Disrespect and Abuse in Obstetric Care in Mexico: An Observational Study of Deliveries in Four Hospitals.

INTRODUCTION: To identify and describe the frequency and characteristics of disrespect and abuse practices towards women during facility-based delivery in four hospitals in two Mexican states in 2017, using a mixed method of direct observation and women's reports of health care experiences. METHODS: A cross-sectional study was performed to describe disrespect and abuse practices in obstetric care (interactions or conditions that are experienced as or intended to be humiliating or undignified) committed by healthcare providers. We included all pregnant women admitted for childbirth (vaginal and cesarean). Semi-structured interviews were also conducted with women, prior to discharge, regarding their experience at delivery. RESULTS: 867 deliveries were observed. 18.8% of women (n = 163) experienced at least one disrespect and abuse event, especially at secondary care facilities. There were a total of 493 disrespect and abuse events, which, on average, represents three events per woman (39.4% were verbal abuse, 32% were physical abuse, and 28.6% were discrimination). In the majority of cases (> 50%), women did not give consent to not recommended invasive procedures and were not provided with adequate information to those procedures. CONCLUSIONS FOR PRACTICE: Direct observation and interviews was a useful tool to identify disrespectful and abusive practices during delivery care. Our findings provide new evidence of the frequency and characteristics of disrespect and abuse during delivery care in Mexico, which can be used to inform maternal health programs. Additionally, these results encourage the creation of surveillance policies and committees in order to guarantee violence-free and dignified treatment of women during delivery care.

Contextual factors favouring success in the accreditation process in Colombian hospitals: a nationwide observational study.

BACKGROUND: To identify context factors associated with and predicting success in the hospital accreditation process, and to contribute to the understanding of the relative relevance of context factors and their organizational level in the success of QI initiatives. METHODS: Analytical study of cases and controls in a sample of hospitals of medium and high complexity in Colombia. Cases (n = 16) are accredited hospitals by the time of preparation of the study (2016) and controls (n = 38) are similar facilities, which have not succeeded to obtain accreditation. Eligibility criteria for both groups included complexity (medium and high), having emergency services, an official quality assurance license, and being in operation for at least 15 years. Besides eligibility criteria, geographical location, and type of ownership (public/private) are used to select controls to match cases. Context measures are assessed using a survey instrument based on the MUSIQ model ("Model for Understanding Success in Quality") adapted and tested in Colombia. Statistical analysis includes descriptive measures for twenty-three context factors, testing for significant statistical differences between accredited and non-accredited hospitals, and assessing the influence and strength of association of context factors on the probability of success in the accreditation process. A multivariate model assesses the predictive probability of achieving accreditation. RESULTS: Eighteen (78.3%) of the twenty-three context factors are significantly different when comparing cases and controls hospitals, particularly at the Microsystem level; all factors are statistically significant in favor of accredited hospitals. Five context factors are strongly associated to the achievement of accreditation but in the logistic multivariable model, only two of them remain with significant OR, one in the Macrosystem, "Availability of economic resources for QI" (OR: 22.1, p: 0,005), and the other in the Microsystem, "Involvement of physicians" (OR: 4.9, p: 0,04). CONCLUSION: This study has applied an instrument, based on the MUSIQ model, which allows assessing the relevance of different context factors and their organizational level in hospitals, to explain success in the accreditation process in Colombia. Internal macrosystem and microsystem seem to be more relevant than external environment factors.

Indicators for monitoring maternal and neonatal quality care: a systematic review.

BACKGROUND: Research and different organizations have proposed indicators to monitor the quality of maternal and child healthcare, such indicators are used for different purposes. OBJECTIVE: To perform a systematic review of indicators for the central phases of the maternal and child healthcare continuum of care (pregnancy, childbirth, newborn care and postpartum). METHOD: A search conducted using international repositories, national and international indicator sets, scientific articles published between 2012 and 2016, and grey literature. The eligibility criteria was documents in Spanish or English with indicators to monitor aspects of the continuum of care phases of interest. The identified indicators were characterized as follows: formula, justification, evidence level, pilot study, indicator type, phase of the continuum, intended organizational level of application, level of care, and income level of the countries. Selection was based on the characteristics associated with scientific soundness (formula, evidence level, and reliability). RESULTS: We identified 1791 indicators. Three hundred forty-six were duplicated, which resulted in 1445 indicators for analysis. Only 6.7% indicators exhibited all requirements for scientific soundness. The distribution by the classifying variables is clearly uneven, with a predominance of indicators for childbirth, hospital care and facility level. CONCLUSIONS: There is a broad choice of indicators for maternal and child healthcare. However, most indicators lack demonstrated scientific soundness and refer to particular continuum phases and levels within the healthcare system. Additional efforts are needed to identify good indicators for a comprehensive maternal and child healthcare monitoring system.

Construction and pilot test of a set of indicators to assess the implementation and effectiveness of the who safe childbirth checklist.

BACKGROUND: The World Health Organization (WHO) launched the "Safe Childbirth Checklist (SCC) Collaboration" in 2012. The SCC is designed to contribute to quality care by providing reminders of evidence-based practices for the prevention and management of the leading causes of maternal and neonatal morbidity and mortality. However, indicators to monitor the implementation and effectiveness of the SCC have not been defined. This study aimed to produce and pilot test a set of valid, reliable and feasible indicators to assess the implementation and effectiveness of the SCC, with an emphasis on best practices. METHODS: As part of the WHO Collaboration, the SCC was adapted to the Mexican context, and a set of indicators was developed to assess the SCC use and adherence to SCC-related best practices. The indicators were pilot tested in three hospitals for feasibility and reliability using the prevalence- and bias-adjusted kappa index (PABAK) for multiple independent evaluators (initial sample, n = 47; second sample, n = 30 to re-test reliability). The data sources were clinical records and cognitive tests drawn from questionnaires to mothers and health professionals. RESULTS: We generated 53 indicators, and 38 of the indicators (those related to best practices and outcomes) were pilot tested. Of these, 26 relate to care for the mother (20 were measured based on clinical records and 6 via questionnaire), and 12 relate to newborn care (9 were medical record-based and 3 were from questionnaires). Feasible indicators were generally also reliable (PABAK≥0.6). Routine feasibility is affected by the frequency of assessed events. CONCLUSIONS: The generated indicators allow an assessment of the implementation and effectiveness of the SCC and the monitoring of quality of care during childbirth and the immediate postpartum period.

[Psychometric validation of an instrument to evaluate the context of quality improvement and accreditation of hospitals]. / Validación psicométrica de instrumento para evaluar contexto de mejora de calidad y acreditación de hospitales.

OBJECTIVE: To adapt and validate an instrument to measure the context factors which favor quality improvement initiatives and accreditation of hospitals. MATERIALS AND METHODS: The model and questionnaire Model for Understanding Success in Quality (MUSIQ) is adapted and validated for application in Spanish-speaking countries and its specific use in hospital accreditation projects. The theoretical construct of its dimensions is assessed by confirmatory factor analysis (Bartlett test and Kaiser-Meyer-Olkim index) and internal consistency (Cronbach's a), in a study carried out in a sample of 54 hospitals of medium and high complexity in Colombia. RESULTS: Instrument with four dimensions of context (environment, macrosystem, microsystem, quality team), composed of 23 elements that are measured through 35 variables. Factor analysis showed statistical significance and adequacy of the dimensions, which had also good internal consistency. CONCLUSIONS: Adapted instrument with useful- ness for measurement of context elements that can promote initiatives of improvement and accreditation in hospitals.

OBJETIVO: Adaptar y validar instrumento para medir elementos del contexto que pueden favorecer iniciativas de mejoramiento de la calidad y acreditación de hospitales. MATERIAL Y MÉTODOS: Se adaptó y validó modelo y cuestionario Model for Understanding Success in Quality (MUSIQ) para aplicación en países hispanoparlantes y uso específico para proyectos de acreditación de hospitales. Se realizó un análisis factorial confirmatorio (test de Bartlett e índice Kaiser-Meyer-Olkim) del constructo teórico de sus dimensiones y se comprueba consistencia interna en estudio realizado en muestra de 54 hospitales de mediana y alta complejidad en Colombia. RESULTADOS: Instrumento con cuatro dimensiones de contexto (ambiente, macrosistema, microsistema, equipo de calidad), compuestas por 23 elementos medidos a través de 35 variables. El análisis factorial mostró significancia estadística y adecuación de las dimensiones que tuvieron también buena consistencia interna. CONCLUSIONES: Instrumento adaptado con utilidad para monitorizar elementos del contexto que pueden favorecer iniciativas de mejora y acreditación en hospitales.

Quality agencies at the global level: characteristics and functions-a narrative review.

PURPOSE: To provide a comparative description of the structure, function and activities of quality agencies around the world and describe the published evidence of their impact on the health system. DATA SOURCES: A narrative review was conducted using the information found on websites, articles, books and gray literature in English and Spanish. STUDY SELECTION: The search process included three complementary approaches: (i) websites of agencies, ministries of health and quality-related official institutions; (ii) evaluations, reports, audits or documents regarding quality agencies; and (iii) scientific articles and gray literature found (key word: quality agency) using Ebsco databases. Information was completed using the 'snowball' technique, tracking internet materials and citing literature of reviewed documents. DATA EXTRACTION: The analytical framework to summarize the information included the agencies' mission, structures, target institutions, activities (following a six-domain model), funding, information management and impact evaluations. RESULTS OF DATA SYNTHESIS: Information was found regarding quality agencies in 62 countries. Those focusing mainly on accreditation were discarded for further analysis. Agencies with a broader focus, according to the six-domain model for quality improvement (QI) strategies, were found in nine countries. Information resulted very heterogeneous in form and substance. However, they share the function of strengthening and advising on 'public goods', through information, knowledge management and development of standards. No impact evaluations of any type were found. CONCLUSION: The characteristics of existing quality agencies are very heterogeneous, being accreditation the main common focus. There is a lack of both a comprehensive approach to QI strategies and a formal assessment of their impact or contribution for improving quality.

[Quality and compliance with Clinical Practice Guidelines of Chronic Noncommunicable Diseases in primary care]. / Calidad y cumplimiento de guías de práctica clínica de enfermedades crónicas no transmisibles en el primer nivel.

OBJECTIVE:: To assess the quality and compliance of clinical practice guidelines (CPG) applicable to chronic non-communicable diseases (CNCD) in primary healthcare (CS), and views of staff on the barriers, facilitators and their use. MATERIALS AND METHODS:: 18 valued CPG with AGREEII, 3 are selected to develop indicators and assess compliance using lot quality acceptance sample (LQAS, standard 75 / 95% threshold 40 / 75% respectively, α:0. 05, ß:0. 10) on 5 CS. 70 professionals surveyed about knowledge and use of CPG. RESULTS:: Average quality of the CPG was 57.2%; low rating in domains: "Applicability" (<25%), "Stakeholder involvement" (43.5%) and "Rigour of development" (55.0%). Compliance in CS ranges from 39 to 53.4%. Professionals show uneven knowledge of CPG; 44 to 45% (according to CPG), they declare that they are not used, they identify as main barriers the lack of training, and their difficult accessibility and management. CONCLUSIONS:: The quality and implementation of evaluated CPG is deficient constituting an opportunity of improvement in health services.

[Satisfaction and perceived quality of people insured by the Social Health Protection in Mexico. Methodological foundations]. / Satisfacción y calidad percibida de afiliados al Sistema de Protección Social en Salud de México. Fundamentos metodológicos.

OBJECTIVE:: To describe the conceptual framework and methods for implementation and analysis of the satisfaction survey of the Mexican System for Social Protection in Health. MATERIALS AND METHODS:: We analyze the methodological elements of the 2013, 2014 and 2015 surveys, including the instrument, sampling method and study design, conceptual framework, and characteristics and indicators of the analysis. RESULTS:: The survey captures information on perceived quality and satisfaction. Sampling has national and State representation. Simple and composite indicators (index of satisfaction and rate of reported quality problems) are built and described. The analysis is completed using Pareto diagrams, correlation between indicators and association with satisfaction by means of multivariate models. CONCLUSIONS:: The measurement of satisfaction and perceived quality is a complex but necessary process to comply with regulations and to identify strategies for improvement. The described survey presents a design and rigorous analysis focused on its utility for improving.

[Organizational capacity for continuous improvement of health services]. / Estrategia integral de formación para la mejora continua de la calidad de los servicios de salud.

While the Mexican health system has achieved significant progress, as reflected in the growing improvement in population health, heterogeneity in the quality of services and its impact on health in different population groups is still a challenge. The costs or poor quality represent about 20 to 40% of the health system's expenditure. We need to develop organizational capacity to implement quality management systems in order to identify, evaluate, prevent and eventually overcome the health system's challenges. A competency-based comprehensive strategy for training human resources is proposed including undergraduate and graduate education as well as continuing education, which will contribute to improve the quality function at the various levels of responsibility in the health system. The proposed strategy responds to the context of the Mexican health system, but it could be adapted to other systems and contexts.

The WHO methodology for point prevalence surveys on antibiotics use in hospitals should be improved: Lessons from pilot studies in four Mexican hospitals.

Point prevalence surveys (PPSs) are a useful option for collecting antimicrobial prescription data in hospitals where regular monitoring is not feasible. The methodology recommended by the World Health Organization (WHO) for conducting PPSs (WPPS), which targets low- and middle-income countries (LMICs), attempts to respond to the lag in these regions to generate estimates for antimicrobial use. However, based on our experience in four third-level public hospitals in Mexico, we identified substantial gaps in the WPPS guide with regards to addressing common challenges for the implementation of PPSs. While the oversimplified narrative of WPPS could facilitate the adoption of this methodology and extend its use, it underestimates the efforts and potential pitfalls for survey preparation, coordination, and reliable implementation. Conducting rigorous pilot studies could reduce the WPPS deficiencies and strengthen the reliability and comparability of the estimates for antimicrobial use.

Avoidable Hospitalization Trends From Ambulatory Care-Sensitive Conditions in the Public Health System in México.

OBJECTIVES: To estimate and identify the variations in rates of Avoidable Hospitalization for Ambulatory Care Sensitive Conditions (AH-ACSC) in public institutions of the Mexican health system during the period 2010-2017. METHODS: Secondary analysis of the hospital discharge database of the Ministry of Health (MoH) from 2010 to 2017. AH for ACSC was calculated by age group and sex per 100,000. Variations per year between institutions were calculated with the extreme quotient (EQ), coefficient of variation (CV) and systematic component of variance (SCV). Adjusted AH rates were calculated by group of causes (acute, chronic and preventable by vaccination). Adjusted AH trend rates were analyzed by Join Point Regression. RESULTS: For the period 2010-2017, the number of AH for ACSC decreased from 676,705 to 612,897, going from almost 13% to 10.7% of hospital discharges. There is consistency in terms of relative variance magnitude. But, with regards to SCV, the change remained constant, and in a second period of 2015-2017, high variation was observed by SCV ≥ 3. All-cause AH is diminishing in all institutions. AH rates for diabetes are the highest, but like other chronic diseases, there was a decline in the period from 2010 to 2017. The relative reduction varied from 15% for heart failure to 38% for complications from diabetes or hypertension, to 75% for angina. CONCLUSIONS: AH for ACSC is an indirect indicator of quality and access to first-level care. Variations by institutions are observed. This variation in CV and SCV across subsystems and states may be due to inequities in the provision of services. The factors that contribute to the burden of AH for ACSC in the Mexican Health System require detailed analysis.

Adaptation and validation of the Screening Questionnaire for Family Abuse of the Elderly in the sociocultural context of Colombia.

In Colombia, like many countries in the world, due to the increase in population of elderly people, mistreatment has increased, which has physical, psychological and social consequences for the individual and major repercussions on society. The detection of abuse is a complex task, among other aspects, due to the concealment of victims and the lack of valid, reliable detection instruments that are in keeping with the sociocultural context. Professionals responsible for dealing with these situations must have an instrument that allows early detection. The objective of this study was to adapt and validate the Family Abuse Screening Questionnaire for Elderly People in Colombia. A cross-sectional study with mixed methods was carried out in two stages from 2017 to 2018. In the first stage, linguistic and semantic adaptation was carried out using translation, synthesis, back translation, expert analysis and pilot testing with 30 abused and non-abused elderly people. In the second stage, the validity and reliability of the questionnaire were obtained by means of an exploratory factor analysis and Cronbach's Alpha, using STATA 13. In the results, we provided a Socially and Culturally Adapted Family Abuse Screening Questionnaire for elderly people in Colombia with a Cronbach's Alpha of 0.82, sensitivity value of 86.9% (p < 0.05) and a specificity value of 84% (p < 0.05), detecting abuse with 4 or more positive responses to abuse. The application of the screening questionnaire by health and social services professionals will prevent further damage to social and physical health in the elderly people in Colombia, as well as reduce the costs of care in institutions.

Good infection prevention practices in three Brazilian hospitals: Implications for patient safety policies.

OBJECTIVE: Healthcare-associated infections (HAI) are a serious patient safety problem. There are effective preventive practices, but little information on adherence in Brazilian hospitals. This study aims at assessing adherence to good HAI prevention practices. METHODS: A cross-sectional observational study was conducted at 3 different types of hospitals (public-federal, public-state and private) in Rio Grande do Norte state, Brazil. A total of 19 structure and process indicators were measured based on 7 National Quality Forum Patient Safety Practices. RESULTS: Overall adherence was low, but higher in the private hospital, followed by the public-federal and public-state institutions. There was adequate maintenance of central venous catheters and high vaccine coverage against the influenza virus among health professionals. However, hand hygiene adherence was low, and surgical antibiotic prophylaxis and prevention of multidrug-resistant bacteria transmission, urinary tract infection by urinary catheter and associated with mechanical ventilation were inadequate. CONCLUSIONS: Despite the availability of evidence-based recommendations, there is ample room for improvement in adherence to safe practices in the hospitals under study, contributing to the heightened risk of unnecessary harm to patients.

Development and validation of a Screening Questionnaire of Family Mistreatment against Older Adults for use in primary care settings in Mexico.

The abuse of older adults is a serious public health issue that can be difficult to identify at the first level of care. Medical and nursing personnel are sometimes unable to identify older adults who suffer family mistreatment. This can occur when victims feel shame or as a result of cultural factors. In the light of this, healthcare personnel require a screening tool that can be used to identify signs of mistreatment. The aim of this study was to develop and validate a screening tool for detecting the familial mistreatment of older adults in primary care settings. A mixed method cross-sectional study was carried out in three phases between 2009 and 2012 in Mexico. The formative phase involved using a qualitative methodology to identify terms that older adults use to identify practices defined as forms of mistreatment. On this basis, the second phase involved the design of a screening tool through the formation of items in collaboration with a panel of experts. These items were tested on older adults to ensure their intelligibility. Finally, validity and reliability levels were evaluated through the application of the screening tool to a sample of older adults at a primary care facility and at a legal centre. These findings were discussed with gerontologists, and the data were analysed through an exploratory factor analysis with orthogonal rotation and Cronbach's alpha using STATA v13. From the results, we generated a screening tool that is culturally and socially tailored to older adults in Mexico. The tool has a Cronbach's alpha of 0.89, a sensitivity value of 86% (p < .05) and a specificity value of 90% (p < .05) for positive answers to the tool's 15 items. Applying this tool at the first level of care could limit damage to older adults' health and could lower the frequency of emergency room use in hospitals.

Reliability and validity of patient reports for physical therapy quality assessment: an empirical analysis regarding the use of exercises for neck pain in Spain.

OBJECTIVE: To determine usefulness and reliability of patient reports as a data source on the use of exercises for neck pain in primary healthcare. DESIGN: Survey research. SUBJECTS: A total of 176 patients with mechanical neck pain, surveyed about their physical therapy experience. METHOD: A questionnaire was constructed on the selection of exercises, instructions for carrying them out and follow-up provided by the physical therapist. The same items reported by the surveyed patients were also reviewed in the physical therapy record. We analysed the reliability and validity of the questionnaire, and used the valid information from the survey to estimate a total of 8 indicators on the quality of care provided. RESULTS: Sensitivity of the items was high (>75%), suggesting that most of the recorded information could be provided by patients, and specificity was quite low, suggesting that they also provide relevant information that was not recorded. These results, particularly low specificity, were not homogeneous among items. Estimates for the indicators demonstrate room for improvement. CONCLUSION: Patient reports could be useful as a complement to other sources of information for physical therapy quality assessment, and they can be reliable and valid substitutes for recorded data about specific aspects of the care provided.

"Clinical approach to fibromyalgia: Synthesis of Evidence-based recommendations, a systematic review".

OBJECTIVES: Efforts have been made to standardise evidence-based practice, but clinical practice guidelines do not always follow strict development methods. The objective of this review is to identify the current guidelines, analyse the variability of its recommendations and make a synthesis for clinical practice. MATERIAL AND METHODS: A systematic review of clinical practice guidelines was made in electronic databases and guidelines databases; using "fibromyalgia" AND ["guideline" OR "Clinical Practice guideline"] as terms, from January for 2003 to July of 2013. Guidelines were selected according to the following criteria: a) aimed to fibromyalgia treatment in adults; b) based on scientific evidence, systematically searched; c) evidence levels and strength of recommendation included; d) written in English or Spanish. RESULTS: From 249 initial results, six guides fulfilled the inclusion criteria. Clinical practice guidelines analysed in this review show great variability both in the presence and level of evidence and in the strength of recommendation of many treatments. Physical exercise and cognitive-behavioural therapy are first-line treatments, showing high level of evidence. Amitriptyline, used for short periods of time for pain control, is the pharmacologic treatment with the most solid evidence. The multimodal approach reported better results than the isolated application of any treatment. CONCLUSIONS: Final recommendations in this review identify optimal treatments, facilitating the translation of evidence into practice and enabling more efficient and effective quality care.

Quality of Diabetes Care: The Challenges of an Increasing Epidemic in Mexico. Results from Two National Health Surveys (2006 and 2012).

BACKGROUND: The quality of diabetes care remains suboptimal according to numerous studies assessing the achievement of quality indicators for diabetes care in various healthcare settings. We report about global and specific quality indicators for diabetes care and their association to glycemic control at the population level in two national health surveys in Mexico. METHODS: We conducted a cross-sectional analysis of the 2006 and 2012 National Health Surveys in Mexico. We examined quality of care for 2,965 and 4,483 adults (≥ 20 years) with diagnosed type 2 diabetes using fourteen simple and two composite indicators derived from self-reported information. In a subsample for both surveys, glycated hemoglobin (HbA1c) was measured at the time of the interview. We obtained survey weight-adjusted estimators using multiple regression models (logistic and linear) with combined data files, including survey year as covariate to assess change. RESULTS: Global quality of care in 2012 was 40.8%, with a relative improvement of 11.7% between 2006 and 2012. Detections of cardiovascular disease risk factors (dyslipidemia and hypertension) were the indicators with the highest improvement, while non-pharmaceutical treatment and diabetic foot exams showed minor changes. We found a significant association between the quality of the process of diabetes care and glycemic control (OR 2.53, 95% CI 1.63-3.94). Age more than 65 years old, the type of health subsystem, gender (males), and high socio-economic status were also significantly associated to glycemic control. CONCLUSIONS: Quality diabetes care and glycemic control improved and are significantly associated. However, according to international standards, the current situation remains suboptimal. A more holistic approach is needed, with an emphasis on improving quality in outpatient care.

[Parenteral nutrition in a general hospital: quality criteria and factors associated with compliance]. / Utilización de la nutrición parenteral total en un hospital general: criterios de calidad y factores asociados a su cumplimiento.

BACKGROUND AND OBJECTIVE: The aim of this study was to analyze the quality in the use of total parenteral nutrition (TPN). PATIENTS AND METHOD: Retrospective study of patients treated with TPN during one year in a general hospital (n = 92). Assessment of quality was performed through measurements of compliance using 20 criteria. These were analyzed both individually and gathered in 3 groups: adjusted (correct indication), safe (absence of complications) and exact TPN (when prescribed diet matched to the administered one). Criteria compliance was compared to standards values (% expected compliance for a quality service). Patient (age, sex, diabetes mellitus) and process (TPN indication, patient's outcome, type of diet) variables were analyzed (using logistic regression models) as potential factors associated with criteria compliance. RESULTS: Compliance of six criteria was significantly below standard values. Simultaneous compliance of all criteria by group was 17% (95% CI: 10-24) in adjusted TPN, 38% (95% CI: 29-47) in safe TPN, and 94% (95% CI: 90-98) in exact TPN. There was a negative association between an age over 65 years and both a correct indication of TPN (OR= 9.4; 95% CI: 1.1-79.8) and the indicator compliance of all criteria in the adjusted TPN group (OR: 2.9 95% CI: 1.03-8.4). The absence of metabolic complications was influenced (p < 0.05) by the use of standardized diets (OR = 0.3; 95% CI: 0.1-0.9). CONCLUSIONS: Quality defects were mainly related to the prescription and the frequency of metabolic complications. In general, TPN is used less appropriately when patients are older than 65 years, and metabolic complications are more frequent when standardized diets are used.

Validación psicométrica de instrumento para evaluar contexto de mejora de calidad y acreditación de hospitales / Psychometric validation of an instrument to evaluate the context of quality improvement and accreditation of hospitals

Resumen: Objetivo: Adaptar y validar instrumento para medir elementos del contexto que pueden favorecer iniciativas de mejoramiento de la calidad y acreditación de hospitales. Material y métodos: Se adaptó y validó modelo y cuestionario Model for Understanding Success in Quality (MUSIQ) para aplicación en países hispanoparlantes y uso específico para proyectos de acreditación de hospitales. Se realizó un análisis factorial confirmatorio (test de Bartlett e índice Kaiser-Meyer-Olkim) del constructo teórico de sus dimensiones y se comprueba consistencia interna en estudio realizado en muestra de 54 hospitales de mediana y alta complejidad en Colombia. Resultados: Instrumento con cuatro dimensiones de contexto (ambiente, macrosistema, microsistema, equipo de calidad), compuestas por 23 elementos medidos a través de 35 variables. El análisis factorial mostró significancia estadística y adecuación de las dimensiones que tuvieron también buena consistencia interna. Conclusión: Instrumento adaptado con utilidad para monitorizar elementos del contexto que pueden favorecer iniciativas de mejora y acreditación en hospitales.

Abstract: Objective: To adapt and validate an instrument to measure the context factors which favor quality improvement initiatives and accreditation of hospitals. Materials and methods: The model and questionnaire Model for Understanding Success in Quality (MUSIQ) is adapted and validated for application in Spanish-speaking countries and its specific use in hospital accreditation projects. The theoretical construct of its dimensions is assessed by confirmatory factor analysis (Bartlett test and Kaiser-Meyer-Olkim index) and internal consistency (Cronbach's α), in a study carried out in a sample of 54 hospitals of medium and high complexity in Colombia. Results: Instrument with four dimensions of context (environment, macrosystem, microsystem, quality team), composed of 23 elements that are measured through 35 variables. Factor analysis showed statistical significance and adequacy of the dimensions, which had also good internal consistency. Conclusion: Adapted instrument with usefulness for measurement of context elements that can promote initiatives of improvement and accreditation in hospitals.

Calidad y cumplimiento de guías de práctica clínica de enfermedades crónicas no transmisibles en el primer nivel / Quality and compliance with Clinical Practice Guidelines of Chronic Noncommunicable Diseases in primary care

Resumen: Objetivo: Evaluar la calidad y cumplimiento de guías de práctica clínica (GPC) aplicables a las enfermedades crónicas no transmisibles (ECNT) en Centros de Salud (CS), y opinión del personal sobre las barreras, facilitadores y su utilización. Material y métodos: De 18 GPC valoradas con Appraisal of Guidelines Research and Evaluation II (AGREEII), se seleccionan tres para elaborar indicadores y evaluar cumplimiento usando Lot Quality Assurance Sampling (LQAS) (estándar 75/95%, umbral 40/75%, respectivamente, α:0.05, β:0.10) en cinco CS. 70 profesionales fueron encuestados sobre conocimiento y utilización de GPC. Resultados: La calidad formal promedio de las GPC fue 57.2%; baja calificación en dominios: “Aplicabilidad” (<25%), “Participación de los implicados” (43.5%) y “Rigor en la elaboración” (55.0%). Su cumplimiento en CS oscila entre 39 y 53.4%. Los profesionales muestran conocimiento desigual de GPC; de 44 a 45% (según GPC) declaran que no se utilizan e identifican como principales barreras la ausencia de capacitación y su difícil accesibilidad y manejo. Conclusiones: La calidad e implantación de GPC evaluadas es deficiente, lo que constituye una oportunidad de mejora en los servicios de salud.

Abstract: Objective: To assess the quality and compliance of clinical practice guidelines (CPG) applicable to chronic non-communicable diseases (CNCD) in primary healthcare (CS), and views of staff on the barriers, facilitators and their use. Materials and methods: 18 valued CPG with AGREEII, 3 are selected to develop indicators and assess compliance using lot quality acceptance sample (LQAS, standard 75 / 95% threshold 40 / 75% respectively, α:0. 05, β:0. 10) on 5 CS. 70 professionals surveyed about knowledge and use of CPG. Results: Average quality of the CPG was 57.2%; low rating in domains: “Applicability” (<25%), “Stakeholder involvement” (43.5%) and “Rigour of development” (55.0%). Compliance in CS ranges from 39 to 53.4%. Professionals show uneven knowledge of CPG; 44 to 45% (according to CPG), they declare that they are not used, they identify as main barriers the lack of training, and their difficult accessibility and management. Conclusions: The quality and implementation of evaluated CPG is deficient constituting an opportunity of improvement in health services.