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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION</span></p><p class="elsevierStylePara">In 1998&#44; the Clinical University Hospital of Barcelona started a global and progressive internal reorganisation process&#44; taking on a decentralised clinical management system based on grouping patients according to pathologies&#46;</p><p class="elsevierStylePara">In July 1999&#44; the Centre Medical Board approved the organisation proposal of the Clinical Institute of Nephrourology &#40;ICNU&#41;&#44; which encompasses the Departments of Nephrology&#44; Urology and Kidney Transplant&#46;</p><p class="elsevierStylePara">The Institute of Clinical Management ICNU started its trajectory&#44; headed by an assistant director appointed by the managing director of the centre as proposed by the Institute&#8217;s Management Commission &#40;Table 1&#41;&#46; The heads of nursing and economic-administration will assist the assistant director in administrative task &#40;Figure 1&#41;&#46; The Institute has full administrative autonomy&#44; managing a budget based on objectives that allow it&#44; for example&#44; to develop and establish innovative techniques and attract new clients&#46;</p><p class="elsevierStylePara">One of the strategic objectives of the ICNU was the acquisition and development of a culture based on the continual improvement of its services which would contribute to a better knowledge of quality appraisal methods in the field of urinary system disease care&#46;</p><p class="elsevierStylePara">The main aims of this study are to present the working dynamics established and to describe the changing outcomes resulting from this innovative programme of care management&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">MATERIAL AND METHODS</span></p><p class="elsevierStylePara">The design of this project corresponds to a time series descriptive epidemiologic study carried out in the area of urinary system diseases at the Clinical University Hospital of Barcelona&#46;</p><p class="elsevierStylePara">A specific and interdisciplinary task force was constituted&#46; The different professional layers were represented from both the ICNU and the Institutional Quality Programme at the Centre&#46; The technical and perceived quality indicators of interest were selected and a consensus was reached on the quality objectives considered most important for the political strategy of the Institute of Nephrourology&#46; These objectives are evaluated and reconsidered annually&#46;</p><p class="elsevierStylePara">It was unanimously agreed to identify at least one quality objective for each of the Departments that make up the Institute&#46; Acknowledgement of these had to conform to the agreement between the Institute and Hospital Management&#46; These should facilitate communication of the methodological standards for ongoing improvement among the Institute&#8217;s professionals&#46; All those aspects in which a potential opportunity for improvement was evident were included&#46;</p><p class="elsevierStylePara">The indicators used to monitor the basic dimensions of Quality<span class="elsevierStyleSup">1</span> were initially those defined by the Hospital Quality Plan &#40;Tables 2 and 3&#41;&#46; It was agreed that they would be expanded because new ones would be suggested or arise&#44; according to the dynamics of the process&#46;</p><p class="elsevierStylePara">The agreement of objectives is detailed in the quality report<span class="elsevierStyleSup">2</span> which assembles all of the information pertaining to quality evaluation at the Institute&#46; The quality report is a vehicle of communication between the Institute and Management through which the change in objectives and indicators throughout the year are followed up&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS</span></p><p class="elsevierStylePara">Over the period in question&#44; patient activity at the Institute increased in all its areas&#46; Admissions varied from 2&#44;386 in 2003 to 2&#44;724 in 2007&#46; The average stay improved from 6&#46;82 to 6&#46;5 days&#46; The total number of outpatient visits increased from 21&#44;362 to 25&#44;909 &#40;first visits went from 2&#44;431 in year 2003 to 3&#44;102 in 2007&#41;&#46; An increase in the complexity of the pathologies treated was also observed as measured using the Average Relative Weight &#40;ARW&#41; of all the Diagnosis Related Groups &#40;DRG&#41; at the Institute&#46; In 2003&#44; this ARW was 1&#46;32 as compared to 2&#46;18 in 2007&#46;</p><p class="elsevierStylePara">The development of the seven technical quality indicators monitored from 2003-2007 and that are considered as medical-surgical management variables are presented in Table 2&#46;</p><p class="elsevierStylePara">Table 3 shows the progress of the five indicators of perceived quality for the same period of time for the different areas of activity of the ICNU&#46;</p><p class="elsevierStylePara">Likewise&#44; the objectives of quality improvement for both technical and perceived quality established by the Institute have been increasing over time&#46; The initial objectives in 2003 were 9 and these progressed on to 16 agreed objectives in 2007&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">Any organisational change carries the need for adaptation to a new reality by the professionals involved&#46; Assuring that quality is not negatively influenced in this period and in subsequent stages is one of the basic tools for the consolidation of any organisational change&#46;<span class="elsevierStyleSup">2&#44;3</span></p><p class="elsevierStylePara">Redefining the care standards aimed at improving patient management and increasing overall efficiency of the organisation was carried out through the design and implementation of a series of Clinical Practice Guides&#46; The majority of the professionals directly involved in treating patient care as set out in the protocol were involved in the development of the Guidelines&#46;<span class="elsevierStyleSup">4</span></p><p class="elsevierStylePara">The results obtained show the success of the changes made&#46; Acceptable standards have been consolidated and these have generated a positive working operation and a culture of ongoing improvement&#46;</p><p class="elsevierStylePara">The necessary balance between average stay&#44; readmissions under 31 days and the complexity of the patients treated&#44; as well as their inter-relationship with other indicators all help to guide in the fulfilment of the social function intrinsic to any Clinical Management Institute<span class="elsevierStyleSup">5</span> which should also be taken into account in this context&#46; Thus&#44; the increase in surgical infection in 2007 can be explained in view of the parallel rise in complexity and expansion of complicated diagnostic-therapeutic interventions in ever older groups&#46;</p><p class="elsevierStylePara">The programme also regularly monitors patient safety and records risks to which the patient may be exposed &#40;surgical infection&#44; bedsores and falls&#41;&#46;<span class="elsevierStyleSup">6&#44;7</span> The Institute actively participates and collaborates in noting the transcendental nature of these activities which are of institutional interest to the Hospital&#46;</p><p class="elsevierStylePara">The patient as the true epicentre of the desired standards and his&#47;her ever-increasing level of active participation in health matters reinforces the importance of knowing the patient&#8217;s point of view regarding the treatment he&#47;she has received&#46; Therefore&#44; annual opinion surveys of hospitalised patients and out-patients<span class="elsevierStyleSup">8&#44;9 </span>are carried out&#46; An assessment of the opinions collected also indicates the aspects to be improved and shows where the Institute is moving in the appropriate direction &#40;Figures 2 and 3&#41;&#46; The analysis of claims presented and their cost inclusion in the rate per patient activity performed &#40;admissions plus outpatient visits&#41; allows pinpointing of the problems and the subsequent proposal of improvement initiatives&#46;<span class="elsevierStyleSup">10&#44;11</span></p><p class="elsevierStylePara">Given the difficulty of having reference standards with which to compare our results&#44;<span class="elsevierStyleSup">12</span> the development of the Institute&#8217;s indicators are analysed by comparing a year to the previous one and its evolutional tendency over the last five years&#46; An internal reference standard is used &#40;epidemiological average&#44; obtained from cases presented over the past five years&#41; &#40;bold-type values in Tables 2 and 3&#41;&#46; This reference value serves as an alert signal in the event that the data from the current year exceeds the usual reference value or even signals an unfavourable or negative development tendency&#46;</p><p class="elsevierStylePara"><a href="grande&#47;20118078&#95;f1&#95;p119&#46;jpg" class="elsevierStyleCrossRefs"><img src="20118078_f1_p119.jpg"></img></a></p><p class="elsevierStylePara">Figure 1&#46; </p><p class="elsevierStylePara"><a href="grande&#47;20118078&#95;t1&#95;p119&#46;jpg" class="elsevierStyleCrossRefs"><img src="20118078_t1_p119.jpg" alt="Management Commission Structure"></img></a></p><p class="elsevierStylePara">Table 1&#46; Management Commission Structure</p><p class="elsevierStylePara"><a href="grande&#47;20118078&#95;t2&#95;p120&#46;jpg" class="elsevierStyleCrossRefs"><img src="20118078_t2_p120.jpg" alt="Changes in technical quality indicators"></img></a></p><p class="elsevierStylePara">Table 2&#46; Changes in technical quality indicators</p><p class="elsevierStylePara"><a href="grande&#47;20118078&#95;t3&#95;p121&#46;jpg" class="elsevierStyleCrossRefs"><img src="20118078_t3_p121.jpg" alt="Changes in perceived quality indicators"></img></a></p><p class="elsevierStylePara">Table 3&#46; Changes in perceived quality indicators</p><p class="elsevierStylePara"><a href="grande&#47;20118078&#95;f2&#95;p121&#46;jpg" class="elsevierStyleCrossRefs"><img src="20118078_f2_p121.jpg"></img></a></p><p class="elsevierStylePara">Figure 2&#46; </p><p class="elsevierStylePara"><a href="grande&#47;20118078&#95;f3&#95;p122&#46;jpg" class="elsevierStyleCrossRefs"><img src="20118078_f3_p122.jpg"></img></a></p><p class="elsevierStylePara">Figure 3&#46; </p>"
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Institute for clinical management of nephrourological diseases: the benefits of a quality care programme
Instituto de Gestión Clínica para las enfermedades Nefro-Urologícas: Utilidad de un Programa de Calidad Asistencial
Manuel Santiñáa, Andreu Prata, Antoni Trillaa, Pilar Arrizabalagab, Antonio Alcarazb, Josep Maria Campistolb
a Dirección de Calidad y Seguridad Clinic, Hospital Clínic de Barcelona, Barcelona, Barcelona, España,
b Instituto Clínic de Nefro-Urología, Hospital Clínic de Barcelona, Barcelona, Barcelona, España,
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The Institute has full administrative autonomy&#44; managing a budget based on objectives that allow it&#44; for example&#44; to develop and establish innovative techniques and attract new clients&#46;</p><p class="elsevierStylePara">One of the strategic objectives of the ICNU was the acquisition and development of a culture based on the continual improvement of its services which would contribute to a better knowledge of quality appraisal methods in the field of urinary system disease care&#46;</p><p class="elsevierStylePara">The main aims of this study are to present the working dynamics established and to describe the changing outcomes resulting from this innovative programme of care management&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">MATERIAL AND METHODS</span></p><p class="elsevierStylePara">The design of this project corresponds to a time series descriptive epidemiologic study carried out in the area of urinary system diseases at the Clinical University Hospital of Barcelona&#46;</p><p class="elsevierStylePara">A specific and interdisciplinary task force was constituted&#46; The different professional layers were represented from both the ICNU and the Institutional Quality Programme at the Centre&#46; The technical and perceived quality indicators of interest were selected and a consensus was reached on the quality objectives considered most important for the political strategy of the Institute of Nephrourology&#46; These objectives are evaluated and reconsidered annually&#46;</p><p class="elsevierStylePara">It was unanimously agreed to identify at least one quality objective for each of the Departments that make up the Institute&#46; Acknowledgement of these had to conform to the agreement between the Institute and Hospital Management&#46; These should facilitate communication of the methodological standards for ongoing improvement among the Institute&#8217;s professionals&#46; All those aspects in which a potential opportunity for improvement was evident were included&#46;</p><p class="elsevierStylePara">The indicators used to monitor the basic dimensions of Quality<span class="elsevierStyleSup">1</span> were initially those defined by the Hospital Quality Plan &#40;Tables 2 and 3&#41;&#46; It was agreed that they would be expanded because new ones would be suggested or arise&#44; according to the dynamics of the process&#46;</p><p class="elsevierStylePara">The agreement of objectives is detailed in the quality report<span class="elsevierStyleSup">2</span> which assembles all of the information pertaining to quality evaluation at the Institute&#46; The quality report is a vehicle of communication between the Institute and Management through which the change in objectives and indicators throughout the year are followed up&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS</span></p><p class="elsevierStylePara">Over the period in question&#44; patient activity at the Institute increased in all its areas&#46; Admissions varied from 2&#44;386 in 2003 to 2&#44;724 in 2007&#46; The average stay improved from 6&#46;82 to 6&#46;5 days&#46; The total number of outpatient visits increased from 21&#44;362 to 25&#44;909 &#40;first visits went from 2&#44;431 in year 2003 to 3&#44;102 in 2007&#41;&#46; An increase in the complexity of the pathologies treated was also observed as measured using the Average Relative Weight &#40;ARW&#41; of all the Diagnosis Related Groups &#40;DRG&#41; at the Institute&#46; In 2003&#44; this ARW was 1&#46;32 as compared to 2&#46;18 in 2007&#46;</p><p class="elsevierStylePara">The development of the seven technical quality indicators monitored from 2003-2007 and that are considered as medical-surgical management variables are presented in Table 2&#46;</p><p class="elsevierStylePara">Table 3 shows the progress of the five indicators of perceived quality for the same period of time for the different areas of activity of the ICNU&#46;</p><p class="elsevierStylePara">Likewise&#44; the objectives of quality improvement for both technical and perceived quality established by the Institute have been increasing over time&#46; The initial objectives in 2003 were 9 and these progressed on to 16 agreed objectives in 2007&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">Any organisational change carries the need for adaptation to a new reality by the professionals involved&#46; Assuring that quality is not negatively influenced in this period and in subsequent stages is one of the basic tools for the consolidation of any organisational change&#46;<span class="elsevierStyleSup">2&#44;3</span></p><p class="elsevierStylePara">Redefining the care standards aimed at improving patient management and increasing overall efficiency of the organisation was carried out through the design and implementation of a series of Clinical Practice Guides&#46; The majority of the professionals directly involved in treating patient care as set out in the protocol were involved in the development of the Guidelines&#46;<span class="elsevierStyleSup">4</span></p><p class="elsevierStylePara">The results obtained show the success of the changes made&#46; Acceptable standards have been consolidated and these have generated a positive working operation and a culture of ongoing improvement&#46;</p><p class="elsevierStylePara">The necessary balance between average stay&#44; readmissions under 31 days and the complexity of the patients treated&#44; as well as their inter-relationship with other indicators all help to guide in the fulfilment of the social function intrinsic to any Clinical Management Institute<span class="elsevierStyleSup">5</span> which should also be taken into account in this context&#46; Thus&#44; the increase in surgical infection in 2007 can be explained in view of the parallel rise in complexity and expansion of complicated diagnostic-therapeutic interventions in ever older groups&#46;</p><p class="elsevierStylePara">The programme also regularly monitors patient safety and records risks to which the patient may be exposed &#40;surgical infection&#44; bedsores and falls&#41;&#46;<span class="elsevierStyleSup">6&#44;7</span> The Institute actively participates and collaborates in noting the transcendental nature of these activities which are of institutional interest to the Hospital&#46;</p><p class="elsevierStylePara">The patient as the true epicentre of the desired standards and his&#47;her ever-increasing level of active participation in health matters reinforces the importance of knowing the patient&#8217;s point of view regarding the treatment he&#47;she has received&#46; Therefore&#44; annual opinion surveys of hospitalised patients and out-patients<span class="elsevierStyleSup">8&#44;9 </span>are carried out&#46; An assessment of the opinions collected also indicates the aspects to be improved and shows where the Institute is moving in the appropriate direction &#40;Figures 2 and 3&#41;&#46; The analysis of claims presented and their cost inclusion in the rate per patient activity performed &#40;admissions plus outpatient visits&#41; allows pinpointing of the problems and the subsequent proposal of improvement initiatives&#46;<span class="elsevierStyleSup">10&#44;11</span></p><p class="elsevierStylePara">Given the difficulty of having reference standards with which to compare our results&#44;<span class="elsevierStyleSup">12</span> the development of the Institute&#8217;s indicators are analysed by comparing a year to the previous one and its evolutional tendency over the last five years&#46; An internal reference standard is used &#40;epidemiological average&#44; obtained from cases presented over the past five years&#41; &#40;bold-type values in Tables 2 and 3&#41;&#46; This reference value serves as an alert signal in the event that the data from the current year exceeds the usual reference value or even signals an unfavourable or negative development tendency&#46;</p><p class="elsevierStylePara"><a href="grande&#47;20118078&#95;f1&#95;p119&#46;jpg" class="elsevierStyleCrossRefs"><img src="20118078_f1_p119.jpg"></img></a></p><p class="elsevierStylePara">Figure 1&#46; </p><p class="elsevierStylePara"><a href="grande&#47;20118078&#95;t1&#95;p119&#46;jpg" class="elsevierStyleCrossRefs"><img src="20118078_t1_p119.jpg" alt="Management Commission Structure"></img></a></p><p class="elsevierStylePara">Table 1&#46; Management Commission Structure</p><p class="elsevierStylePara"><a href="grande&#47;20118078&#95;t2&#95;p120&#46;jpg" class="elsevierStyleCrossRefs"><img src="20118078_t2_p120.jpg" alt="Changes in technical quality indicators"></img></a></p><p class="elsevierStylePara">Table 2&#46; Changes in technical quality indicators</p><p class="elsevierStylePara"><a href="grande&#47;20118078&#95;t3&#95;p121&#46;jpg" class="elsevierStyleCrossRefs"><img src="20118078_t3_p121.jpg" alt="Changes in perceived quality indicators"></img></a></p><p class="elsevierStylePara">Table 3&#46; Changes in perceived quality indicators</p><p class="elsevierStylePara"><a href="grande&#47;20118078&#95;f2&#95;p121&#46;jpg" class="elsevierStyleCrossRefs"><img src="20118078_f2_p121.jpg"></img></a></p><p class="elsevierStylePara">Figure 2&#46; </p><p class="elsevierStylePara"><a href="grande&#47;20118078&#95;f3&#95;p122&#46;jpg" class="elsevierStyleCrossRefs"><img src="20118078_f3_p122.jpg"></img></a></p><p class="elsevierStylePara">Figure 3&#46; </p>"
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Article information
ISSN: 20132514
Original language: English
DOI:10.3265/Nefrologia.2009.29.2.4988.en.full
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