ISSN:1356-1294    

DOI:10.1111/j.1365-2753.1996.tb00022.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

ISSN:1356-1294    

DOI:10.1111/j.1365-2753.1996.tb00023.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

ISSN:1356-1294    

DOI:10.1111/j.1365-2753.1996.tb00024.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

AbstractSuccessful audit of clinical practice focuses upon the systematic investigation of key aspects of the everyday work of busy clinicians. We contend that the nature and quality of local clinical practice can be characterized by critical examinations of the effectiveness and appropriateness of practice and the efficiency with which effective, appropriate clinical care is delivered to patients. When such a baseline has been established, it becomes possible to compare and contrast characterized local practice with so‐called ‘evidence‐based’ practice and agree changes aimed at narrowing the discrepancy between the two. The nature of such changes can be described and their implementation into practice studied, with subsequent quantitative measurement and qualitative description of the resulting benefits to patients. A proper understanding of the concepts of efficiency, appropriateness and effectiveness in clinical care is clearly fundamental to the successful design and applications of methodologies aimed at securing measurable improvements in the quality of patient care. In this first of two articles we examine the concepts of efficiency and appropriateness in clinical practice, with particular emphasis on cost‐effectiveness and utilization review. The clinical effectiveness of health care intervention is treated in detail within the second paper, to be published within Volume 2 Number 2 of theJournal of Evaluation in Clinical Practice(Mileset

ISSN:1356-1294    

DOI:10.1111/j.1365-2753.1996.tb00025.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

AbstractIt is increasingly recognized that the repeated rhetorical emphasis from 1989 to date on achieving measurable benefits to patients from audit, in the face of inattention to the development of methodologies with which to realize such benefits in operational practice, has represented a serious deficiency in strategic planning and direction and a consequent failure to establish functional clinical audit within the NHS. A grand revision of strategy is therefore necessary, and this should begin with the development of a research‐based method of audit, the training of clinicians and audit support staff in its use and a subsequent trial of its effectiveness prior to its implementation within the NHS. Only then will measurable improvements become possible, value for money be assured and clinicians' attitudes to audit chang

ISSN:1356-1294    

DOI:10.1111/j.1365-2753.1996.tb00026.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

AbstractWriting inMedical Educationin 1982, Fowkes (1982) noted the lack of general agreement within the medical profession on methods of audit, a deficiency previously articulated by Shaw (1980) and later emphasized by McIntyre (1985). More recently, a study by Black&Thompson (1993) of consultant and junior medical staff in four London district general hospitals revealed that ‘many doctors did not understand how to undertake audit’, and major research by both Hopkins (1993, 1994) and Butteryet al.(1994) described a multiplicity of methodological deficiencies in the general approaches to audit adopted by clinicians since the promulgation of the White Paper definition in 1989. Soundness of methodological approach is fundamental to securing the success of clinical audit within Provider organizations and is thus central to the generation of measurable improvements in the quality of clinical care being delivered to patients. It is therefore disturbing that methodological deficiencies may still be observed in general approaches to audit (Butteryet al.1994), with no author yet recommending a formal system for critical inquiry into clinical practice. It was the recognition of the unsatisfactory nature of this situation which led us to develop a system aimed at assessing, in a critical fashion, the quality of the totality of care dispensed within NHS provider organizations. The system is presented here for the first t

ISSN:1356-1294    

DOI:10.1111/j.1365-2753.1996.tb00027.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

AbstractThe critical examination of clinical practice should be an integral part of patient care. It includes the development and implementation of guidelines, together with continuous evaluation of clinical process and outcomes to improve the quality of care provided. Clinical audit has not been successful in achieving this. The use of Integrated Care Pathways facilitates the introduction of guidelines and the continuous evaluation of clinical practice. Improvements are achieved by frequently revising the pathways to reflect current, local best practice.Integrated Care Pathways define the expected course of events in the care of a patient with a particular condition, within a set time‐scale. A pathway is divided into time intervals during which specific goals and expected progress are defined, together with appropriate investigations and treatment. A pathway reflects the activities of a multidisciplinary team and can incorporate established guidelines and evidence‐based medicine. It is usually unique to the institution in which it was developed. The pathway forms part of the clinical record of every patient. All variations from the pathway are documented, and the reasons for the variations analysed. Solutions are developed to address the causes of potentially avoidable variation, and the pathway is revised to incorporate these improvements. Integrated Care Pathways provide a powerful audit tool, as all aspects of the process and outcome of clinical practice can be constantly monitored. Variations from set standards are minimized, and improvements are rapidly incorporated into routine practice and subsequently re‐eval

ISSN:1356-1294    

DOI:10.1111/j.1365-2753.1996.tb00028.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

AbstractWith the development of an internal market for health care, ‘purchasing for outcomes’ has become an important if somewhat rhetorical catchphrase. While there is emerging understanding about how it can be pursued, doubts are being expressed over an outcomes rather than a process emphasis. This debate has been confused by a failure to differentiate the role and importance of monitoring outcomes at an individual patient care level from those at an aggregate population/purchaser level.The clinical need to collect outcomes data on individual patient care within routine care settings places additional requirements on measurement development and selection. Traditional measurement criteria, stressing reliability, validity and responsiveness to change, must be supplemented by criteria of feasibility of use, clinical utility and acceptability. One option is to select domains or items of interest from longer instruments initially designed for research, carefully selected in relation to the purposes of measurement. Further measurement criteria must be addressed which stress the relevance of the proposed instrument to the condition and to the participants in the clinical interaction: in particular, patient‐centredness and sensitivity to the setting.Monitoring the outcomes of individual patient care within routine clinical practice poses considerable challenges to researchers who are developing instruments and to clinicians who collect and use the data. A shift in emphasis is required towards more context‐specific tests, addressing relevance to lay perceptions, to clinical use and to the condition and setting under review. The content validity, the responsiveness to patient‐relevant and clinically relevant change and, of course, reliability must have greater primacy. In this way, outcome data which measure the quality of clinical practice and which provide appropriate criteria for research into effectiveness can be

ISSN:1356-1294    

DOI:10.1111/j.1365-2753.1996.tb00029.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

AbstractResearch of all types plays a fundamental role in setting health care priorities, in part by informing the development of robust clinical practice guidelines. Today's investments in research may make tomorrow's choices about who gets what kinds of care easier, not more difficult. The converse also holds: today's investments in providing care, if made at the significant expense of research, will not make tomorrow's choices about care any easier. In making choices and balancing priorities, the centrality of health services research must be understood. The information necessary to make the hard choices about priorities in health care today may be generated as much, if not more, from investments in this field of inquiry as from equivalent investments in other arenas of scientific endeavour, because of the growing need for information about the effectiveness of health care services for use both in improving the quality of health care and in making better use of health resources.

ISSN:1356-1294    

DOI:10.1111/j.1365-2753.1996.tb00030.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

ISSN:1356-1294    

DOI:10.1111/j.1365-2753.1996.tb00031.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY