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}
Pub Date : 2019-11-08DOI: 10.1136/bmjqs-2019-009854
O. Wegwarth, N. Pashayan
Most patients likely assume that physicians offer medical procedures backed by solid, scientific evidence that demonstrates their superiority—or at least non-inferiority—to alternative approaches.1 Doing otherwise would waste healthcare resources urgently needed elsewhere in the system and also would jeopardise patient health and safety as well as undermine patients’ trust in medicine2 and care. In some instances, however, physicians’ healthcare practices appear to act against scientific evidence.3–5 For example, evidence from two large randomised controlled trials6 7 on ovarian cancer screening’s effectiveness showed that the screening has no mortality benefits—neither cancer-specific nor overall—in average-risk women but considerable harms, including false-positive surgeries in women without ovarian cancer. Consequently, the US Preventive Services Task Force and medical associations worldwide recommend against ovarian cancer screening.8 Nevertheless, a considerable number of US gynaecologists persist in recommending the screening to average-risk women.9 To understand why physicians continue using a practice called into question by scientific evidence, we investigated gynaecologists’ reasons for or against recommending ovarian cancer screening, their assumptions about why other gynaecologists recommend it, and the association between their knowledge of basic concepts of cancer screening statistics10 and recommendation behaviour. We surveyed a national sample of US outpatient gynaecologists stratified by the distribution of gender and years in practice of gynaecologists in the American Medical Association (AMA) Masterfile (table 1). The survey (see online supplementary materials) was part of a larger …
{"title":"When evidence says no: gynaecologists’ reasons for (not) recommending ineffective ovarian cancer screening","authors":"O. Wegwarth, N. Pashayan","doi":"10.1136/bmjqs-2019-009854","DOIUrl":"https://doi.org/10.1136/bmjqs-2019-009854","url":null,"abstract":"Most patients likely assume that physicians offer medical procedures backed by solid, scientific evidence that demonstrates their superiority—or at least non-inferiority—to alternative approaches.1 Doing otherwise would waste healthcare resources urgently needed elsewhere in the system and also would jeopardise patient health and safety as well as undermine patients’ trust in medicine2 and care. In some instances, however, physicians’ healthcare practices appear to act against scientific evidence.3–5 For example, evidence from two large randomised controlled trials6 7 on ovarian cancer screening’s effectiveness showed that the screening has no mortality benefits—neither cancer-specific nor overall—in average-risk women but considerable harms, including false-positive surgeries in women without ovarian cancer. Consequently, the US Preventive Services Task Force and medical associations worldwide recommend against ovarian cancer screening.8 Nevertheless, a considerable number of US gynaecologists persist in recommending the screening to average-risk women.9 To understand why physicians continue using a practice called into question by scientific evidence, we investigated gynaecologists’ reasons for or against recommending ovarian cancer screening, their assumptions about why other gynaecologists recommend it, and the association between their knowledge of basic concepts of cancer screening statistics10 and recommendation behaviour. We surveyed a national sample of US outpatient gynaecologists stratified by the distribution of gender and years in practice of gynaecologists in the American Medical Association (AMA) Masterfile (table 1). The survey (see online supplementary materials) was part of a larger …","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"29 1","pages":"521 - 524"},"PeriodicalIF":0.0,"publicationDate":"2019-11-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjqs-2019-009854","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49302691","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-2019-009808
J. Klasen, E. Driessen, P. Teunissen, L. Lingard
Background Learning is in delicate balance with safety, as faculty supervisors try to foster trainee development while safeguarding patients. This balance is particularly challenging if trainees are allowed to experience the educational benefits of failure, acknowledged as a critical resource for developing competence and resilience. While other educational domains allow failure in service of learning, however, we do not know whether or not this strategy applies to clinical training. Methods We conducted individual interviews of clinical supervisors, asking them whether they allowed failure for educational purposes in clinical training and eliciting their experiences of this phenomenon. Participants’ accounts were descriptively analysed for recurring themes. Results Twelve women and seven men reported 48 specific examples of allowing trainee failure based on their judgement that educational value outweighed patient risk. Various kinds of failures were allowed: both during operations and technical procedures, in medication dosing, communication events, diagnostic procedures and patient management. Most participants perceived minimal consequences for patients, and many described their rescue strategies to prevent an allowed failure. Allowing failure under supervision was perceived to be important for supporting trainee development. Conclusion Clinical supervisors allow trainees to fail for educational benefit. In doing so, they attempt to balance patient safety and trainee learning. The educational strategy of allowing failure may appear alarming in the zero-error tolerant culture of healthcare with its commitment to patient safety. However, supervisors perceived this strategy to be invaluable. Viewing failure as inevitable, they wanted trainees to experience it in protected situations and to develop effective technical and emotional responses. More empirical research is required to excavate this tacit supervisory practice and support its appropriate use in workplace learning to ensure both learning and safety.
{"title":"‘Whatever you cut, I can fix it’: clinical supervisors’ interview accounts of allowing trainee failure while guarding patient safety","authors":"J. Klasen, E. Driessen, P. Teunissen, L. Lingard","doi":"10.1136/bmjqs-2019-009808","DOIUrl":"https://doi.org/10.1136/bmjqs-2019-009808","url":null,"abstract":"Background Learning is in delicate balance with safety, as faculty supervisors try to foster trainee development while safeguarding patients. This balance is particularly challenging if trainees are allowed to experience the educational benefits of failure, acknowledged as a critical resource for developing competence and resilience. While other educational domains allow failure in service of learning, however, we do not know whether or not this strategy applies to clinical training. Methods We conducted individual interviews of clinical supervisors, asking them whether they allowed failure for educational purposes in clinical training and eliciting their experiences of this phenomenon. Participants’ accounts were descriptively analysed for recurring themes. Results Twelve women and seven men reported 48 specific examples of allowing trainee failure based on their judgement that educational value outweighed patient risk. Various kinds of failures were allowed: both during operations and technical procedures, in medication dosing, communication events, diagnostic procedures and patient management. Most participants perceived minimal consequences for patients, and many described their rescue strategies to prevent an allowed failure. Allowing failure under supervision was perceived to be important for supporting trainee development. Conclusion Clinical supervisors allow trainees to fail for educational benefit. In doing so, they attempt to balance patient safety and trainee learning. The educational strategy of allowing failure may appear alarming in the zero-error tolerant culture of healthcare with its commitment to patient safety. However, supervisors perceived this strategy to be invaluable. Viewing failure as inevitable, they wanted trainees to experience it in protected situations and to develop effective technical and emotional responses. More empirical research is required to excavate this tacit supervisory practice and support its appropriate use in workplace learning to ensure both learning and safety.","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"29 1","pages":"727 - 734"},"PeriodicalIF":0.0,"publicationDate":"2019-11-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjqs-2019-009808","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48039914","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 : 2019-11-06DOI: 10.1136/bmjqs-2019-010208
Anupama Goyal, Hanna Glanzman, M. Quinn, Komalpreet Tur, Sweta Singh, S. Winter, Ashley Snyder, V. Chopra
Objective To understand patient and nurse views on usability, design, content, barriers and facilitators of hospital whiteboard utilisation in patient rooms. Design Multimethods study. Setting Adult medical-surgical units at a quaternary care academic centre. Participants Four hundred and thirty-eight adult patients admitted to inpatient units participated in bedside surveys. Two focus groups with a total of 13 nurses responsible for updating and maintaining the whiteboards were conducted. Results Most survey respondents were male (55%), ≥51 years of age (69%) and admitted to the hospital ≤4 times in the past 12 months (90%). Over 95% of patients found the whiteboard helpful and 92% read the information on the whiteboard frequently. Patients stated that nurses, not doctors, were the most frequent user of whiteboards (93% vs 9.4%, p<0.001, respectively). Patients indicated that the name of the team members (95%), current date (87%), upcoming tests/procedures (80%) and goals of care (63%) were most useful. While 60% of patients were aware that they could use the whiteboard for questions/comments for providers, those with ≥5 admissions in the past 12 months were significantly more likely to be aware of this aspect (p<0.001). In focus groups, nurses reported they maintained the content on the boards and cited lack of access to clinical information and limited use by doctors as barriers. Nurses suggested creating a curriculum to orient patients to whiteboards on admission, and educational programmes for physicians to increase whiteboard utilisation. Conclusion Bedside whiteboards are highly prevalent in hospitals. Orienting patients and their families to their purpose, encouraging daily use of the medium and nurse–physician engagement around this tool may help facilitate communication and information sharing.
{"title":"Do bedside whiteboards enhance communication in hospitals? An exploratory multimethod study of patient and nurse perspectives","authors":"Anupama Goyal, Hanna Glanzman, M. Quinn, Komalpreet Tur, Sweta Singh, S. Winter, Ashley Snyder, V. Chopra","doi":"10.1136/bmjqs-2019-010208","DOIUrl":"https://doi.org/10.1136/bmjqs-2019-010208","url":null,"abstract":"Objective To understand patient and nurse views on usability, design, content, barriers and facilitators of hospital whiteboard utilisation in patient rooms. Design Multimethods study. Setting Adult medical-surgical units at a quaternary care academic centre. Participants Four hundred and thirty-eight adult patients admitted to inpatient units participated in bedside surveys. Two focus groups with a total of 13 nurses responsible for updating and maintaining the whiteboards were conducted. Results Most survey respondents were male (55%), ≥51 years of age (69%) and admitted to the hospital ≤4 times in the past 12 months (90%). Over 95% of patients found the whiteboard helpful and 92% read the information on the whiteboard frequently. Patients stated that nurses, not doctors, were the most frequent user of whiteboards (93% vs 9.4%, p<0.001, respectively). Patients indicated that the name of the team members (95%), current date (87%), upcoming tests/procedures (80%) and goals of care (63%) were most useful. While 60% of patients were aware that they could use the whiteboard for questions/comments for providers, those with ≥5 admissions in the past 12 months were significantly more likely to be aware of this aspect (p<0.001). In focus groups, nurses reported they maintained the content on the boards and cited lack of access to clinical information and limited use by doctors as barriers. Nurses suggested creating a curriculum to orient patients to whiteboards on admission, and educational programmes for physicians to increase whiteboard utilisation. Conclusion Bedside whiteboards are highly prevalent in hospitals. Orienting patients and their families to their purpose, encouraging daily use of the medium and nurse–physician engagement around this tool may help facilitate communication and information sharing.","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":" ","pages":"1 - 2"},"PeriodicalIF":0.0,"publicationDate":"2019-11-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjqs-2019-010208","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47370571","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 : 2019-11-04DOI: 10.1136/bmjqs-2019-009729
K. Chaiyachati, S. Kangovi
The study by Naouri et al in this issue of BMJ Quality and Safety describes an ambitious, 24-hour cross-sectional physician survey and chart review of all the emergency departments (ED) in France to characterise the ‘inappropriateness’ of ED visits.1 The determination of inappropriateness for any given visit was based on (A) physician opinion, (B) physician determination of ambulatory care sensitivity, or (C) resource utilisation. Based on these measures, the authors concluded that between 13% and 27% of ED visits were inappropriate. Further, patients with supplemental public insurance (a proxy for the socioeconomic disadvantaged in France) were 15%–33% more likely to use the ED inappropriately. Naouri’s study is part of a growing body of literature that characterises ED use as inappropriate, avoidable, ambulatory care sensitive or preventable.2 3 While there is precedent and potential merit in classifying healthcare services based on their value,4 this trend raises some concerns—as the authors rightly conclude—when describing the use of EDs by disadvantaged populations. Determining the patient’s ED visit as inappropriate, without consideration of broader contextual factors, is an example of attribution bias: the tendency for people to overemphasise individual and personality-based explanations for behaviours while underemphasising situational explanations.5 We may blame patients for visiting the ED inappropriately, when in reality, healthcare systems are often designed to funnel patients towards …
{"title":"Inappropriate ED visits: patient responsibility or an attribution bias?","authors":"K. Chaiyachati, S. Kangovi","doi":"10.1136/bmjqs-2019-009729","DOIUrl":"https://doi.org/10.1136/bmjqs-2019-009729","url":null,"abstract":"The study by Naouri et al in this issue of BMJ Quality and Safety describes an ambitious, 24-hour cross-sectional physician survey and chart review of all the emergency departments (ED) in France to characterise the ‘inappropriateness’ of ED visits.1 The determination of inappropriateness for any given visit was based on (A) physician opinion, (B) physician determination of ambulatory care sensitivity, or (C) resource utilisation. Based on these measures, the authors concluded that between 13% and 27% of ED visits were inappropriate. Further, patients with supplemental public insurance (a proxy for the socioeconomic disadvantaged in France) were 15%–33% more likely to use the ED inappropriately.\u0000\u0000Naouri’s study is part of a growing body of literature that characterises ED use as inappropriate, avoidable, ambulatory care sensitive or preventable.2 3 While there is precedent and potential merit in classifying healthcare services based on their value,4 this trend raises some concerns—as the authors rightly conclude—when describing the use of EDs by disadvantaged populations.\u0000\u0000Determining the patient’s ED visit as inappropriate, without consideration of broader contextual factors, is an example of attribution bias: the tendency for people to overemphasise individual and personality-based explanations for behaviours while underemphasising situational explanations.5 We may blame patients for visiting the ED inappropriately, when in reality, healthcare systems are often designed to funnel patients towards …","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"29 1","pages":"441 - 442"},"PeriodicalIF":0.0,"publicationDate":"2019-11-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjqs-2019-009729","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47613839","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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