BMJ Open Quality最新文献

Background: Reducing the prevalence of hospital-acquired complications (HACs) is paramount for both patient safety and hospital financial performance because of its impact on patient's recovery and health service delivery by diverting resources away from other core patient care activities. While numerous reports are available in the literature for projects that successfully reduce specific HAC, questions remain about the sustainability of this isolated approach and there may be benefits for more wholistic programmes that aim to align prevention strategies across a hospital. This study describes such a programme that uses evidence and theories in the literature to achieve and sustain a reduction in HACs in an Australian local health service between 2019 and 2022.

Methods: An organisation-wide HACs Reduction Programme underpinned by a 3-pillar strategic framework (complete documentation, accurate coding, clinical effectiveness) and a 5-year roadmap to clinical excellence was developed. Priorities were identified through Pareto analysis and aligned at organisational, service and specialty levels. The Institute for Healthcare Improvement (IHI) 90-day cycle was modified to implement contextualised evidence-based interventions supported by the application of the Awareness, Desire, Knowledge, Ability and Reinforcement change management model. Under this wholistic umbrella, specific projects were data-driven, evidence-based and outcome-oriented to promote clinical engagement and a continuous improvement culture.

Results: Overall mean HAC rate per 10 000 episodes of care decreased from a baseline of 459.5 across 2017 and 2018 to 363.1 in 2019 and remained lower through to the end of 2022 indicating sustained improvement in performance.

Conclusion: A wholistic approach to reduce HACs increased the likelihood of multidisciplinary integration for contextualised strategies and interventions. Improvement work, particularly in relation to patient outcomes, is a dynamic process that needs to be intentionally cultivated, targeted and coordinated. The modified IHI 90-day cycle proved to be an effective tool for implementation that contributed to sustained change.

Background: An advance care plan outlines a patient's wishes regarding medical treatment or goals of care in the case that they become unable to communicate or to make decisions. An advance care directive (ACD) is an advance care plan that has been formally recorded and has legal status. Despite ACDs playing an important role in person-centred end-of-life care, an earlier retrospective medical records audit demonstrated that only 11% (58/531) of people who died due to a terminal illness had an ACD.The aim of this project was to increase the proportion of patients with a terminal illness completing an ACD. A secondary outcome was to measure the impact of ACDs on hospital and intensive care unit (ICU) admissions in the last 6 months of life.This multifaceted project comprised (1) education for health professionals and the public; (2) individual support for patients on request; (3) development of online resources for health professionals and the general public; and (4) monthly team meetings.

Method: The proportion of ACDs completed and hospital and ICU admissions during the last 6 months of life, were extracted via medical record audits.Written consent was required for patients to participate, including being contacted by the project team and accessing their medical records.

Results: 112 patients consented to participate in the project and 109 (97%) completed an ACD. There was no reduction in the average number of hospital admissions, while ICU admissions reduced from 14% (n=74) to 0%.

Conclusion: The targeted, multifaceted approach to education and support for completion of ACDs, resulted in a significant increase in ACD completion and a major reduction in ICU admissions.

Background: Sepsis is a global healthcare challenge and a leading cause of morbidity and mortality. In the USA, the Centers for Medicare & Medicaid Services has integrated the Severe Sepsis and Septic Shock Management Bundle (SEP-1) into their Core Quality Measures, which has been linked to lower mortality rates. However, SEP-1's multiple bundle elements present compliance challenges without comprehensive education and a collaborative approach involving nurses and providers (attending physicians, resident physicians, nurse practitioners and physician assistants).

Methods: We developed a virtual longitudinal, case-based curriculum using Kern's six-step approach to curriculum development and evaluated its effectiveness using the Kirkpatrick model. The curriculum was distributed hospital-wide over a 32-month period.

Results: A total of 3616 responses were received for the Sepsis Case-Based Curriculum modules, with 47% from nurses and 53% from providers. Responses were distributed similarly among medical and surgical specialties, as well as intensive care units. Nurses' responses were 56% correct, and providers' responses were 51% correct. Most respondents expressed a likelihood of applying the learning to their practice and reported increased knowledge of sepsis. Themes from participant feedback indicated that they found the activity informative and applicable to real-world cases. Additionally, the hospital's SEP-1 bundle compliance improved from 71% (Q1 2021) to 80% (Q3 2023) during the study period.

Conclusion: Meeting SEP-1 bundle elements requires a team-based approach involving providers and nurses. Given the busy hospital environment and diverse care providers, a longitudinal, engaging and concise educational curriculum related to real-life scenarios can enhance sepsis and SEP-1 education.

Introduction: Breast pain is not typically a symptom of breast cancer, yet nationally 20% of 2-week wait (2WW) breast referrals are breast pain alone. The East Midlands Breast Pain Pathway improves patient experience and frees capacity in secondary care diagnostic breast clinics, managing women with breast pain only in a community setting. We report the results of implementation of community breast pain clinics (CBPCs) at sites in Derbyshire (catchment population ~1 million), with 12 months follow-up data.

Results: 1036 patients were seen at CBPCs between June 2021 and February 2023. The median patient age was 49 (range 16-88) years. 993 patients (95.8%) were discharged from the clinic with breast pain management advice. 43 (4.2%) patients were referred for further assessment at a 2WW breast diagnostic clinic. Objective family history risk assessment identified 124 patients (12.3%) above population risk of breast cancer, who were offered referral to familial cancer services for ongoing management.

Discussion: Seven patients were diagnosed with breast cancer at or within 12 months of CBPC attendance. Five patients were diagnosed through attending the CBPC, one patient was subsequently referred to 2WW clinic with a new symptom and had a mammographically occult tumour and one was diagnosed following a subsequent routine breast screening invitation. Two of the five patients had a personal history of breast cancer which was a stated exclusion criterion for the CBPC. Breast cancer incidence in women with breast pain only and fulfilling CBPC referral criteria was 4.8/1000, confirming that this population is at low risk of developing breast cancer.Patient service satisfaction was high with 99% (n=1022) 'extremely likely or likely' to recommend the service.

Conclusion: The results confirm the pathway is the first to demonstrate women can be safely managed with breast pain alone in a community setting with high levels of patient satisfaction.

Objectives: Regular hygiene trainings are an important way to refresh and improve knowledge about hygiene measures and the prevention of healthcare-associated infections. We aimed to develop an e-learning course to allow healthcare workers (HCWs) to learn these contents through a self-paced online format.

Methods: We developed an interactive hygiene training for HCWs of a tertiary care hospital using different content types of the HTML-5 package (H5P) plugin embedded into a Moodle-based learning management system. We evaluated the course using a short online questionnaire.

Results: We present various suitable topics for online hygiene trainings as well as their implementation in an e-learning course. Examples include content on hand hygiene indications and techniques, information on multidrug-resistant organisms and other current topics in infection control. HCWs reported high overall satisfaction, perceived increase in knowledge, practical relevance as well as good usability and comprehensibility.

Discussion: Currently available commercial and non-commercial hygiene trainings present a number of specific advantages but also drawbacks. The presented approach combines the advantages of both approaches. The majority of the presented content can be readily adapted to suit various hospitals and care facilities or serve as inspiration for creating similar courses while remaining cost-effective.

Conclusion: H5P course presentations are a low-threshold, cost-effective way to implement digital hygiene trainings in a wide variety of clinical settings.

Adults receiving centre-based haemodialysis (HD) have low levels of patient activation which are associated with poorer outcomes. Shared haemodialysis care (SHC) describes an intervention whereby individuals are supported to undertake elements of their treatment to improve their activation levels and promote better self-care. This project aimed to increase the proportion of those performing SHC in seven HD centres within the Oxford Kidney Unit's catchment area. Sequential Plan-Do-Study-Act (PDSA) cycles effected change first in two central HD centres, in cycles 1 and 2, before rolling out to five satellite HD centres, in cycles 3 and 4. Cycle 1 explored and transformed staff perceptions regarding SHC using a questionnaire and teaching sessions while in cycle 2, staff partnered with patients to develop leaflets and noticeboards to improve awareness and participation. These interventions were then rolled out to the remaining HD centres in PDSA cycles 3 and 4. Other interventions included: Enrolling staff and patients in virtual training courses; designating SHC 'Champions'; engagement with a national SHC forum; and changes to the electronic patient record to enable the monitoring of patient SHC opportunity and to promote sustainable change. Outcome measurement data on the number of patients performing SHC and the number at different defined stages of SHC competency were captured monthly. In April 2022, only 4% (19/483) of those receiving centre-based HD performed any aspect of SHC. By the end of the project in December 2023, this had increased to 43% (220/511). There was a significant and sustained growth in the stage of patient SHC competency as well as the number of patients performing SHC in each HD centre. The project demonstrated that it is possible to implement, scale-up and maintain a multisite SHC programme even with little baseline staff and patient SHC experience.

Purpose: Climate change is now the greatest threat to human survival. The healthcare system contributes significantly to global pollution and greenhouse gas emissions. Individual practitioners play an important role in helping to reduce these impacts in day-to-day practice. Deimplementation of unnecessary processes and products, such as exam table paper, in medical offices is one simple approach to incorporating principles of planetary health into practice. All quality improvement (QI) projects must start to consider environmental impacts to fully evaluate change ideas.

Methods: We designed a single Plan-Do-Study-Act cycle using the Institute for Health Improvement Model for Improvement. We removed the exam table paper from our primary care office and measured changes in staff time, laundry, financial costs, paper use and carbon dioxide (CO₂) emissions.

Results: Eliminating exam table paper in our clinic resulted in modest annual cost savings of $C718 and improved staff efficiency and motivation to introduce other green office practices. In our clinic alone, this change will save 8.2 km of exam table paper, 10 trees and 148 kg of CO2e (equivalent to driving 1233 km) every year. There were no negative consequences or feedback.

Conclusions: This simple QI project demonstrates the feasibility of implementing a small change in a primary care clinic that can improve environmental sustainability with multiple co-benefits. If all family physicians in Canada eliminated exam table paper in their offices, it would result in savings of approximately 95 940 km of paper, 121 680 trees, $C8 400 600 and 3054 T CO₂ emissions, equivalent to driving around the world 360 times.

Resilience in nursing medication administration practice: a systematic review with narrative synthesis.

Objective: Little is known about how nurses adapt medication administration practices to preserve safety. The capacity to adapt and respond before harm occurs has been labelled 'resilience'. Current evidence examining medication safety largely focuses on errors and what goes wrong. This review aimed to synthesise evidence for the application of resilience principles and practices in nursing medication administration.

Design: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guided the review, which was registered with PROSPERO.

Data sources: MEDLINE, EMBASE, PsychINFO and CINAHL databases were searched from 14 August 2020 to 1 January 2021 for English-language studies.

Methods: A systematic review of empirical studies of any design relating to resilience and safety in nursing medication administration in the inpatient setting was conducted. Methodological quality was appraised using the Mixed Methods Appraisal Tool. Data were synthesised thematically.

Results: Thirty-two studies with a range of methodologies of mostly good quality met the inclusion criteria. Eleven interventional studies included two that evaluated the effectiveness of education interventions and nine exploratory studies with outcomes showing the impact of an intervention designed or examined to build resilience. Twenty-one non-interventional studies showed how resilience principles are put into practice. Only three studies explicitly named the concept of resilience. Resilient medication administration strategies result from five triggers.

Conclusions: Nurses' resilience practices were found to be responses to identified trigers that threaten safety and productivity. These were often short term, real-time proactive adaptations to preserve safety, compensating for and responding to complexities in the modern healthcare setting.

Prospero registration number: CRD42018087928.

Background: Cultural, religious and spiritual (CRS) needs become increasingly important to individuals as they approach the end of life. CRS needs often remain unmet for patients dying in an acute hospital setting. The 'Just Ask' quality improvement project was designed to explore barriers to routine assessment of CRS needs, and to design resources and intervention to support staff to increase assessment of these needs.

Aims: The primary aim of the project was to increase the number of patients receiving end-of-life care in hospital with a documented CRS needs assessment from 43% (based on audit data) to greater than 50% over the 9-month project.

Design: The study occurred in two phases.The scoping phase evaluated the current service, enablers, barriers and confidence in assessing CRS needs using an online staff survey and four staff focus groups. Results were analysed using qualitative content analysis, descriptive statistics and thematic analysis and informed the intervention phase.The intervention phase consisted of two Plan-Do-Study-Act (PDSA) cycles focusing on resource visibility/accessibility, organisational value placed on CRS needs assessment and staff education.Outcomes (documented CRS needs assessment) were measured by case notes review over 3 month periods - 1 year prior to and after the PDSA cycles. The impact of education interventions on staff confidence relating to CRS needs assessment were measured via an anonymous questionnaire.

Outcome: Documented assessment of CRS needs increased from 43% to 57% in patients receiving end-of-life care in our hospital. Staff confidence scores in CRS needs assessment increased by 46-87%.

Conclusions: The factors that influence the addressing of CRS needs in a busy hospital are multifactorial. Organisational culture, appropriate resource provision and visibility, and education are essential factors in supporting staff to recognise, understand and engage with CRS needs assessment in patients receiving end-of-life care in hospital.

Care-planning is vital to the delivery of timely, person-centred, safe and effective care. Despite the understanding of the benefits of person-centred care-plan in both services, occupational therapists (OTs) within our forensic and rehabilitation services had difficulties in inputting into patient care-plan an efficient and person-centred manner.The OT team developed a Quality Improvement (QI) project to improve the efficiency of the OT process to create more time for care-planning and improve person-centredness of OT input into care-plans to 82% in the forensic services and rehabilitation services by December 2023.The results indicated an increase in the person-centredness of care-plans from 63.64% to 84.34% within the rehabilitation service and an increase from 65.15% to 95.45% in the forensic service. This project used feedback from patients to develop our input into care-plans. The project also increased the efficiency of the admission process and released time to be spent on care-planning and treatment.We improved the quality of our input to care-plans in a sustainable way by using the Royal Academy of Improvement sustainability measure and taking actions which included training our band 6 and 7 OTs to complete their monthly audit and reporting this as part of the head of nursing report for assurance in our monthly Clinical and Operational Assurance Team meetings. These actions ensured that our project fitted with the organisation's strategic aims and values. We also used low carbon alternatives by holding most of our improvement meetings online and eliminating the use of paper.Lastly, we improved the generalisability of this project by using the Goal Directed Care Plan audit tool, which is a well-researched, evidence-based tool created by service-users, carers and members of staff. This was used to train members of staff and develop an example of a person-centred input into care-plans to improve their practice.