivo en los desenlaces de morbi-mortalidad, a través de dos 2 mecanismo principales: la conformación de un equipo multidisciplinario de primera respuesta para los pacientes más graves y la estandarización de criterios específicos para la activación de dicho equipo; por lo que se elaboró un modelo ajustado a las necesidades y recursos del hospital.

Abstract Objective: To develop a proposal of a trauma code accessible to the local characteristics of a tertiary general hospital (Hospital Calderón Guardia) based on the best clinical evidence available. Methods: A literary search was made of national and international scientific papers regarding several aspects about trauma code, it´s implementation, it´s challenges, main benefits, and it´s limitations in 3 main web search portals: Scielo, PubMed and Ovid. We included paper studies in English and Spanish. Results: Thirty scientific papers from index journals were selected for review and the following data were extracted: Trauma team conformation, trauma team activation criteria, levels for trauma team activation, local experience, and limitations. That information allowed us to identify 2 main beneficial elements: the conformation of the trauma team and the standardization of the specific criteria necessary for its activation. Also, we elaborated a proposal for a viable model in accordance with our resources. Conclusion: According to scientific review, trauma code implementation in any institution associates a positive impact in clinical patient outcomes through 2 main mechanisms: the conformation of a multidisciplinary trauma team response of severe trauma patients, and the standardization of criteria for activation of the trauma teams. With these findings we elaborated a proposal adjusted to the needs and resources of Hospital Rafael Angel Calderon Guardia.

Hospital surveys of prescribing practices with psychotherapeutic drugs. A critical examination.

Hospital surveys of psychotherapeutic drug prescribing in the United States have been generally critical of the treatment practices of physicians and have been used to support claims that psychotherapeutic drugs are overprescribed and misused. This report examined several recent multihospital surveys of psychotherapeutic drug use and concludes that the surveys have failed to provide sufficient information to determine the appropriateness of treatment practices. The limitations of these surveys and the need to develop more adequate information about physician prescribing patterns are discussed.

What is the measure of a safe hospital? Medication errors missed by risk management, clinical staff, and surveyors.

Research in the last decade has identified medication errors as a more frequent cause of unintended harm than was previously thought. Inpatient medication errors and error-prone medication usage are detected internally by medication error reporting and externally through hospital licensing and accreditation surveys. A hospital's rate of medication errors is one of several measures of patient safety available to staff. However, prospective patients and other interested parties must rely upon licensing and accreditation scores, along with varying access to outcome data, as their sole measures of patient safety. We have previously reported that much higher rates of medication errors were found when an independent audit was used compared with rates determined by the usual process of self-report. In this study, we summarize these earlier findings and then compare the error detection sensitivity of licensing and accreditation surveys with that of an independent audit. When experienced surveyors fail to detect a highly error prone medication usage system, it raises questions about the validity of survey scores as a measure of safety (i.e., lack of medication errors). Replication of our findings in other hospital settings is needed. We also recommend measures for improving patient safety by reducing error rates and increasing error detection.

"No-commitment week": a feasibility study.

To determine the extent to which involuntary hospitalization is overused, a "No-Commitment Week" was set aside, during which emergency room psychiatrists committed only patients in absolute need of hospitalization. Compared with the week before and the week after, there was no significant difference in the number of patients committed during No-Commitment Week. The authors propose replication of the study on a larger scale but suggest that decisions about involuntary hospitalization in public mental hospitals are the result of societal attitudes, which will be subject to change as long as society itself continues to change.

The future of state hospitals: should there be one?

The recognition of the serious problems of state hospitals that dominated public policy in the 1960s has been largely overshadowed in recent years by a preoccupation with the problems of deinstitutionalization. The current backlash against the community movement threatens to legitimize once again the state hospital as an acceptable solution to the problems of the severely mentally ill. The author argues that state hospitals are deficient not simply because they provide an inferior quality of care but because they provide the wrong kind of care for most of their patients. He suggests that most state hospitals be completely replaced by a fundamentally different system.

Introducing quality assurance to a state hospital medical staff.

Establishing a quality assurance program in a developing state hospital requires considering the unique problems of being a physician in such a setting. The hospital and medical staff must be developed to the point where consideration of quality of care is a feasible goal. Managers can take advantage of the interests of individual medical staff as well as serendipitous factors promoting a program.

Rationality in medical treatment decisions: is there a sunk-cost effect?

OBJECTIVE: To assess residents' propensity to display the sunk-cost effect, an irrational decision-making bias, in medical treatment decisions; and to compare residents' and undergraduates' susceptibility to the bias in non-medical, everyday behaviors. DESIGN: Cross-sectional, in-person survey. SETTING: Louisiana State University, two locations: Medical Center-Baton Rouge and Main Campus-Psychology Department. PARTICIPANTS: Internal medicine and family practice residents (N = 36, Mdn age = 27) and college undergraduates (N = 40, Mdn age = 20). MEASUREMENTS AND MAIN RESULTS: Residents evaluated medical and non-medical situations that varied the amount of previous investment and whether the present decision maker was the same or different from the person who had made the initial investment. They rated reasons both for continuing the initial decision (e.g., stay with the medication already in use) and for switching to a new alternative (e.g., a different medication). There were two main findings: First, the residents' ratings of whether to continue or switch medical treatments were not influenced by the amount of the initial investment (p's>0.05). Second, residents' reasoning was more normative in medical than in non-medical situations, in which it paralleled that of undergraduates (p's<0.05). CONCLUSIONS: Medical residents' evaluation of treatment decisions reflected good reasoning, in that they were not influenced by the amount of time and/or money that had already been invested in treating a patient. However, the residents did demonstrate a sunk-cost effect in evaluating non-medical situations. Thus, any advantage in decision making that is conferred by medical training appears to be domain specific.

P.R.N. (As-needed) orders and exposure of psychiatric inpatients to unnecessary psychotropic medications.

OBJECTIVE: The objective of this study was to evaluate whether the practice of writing standing p.r.n. (as-needed) orders exposes psychiatric inpatients to unnecessary psychotropic medications. METHODS: Medical records for 223 new hospital admissions between July 15 and October 15, 1999, when p.r.n. orders were allowed, and 224 new admissions between November 15, 1999, and February 15, 2000, when p.r.n. orders were not allowed and only "now" orders were permitted, were reviewed from the three acute adult psychiatric units of the Arkansas State Hospital in Little Rock. Data were collected on demographic and clinical characteristics, scheduled and unscheduled psychotropic medications as noted in the medication administration records, use of seclusion and restraint, and incident reports of physical aggression. The mean numbers of unscheduled psychotropic medication doses administered during the two periods were compared. RESULTS: The number of unscheduled psychotropic medications administered decreased from 1,812 in the first period to 976 in the second period (adjusted mean doses per admission, 7.8 to 4.3). The decrease in use of unscheduled medications when standing p.r.n. orders were no longer allowed was not associated with corresponding increases in adverse events: there were fewer incidents of restraint (four compared with eight), fewer incidents of seclusion (41 compared with 48), and fewer incidents of physical aggression (35 compared with 40). In addition, there were no significant changes in the dosages of scheduled psychotropic medications on day 7 of admission, indicating that physicians were not increasing dosages in response to the elimination of p.r.n. orders. CONCLUSIONS: The practice of writing p.r.n. orders may expose psychiatric inpatients to unnecessary psychotropic medications.

State hospitals' responses to the sexual behavior of psychiatric inpatients.

To determine state psychiatric hospitals' responses to sexual behavior among inpatients, the authors sent a questionnaire to the directors of 86 state facilities. Eighty-eight percent of the 57 respondents considered sexual behavior to be a clinical problem. Most had a policy addressing sexual activities among patients, and 75 percent had psychoeducational programs. Although most of the hospitals that responded to the survey recognized the clinical and ethical issues associated with patients' sexuality, greater acknowledgement of these issues and sharing of information could promote the formulation of broader regional or national guidelines.

A comparative study of the psychiatric care between locum tenens and staff physicians in a state hospital.

Artificial neural networks (ANNs) were used to measure the quality of care (Q) at two admission units in a state psychiatric hospital, each unit having two treatment teams, one led by a permanent (PM) staff physician, and one led by various locum tenens (LT) physicians. An LT physician's tour of duty (TOD) averaged approximately 30 days. Over nearly a 2 1/2-year period the four treatment teams received 744 admissions. Our previous research has reported measuring Q using percent accurate prediction of hospital length-of-stay (LOS), divided by a measure of severity of patient illness. We calculated Q for each treatment team's test set of patients using a trained ANN for each team. All the teams' test sets were run through each of the trained ANNs resulting in a set of four Q values for each ANN. We defined the standard deviation of Qs resulting from a single team's test set run through it own as well as the other three teams' ANNs as representative of the "diversity" of the patients in that test set. We defined the reciprocal of the standard deviation of the Qs resulting from each of the teams' test sets run through a single team's ANN as that team's "robustness." The product of "robustness" times "diversity" was defined as the value (V) of the treatment team. The V of the PM physician-led teams was 1.9 times that of the LT physician-led teams. We normalized V for patient entropy (uncertainty) with a metric called the "risk ratio" (RR), derived from Boltzmann's law. This resulted in the V/RR of one PM physician-led team as superior, despite treating patients with the highest risk. The LT physician-led teams, despite having fewer patients afflicted with the more problematic diagnosis of schizophrenia, were handicapped by not having preexisting therapeutic relationships with their patients, giving both LT teams low robustness. There was no statistically significant difference in patient LOS between the teams. Because the greatest change in team composition was due to LT physicians, we assumed that the differences in V/RR were due to the short (30-day) TOD and not to any skill deficits in the LT physicians. This article explores a new paradigm which compares the value of patient care in separate delivery systems despite differences in severity of illness, case-mix, and uncertainty associated with an imperfect therapeutic environment.