Qualitative improvement of health services is essential in order to offer a level of assistance that can respond to the evolving needs of patients. The current National Health Service (NHS) law (DL 502/1992 and 517/2003) states that the qualitative evaluation of health services is fundamental. Article 14, which concerns the rights of citizens suffering from any disease, is of particular importance as it imposes the adoption of Quality indicators concerning the customisation of assistance, the right of information, food and accommodation services, and activities directed towards disease prevention. From the point of view of this evolution, the patient, or better, the client/customer, takes on a central and crucial role around which the different health organisation responsibilities move (Fig. 1).
The assessment and monitoring of patient satisfaction requires the personal commitment of a health care professional in order to build up a Quality system as a basis for continuing Quality improvement (Fig. 2).
Around this cultural evolution we would like to highlight two aspects that are equally important and tightly-linked. The first is the search for efficacy and effi- ciency of the offered health service; that is, the ability to find the most appropriate
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P. Pescatori, R. Cadinu
Quality system
organisation, responsibilities, resources, and technical equipment needed for Quality management
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system Documents
Fig. 1.
Quality system architecture
therapeutic strategies for each customer, and to offer them in the shortest time and using minimal resources. The second aspect that can be highlighted within this process of continuing improvement concerns quality of life. In other words, consolidating the patient’s degree of independence and his/her possibility to retain social activities and relationships.
It is important to note that society members themselves have come to play a more central role in the management of their own health. However, as reported in this book, the patient needs to be accompanied and supported by health person- nel in this process (Fig. 3).
In fact, the role of specialist nursing has become increasingly important; it is indispensable for the education of the patient about his/her disease, its conse- quences, and its impact on quality of life, in addition to managing the therapeutic plan. Within this context, particular attention should be paid to the role of the families, who are more and more involved in disease management to the point where they effectively become caregivers, and thus active protagonists within the therapeutic treatment. They care directly about the health needs of the patient and they assist the patient to comply with therapeutic protocols (Fig. 4).
The caregiver’s role is central to disease management and it has even more rel- evance when it is linked to the treatment of chronic disease and particularly, of chronic respiratory disease. This is because treatment of chronic respiratory dis- ease necessitates continual drug administration and life-style changes in order to obtain the necessary therapeutic goals. In these cases, the caregiver’s role is often central not only for the technical reasons that we will discuss later, but also for pro-
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Fig. 2.
Quality system is the basis for continuing Quality improvement
viding the constant psychological support that these patients need (Fig. 5).
There is often a gap between patient expectation and achievement of thera- peutic goals. These goals do not aim to cure the patient, but rather to improve gen- eral health status and to prevent acute events. Within this context, the psychologi-
The patient
Fig. 3.
The patient is in the center of nursing activities
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The patient The family
Fig. 4.
Continuous education of the patient and caregiver improves compliance
cal status of the patient might have a detrimental effect on their adhesion to ther- apeutic treatments in the long-term. Therefore, the caregiver acts as an irreplace- able positive stimulus and psychological support for the patient.
Health personnel can thus not ignore compliance of the patient/caregiver cou- ple or their willingness to collaborate and adhere to therapeutic plans. This neces- sitates the adoption of professional strategies to improve compliance, in particular:
• simple therapeutic schemes
• a good physician---nurse---patient relationship
• continuous education of the patient and caregiver
• verification of treatment comprehension in the long-term.
A crucial point to consider is the process of educating the patient and caregiv- er, which requires specific pedagogic knowledge. It is necessary to propose educa- tional plans that are appropriate to the patient’s disease and to consider progressive transfer of therapeutic competency from the health professionals to the patient and/or his/her caregiver, thus promoting autonomy and active collaboration.
Through our Specialist Centre, which provides education to patients affected by respiratory insufficiency undergoing long-term oxygen treatment (LTOT), we have established that these patients acquire:
• a knowledge of their disease and related medications
• the capability to carry out procedures useful to treatment
• the ability to be helped by caregivers that follow a parallel training.
The utility and necessity of continuous and appropriate education has become even more relevant, considering that assistance is moving more and more towards a home-based model. This is a model that our Specialist Centre supports as a strategic choice and has been practising for many years (Fig. 6).
Continuity in specialist care
Fig. 5.
Assistance moves towards a home-based model
Many of our patients, particularly those on LTOT, follow a ‘hospitalised home’
regime. In these cases, it is obvious that the education of the patient and caregiver about therapy is of prime importance. At the start of the therapy, we establish a module for data collection in the patient’s home; this module can, via normal tele- phone lines, send parameters such as oxymetry values, oxygen consumption and heart frequency to our Specialist Centre, thus giving us the possibility to maintain a constant telemetric evaluation of the patient’s status, especially important in more complex cases. This technology not only gives the patient the ability to send an SOS message to the hospital, but its adoption has offered us the chance to mon- itor patients more carefully and has given us the opportunity to acquire important data on disease progression. On the other hand, use of this technology requires specific training in the correct use of software, hardware and other devices.
This treatment model necessitates a training program that includes instruc- tions on:
• device and accessory use given in the patient’s home
• respiratory medication administration (in particular, correct utilisation of metered-dose inhalers and dry powder inhalers)
• adhesion to prescribed therapies
• stroller utilisation
• possible life-style changes.
In the first phase, it is necessary to monitor compliance of the patient/caregiv- er couple strictly, and to initiate a close collaboration with the health team: future
Nursing
Patient and family
Family physician Specialist Centre
Fig. 6.
