Method for developing national quality indicators based on manual data extraction from medical records

Couralet, Mélanie; Leleu, Henri; Capuano, Fréderic; Marcotte, Leah M.; Nitenberg, Gérard; Sicotte, Claude; Minvielle, Étienne

doi:10.1136/bmjqs-2012-001170

Cited by 20 publications

(13 citation statements)

References 24 publications

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“…The team’s main remit is to develop validated QIs for on behalf of the French healthcare authorities [23]. The task of developing QIs for SCPs was set by the French Ministry of Health and the National Authority for Health ( Haute Autorité de Santé - HAS) who commissioned the present study and officially exempted us from Ethics Committee approval.…”

Section: Methodsmentioning

confidence: 99%

Main barriers to effective implementation of stroke care pathways in France: a qualitative study

Gache

Leleu

Nitenberg

et al. 2014

BMC Health Serv Res

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BackgroundStroke Care Pathways (SCPs) aim to improve quality of care by providing better access to stroke units, rehabilitation centres, and home care for dependent patients. The objective of this study was to identify the main barriers to effective implementation of SCPs in France.MethodsWe selected 4 types of SCPs currently implemented in France that differed in terms of geographical location, population size, socio-economic conditions, and available health care facilities. We carried out 51 semi-structured interviews of 44 key health professionals involved in these SCPs and used the interview data to (i) create a typology of the organisational barriers to effective SCP implementation by axial coding, (ii) define barrier contents by vertical coding. The typology was validated by a panel of 15 stroke care professionals.ResultsFour main barriers to effective SCP implementation were identified: lack of resources (31/44 interviewees), coordination problems among staff (14/44) and among facilities (27/44), suboptimal professional and organisational practices (16/44), and inadequate public education about stroke (13/44). Transposition of the findings onto a generic SCP highlighted alternative care options and identified 10 to 17 barriers that could disrupt continuity of care.ConclusionLack of resources was considered to be the chief obstacle to effective SCP implementation. However, the main weakness of existing SCPs was poor communication and cooperation among health professionals and among facilities. We intend to use this knowledge to construct a robust set of quality indicators for use in SCP quality improvement initiatives, in comparisons between SCPs, and in the assessment of the effective implementation of clinical practice guidelines.

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Section: Methodsmentioning

confidence: 99%

Main barriers to effective implementation of stroke care pathways in France: a qualitative study

Gache

Leleu

Nitenberg

et al. 2014

BMC Health Serv Res

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“…The QIs were codeveloped by COMPAQ-HPST, the French National Authority for Health, and the French College of Cardiology 15. Eligible patients had to have been hospitalised for more than 24 h in 2010 with a diagnosis of AMI (diagnosis codes I21 or I22 ICM-10).…”

Section: Methodsmentioning

confidence: 99%

Hospital performance based on treatment delays: comparison of ranking methods

et al. 2013

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“…Medical records are an important tool for clinical care delivery, quality assessment and improvement 1–3. Properly maintained documentation of clinical encounters facilitates better continuation of care across time and providers, provides objective evidence through which to evaluate and monitor clinical practice, and serves as the basis for healthcare payment and reimbursement systems 4 5.…”

Section: Introductionmentioning

confidence: 99%

Using standardised patients to assess the quality of medical records: an application and evidence from rural China

Zhou

et al. 2019

BMJ Qual Saf

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BackgroundMedical records play a fundamental role in healthcare delivery, quality assessment and improvement. However, there is little objective evidence on the quality of medical records in low and middle-income countries.ObjectiveTo provide an unbiased assessment of the quality of medical records for outpatient visits to rural facilities in China.MethodsA sample of 207 township health facilities across three provinces of China were enrolled. Unannounced standardised patients (SPs) presented to providers following standardised scripts. Three weeks later, investigators returned to collect medical records from each facility. Audio recordings of clinical interactions were then used to evaluate completeness and accuracy of available medical records.ResultsMedical records were located for 210 out of 620 SP visits (33.8%). Of those located, more than 80% contained basic patient information and drug treatment when mentioned in visits, but only 57.6% recorded diagnoses. The most incompletely recorded category of information was patient symptoms (74.3% unrecorded), followed by non-drug treatments (65.2% unrecorded). Most of the recorded information was accurate, but accuracy fell below 80% for some items. The keeping of any medical records was positively correlated with the provider’s income (β 0.05, 95% CI 0.01 to 0.09). Providers at hospitals with prescription review were less likely to record completely (β −0.87, 95% CI −1.68 to 0.06). Significant variation by disease type was also found in keeping of any medical record and completeness.ConclusionDespite the importance of medical records for health system functioning, many rural facilities have yet to implement systems for maintaining patient records, and records are often incomplete when they exist. Prescription review tied to performance evaluation should be implemented with caution as it may create disincentives for record keeping. Interventions to improve record keeping and management are needed.

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Method for developing national quality indicators based on manual data extraction from medical records

Cited by 20 publications

References 24 publications

Main barriers to effective implementation of stroke care pathways in France: a qualitative study

Main barriers to effective implementation of stroke care pathways in France: a qualitative study

Hospital performance based on treatment delays: comparison of ranking methods

Using standardised patients to assess the quality of medical records: an application and evidence from rural China

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