Pub Date : 2019-12-03DOI: 10.1136/bmjqs-2019-009824
K. Sauro, W. Ghali, H. Stelfox
> Insanity—doing the same thing over and over again, and expecting different results.1 Anyone who has received or delivered care understands it is vulnerable to fail. After each failure, the narrative is familiar and recited often—continuous quality improvement is invoked, and performance measurement is touted as a core strategy. Yet, does any of this make a difference? Almost 20 years ago the Institute of Medicine published ‘To Err is Human’, a widely cited report that highlighted the all-too-frequent occurrence of adverse events, negative and unintended consequences of healthcare.2 An estimated 1 in 10 hospital admissions results in an adverse event3 and 98 000 deaths occur per year as a consequence of adverse events.2 4 In addition to the human cost, adverse events burden the healthcare system—they increase hospital length of stay by an average of 10 days and cost in excess of $414 million per year.5 It is hard to know just how safe care is. Measuring safety is imperfect and there is little evidence that it makes care safer. But we have an ethical imperative to do no harm, which requires us to understand how safe care actually is. Measurement is therefore needed, because after all, we cannot fix or improve what we do not measure. Despite several commentaries discussing the advantages of existing methods to measure adverse events, controversy about the best method remains.6–16 Many resources have been devoted to determining the most valid method for detecting adverse events, and even more resources have gone towards implementing these measurement approaches within organisations. Discouragingly, however, these approaches have done little to improve the safety of care.17 18 Unlike previous discussions, we submit that the volume and complexity of patient–healthcare system interactions necessitates the development of new, more efficient yet accurate methods for detecting adverse events …
{"title":"Measuring safety of healthcare: an exercise in futility?","authors":"K. Sauro, W. Ghali, H. Stelfox","doi":"10.1136/bmjqs-2019-009824","DOIUrl":"https://doi.org/10.1136/bmjqs-2019-009824","url":null,"abstract":"> Insanity—doing the same thing over and over again, and expecting different results.1\u0000\u0000Anyone who has received or delivered care understands it is vulnerable to fail. After each failure, the narrative is familiar and recited often—continuous quality improvement is invoked, and performance measurement is touted as a core strategy. Yet, does any of this make a difference?\u0000\u0000Almost 20 years ago the Institute of Medicine published ‘To Err is Human’, a widely cited report that highlighted the all-too-frequent occurrence of adverse events, negative and unintended consequences of healthcare.2 An estimated 1 in 10 hospital admissions results in an adverse event3 and 98 000 deaths occur per year as a consequence of adverse events.2 4 In addition to the human cost, adverse events burden the healthcare system—they increase hospital length of stay by an average of 10 days and cost in excess of $414 million per year.5 It is hard to know just how safe care is. Measuring safety is imperfect and there is little evidence that it makes care safer. But we have an ethical imperative to do no harm, which requires us to understand how safe care actually is. Measurement is therefore needed, because after all, we cannot fix or improve what we do not measure.\u0000\u0000Despite several commentaries discussing the advantages of existing methods to measure adverse events, controversy about the best method remains.6–16 Many resources have been devoted to determining the most valid method for detecting adverse events, and even more resources have gone towards implementing these measurement approaches within organisations. Discouragingly, however, these approaches have done little to improve the safety of care.17 18 Unlike previous discussions, we submit that the volume and complexity of patient–healthcare system interactions necessitates the development of new, more efficient yet accurate methods for detecting adverse events …","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"29 1","pages":"341 - 344"},"PeriodicalIF":0.0,"publicationDate":"2019-12-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjqs-2019-009824","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41608950","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-12-03DOI: 10.1136/bmjqs-2019-009754
Christine D Jones, R. Boxer
Home care services support the goal of many patients and caregivers to live independently at home and to ‘age in place’. Home care referrals in the USA have increased nearly 60% from 2002 to 2016 resulting in an over 88% increase in spending to over US$18 billion for Medicare beneficiaries.1 In a recent 2015–2016 survey in Canada, an estimated 881 800 households, or just over 6% of all households, used home care services including nursing and personal/home support services.2 Despite the widespread use of home care services in many countries, relatively little is known about how to optimise patient outcomes in home care. Many questions remain about which patients are most likely to benefit, which services (eg, nursing, therapies, personal care) are most beneficial for which patients and what intensity and duration of services are ideal for different patient populations. Recently, de Mestral and colleagues identified that home care nursing was associated with lower odds of emergency department (ED)visits and rehospitalisations for patients discharged after elective vascular surgeries (ie, carotid endarterectomy, endovascular aortic aneurysm repair and bypass for lower extremity peripheral arterial disease) in Canada.3 This study is important because it adds to the evidence by examining home care in a population very different from the majority of studies focused on the effect of home care on patient outcomes. Most studies focus on patients with heart failure (HF) and the results have been mixed. One major difference to highlight is that the risk for ED visits and rehospitalisations in patients following an elective vascular surgery procedure is lower compared with patients who have an unplanned HF hospitalisation. The former population would have a lower risk of 30-day readmissions (~6%–19% readmission rate) compared with patients with HF who are readmitted more …
{"title":"Home care after elective vascular surgery: still more questions than answers","authors":"Christine D Jones, R. Boxer","doi":"10.1136/bmjqs-2019-009754","DOIUrl":"https://doi.org/10.1136/bmjqs-2019-009754","url":null,"abstract":"Home care services support the goal of many patients and caregivers to live independently at home and to ‘age in place’. Home care referrals in the USA have increased nearly 60% from 2002 to 2016 resulting in an over 88% increase in spending to over US$18 billion for Medicare beneficiaries.1 In a recent 2015–2016 survey in Canada, an estimated 881 800 households, or just over 6% of all households, used home care services including nursing and personal/home support services.2 Despite the widespread use of home care services in many countries, relatively little is known about how to optimise patient outcomes in home care. Many questions remain about which patients are most likely to benefit, which services (eg, nursing, therapies, personal care) are most beneficial for which patients and what intensity and duration of services are ideal for different patient populations.\u0000\u0000Recently, de Mestral and colleagues identified that home care nursing was associated with lower odds of emergency department (ED)visits and rehospitalisations for patients discharged after elective vascular surgeries (ie, carotid endarterectomy, endovascular aortic aneurysm repair and bypass for lower extremity peripheral arterial disease) in Canada.3 This study is important because it adds to the evidence by examining home care in a population very different from the majority of studies focused on the effect of home care on patient outcomes. Most studies focus on patients with heart failure (HF) and the results have been mixed. One major difference to highlight is that the risk for ED visits and rehospitalisations in patients following an elective vascular surgery procedure is lower compared with patients who have an unplanned HF hospitalisation. The former population would have a lower risk of 30-day readmissions (~6%–19% readmission rate) compared with patients with HF who are readmitted more …","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"29 1","pages":"968 - 970"},"PeriodicalIF":0.0,"publicationDate":"2019-12-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjqs-2019-009754","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47308461","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-27DOI: 10.1136/bmjqs-2019-010088
Y. Zurynski, K. Churruca, G. Arnolda, S. Dalton, H. P. Ting, P. Hibbert, Charlotte J Molloy, L. Wiles, Carl de Wet, J. Braithwaite
Objective To assess quality of care for children presenting with acute abdominal pain using validated indicators. Design Audit of care quality for acute abdominal pain according to 21 care quality indicators developed and validated in four stages. Setting and participants Medical records of children aged 1–15 years receiving care in 2012–2013 were sampled from 57 general practitioners, 34 emergency departments (ED) and 28 hospitals across three Australian states; 6689 medical records were screened for visits for acute abdominal pain and audited by trained paediatric nurses. Outcome measures Adherence to 21 care quality indicators and three bundles of indicators: bundle A-History; bundle B-Examination; bundle C-Imaging. Results Five hundred and fourteen children had 696 visits for acute abdominal pain and adherence was assessed for 9785 individual indicators. The overall adherence was 69.9% (95% CI 64.8% to 74.6%). Adherence to individual indicators ranged from 21.6% for assessment of dehydration to 91.4% for appropriate ordering of imaging. Adherence was low for bundle A-History (29.4%) and bundle B-Examination (10.2%), and high for bundle C-Imaging (91.4%). Adherence to the 21 indicators overall was significantly lower in general practice (62.7%, 95% CI 57.0% to 68.1%) compared with ED (86.0%, 95% CI 83.4% to 88.4%; p<0.0001) and hospital inpatient settings (87.9%, 95% CI 83.1% to 91.8%; p<0.0001). Conclusions There was considerable variation in care quality for indicator bundles and care settings. Future work should explore how validated care quality indicator assessments can be embedded into clinical workflows to support continuous care quality improvement.
目的使用经验证的指标评估儿童急性腹痛的护理质量。根据分四个阶段制定和验证的21项护理质量指标，对急性腹痛的护理质量进行设计审计。设定和参与者2012-2013年接受护理的1-15岁儿童的医疗记录是从澳大利亚三个州的57名全科医生、34个急诊科（ED）和28家医院抽取的；6689份医疗记录被筛查为急性腹痛就诊，并由受过培训的儿科护士进行审计。结果测量对21项护理质量指标和三组指标的遵守情况：A-History；束B检查；束C-Imaging。结果514名儿童因急性腹痛就诊696次，对9785项个体指标的依从性进行了评估。总体依从性为69.9%（95%CI 64.8%-74.6%）。对个别指标的依从性从评估脱水的21.6%到适当的成像顺序的91.4%不等。A束病史（29.4%）和B束检查（10.2%）的依从性较低，C束成像（91.4%）的依从率较高。全科医生对21项指标的总体依从性显著较低（62.7%，95% CI 57.0%至68.1%）与ED（86.0%、95% CI为83.4%～88.4%；p＜0.0001）和医院住院环境（87.9%，95% CI 83.1%～91.8%；p＜0.0001）。结论指标束和护理环境的护理质量存在相当大的差异。未来的工作应该探索如何将经过验证的护理质量指标评估嵌入临床工作流程，以支持持续的护理质量改进。
{"title":"Quality of care for acute abdominal pain in children","authors":"Y. Zurynski, K. Churruca, G. Arnolda, S. Dalton, H. P. Ting, P. Hibbert, Charlotte J Molloy, L. Wiles, Carl de Wet, J. Braithwaite","doi":"10.1136/bmjqs-2019-010088","DOIUrl":"https://doi.org/10.1136/bmjqs-2019-010088","url":null,"abstract":"Objective To assess quality of care for children presenting with acute abdominal pain using validated indicators. Design Audit of care quality for acute abdominal pain according to 21 care quality indicators developed and validated in four stages. Setting and participants Medical records of children aged 1–15 years receiving care in 2012–2013 were sampled from 57 general practitioners, 34 emergency departments (ED) and 28 hospitals across three Australian states; 6689 medical records were screened for visits for acute abdominal pain and audited by trained paediatric nurses. Outcome measures Adherence to 21 care quality indicators and three bundles of indicators: bundle A-History; bundle B-Examination; bundle C-Imaging. Results Five hundred and fourteen children had 696 visits for acute abdominal pain and adherence was assessed for 9785 individual indicators. The overall adherence was 69.9% (95% CI 64.8% to 74.6%). Adherence to individual indicators ranged from 21.6% for assessment of dehydration to 91.4% for appropriate ordering of imaging. Adherence was low for bundle A-History (29.4%) and bundle B-Examination (10.2%), and high for bundle C-Imaging (91.4%). Adherence to the 21 indicators overall was significantly lower in general practice (62.7%, 95% CI 57.0% to 68.1%) compared with ED (86.0%, 95% CI 83.4% to 88.4%; p<0.0001) and hospital inpatient settings (87.9%, 95% CI 83.1% to 91.8%; p<0.0001). Conclusions There was considerable variation in care quality for indicator bundles and care settings. Future work should explore how validated care quality indicator assessments can be embedded into clinical workflows to support continuous care quality improvement.","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"29 1","pages":"509 - 516"},"PeriodicalIF":0.0,"publicationDate":"2019-11-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjqs-2019-010088","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41993959","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-27DOI: 10.1136/bmjqs-2019-010056
K. Reeves, Samuel Chan, Alastair Marsh, S. Gallier, C. Wigley, K. Khunti, R. Lilford
Objective To examine implementation of evidence in orthopaedic practice following publication of the results of three pivotal clinical trials. Design Case studies based on three orthopaedic trials funded in sequence by the National Institute for Health Research Health Technology Assessment (HTA) programme. These trials dealt with treatment of fractures of the humerus, radius and ankle, respectively. For each case study, we conducted time-series analyses to examine the relationship between publication of findings and the implementation (or not) of the findings. Results The results of all three trials favoured the less expensive and less invasive option. In two cases, a change of practice, in line with the evidence that eventually emerged, preceded publication. Furthermore, the upturn in use of the intervention most supported by each of these two trials corresponded to the start of recruitment to the respective trial. The remaining trial failed to influence practice despite yielding clear-cut evidence. Conclusions Implementation of results of all three HTA orthopaedic trials favoured the less expensive and less invasive option. In two of the three studies, a change in practice, in line with the evidence that eventually emerged, preceded publication of that evidence. A trend or a change in practice, at around the start of the trial, indicates that the direction of causation opposes our hypothesis that publication of trial findings would lead to changes in practice. Our results provide provocative insight into the nuanced topic of research and practice, but further qualitative work is needed to fully explain what led to the pre-emptive change in practice we observed and why there was no change in the third case.
{"title":"Implementation of research evidence in orthopaedics: a tale of three trials","authors":"K. Reeves, Samuel Chan, Alastair Marsh, S. Gallier, C. Wigley, K. Khunti, R. Lilford","doi":"10.1136/bmjqs-2019-010056","DOIUrl":"https://doi.org/10.1136/bmjqs-2019-010056","url":null,"abstract":"Objective To examine implementation of evidence in orthopaedic practice following publication of the results of three pivotal clinical trials. Design Case studies based on three orthopaedic trials funded in sequence by the National Institute for Health Research Health Technology Assessment (HTA) programme. These trials dealt with treatment of fractures of the humerus, radius and ankle, respectively. For each case study, we conducted time-series analyses to examine the relationship between publication of findings and the implementation (or not) of the findings. Results The results of all three trials favoured the less expensive and less invasive option. In two cases, a change of practice, in line with the evidence that eventually emerged, preceded publication. Furthermore, the upturn in use of the intervention most supported by each of these two trials corresponded to the start of recruitment to the respective trial. The remaining trial failed to influence practice despite yielding clear-cut evidence. Conclusions Implementation of results of all three HTA orthopaedic trials favoured the less expensive and less invasive option. In two of the three studies, a change in practice, in line with the evidence that eventually emerged, preceded publication of that evidence. A trend or a change in practice, at around the start of the trial, indicates that the direction of causation opposes our hypothesis that publication of trial findings would lead to changes in practice. Our results provide provocative insight into the nuanced topic of research and practice, but further qualitative work is needed to fully explain what led to the pre-emptive change in practice we observed and why there was no change in the third case.","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"29 1","pages":"374 - 381"},"PeriodicalIF":0.0,"publicationDate":"2019-11-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjqs-2019-010056","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46541518","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-27DOI: 10.1136/bmjqs-2019-009890
Yuju Wu, Huan Zhou, Xiao Ma, Yaojiang Shi, H. Xue, Chengchao Zhou, Hongmei Yi, Alexis Medina, Jason Li, S. Sylvia
Background Medical 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. Objective To provide an unbiased assessment of the quality of medical records for outpatient visits to rural facilities in China. Methods A 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. Results Medical 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. Conclusion Despite 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.
医疗记录在医疗服务提供、质量评估和改进中发挥着重要作用。然而，关于低收入和中等收入国家医疗记录质量的客观证据很少。目的对中国农村医疗机构门诊病历质量进行客观评价。方法选取全国3省207个乡镇卫生院为研究对象。未通知的标准化患者(SPs)按照标准化处方提交给提供者。三周后，调查人员返回每家医院收集医疗记录。然后使用临床相互作用的录音来评估现有医疗记录的完整性和准确性。结果620例SP就诊中，有210例(33.8%)找到病历。在这些医院中，80%以上的医院在就诊时提到了患者的基本信息和药物治疗情况，但只有57.6%的医院记录了诊断情况。记录最不完整的信息类别是患者症状(74.3%未记录)，其次是非药物治疗(65.2%未记录)。大多数记录的信息是准确的，但有些项目的准确性低于80%。保留任何医疗记录与提供者的收入呈正相关(β 0.05, 95% CI 0.01至0.09)。有处方审查的医院的提供者不太可能记录完整(β - 0.87, 95% CI - 1.68至0.06)。在病历保存和完整性方面，疾病类型也存在显著差异。尽管医疗记录对卫生系统的运作很重要，但许多农村设施尚未实施维护患者记录的系统，即使有记录，也往往不完整。与绩效评价挂钩的处方审查应谨慎实施，因为它可能会对记录保存产生不利影响。改善记录保存和管理的干预措施是必要的。
{"title":"Using standardised patients to assess the quality of medical records: an application and evidence from rural China","authors":"Yuju Wu, Huan Zhou, Xiao Ma, Yaojiang Shi, H. Xue, Chengchao Zhou, Hongmei Yi, Alexis Medina, Jason Li, S. Sylvia","doi":"10.1136/bmjqs-2019-009890","DOIUrl":"https://doi.org/10.1136/bmjqs-2019-009890","url":null,"abstract":"Background Medical 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. Objective To provide an unbiased assessment of the quality of medical records for outpatient visits to rural facilities in China. Methods A 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. Results Medical 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. Conclusion Despite 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.","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"29 1","pages":"491 - 498"},"PeriodicalIF":0.0,"publicationDate":"2019-11-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjqs-2019-009890","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48529082","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-27DOI: 10.1136/bmjqs-2019-009716
Kirstin A Manges, Patricia S. Groves, Amany Farag, R. Peterson, Joanna Harton, S. Greysen
Background Little is known about how team processes impact providers’ abilities to prepare patients for a safe hospital discharge. Teamwork Shared Mental Models (teamwork-SMMs) are the teams’ organised understanding of individual member’s roles, interactions and behaviours needed to perform a task like hospital discharge. Teamwork-SMMs are linked to team effectiveness in other fields, but have not been readily investigated in healthcare. This study examines teamwork-SMMs to understand how interprofessional teams coordinate care when discharging patients. Methods This mixed methods study examined teamwork-SMMs of inpatient interprofessional discharge teams at a single hospital. For each discharge event, we collected data from the patient and their discharge team (nurse, physician and coordinator) using interviews and questionnaires. We quantitatively determined the discharge teams’ teamwork-SMM components of quality and convergence using the Shared Mental Model Scale, and then explored their relationships to patient-reported preparation for posthospital care. We used qualitative thematic analysis of narrative cases to examine the contextual differences of discharge teams with higher versus lower teamwork-SMMs. Results The sample included a total of 106 structured patient interviews, 192 provider day-of-discharge questionnaires and 430 observation hours to examine 64 discharge events. We found that inpatient teams with better teamwork-SMMs (ie, higher perceptions of teamwork quality or greater convergence) were more effective at preparing patients for post-hospital care. Additionally, teams with high and low teamwork-SMMs had different experiences with team cohesion, communication openness and alignment on the patient situation. Conclusions Examining the quality and agreement of teamwork-SMMs among teams provides a better understanding of how teams coordinate care and may facilitate the development of specific team-based interventions to improve patient care at hospital discharge.
{"title":"A mixed methods study examining teamwork shared mental models of interprofessional teams during hospital discharge","authors":"Kirstin A Manges, Patricia S. Groves, Amany Farag, R. Peterson, Joanna Harton, S. Greysen","doi":"10.1136/bmjqs-2019-009716","DOIUrl":"https://doi.org/10.1136/bmjqs-2019-009716","url":null,"abstract":"Background Little is known about how team processes impact providers’ abilities to prepare patients for a safe hospital discharge. Teamwork Shared Mental Models (teamwork-SMMs) are the teams’ organised understanding of individual member’s roles, interactions and behaviours needed to perform a task like hospital discharge. Teamwork-SMMs are linked to team effectiveness in other fields, but have not been readily investigated in healthcare. This study examines teamwork-SMMs to understand how interprofessional teams coordinate care when discharging patients. Methods This mixed methods study examined teamwork-SMMs of inpatient interprofessional discharge teams at a single hospital. For each discharge event, we collected data from the patient and their discharge team (nurse, physician and coordinator) using interviews and questionnaires. We quantitatively determined the discharge teams’ teamwork-SMM components of quality and convergence using the Shared Mental Model Scale, and then explored their relationships to patient-reported preparation for posthospital care. We used qualitative thematic analysis of narrative cases to examine the contextual differences of discharge teams with higher versus lower teamwork-SMMs. Results The sample included a total of 106 structured patient interviews, 192 provider day-of-discharge questionnaires and 430 observation hours to examine 64 discharge events. We found that inpatient teams with better teamwork-SMMs (ie, higher perceptions of teamwork quality or greater convergence) were more effective at preparing patients for post-hospital care. Additionally, teams with high and low teamwork-SMMs had different experiences with team cohesion, communication openness and alignment on the patient situation. Conclusions Examining the quality and agreement of teamwork-SMMs among teams provides a better understanding of how teams coordinate care and may facilitate the development of specific team-based interventions to improve patient care at hospital discharge.","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"29 1","pages":"499 - 508"},"PeriodicalIF":0.0,"publicationDate":"2019-11-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjqs-2019-009716","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49096285","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-20DOI: 10.1136/bmjqs-2019-010547
J. Meddings, Ashwin Gupta, N. Houchens
Healthcare quality and safety span multiple topics across the spectrum of academic and clinical disciplines. Keeping abreast of the rapidly growing body of work can be challenging. In this series, we provide succinct summaries of selected relevant studies published in the last several months. Some articles will focus on a particular theme, while others will highlight unique publications from high-impact medical journals. ### Key points Infection prevention and antimicrobial stewardship programmes are rapidly evolving.1 2 Like many patient safety initiatives, these programmes initially focused on encouraging the individual healthcare provider to follow guidelines, primarily through education, hand hygiene feedback and restricting use of higher-risk antibiotics. However, more recently there is recognition that infection prevention and antimicrobial …
{"title":"Quality and safety in the literature: January 2020","authors":"J. Meddings, Ashwin Gupta, N. Houchens","doi":"10.1136/bmjqs-2019-010547","DOIUrl":"https://doi.org/10.1136/bmjqs-2019-010547","url":null,"abstract":"Healthcare quality and safety span multiple topics across the spectrum of academic and clinical disciplines. Keeping abreast of the rapidly growing body of work can be challenging. In this series, we provide succinct summaries of selected relevant studies published in the last several months. Some articles will focus on a particular theme, while others will highlight unique publications from high-impact medical journals. \u0000\u0000### Key points\u0000\u0000Infection prevention and antimicrobial stewardship programmes are rapidly evolving.1 2 Like many patient safety initiatives, these programmes initially focused on encouraging the individual healthcare provider to follow guidelines, primarily through education, hand hygiene feedback and restricting use of higher-risk antibiotics. However, more recently there is recognition that infection prevention and antimicrobial …","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"29 1","pages":"86 - 90"},"PeriodicalIF":0.0,"publicationDate":"2019-11-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjqs-2019-010547","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46541221","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-20DOI: 10.1136/bmjqs-2019-009905
B. Khurana, S. Seltzer, I. Kohane, G. Boland
On 25 November 2018, the United Nations chillingly reported that the most dangerous place for women is inside their own homes. Each year more than half of female homicides are committed by current or former intimate partners or family members.1 Intimate partner violence (IPV), within the domestic violence spectrum, is defined as physical, sexual or emotional violence between partners or former partners.2 It is a serious public health concern with millions of people experiencing violence at the hands of an intimate partner. WHO recognizes IPV as a global issue, prevalent at epidemic proportions in every society, socioeconomic and educational group. According to the National Intimate Partner and Sexual Violence Survey, one in four women and one in nine men in USA have reported severe form of physical violence by an intimate partner during their lifetime.3 Despite the high prevalence and urgency of this critical public health issue, IPV continues to be profoundly underdiagnosed and is considered a persistent hidden epidemic. In addition to physical injuries, IPV has both short-term and long-term negative health consequences including asthma, irritable bowel syndrome, diabetes, poor reproductive health, chronic pain syndrome and mental health problems.4 With victims of IPV seeking medical care more often, healthcare providers can play a vital role in reducing the devastating impact of IPV by representing a trusting source of divulging abuse. The major obstacle to its early detection and intervention is victim under-reporting of physical violence to healthcare providers. Screening for IPV can be an effective tool for detecting and preventing future violence. However, several barriers limit the use and success of these screening programs. Due to shame, privacy, economic dependency, fear of retaliation, legal factors or lack of trust of providers, a patient may not self-report and even fabricate the history of her injury.5 …
{"title":"Making the ‘invisible’ visible: transforming the detection of intimate partner violence","authors":"B. Khurana, S. Seltzer, I. Kohane, G. Boland","doi":"10.1136/bmjqs-2019-009905","DOIUrl":"https://doi.org/10.1136/bmjqs-2019-009905","url":null,"abstract":"On 25 November 2018, the United Nations chillingly reported that the most dangerous place for women is inside their own homes. Each year more than half of female homicides are committed by current or former intimate partners or family members.1 Intimate partner violence (IPV), within the domestic violence spectrum, is defined as physical, sexual or emotional violence between partners or former partners.2 It is a serious public health concern with millions of people experiencing violence at the hands of an intimate partner. WHO recognizes IPV as a global issue, prevalent at epidemic proportions in every society, socioeconomic and educational group. According to the National Intimate Partner and Sexual Violence Survey, one in four women and one in nine men in USA have reported severe form of physical violence by an intimate partner during their lifetime.3 Despite the high prevalence and urgency of this critical public health issue, IPV continues to be profoundly underdiagnosed and is considered a persistent hidden epidemic. In addition to physical injuries, IPV has both short-term and long-term negative health consequences including asthma, irritable bowel syndrome, diabetes, poor reproductive health, chronic pain syndrome and mental health problems.4 With victims of IPV seeking medical care more often, healthcare providers can play a vital role in reducing the devastating impact of IPV by representing a trusting source of divulging abuse. The major obstacle to its early detection and intervention is victim under-reporting of physical violence to healthcare providers. Screening for IPV can be an effective tool for detecting and preventing future violence. However, several barriers limit the use and success of these screening programs. Due to shame, privacy, economic dependency, fear of retaliation, legal factors or lack of trust of providers, a patient may not self-report and even fabricate the history of her injury.5 …","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"29 1","pages":"241 - 244"},"PeriodicalIF":0.0,"publicationDate":"2019-11-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjqs-2019-009905","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43804627","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-20DOI: 10.1136/bmjqs-2019-009955
H. Yamamoto, H. Miyata, K. Tanemoto, Y. Saiki, H. Yokoyama, Eriko Fukuchi, N. Motomura, Y. Ueda, S. Takamoto
Background In 2015, an academic-led surgical quality improvement (QI) programme was initiated in Japan to use database information entered from 2013 to 2014 to identify institutions needing improvement, to which cardiovascular surgery experts were sent for site visits. Here, posthoc analyses were used to estimate the effectiveness of the QI programme in reducing surgical mortality (30-day and in-hospital mortality). Methods Patients were selected from the Japan Cardiovascular Surgery Database, which includes almost all cardiovascular surgeries in Japan, if they underwent isolated coronary artery bypass graft (CABG), valve or thoracic aortic surgery from 2013 to 2016. Difference-in-difference methods based on a generalised estimating equation logistic regression model were used for pre-post comparison after adjustment for patient-level expected surgical mortality. Results In total, 238 778 patients (10 172 deaths) from 590 hospitals, including 3556 patients seen at 10 hospitals with site visits, were included from January 2013 to December 2016. Preprogramme, the crude surgical mortality for site visit and non-site visit institutions was 9.0% and 2.7%, respectively, for CABG surgery, 10.7% and 4.0%, respectively, for valve surgery and 20.7% and 7.5%, respectively, for aortic surgery. Postprogramme, moderate improvement was observed at site visit hospitals (3.6%, 9.6% and 18.8%, respectively). A difference-in-difference estimator showed significant improvement in CABG (0.29 (95% CI 0.15 to 0.54), p<0.001) and valve surgery (0.74 (0.55 to 1.00); p=0.047). Improvement was observed within 1 year for CABG surgery but was delayed for valve and aortic surgery. During the programme, institutions did not refrain from surgery. Conclusions Combining traditional site visits with modern database methodologies effectively improved surgical mortality in Japan. These universal methods could be applied via a similar approach to contribute to achieving QI in surgery for many other procedures worldwide.
{"title":"Quality improvement in cardiovascular surgery: results of a surgical quality improvement programme using a nationwide clinical database and database-driven site visits in Japan","authors":"H. Yamamoto, H. Miyata, K. Tanemoto, Y. Saiki, H. Yokoyama, Eriko Fukuchi, N. Motomura, Y. Ueda, S. Takamoto","doi":"10.1136/bmjqs-2019-009955","DOIUrl":"https://doi.org/10.1136/bmjqs-2019-009955","url":null,"abstract":"Background In 2015, an academic-led surgical quality improvement (QI) programme was initiated in Japan to use database information entered from 2013 to 2014 to identify institutions needing improvement, to which cardiovascular surgery experts were sent for site visits. Here, posthoc analyses were used to estimate the effectiveness of the QI programme in reducing surgical mortality (30-day and in-hospital mortality). Methods Patients were selected from the Japan Cardiovascular Surgery Database, which includes almost all cardiovascular surgeries in Japan, if they underwent isolated coronary artery bypass graft (CABG), valve or thoracic aortic surgery from 2013 to 2016. Difference-in-difference methods based on a generalised estimating equation logistic regression model were used for pre-post comparison after adjustment for patient-level expected surgical mortality. Results In total, 238 778 patients (10 172 deaths) from 590 hospitals, including 3556 patients seen at 10 hospitals with site visits, were included from January 2013 to December 2016. Preprogramme, the crude surgical mortality for site visit and non-site visit institutions was 9.0% and 2.7%, respectively, for CABG surgery, 10.7% and 4.0%, respectively, for valve surgery and 20.7% and 7.5%, respectively, for aortic surgery. Postprogramme, moderate improvement was observed at site visit hospitals (3.6%, 9.6% and 18.8%, respectively). A difference-in-difference estimator showed significant improvement in CABG (0.29 (95% CI 0.15 to 0.54), p<0.001) and valve surgery (0.74 (0.55 to 1.00); p=0.047). Improvement was observed within 1 year for CABG surgery but was delayed for valve and aortic surgery. During the programme, institutions did not refrain from surgery. Conclusions Combining traditional site visits with modern database methodologies effectively improved surgical mortality in Japan. These universal methods could be applied via a similar approach to contribute to achieving QI in surgery for many other procedures worldwide.","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"29 1","pages":"560 - 568"},"PeriodicalIF":0.0,"publicationDate":"2019-11-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjqs-2019-009955","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49374929","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-19DOI: 10.1136/bmjqs-2019-009948
Allison H. Oakes, Mitesh S. Patel
In any healthcare setting, the quality of care depends on the effectiveness of a given treatment, and on the way that the treatment is delivered. The complexities of modern healthcare have created gaps in our ability to consistently deliver the most effective and efficient care. As a result, significant undertreatment and overtreatment co-occur.1–3 This reality has led diverse stakeholders to overhaul the environment, context and systems in which healthcare professionals practice. However, while well intentioned, most ‘advances’ in healthcare delivery rely on untested or poorly tested interventions.4 5 This means that effective interventions don’t scale as fast as they should and that ineffective interventions persist despite providing no benefit. The current status quo presents an opportunity improve the delivery of care through a more systematic approach. Successful innovation requires experimentation. Embedded research teams around the world have started to systematically test the impact of using subtle changes to the way information is framed or choices are offered to nudge medical decision making.6 7 The trial by Schmidtke demonstrates the feasibility and necessity of rapid-cycle, randomised testing within a healthcare system.8 The authors randomly assigned 7540 front-line staff to either receive a standard letter reminding them of influenza vaccination or one of three letters that used insights from behavioural economics to try and better nudge healthcare workers through different ways of framing social norms. Despite this effort, they found that all four arms had the same vaccination rate of 43%, meaning none of the social norm interventions led to meaningful changes in behaviour. All too often, policies and programmes that ‘make sense’ have been implemented without any kind of formal evaluation. In the Schmidtke trial, however, the rigorous study design allowed researchers to quickly and decisively conclude that the social norms letters were no better than a …
{"title":"A nudge towards increased experimentation to more rapidly improve healthcare","authors":"Allison H. Oakes, Mitesh S. Patel","doi":"10.1136/bmjqs-2019-009948","DOIUrl":"https://doi.org/10.1136/bmjqs-2019-009948","url":null,"abstract":"In any healthcare setting, the quality of care depends on the effectiveness of a given treatment, and on the way that the treatment is delivered. The complexities of modern healthcare have created gaps in our ability to consistently deliver the most effective and efficient care. As a result, significant undertreatment and overtreatment co-occur.1–3 This reality has led diverse stakeholders to overhaul the environment, context and systems in which healthcare professionals practice. However, while well intentioned, most ‘advances’ in healthcare delivery rely on untested or poorly tested interventions.4 5 This means that effective interventions don’t scale as fast as they should and that ineffective interventions persist despite providing no benefit. The current status quo presents an opportunity improve the delivery of care through a more systematic approach.\u0000\u0000Successful innovation requires experimentation. Embedded research teams around the world have started to systematically test the impact of using subtle changes to the way information is framed or choices are offered to nudge medical decision making.6 7 The trial by Schmidtke demonstrates the feasibility and necessity of rapid-cycle, randomised testing within a healthcare system.8 The authors randomly assigned 7540 front-line staff to either receive a standard letter reminding them of influenza vaccination or one of three letters that used insights from behavioural economics to try and better nudge healthcare workers through different ways of framing social norms. Despite this effort, they found that all four arms had the same vaccination rate of 43%, meaning none of the social norm interventions led to meaningful changes in behaviour. All too often, policies and programmes that ‘make sense’ have been implemented without any kind of formal evaluation. In the Schmidtke trial, however, the rigorous study design allowed researchers to quickly and decisively conclude that the social norms letters were no better than a …","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"29 1","pages":"179 - 181"},"PeriodicalIF":0.0,"publicationDate":"2019-11-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjqs-2019-009948","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47398614","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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