To identify factors associated with service quality provided by agencies implementing a basic package of health services in Afghanistan.

Cross-sectional survey of outpatient health facilities, health workers, patients and caretakers.

Primary health care facilities in every province of Afghanistan.

Composite scale measuring the quality of clinical processes in four areas: patient histories, physical examinations, communication and time spent with patient.

No difference in service quality was observed between male and female providers or between male and female patients, but when both the provider and patient were female quality was much higher. Overall, the quality of care at non-governmental organization and government-managed health facilities did not differ, but the poor received higher quality care at non-governmental facilities than at government facilities. Doctors provided higher quality care than lower level providers. Provision of six or more supervisory visits in the last 6 months was associated with higher service quality. Training doctors in integrated management of childhood illness was not associated with quality, but when lower level health workers received such training the quality of patient–provider communication was higher. Other recurrent inputs and geographic remoteness are not associated with the quality of care provided.

The government's strategy to form partnerships with non-governmental organizations has led to higher quality of care provided to the poor. This represents a promising start in the reconstruction of Afghanistan's health system and provides useful evidence to other countries striving to increase access to quality care for the poor.

To identify factors associated with client perceptions of the quality of primary care services in Afghanistan.

Cross-sectional survey of outpatient health facilities, health workers, patients and caretakers.

Primary health care facilities in every province of Afghanistan.

Numerical scale of client perceptions of service quality.

Clients report relatively high levels of perceived quality in Afghanistan. Most of the variation that is explained relates specifically to the patient's interaction with the health worker and not to other health facility characteristics, such as cleanliness, infrastructure, service capacity and the presence of equipment or drugs. The strongest determinants of client-perceived quality identified are health worker thoroughness in taking patient histories, conducting physical examinations and communicating with patients. Being seen by a doctor and being from a household in the poorest quintile are also associated with higher perceived quality. For female patients, being seen by a female provider is associated with higher perceived quality, while for male patients time and money spent for travel to the health facility are negatively associated with perceived quality.

Clinical quality and client perceived quality appear to be mutually reinforcing, and efforts to improve health worker performance in taking histories, conducting exams and communicating with patients are likely to increase client perceived quality in this setting. Client perceptions of service quality assume additional importance in Afghanistan, where the perceived legitimacy of the government may depend partially on its ability to convince the population that it can deliver essential health services.

Quality improvement efforts are increasingly common in the United States; however, their use in developing countries is limited. We sought to evaluate the impact of a large-scale intervention on several key management indicators through hospital quality improvement efforts.

Pre–post-descriptive study of 14 hospitals in Ethiopia.

Six regions and two city administrations in Ethiopia.

Hospital leaders and management mentors in participating hospitals.

In collaboration with the Ministry of Health and the Clinton HIV/AIDS Initiative, we implemented a countrywide quality improvement initiative in which 24 mentors with hospital administration experience were placed for 1 year in Ethiopia to work side-by-side with hospital management teams. We also provided a professional development course to enhance quality improvement skills.

Presence of 75 key management indicators; reported management skills of hospital leaders by the mentors.

In pre–post analysis, we found improvement in 45 of the 75 (60%) key management indicators between August 2006 and May 2007. The changes reflected a total of 105 management indicators improved across the 14 hospitals, which equates to a per-hospital mean of 7.5 (standard deviation 5.9) improvements. Reported management skills of hospital leaders improved in several management domains, although their reported confidence in these skills remained largely unchanged.

Our findings indicate that quality improvement efforts can be effective in improving hospital management in developing countries. Longer follow-up is required to assess the sustainability of the hospital improvements accomplished.

The aim of this study was to evaluate the relevance of the signals generated by a computerized drug–drug interaction detection system and to design a classification of overridden drug–drug interaction alerts.

Prospective study over two months.

Five hundred and ten-bed university paediatric hospital.

In Robert Debré Hospital physicians generate drug orders online using a computerized physician order entry system that also detects drug–drug interactions in real time. We analysed the relevance of a sample of alerts overridden by physicians.

We analysed a sample of 613 overridden alerts. We defined three categories of overridden alerts: informational errors (35); system errors (244) and accurate alerts (334). Two reasons account for 40% of false-positive alerts: an inability of the system to recognize real conflicts between drug treatments and guidelines stating that the two drugs can be used together, because the benefit outweighs the risk of side effects due to the drug–drug interaction.

We created a classification of overridden alerts, in the context of computerized physician order entry system coupled with a drug–drug interaction detection system. There is clearly room for improvement in the development of drug–drug interaction software. This classification should make it possible to break this work down into smaller tasks, making it possible to decrease the sensitivity to background noise of drug–drug interaction detection systems.

The purpose of this study was to determine risk factors of adverse events in five surgical procedures.

Retrospective record review was used to determine adverse events and risk factors of 1177 surgical admissions. Procedures included in this study were transurethral resection of prostate, hysterectomy, hip and knee arthroplasty, cholecystectomy and herniorrhaphy. Risk factors included comorbidity, lifestyle factors and medications. Stepwise multiple logistic regression was used to determine predictors of adverse events.

Two teaching hospitals in regional New South Wales, Australia.

1177 surgical admissions for five high volume procedures.

Identified predictors of adverse events in surgical admissions.

The adverse event rate was 23.1% for all procedures (range 17.5–33.7% for the five procedures). Two factors were strongly predictive of an adverse event in all surgical admissions: age >70 years [odds ratio (OR) 1.9, 95% confidence intervals (CI) 1.3–2.6] and duration of operation (P = 0.005). Other predictive factors were: contaminated surgical site (OR 2.1, 95% CI 1.2–3.7) and anaemia (OR 1.8, 95% CI 1.1–2.8). Predictive factors of individual procedures included: urine retention (transurethral resection of the prostate); extended duration of operation and asthma (hysterectomy); acute admissions and extended duration of operation (cholecystectomy); and warfarin type drugs, ethanol abuse, failed prostheses, GI ulcer/inflammation, rheumatoid arthritis, and ischaemic heart disease (hip and knee joint arthroplasty).

The results of this study suggest that five factors should be routinely monitored for patients undergoing these procedures: age >70 years, type of procedure, duration of operation >2 h, contaminated surgical site and anaemia.

To develop a standard taxonomy for inpatient complaints that could be adopted in a wide array of health service institutions.

A taxonomy was developed by merging the coding schemes from eight prior studies of patient complaints, and then by revising the received coding scheme in light of the codes and clarifications that emerged from a content analysis of patient complaints.

Two Boston area hospitals.

Stratified random sample of 1216 complaints from patients in 2004.

None.

Patient complaints codes, provider codes and inter-rater reliability.

A taxonomy comprising 22 patient complaint codes and five provider codes was developed. Inter-rater agreement for complaint codes was good (median Kappa statistic 0.66, interquartile range 0.55–0.80). Four codes were each used in more than 10% of the patient complaints filed: unprofessional conduct (19%); poor provider–patient communication (17%); treatment and care of patient (16%); and, having to wait for care (11%). Of the coding for the profession of the person complained about, 47% of the patient complaints were about staff in general or did not specify a particular profession; 22% identified a physician or dentist; 12% nursing staff; 11% administrative or support staff and 8% allied clinical health professionals.

Standardized coding of patient complaint data may provide an opportunity for quality improvement, patient satisfaction and changes in patient care.

To explore patients' and family members' perceptions of Open Disclosure of adverse events that occurred during their health care.

We interviewed 23 people involved in adverse events and incident disclosure using a semi-structured, open-ended guide. We analyzed transcripts using thematic discourse analysis.

Four States in Australia: New South Wales, Victoria, Queensland and South Australia.

Twenty-three participants were recruited as part of an evaluation of the Australian Open Disclosure pilot commissioned by the Australian Commission on Safety and Quality in Health Care.

All participants (except one) appreciated the opportunity to meet with staff and have the adverse event explained to them. Their accounts also reveal a number of concerns about how Open Disclosure is enacted: disclosure not occurring promptly or too informally; disclosure not being adequately followed up with tangible support or change in practice; staff not offering an apology, and disclosure not providing opportunities for consumers to meet with the staff originally involved in the adverse event. Analysis of participants' accounts suggests that a combination of formal Open Disclosure, a full apology, and an offer of tangible support has a higher chance of gaining consumer satisfaction than if one or more of these components is absent.

Staff need to become more attuned in their disclosure communication to the victim s perceptions and experience of adverse events, to offer an appropriate apology, to support victims long-term as well as short-term, and to consider using consumers' insights into adverse events for the purpose of service improvement.

To explore the extent to which quality improvement activities are implemented in the Norwegian long-term care system for older people, and to determine if variations in the extent and scope of quality improvement activities are associated with the characteristics of the first-line care leaders, the sector or the size of the municipality.

A cross-sectional telephone survey supplemented with information from public records and official municipal websites. Data were organized according to six total quality management components, and a sum score was developed to measure quality improvement. Variations in the extent of quality improvement activities were analysed using multivariate analysis.

Thirty-two Norwegian municipalities stratified according to region and population size.

Sixty-four first-line leaders in nursing homes and home-based care.

A sum score has been used as a measure of quality improvement activities.

The unit's quality improvement activities varied by quality improvement components and by municipality. The technical component that requires training in tools and techniques was low; the general components as ‘leader's involvement’ and ‘employee participation’ were more common. The size of the populations of the municipalities showed a significant independent association with the scope of quality activities.

The six quality improvement components varied from high to extremely low, and the large municipalities had more quality activities than small- or medium-sized municipalities.