Terminología y comunicación interniveles asistenciales / Terminology and communication between healthcare levels

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[Goals and reality of quality circles in outpatient care in Germany]. / Anspruch und Wirklichkeit von Qualitätszirkeln in der ambulanten Versorgung.

In Germany's outpatient care, quality circles are strongly encouraged as a tool for peer review in order to implement quality assurance and management in daily practice. This paper presents an overview of the status of implementing quality circles in outpatient care. The main features of successful quality circles are described in terms of conditions, structures, and methodological approach. The objectives of quality circles are outlined, and it is discussed to which extent the quality circle concept is established. Recommendations for further developments of quality circles are drawn from this analysis.

Subjetividade e projetos coletivos: mal-estar e governabilidade nas organizaçöes de saúde / Subjectivity and collective projects: discontents and governability in health organizations

Procura explorar algumas questöes derivadas das relaçöes entre subjetividade, processos intersubjetivos/grupais e processos de planejamento e gestäo nas organizaçöes de saúde. Essa problemática tem-se destacado, fundamentalmente, a partir da constataçäo dos obstáculos à implementaçäo dos processos de mudança nas organizaçöes, bem como dos limites dos instrumentais teórico-metodológicos disponíveis em planejamento e gestäo para favorecer tais processos. O setor saúde no Brasil tem sido, simultânea e paradoxalmente, espaço de experimentaçäo de propostas inovadoras nos campos da assistência e da gestäo pública, bem como locus privilegiado de manifestaçäo das contradiçöes sociais e do intenso processo de exclusäo, segregaçäo e desvalorizaçäo da vida que tem marcado nossa sociedade. Neste contexto, o que nos interessa essencialmente examinar é até que ponto é viável a construçäo de projetos coletivos, no âmbito das organizaçöes de saúde, e como é possível abordar suas dimensöes cultural, subjetiva e inconsciente - condiçäo, nos parece, indispensável para se aprender sobre os limites (e possibilidades) de governabilidade dessas organizaçöes.

[Family practice quality circles between goals and reality--an interaction analysis]. / Hausärztliche Qualitätszirkel zwischen Anspruch und Wirklichkeit--eine Interaktionsanalyse.

Quality circles are considered a key method for quality assurance in health care. However, there is a lack of systematic evaluation for quality circles in general practice, especially regarding the process quality of quality circle work. This article presents the results of an interaction analysis completing the systematic evaluation of quality circles in general practice in a region of south Germany. Using the so-called conference encoding method for interaction analysis we analyzed 7 out of 25 evaluated quality circles and 2348 interactions between the quality circle members. The participation rate of the moderators is high compared to the relative low contribution of the group members to the quality circle work. We could show that quality circles work topic-oriented, there is a wide exchange of experience between the group members and the group climate is positive. However, there were almost no specific activities to develop guidelines for diagnostic and therapeutic procedures. The results showed a significant discrepancy between the aims of quality circles and their practical realisation. Besides improved option for information and training programs for moderators and participants, we recommend further evaluation studies complemented with specific analysis of the process quality for example with the conference encoding method.

Quality circles in ambulatory care: state of development and future perspective in Germany.

OBJECTIVE: To survey the quantitative development of quality circles (peer review groups; QC) and their moderators in ambulatory care in Germany, to describe approaches to documentation and evaluation, to establish what types of facilities and support is available and to assess opinions on the future importance of QC. DESIGN: Cross-sectional survey using a standardized questionnaire and supplementary telephone interviews. SETTING: All 23 German regional Associations of Statutory Health Insurance Physicians (ASHIP) were surveyed. RESULTS: The total number of QC in ambulatory care in Germany increased rapidly from 16 in 1993 to 1633 in June 1996, with about 17% (range 1.0-52.1%) of all practicing physicians (112 158) currently involved. Throughout Germany, 2403 moderators were trained in 168 training courses by the qualifying date. Follow-up meetings were held or being planned in 20 ASHIP, with approximately 39% (23-95%) of the moderators participating. Systematic documentation of QC work was undertaken or planned in all 23 ASHIIP, and 10 ASHIP carried out comparative evaluation, with at least five others planning to start it. The ASHIP promoted the work of QC by providing organizational (22) or financial (20) support, materials (20) or mediation of resource persons (16). Eleven ASHIP received grants from drug companies. ASHIP rated the future importance of QC as increasing (18) or stable (four), but in no case as decreasing. CONCLUSIONS AND RECOMMENDATIONS: The quantitative growth of QC in Germany is encouraging, but the extent of support and evaluation appears insufficient. Increased methodological support and facilitation, follow-up meetings on a more regular basis, improved documentation and evaluation of individual QC, and problem oriented evaluation of their impact on health care are essential for further successful development. Principles, problems and solutions discussed may be relevant for similar QI activities in other countries.

[Multidisciplinary quality assurance circles--a quality assurance model for child and adolescent psychiatry clinics]. / Der multidisziplinäre Qualitätssicherungszirkel--ein Qualitätssicherungsmodell für kinder- und jugendpsychiatrische Kliniken.

A complex medical field such as Child and Adolescent Psychiatry can only meet the expanding problems of quality management by multi-disciplinary cooperation. The quality control circle is the central element of the quality control process and of further advances to quality management. In a critical experience-report the concepts, practical issues and further questions of a continuing quality management conference at a University hospital are outlined. It concentrates on practical and process-oriented problems that concern the integration of quality management in practice and research.

[General practice quality circles in the large city. Participation by Hamburg general physicians]. / Hausärztliche Qualitätszirkel in der Grossstadt. Teilnahmeverhalten von Hamburger Allgemeinärzten.

Quality circles (peer review) will play an increasing and important role in ambulatory care when they are based on voluntary participation and in a setting of open discussion. Goal is the further qualification of physicians by critical reflections on their practice based on learning processes and the experiences of the participants. Reported are experiences from the unit for primary care and health service research of the Hamburg University on implementing quality circles. Engagement in quality assurance may be helpful in the shaping and professionalisation of general practice.

Deming meets Braverman: toward a progressive analysis of the continuous quality improvement paradigm.

The continuous quality improvement (CQI) model has rapidly become the dominant management paradigm in U.S. industrial and health care leadership circles. Despite its widespread corporate acceptance and its relevance to public sector policy issues, there has been a paucity of progressive analysis of CQI. The authors begin by noting remarkable similarities between CQI critiques of Taylorism (so-called scientific management of work) with those made by Braverman, a leading Marxist analyst of the work process. Each of the 14 principles of CQI pioneer W. E. Deming are explained and analyzed for their progressive content. These pluses are then contrasted with 18 problematic issues in an attempt to challenge and go beyond the constraints of CQI as it is currently being applied in health care and other sectors. These issues include (1) mismatch between rhetoric and reality, (2) public sector issues, and (3) broader contradictions. The authors emphasize the genuine need for improving health care quality and the relevance of CQI for addressing this need. They challenge progressives to grapple with the profound contradictions by the CQI paradigm inviting a broader dialogue on CQI's meaning for improving the public's health.

System for quality management.

Total quality management will provide important benefits for organizations that are involved with the delivery of occupational and environmental health care. These organizations should shift from traditional medical management to the new paradigm. Identification of a set of relevant parameters for this new management system is necessary to implement the quality culture within our professional settings. An exhaustive literature search was undertaken on the topic of total quality management to delineate a framework for consideration by occupational and environmental health managers. Proposed are essential components of a management system for quality excellence which are derived from review of reported approaches among health care organizations and industry, various lists of quality principles and criteria, and classical systems theory.

Quality screening and management using claims data in a managed care setting.

Quality screening and management (QSM), developed by United HealthCare Corporation for its own health plans but applicable to other settings, analyzes health care provided to an enrolled population using claims and administrative data supplemented, when necessary, with medical record review. For selected topics/conditions, QSM compares the care received by patients to that recommended by established practice guidelines and also reports and describes quality through incidence rates, condition-specific process and outcome measures, occurrence of adverse events, and use of preventive services. Results of the analyses are linked to appropriate quality management actions and are used to identify strategies for improvement. Data permit health plans to make performance comparisons on individual indicators and longitudinal comparisons on the effectiveness of quality improvement initiatives.

Beyond quality circles: self-managing teams.

A more extreme form of change than QCs, self-managing teams are informally estimated to have evolved in more than 200 U.S. plants. Indications are, however, that this is but the beginning--despite middle managers' fears that such teams will erode their power.