Organizational Characteristics Associated with High Performance in Medicare's Comprehensive End-Stage Renal Disease Care Initiative.

BACKGROUND AND OBJECTIVES: Medicare plans to extend financial structures tested through the Comprehensive End-Stage Renal Disease Care (CEC) Initiative-an alternative payment model for maintenance dialysis providers-to promote high-value care for beneficiaries with kidney failure. The End-Stage Renal Disease Seamless Care Organizations (ESCOs) that formed under the CEC Initiative varied greatly in their ability to generate cost savings and improve patient health outcomes. This study examined whether organizational or community characteristics were associated with ESCOs' performance. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We used a retrospective pooled cross-sectional analysis of all 37 ESCOs participating in the CEC Initiative during 2015-2018 (n=87 ESCO-years). Key exposures included ESCO characteristics: number of dialysis facilities, number and types of physicians, and years of CEC Initiative experience. Outcomes of interest included were above versus below median gross financial savings (2.4%) and standardized mortality ratio (0.93). We analyzed unadjusted differences between high- and low-performing ESCOs and then used multivariable logistic regression to construct average marginal effect estimates for parameters of interest. RESULTS: Above-median gross savings were obtained by 23 (52%) ESCOs with no program experience, 14 (32%) organizations with 1 year of experience, and seven (16%) organizations with 2 years of experience. The adjusted likelihoods of achieving above-median gross savings were 23 (95% confidence interval, 8 to 37) and 48 (95% confidence interval, 24 to 68) percentage points higher for ESCOs with 1 or 2 years of program experience, respectively (versus none). The adjusted likelihood of achieving above-median gross savings was 1.7 (95% confidence interval, -3 to -1) percentage points lower with each additional affiliated dialysis facility. Adjusted mortality rates were lower for ESCOs located in areas with higher socioeconomic status. CONCLUSIONS: Smaller ESCOs, organizations with more experience in the CEC Initiative, and those located in more affluent areas performed better under the CEC Initiative.

An EU approach to health system performance assessment: Building trust and learning from each other.

EU countries have recently joined forces to carry out common work on health systems performance assessment (HSPA). After the signature of the Tallinn Charter in 2008, a small group of countries brought the issue of HSPA on the EU agenda; this led the European commission and member states to set up an expert group on HSPA in 2014. This group started by facilitating the exchange of best practices and lessons learnt, with an eye to avoiding duplications with activities of international organisations. While progressing on its work, the group broadened its scope: it stepped into concrete work on policy priorities such as the assessment of quality of care, integrated care and primary care. It also moved into the organisation of country-tailored events and of advocacy activities. We identify three main strength factors of the EU expert group on HSPA. First, it is built through a bottom-up participatory approach, which promotes a sense of ownership by the members. Second, it developed a flexible and pragmatic attitude, which makes it able to constantly adapt to emerging needs and priorities. Finally, the group positioned itself in a niche that was still to be exploited: the identification of ways to translate HSPA findings into effective policy making.

Evaluating the Clinical Practice Model's Strengths and Improvement Opportunities Using the Professional Practice Framework Assessment Survey: One Integrated Healthcare System's Experience.

OBJECTIVES: The aims of this study are (1) to describe the division, organizational strengths, and improvement opportunities of self-reported behaviors indicative of the multidimensional construct of professional practice and (2) to understand demographic characteristics that contributed to these strengths and improvement opportunities. BACKGROUND: Prior to implementing a system-wide interdisciplinary shared governance structure, ProHealth Care measured staff attitudes toward the multidimensional construct of professional practice as proposed within the Clinical Practice Model framework using the Professional Practice Framework Assessment Survey (PPFA-S). METHODS: Clinical and support staff were invited to share their views toward professional practice using the previously validated, reliable tool, the PPFA-S. RESULTS: Partnering relationships, scope of practice, and shared purpose were strengths. Strategies were initiated to strengthen networking councils, integrated competency, evidence-based practice, transformative capacity, and clinical tools. CONCLUSIONS: The survey identified professional practice strengths and improvement opportunities across the organization as well as factors contributing to these strengths and opportunities. These findings were useful to help guide system integration.

A Concept Analysis of Patient Participation in Intermediate Care.

OBJECTIVE: Although the concept of patient participation has been discussed for a number of years, there is still no clear definition of what constitutes the multidimensional concept, and the application of the concept in an intermediate care (IC) context lacks clarity. Therefore this paper seeks to identify and explore the attributes of the concept, to elaborate ways of understanding the concept of patient participation for geriatric patients in the context of IC. METHODS: Walker and Avant's model of Concept analysis [1] based on a literature review. RESULTS: Patient participation in the context of IC can be defined as a dynamic process emphasizing the person as a whole, focusing on the establishment of multiple alliances that facilitate individualized information and knowledge exchange, and ensuring a reciprocal engagement in activities within flexible and interactive/dynamic organizational structures. CONCLUSION: Patient participation in IC means involving patients and their relatives in holistic interdisciplinary collaborative decision-making. The results highlight the complexity of patient participation and contribute to a greater understanding of the influence of organizational structure and management. PRACTICAL IMPLICATIONS: The present study may provide a practical framework for researchers, policy makers and health professionals to facilitate patient participation in IC services.

[In search of a travel guide-results from a survey of E­health startup companies]. / Reiseführer gesucht ­ Ergebnisse einer Umfrage bei E­Health-Start-ups.

As is the case in other sectors, innovative digital products have started to enter the health market, too. If digital products like apps are considered medical devices, startups are often confronted with regulatory procedures that they deem to be slow and with which they are not familiar. This applies to both the certification procedures and the requirements and procedures for reimbursement, where problems could occur. The aim of this article is to better understand the startups' experience in navigating through these procedures, the hurdles they encounter, and their need for support. Therefore, the digital association Bitkom e. V. and the Federal Institute for Drugs and Medical Devices (BfArM) conducted a web-based survey on five themes with a total of 23 questions. These questions focused inter alia on the composition of the team, product planning, familiarity with regulatory requirements, experience with institutions and different sources of information, the assessment of challenges in the process, and the resulting need for support.The analysis on the basis of 18 complete replies has shown that startups work on products with documentation and communications functions, but also integrate diagnostic and therapeutic features. The latter are characteristics of medical devices. Startups consider themselves to be relatively familiar with regulatory requirements regarding medical devices. The largest hurdles are associated with reimbursement: long and costly processes until the startups' products could be reimbursed.Both with regard to reimbursement and certification, startups see a need for low-threshold, cost-efficient advisory services and a simplification and acceleration of existing procedures with regard to medical devices.

Aspectos metodológicos de los procesos asistenciales integrados (PAI) / Methodological aspects of integrated care pathways

Un proceso asistencial integrado (PAI) es una herramienta cuyo propósito es aumentar la efectividad de las actuaciones clínicas a través de una mayor coordinación y garantía de continuidad asistencial. Los PAI sitúan al paciente como el eje central de la organización asistencial. Se definen como el conjunto de actividades que realizan los proveedores de la atención sanitaria con la finalidad de incrementar el nivel de salud y el grado de satisfacción de la población que recibe los servicios. La elaboración de un PAI precisa analizar el flujo de actividades, la interrelación entre profesionales y dispositivos asistenciales y las expectativas del paciente. En este artículo se presenta y se discute la metodología para la elaboración de un PAI, así como los factores de éxito para su definición y su efectiva implantación. Se explica también, a modo de ejemplo, el reciente PAI para hipoglucemias en personas con diabetes mellitus tipo 2 elaborado por un equipo multidisciplinar y avalado por varias sociedades científicas (AU)

An Integrated Healthcare Pathway (PAI) is a tool which has as its aim to increase the effectiveness of clinical performance through greater coordination and to ensure continuity of care. PAI places the patient as the central focus of the organisation of health services. It is defined as the set of activities carried out by the health care providers in order to increase the level of health and satisfaction of the population receiving services. The development of a PAI requires the analysis of the flow of activities, the inter-relationships between professionals and care teams, and patient expectations. The methodology for the development of a PAI is presented and discussed in this article, as well as the success factors for its definition and its effective implementation. It also explains, as an example, the recent PAI for Hypoglycaemia in patients with Type 2 Diabetes Mellitus developed by a multidisciplinary team and supported by several scientific societies (AU)

[A standard data set for the evaluation of venous leg ulcers in selective contracts : National consensus]. / Standarddatensatz für die Evaluation bei Selektivverträgen bei Ulcus cruris : Nationaler Konsensus.

BACKGROUND: Selective agreements are becoming increasingly important in health care management. To date, no standard recommendations for the evaluation of selective contracts are available. OBJECTIVES: Against this background, a recommendation on the evaluation of selective contracts in patients with leg ulcers (LU) was developed and approved by the nationwide consensus conference. MATERIALS AND METHODS: Based on a systematic literature review and followed by a manual search through other possible evaluation indicators in the care of patients with LU, a Delphi-based consensus process was performed by various scientific societies, professional associations, insurances and supply networks. RESULTS: For the evaluation of efficiency and quality of care, a recommendation on the evaluation of selective agreements with patients with LU was consented in six meetings and in five multistage online surveys. In total, 44 evaluation indicators were identified in the quality subareas structure, process, and outcome. The outcome indicators are divided into clinical, patient-related, and cost-related indicators. CONCLUSIONS: The developed evaluation indicators represent the quality of care in patients with LU. The indicators can be applied individually, depending on the agreed contract-specific supply target. After implementation of this national standard, the comparability of selective agreements in the management of patients with LU can be ensured and consolidated.

[Seven years of the National Action League for People with Rare Diseases : NAMSE - a success story?!] / 7 Jahre Nationales Aktionsbündnis für Menschen mit Seltenen Erkrankungen : NAMSE ­ ein Erfolgsmodell?!

It is estimated that four million people in Germany are living with a rare disease; in the EU, approximately 30 million people are affected. All rare diseases are chronic, linked to invalidity and/or restricted life expectancy, and their symptoms are often already manifest in childhood. Some 80% of rare diseases are genetically determined; they can rarely be cured. Furthermore, the pathogenesis of many rare diseases is unknown.In a move to ameliorate the situation of persons with rare diseases, the National Action League for People with Rare Diseases (NAMSE) published the National Plan of Action for People with Rare Diseases containing 52 measures that aim to achieve the desired improvements. More than half of these measures have already been implemented or are currently in the process of implementation. The Federal Ministry of Health is supporting this implementation process with numerous projects.NAMSE has achieved a great deal as a result of the National Plan of Action for People with Rare Diseases, even though not all of the measures included in the National Plan of Action have been implemented. The first results of individual measures are already becoming apparent. In order to achieve long-lasting improvements in the prevention, diagnosis and therapy of rare diseases, initiatives will have to be coordinated in the future as well.The Federal Ministry of Health will be funding the NAMSE Coordinating Office until mid-2018, thus ensuring that NAMSE will remain operational until that time. All of the partners collaborating in the Action League agree on the need for NAMSE, together with its coordinating office, to remain in place. To this end, a structure that keeps the health care situation of persons with rare diseases under observation, that suggests solutions and offers a possibility for the parties involved to network, is necessary. The question of conducting a legal restructuring of NAMSE in the future that will be sustainable in the long term is currently under discussion.

The medical and scientific responsibility of pollen information services.

Pollen information as such is highly valuable and was considered so far as a self-evident good free for the public. The foundation for reliable and serious pollen information is the careful, scientific evaluation of pollen content in the air. However, it is essential to state and define now the requirements for pollen data and qualifications needed for institutions working with pollen data in the light of technical developments such as automated pollen counting and various political interests in aerobiology including attempts to finally acknowledge pollen and spores as relevant biological particles in the air worth being considered for pollution and health directives. It has to be emphasized that inadequate pollen forecasts are a considerable health risk for pollen allergy sufferers. Therefore, the responsibility of institutions involved in pollen monitoring and forecasting is high and should be substantiated with respective qualifications and know-how. We suggest here for the first time a portfolio of quality criteria and demand rigorous scientific monitoring and certification of such institutions in the interest and for the protection of persons affected by a pollen allergy.

Control interno de la calidad vs control externo de la calidad / Internal quality control vs external quality control

El control interno de la calidad es el procedimiento que monitoriza la calidad de los resultados y permite aceptar o rechazar las series analíticas. Existen 2 variedades, el modelo de gestión interna, donde el tratamiento estadístico de los resultados control se realiza únicamente con los datos obtenidos por el propio laboratorio, y el control interno con gestión externa, donde el procesamiento estadístico se realiza con los datos obtenidos por el propio laboratorio y por otros laboratorios. Ambos sirven para calcular la imprecisión analítica y no son adecuados para evaluar el error total ni el sesgo. El control externo de la calidad es la determinación del desempeño de cada laboratorio mediante la comparación con otros laboratorios. Existen 3 modelos, los 2 primeros: evaluación externa de la calidad y ensayo de aptitud son muy similares, y se centran en las prestaciones analíticas, mientras que el tercero, denominado garantía externa de la calidad, tiene en cuenta todas las fases del laboratorio. Con el control externo de la calidad, en cualquiera de sus modelos, se mide el error total de cada mensurando, porque la muestra de control, que es ciega para el participante, se analiza una única vez. A largo plazo, cuando se dispone de todos los resultados del programa, se puede medir el error sistemático o sesgo. A la luz de los requisitos legales vigentes, las buenas prácticas del laboratorio y los artículos de referencia internacionales, el control interno de la calidad no es ni sustituye al control de la calidad externo (AU)

Internal quality control is the procedure used for monitoring the analytical process and to accept or reject the analytical run. There are two models: internal quality control that exclusively uses the control results from the own laboratory, and internal control externally managed, that also uses control data from other laboratories reported to an external organization. Both of them measure the analytical imprecision but are not adequate to estimate neither bias nor inaccuracy (total error). External quality control evaluates the laboratory performance by comparing with other laboratories, through an external organization. There are three models, external quality assessment and proficiency testing which are almost the same and are focused on the analytical process and external quality assurance that applies to all laboratory processes. The three models of external control measure total error, because the control sample (blind for the laboratory) is tested in singleton. At long-term, when all results for one cycle are available, laboratory bias may also been calculated. From the light of legal requirements, good laboraotry practices and papers from widely accepted authors, internal quality control is not and do not substitute external quality control (AU)

Iranian nurses perspectives on assessment of safe care: an exploratory study.

AIM: To explore the perspectives and experiences of nurse instructors and clinical nurses regarding the assessment of safe nursing care and its components in clinical practice. BACKGROUND: Safe nursing care is a key aspect of risk management in the healthcare system. The assessment of safe nursing care and identification of its components are primary steps to establish patient safety and risk management and enhance the quality of care in clinical practice. METHODS: This was an interview study, with qualitative content analysis. Semi-structured interviews were conducted with 16 nurse instructors and clinical nurses including nurse managers chosen by purposive sampling based on theoretical saturation. Data collection and analysis were carried out simultaneously until data saturation was reached. RESULTS: Data analysis led to the extraction of four main themes: holistic assessment of safe nursing care; team working and assessment of safe nursing care; ethical issues; and challenges of safe nursing care assessment. CONCLUSION: Identifying these four components in the assessment of safe nursing care offers a contribution to the understanding of the elements of safe care assessment and the potential for improved patient safety. IMPLICATIONS FOR NURSING MANAGEMENT: Safe care management requires the accurate and reliable assessment of safe nursing care and the need for strategies for reporting actual or potential unsafe care and errors to ensure patient safety.

Rehabilitation - a new approach. Part four: a new paradigm, and its implications.

This editorial proposes changes in healthcare services that should greatly improve the health status of all patients with disability. The main premises are that: rehabilitation usually involves many actions delivered by many people from different organisations over a prolonged period; specific rehabilitation actions cover a wide range of professional activities, with face to face therapy only being one; and the primary patient activity that improves function is practice of personally relevant activities in a safe environment. This editorial argues that: rehabilitation should occur at all times and in all settings, in parallel with medical care in order to maximise recovery and to avoid loss of fitness, skills and confidence associated with rest and being cared for; hospitals and other healthcare settings should adapt the environment to encourage practice of activities at all times; and that measuring rehabilitation, whether in research or for re-imbursement, should not simply consider face-to-face 'therapy time' but must include: all the other important activities undertaken by the team; 'structures' such as the appropriateness of the environment; and a process measure of the time spent by patients undertaking activities.

Triple Aim in Canada: developing capacity to lead to better health, care and cost.

QUALITY PROBLEM: Many modern health systems strive for 'Triple Aim' (TA)-better health for populations, improved experience of care for patients and lower costs of the system, but note challenges in implementation. Outcomes of applying TA as a quality improvement framework (QI) have started to be realized with early lessons as to why some systems make progress while others do not. INITIAL ASSESSMENT: Limited evidence is available as to how organizations create the capacity and infrastructure required to design, implement, evaluate and sustain TA systems. CHOICE OF SOLUTION: To support embedding TA across Canada, the Canadian Foundation for Healthcare Improvement supported enrolment of nine Canadian teams to participate in the Institute for Healthcare Improvement's TA Improvement Community. IMPLEMENTATION: Structured support for TA design, implementation, evaluation and sustainability was addressed in a collaborative programme of webinars and action periods. Teams were coached to undertake and test small-scale improvements before attempting to scale. EVALUATION: A summative evaluation of the Canadian cohort was undertaken to assess site progress in building TA infrastructure across various healthcare settings. The evaluation explored the process of change, experiences and challenges and strategies for continuous QI. LESSONS LEARNED: Delivering TA requires a sustained and coordinated effort supported by strong leadership and governance, continuous QI, engaged interdisciplinary teams and partnering within and beyond the healthcare sector.