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}
Pub Date : 2019-11-15DOI: 10.1136/bmjqs-2019-010002
J. Rumball-Smith, K. Ross, D. Bates
Internationally, the last decade has seen the rapid adoption of electronic health records (EHRs) in hospitals and ambulatory care; EHRs are now an accepted enabler of a high-performing health system.1 However, the uptake and extent of use of this technology varies substantially. At the country level, Estonia and Sweden are among those nations with mature, interoperable EHRs with high patient access.2 3 In contrast, Switzerland and the UK have only patchy adoption in secondary care,4 5 and New Zealand, an early exemplar of primary care digitisation,6 has not yet integrated this information nationally, nor that of hospitals, at scale. Within countries also, there is variation. Even in jurisdictions with high overall rates of adoption, some providers are sophisticated ‘super-users’ of EHRs, whereas others use only their rudimentary functionalities.7–9 The adoption and full employment of an EHR reflects multiple factors, not the least of which are the financial and non-financial costs of procuring and implementing these platforms.10 Federal-level investment—including policy development, use of legislative levers, and support with resources or subsidies—undoubtedly affects the speed of adoption.11 However, even within a maximally supportive environment, there are those who remain ‘EHR-wary’, citing both uncertain benefit and risk of harm (particularly to clinicians). In this viewpoint, we argue that these EHR concerns may be overstated, irrelevant and/or mitigable, and should neither be used to justify delays in adoption nor full use. We maintain that late adopters and ‘under-users’—be they countries, hospitals or individual clinicians—should embrace this technology, and would benefit from prioritising its adoption and comprehensive use. We acknowledge …
{"title":"Late adopters of the electronic health record should move now","authors":"J. Rumball-Smith, K. Ross, D. Bates","doi":"10.1136/bmjqs-2019-010002","DOIUrl":"https://doi.org/10.1136/bmjqs-2019-010002","url":null,"abstract":"Internationally, the last decade has seen the rapid adoption of electronic health records (EHRs) in hospitals and ambulatory care; EHRs are now an accepted enabler of a high-performing health system.1 However, the uptake and extent of use of this technology varies substantially. At the country level, Estonia and Sweden are among those nations with mature, interoperable EHRs with high patient access.2 3 In contrast, Switzerland and the UK have only patchy adoption in secondary care,4 5 and New Zealand, an early exemplar of primary care digitisation,6 has not yet integrated this information nationally, nor that of hospitals, at scale. Within countries also, there is variation. Even in jurisdictions with high overall rates of adoption, some providers are sophisticated ‘super-users’ of EHRs, whereas others use only their rudimentary functionalities.7–9\u0000\u0000The adoption and full employment of an EHR reflects multiple factors, not the least of which are the financial and non-financial costs of procuring and implementing these platforms.10 Federal-level investment—including policy development, use of legislative levers, and support with resources or subsidies—undoubtedly affects the speed of adoption.11 However, even within a maximally supportive environment, there are those who remain ‘EHR-wary’, citing both uncertain benefit and risk of harm (particularly to clinicians). In this viewpoint, we argue that these EHR concerns may be overstated, irrelevant and/or mitigable, and should neither be used to justify delays in adoption nor full use. We maintain that late adopters and ‘under-users’—be they countries, hospitals or individual clinicians—should embrace this technology, and would benefit from prioritising its adoption and comprehensive use.\u0000\u0000We acknowledge …","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"29 1","pages":"238 - 240"},"PeriodicalIF":0.0,"publicationDate":"2019-11-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjqs-2019-010002","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45202587","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 : 2019-11-13DOI: 10.1136/bmjqs-2019-009422
Myrtede C. Alfred, K. Catchpole, E. Huffer, Larry Fredendall, K. Taaffe
Background Few studies have explored the work of sterile processing departments (SPD) from a systems perspective. Effective decontamination is critical for removing organic matter and reducing microbial levels from used surgical instruments prior to disinfection or sterilisation and is delivered through a combination of human work and supporting technologies and processes. Objective In this paper we report the results of a work systems analysis that sought to identify the complex multilevel interdependencies that create performance variation in decontamination and identify potential improvement interventions. Methods The research was conducted at a 700-bed academic hospital with two reprocessing facilities decontaminating approximately 23 000 units each month. Mixed methods, including 56 hours of observations of work as done, formal and informal interviews with relevant stakeholders and analysis of data collected about the system, were used to iteratively develop a process map, task analysis, abstraction hierarchy and a variance matrix. Results We identified 21 different performance shaping factors, 30 potential failures, 16 types of process variance, and 10 outcome variances in decontamination. Approximately 2% of trays were returned to decontamination from assembly, while decontamination problems were found in about 1% of surgical cases. Staff knowledge, production pressures, instrument design, tray composition and workstation design contributed to outcomes such as reduced throughput, tray defects, staff injuries, increased inventory and equipment costs, and patient injuries. Conclusions Ensuring patients and technicians’ safety and efficient SPD operation requires improved design of instruments and the decontamination area, skilled staff, proper equipment maintenance and effective coordination of reprocessing tasks.
{"title":"Work systems analysis of sterile processing: decontamination","authors":"Myrtede C. Alfred, K. Catchpole, E. Huffer, Larry Fredendall, K. Taaffe","doi":"10.1136/bmjqs-2019-009422","DOIUrl":"https://doi.org/10.1136/bmjqs-2019-009422","url":null,"abstract":"Background Few studies have explored the work of sterile processing departments (SPD) from a systems perspective. Effective decontamination is critical for removing organic matter and reducing microbial levels from used surgical instruments prior to disinfection or sterilisation and is delivered through a combination of human work and supporting technologies and processes. Objective In this paper we report the results of a work systems analysis that sought to identify the complex multilevel interdependencies that create performance variation in decontamination and identify potential improvement interventions. Methods The research was conducted at a 700-bed academic hospital with two reprocessing facilities decontaminating approximately 23 000 units each month. Mixed methods, including 56 hours of observations of work as done, formal and informal interviews with relevant stakeholders and analysis of data collected about the system, were used to iteratively develop a process map, task analysis, abstraction hierarchy and a variance matrix. Results We identified 21 different performance shaping factors, 30 potential failures, 16 types of process variance, and 10 outcome variances in decontamination. Approximately 2% of trays were returned to decontamination from assembly, while decontamination problems were found in about 1% of surgical cases. Staff knowledge, production pressures, instrument design, tray composition and workstation design contributed to outcomes such as reduced throughput, tray defects, staff injuries, increased inventory and equipment costs, and patient injuries. Conclusions Ensuring patients and technicians’ safety and efficient SPD operation requires improved design of instruments and the decontamination area, skilled staff, proper equipment maintenance and effective coordination of reprocessing tasks.","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"29 1","pages":"320 - 328"},"PeriodicalIF":0.0,"publicationDate":"2019-11-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjqs-2019-009422","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47634002","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 : 2019-11-13DOI: 10.1136/bmjqs-2019-009546
P. Tyler, Alan Fossa, J. Joseph, L. Sanchez
Background Understanding factors that drive admissions is critical to containing cost and optimising hospital operations. We hypothesised that, due to multiple factors, emergency physicians would be more likely to admit a patient seen later in their shift. Methods Retrospective study examining all patient visits at a large academic hospital from July 2010 to July 2016. Patients with missing data (n=191) were excluded. 294 031 emergency department (ED) visits were included in the final analysis. The exposure of interest was the time during the shift at which a patient was first evaluated by the clinician, and outcome was hospital admission. We used a generalised estimating equation with physician as the clustering level to adjust for patient age, gender, Emergency Severity Index (ESI, 1=most severe illness, 5=least severe illness) and 24 hours clock time. We also conducted a stratified analysis by three ESI categories. Results From the 294 031 ED visits, 5977 were seen in the last hour of the shift. Of patients seen in the last shift hour, 43% were admitted versus 39% seen at any other time during the shift. There was a significant association between being evaluated in the last hour (RR 1.03, 95% CI 1.01 to 1.06) and last quarter (RR 1.02, 1.01 to 1.03) of shift and the likelihood of admission. Patients with an ESI Score of 4–5 saw the largest effect sizes (RR 1.62, 0.996–2.635 for last hour and RR 1.24, 0.996–1.535 for last quarter) but these were not statistically significant. Additionally, there was a trend towards increased likelihood of admission later in shift; the relative risk of admission was 1.04 in hour 6, (1.02–1.05), 1.03 in hour 7 (1.01–1.05), 1.04 in hour 8 (1.01–1.06) and 1.06 in hour 9 (1.013–1.101). Conclusions There is a small but significant association between a patient being evaluated later in an emergency physician’s shift and their likelihood of being admitted to the hospital.
{"title":"Later emergency provider shift hour is associated with increased risk of admission: a retrospective cohort study","authors":"P. Tyler, Alan Fossa, J. Joseph, L. Sanchez","doi":"10.1136/bmjqs-2019-009546","DOIUrl":"https://doi.org/10.1136/bmjqs-2019-009546","url":null,"abstract":"Background Understanding factors that drive admissions is critical to containing cost and optimising hospital operations. We hypothesised that, due to multiple factors, emergency physicians would be more likely to admit a patient seen later in their shift. Methods Retrospective study examining all patient visits at a large academic hospital from July 2010 to July 2016. Patients with missing data (n=191) were excluded. 294 031 emergency department (ED) visits were included in the final analysis. The exposure of interest was the time during the shift at which a patient was first evaluated by the clinician, and outcome was hospital admission. We used a generalised estimating equation with physician as the clustering level to adjust for patient age, gender, Emergency Severity Index (ESI, 1=most severe illness, 5=least severe illness) and 24 hours clock time. We also conducted a stratified analysis by three ESI categories. Results From the 294 031 ED visits, 5977 were seen in the last hour of the shift. Of patients seen in the last shift hour, 43% were admitted versus 39% seen at any other time during the shift. There was a significant association between being evaluated in the last hour (RR 1.03, 95% CI 1.01 to 1.06) and last quarter (RR 1.02, 1.01 to 1.03) of shift and the likelihood of admission. Patients with an ESI Score of 4–5 saw the largest effect sizes (RR 1.62, 0.996–2.635 for last hour and RR 1.24, 0.996–1.535 for last quarter) but these were not statistically significant. Additionally, there was a trend towards increased likelihood of admission later in shift; the relative risk of admission was 1.04 in hour 6, (1.02–1.05), 1.03 in hour 7 (1.01–1.05), 1.04 in hour 8 (1.01–1.06) and 1.06 in hour 9 (1.013–1.101). Conclusions There is a small but significant association between a patient being evaluated later in an emergency physician’s shift and their likelihood of being admitted to the hospital.","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"29 1","pages":"465 - 471"},"PeriodicalIF":0.0,"publicationDate":"2019-11-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjqs-2019-009546","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45608465","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 : 2019-11-13DOI: 10.1136/bmjqs-2019-009712
Kimberly A. Fisher, T. Gallagher, Kelly M. Smith, Yanhua Zhou, S. Crawford, A. Amroze, K. Mazor
Background Many patients are reluctant to speak up about breakdowns in care, resulting in missed opportunities to respond to individual patients and improve the system. Effective approaches to encouraging patients to speak up and responding when they do are needed. Objective To identify factors which influence speaking up, and to examine the impact of apology when problems occur. Design Randomised experiment using a vignette-based questionnaire describing 3 care breakdowns (slow response to call bell, rude aide, unanswered questions). The role of the person inquiring about concerns (doctor, nurse, patient care specialist), extent of the prompt (invitation to patient to share concerns) and level of apology were varied. Setting National online survey. Participants 1188 adults aged ≥35 years were sampled from an online panel representative of the entire US population, created and maintained by GfK, an international survey research organisation; 65.5% response rate. Main outcomes and measures Affective responses to care breakdowns, intent to speak up, willingness to recommend the hospital. Results Twice as many participants receiving an in-depth prompt about care breakdowns would (probably/definitely) recommend the hospital compared with those receiving no prompt (18.4% vs 8.8% respectively (p=0.0067)). Almost three times as many participants receiving a full apology would (probably/definitely) recommend the hospital compared with those receiving no apology (34.1% vs 13.6% respectively ((p<0.0001)). Feeling upset was a strong determinant of greater intent to speak up, but a substantial number of upset participants would not ‘definitely’ speak up. A more extensive prompt did not result in greater likelihood of speaking up. The inquirer’s role influenced speaking up for two of the three breakdowns (rudeness and slow response). Conclusions Asking about possible care breakdowns in detail, and offering a full apology when breakdowns are reported substantially increases patients’ willingness to recommend the hospital.
{"title":"Communicating with patients about breakdowns in care: a national randomised vignette-based survey","authors":"Kimberly A. Fisher, T. Gallagher, Kelly M. Smith, Yanhua Zhou, S. Crawford, A. Amroze, K. Mazor","doi":"10.1136/bmjqs-2019-009712","DOIUrl":"https://doi.org/10.1136/bmjqs-2019-009712","url":null,"abstract":"Background Many patients are reluctant to speak up about breakdowns in care, resulting in missed opportunities to respond to individual patients and improve the system. Effective approaches to encouraging patients to speak up and responding when they do are needed. Objective To identify factors which influence speaking up, and to examine the impact of apology when problems occur. Design Randomised experiment using a vignette-based questionnaire describing 3 care breakdowns (slow response to call bell, rude aide, unanswered questions). The role of the person inquiring about concerns (doctor, nurse, patient care specialist), extent of the prompt (invitation to patient to share concerns) and level of apology were varied. Setting National online survey. Participants 1188 adults aged ≥35 years were sampled from an online panel representative of the entire US population, created and maintained by GfK, an international survey research organisation; 65.5% response rate. Main outcomes and measures Affective responses to care breakdowns, intent to speak up, willingness to recommend the hospital. Results Twice as many participants receiving an in-depth prompt about care breakdowns would (probably/definitely) recommend the hospital compared with those receiving no prompt (18.4% vs 8.8% respectively (p=0.0067)). Almost three times as many participants receiving a full apology would (probably/definitely) recommend the hospital compared with those receiving no apology (34.1% vs 13.6% respectively ((p<0.0001)). Feeling upset was a strong determinant of greater intent to speak up, but a substantial number of upset participants would not ‘definitely’ speak up. A more extensive prompt did not result in greater likelihood of speaking up. The inquirer’s role influenced speaking up for two of the three breakdowns (rudeness and slow response). Conclusions Asking about possible care breakdowns in detail, and offering a full apology when breakdowns are reported substantially increases patients’ willingness to recommend the hospital.","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"29 1","pages":"313 - 319"},"PeriodicalIF":0.0,"publicationDate":"2019-11-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjqs-2019-009712","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47380070","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 : 2019-11-08DOI: 10.1136/bmjqs-2018-008976
Iulian Ilies, D. Anderson, J. Salem, A. Baker, Margo Jacobsen, J. Benneyan
Objective Surgical site infections (SSIs) are common costly hospital-acquired conditions. While statistical process control (SPC) use in healthcare has increased, limited rigorous empirical research compares and optimises these methods for SSI surveillance. We sought to determine which SPC chart types and design parameters maximise the detection of clinically relevant SSI rate increases while minimising false alarms. Design Systematic retrospective data analysis and empirical optimisation. Methods We analysed 12 years of data on 13 surgical procedures from a network of 58 community hospitals. Statistically significant SSI rate increases (signals) at individual hospitals initially were identified using 50 different SPC chart variations (Shewhart or exponentially weighted moving average, 5 baseline periods, 5 baseline types). Blinded epidemiologists evaluated the clinical significance of 2709 representative signals of potential outbreaks (out of 5536 generated), rating them as requiring ‘action’ or ‘no action’. These ratings were used to identify which SPC approaches maximised sensitivity and specificity within a broader set of 3600 individual chart variations (additional baseline variations and chart types, including moving average (MA), and five control limit widths) and over 32 million dual-chart combinations based on different baseline periods, reference data (network-wide vs local hospital SSI rates), control limit widths and other calculation considerations. Results were validated with an additional year of data from the same hospital cohort. Results The optimal SPC approach to detect clinically important SSI rate increases used two simultaneous MA charts calculated using lagged rolling baseline windows and 1 SD limits. The first chart used 12-month MAs with 18-month baselines and best identified small sustained increases above network-wide SSI rates. The second chart used 6-month MAs with 3-month baselines and best detected large short-term increases above individual hospital SSI rates. This combination outperformed more commonly used charts, with high sensitivity (0.90; positive predictive value=0.56) and practical specificity (0.67; negative predictive value=0.94). Conclusions An optimised combination of two MA charts had the best performance for identifying clinically relevant small but sustained above-network SSI rates and large short-term individual hospital increases.
{"title":"Large-scale empirical optimisation of statistical control charts to detect clinically relevant increases in surgical site infection rates","authors":"Iulian Ilies, D. Anderson, J. Salem, A. Baker, Margo Jacobsen, J. Benneyan","doi":"10.1136/bmjqs-2018-008976","DOIUrl":"https://doi.org/10.1136/bmjqs-2018-008976","url":null,"abstract":"Objective Surgical site infections (SSIs) are common costly hospital-acquired conditions. While statistical process control (SPC) use in healthcare has increased, limited rigorous empirical research compares and optimises these methods for SSI surveillance. We sought to determine which SPC chart types and design parameters maximise the detection of clinically relevant SSI rate increases while minimising false alarms. Design Systematic retrospective data analysis and empirical optimisation. Methods We analysed 12 years of data on 13 surgical procedures from a network of 58 community hospitals. Statistically significant SSI rate increases (signals) at individual hospitals initially were identified using 50 different SPC chart variations (Shewhart or exponentially weighted moving average, 5 baseline periods, 5 baseline types). Blinded epidemiologists evaluated the clinical significance of 2709 representative signals of potential outbreaks (out of 5536 generated), rating them as requiring ‘action’ or ‘no action’. These ratings were used to identify which SPC approaches maximised sensitivity and specificity within a broader set of 3600 individual chart variations (additional baseline variations and chart types, including moving average (MA), and five control limit widths) and over 32 million dual-chart combinations based on different baseline periods, reference data (network-wide vs local hospital SSI rates), control limit widths and other calculation considerations. Results were validated with an additional year of data from the same hospital cohort. Results The optimal SPC approach to detect clinically important SSI rate increases used two simultaneous MA charts calculated using lagged rolling baseline windows and 1 SD limits. The first chart used 12-month MAs with 18-month baselines and best identified small sustained increases above network-wide SSI rates. The second chart used 6-month MAs with 3-month baselines and best detected large short-term increases above individual hospital SSI rates. This combination outperformed more commonly used charts, with high sensitivity (0.90; positive predictive value=0.56) and practical specificity (0.67; negative predictive value=0.94). Conclusions An optimised combination of two MA charts had the best performance for identifying clinically relevant small but sustained above-network SSI rates and large short-term individual hospital increases.","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"29 1","pages":"472 - 481"},"PeriodicalIF":0.0,"publicationDate":"2019-11-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjqs-2018-008976","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42889404","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 : 2019-11-08DOI: 10.1136/bmjqs-2019-010384
S. Zabar, K. Hanley, Jeffrey A. Wilhite, L. Altshuler, A. Kalet, C. Gillespie
Evidence suggests that the quality of a doctor’s communication, including non-verbal interaction, data-gathering skills, levels of empathy, ability to summarise and clarify, information sharing and interactive patient educational strategies, is associated with positive patient health outcomes.1–4 In this issue, Amelung et al 5 contribute to this evidence using observational data combined with in-depth qualitative analysis to explore how misalignment and misunderstanding in the doctor–patient interaction can lead to negative ‘interim’ outcomes critical to patient safety. This accumulation of evidence provides even clearer targets for the education of physicians. Our medical education research group has called for the identification and definition of Educationally Sensitive Patient Outcomes (ESPOs)—those interim outcomes that can be maximised through education and training of physicians and that are critical to ultimate health outcomes.6 7 Having the skills to ensure that a patient is fully informed and activated to act in his or her own best interest is an ESPO—an outcome directly attributable to physician practices, at least in part, that we as educators can teach and measure. Amelung and colleagues found that a failure to achieve consensus at the end of the care visit often manifested as a ‘false’ sense of concordance between physician and patient, leading to lack of patient follow-through and/or dissatisfaction.5 This finding illustrates the critical importance of patient education, an essential aspect of the Calgary/Cambridge model8 that often gets short shrift in the broader communication literature. Teach-back is the simplest and most commonly used core skill in patient education. It is effective in creating dialogue that facilitates trust, shared understanding, accurate information gathering and most importantly patient activation—patients who are empowered to and engaged in actively managing their health.6 9 Our work, using standardised performance-based assessment of medical students and residents, has consistently shown that (1) patient education …
{"title":"In the room where it happens: do physicians need feedback on their real-world communication skills?","authors":"S. Zabar, K. Hanley, Jeffrey A. Wilhite, L. Altshuler, A. Kalet, C. Gillespie","doi":"10.1136/bmjqs-2019-010384","DOIUrl":"https://doi.org/10.1136/bmjqs-2019-010384","url":null,"abstract":"Evidence suggests that the quality of a doctor’s communication, including non-verbal interaction, data-gathering skills, levels of empathy, ability to summarise and clarify, information sharing and interactive patient educational strategies, is associated with positive patient health outcomes.1–4 In this issue, Amelung et al 5 contribute to this evidence using observational data combined with in-depth qualitative analysis to explore how misalignment and misunderstanding in the doctor–patient interaction can lead to negative ‘interim’ outcomes critical to patient safety. This accumulation of evidence provides even clearer targets for the education of physicians. Our medical education research group has called for the identification and definition of Educationally Sensitive Patient Outcomes (ESPOs)—those interim outcomes that can be maximised through education and training of physicians and that are critical to ultimate health outcomes.6 7 Having the skills to ensure that a patient is fully informed and activated to act in his or her own best interest is an ESPO—an outcome directly attributable to physician practices, at least in part, that we as educators can teach and measure. Amelung and colleagues found that a failure to achieve consensus at the end of the care visit often manifested as a ‘false’ sense of concordance between physician and patient, leading to lack of patient follow-through and/or dissatisfaction.5 This finding illustrates the critical importance of patient education, an essential aspect of the Calgary/Cambridge model8 that often gets short shrift in the broader communication literature. Teach-back is the simplest and most commonly used core skill in patient education. It is effective in creating dialogue that facilitates trust, shared understanding, accurate information gathering and most importantly patient activation—patients who are empowered to and engaged in actively managing their health.6 9 Our work, using standardised performance-based assessment of medical students and residents, has consistently shown that (1) patient education …","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"29 1","pages":"182 - 184"},"PeriodicalIF":0.0,"publicationDate":"2019-11-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjqs-2019-010384","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49520916","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}
京公网安备 11010802042870号
京ICP备2023020795号-1
扫码关注我们
求助内容：
应助结果提醒方式：