BMJ Open Quality最新文献

Objectives: The Russian Federation inherited from the USSR a vast and poor healthcare system. Since 1996, the move to evidence-guided care has been initiated. The objective is to describe the last 10 years' significant progress in the development of the centralised system of guidelines and quality assurance.

Methods: For the narrative review, we searched MEDLINE and the Central Medical Library, Moscow for reports relevant to the quality of healthcare and used our collections of the grey literature for the policy review. Neither patients nor the public were involved in the design and execution of this study.

Results: Legislation 2011 recognised clinical practice guidelines (CPGs) as an important tool in developing evidence-based practice. On top of the system are regulations of a new type-orders of medical care-which prescribe the patients' track in the healthcare system, as well as the necessary staffing and equipment for participating organisations. CPGs describe the recommended interventions. Third, documents called 'standards' are derived from CPGs to calculate the average cost for costing diagnosis related groups and informing other payment decisions. At the same time, the Ministry of Health promotes the certification of medical organisations and introduces lean at the outpatient facilities. The criminal prosecution of physicians became more frequent, disturbing the profession.

Conclusions: A wide range of initiatives in quality assurance promise improvement in the quality of health care. Unfortunately, the insufficient and reduced funding, as well as solutions with unknown effectiveness, may limit prospects for improvement.

Background: Intrathecal baclofen (ITB) is a recognised treatment for severe spasticity. ITB users need to attend a specialist clinic regularly for their pump to be refilled and reprogrammed. Many patients travel significant distances and require hospital transport which is inconvenient, stressful and costly. These challenges inspired the University College London Hospitals (UCLH) spasticity team to explore establishing a community outreach clinic, staffed by the UCLH team, to provide care closer to home for this complex group.

Method: By mapping the patient cohort, using their general practitioner postcode, we identified patient clusters including those in the same long-term care facilities. In tandem, accessible healthcare locations within North Central London were identified and approached.

Results: The UCLH ITB outreach service was launched in December 2022. Over the next 15 months a total of six sites were established. In 2024, over a 12 month period, 28 outreach clinics were completed, with a total of 125 patients assessed and pumps refilled in the community. Transport and healthcare cost savings were realised, and patients reported positive, practical and emotional benefits.

Conclusion: This initiative improved patient care as well as creating a local strategy for joint working through forging new relationships and embracing shared learning.

Objectives: The integration of artificial intelligence (AI) technologies into clinical practice holds significant promise for enhancing healthcare delivery, yet substantial barriers remain to their widespread adoption. This narrative review aimed, first, to identify key facilitators and barriers to the implementation of AI technologies in patient care, and, second, to introduce a comprehensive list of evidence-based recommendations for successful AI integration in healthcare organisations.

Design: We conducted a narrative review across four electronic databases to identify peer-reviewed studies published within the last decade. Following the stepwise selection and review procedure, thematic content analysis was performed.

Sample: A total of 26 studies was included.

Results: We identified 55 dimensions of facilitators or barriers to AI implementation. These were classified according to the Systems Engineering Initiative for Patient Safety work system model. Key dimensions included efficiency, compatibility with local IT infrastructure, stakeholder involvement, transparency and clinician trust. Drawing upon the 25 most frequently reported dimensions of facilitators and barriers, we developed a set of recommendations.

Conclusions: This review consolidates the current literature on implementation challenges of AI in everyday clinical care practice to offer insights for healthcare organisations and professionals to navigate the challenges of AI implementation. Our findings provide a comprehensive overview of the sociotechnical complexities surrounding AI adoption, and our compilation of recommendations can help to guide future efforts in leveraging AI to improve clinical workflows and patient care.

Background: Our hospital is an urban academic multisite facility in Southwestern Ontario. The General Adult Ambulatory Mental Health Service (GAAMHS) delivers acute urgent and non-urgent outpatient (O-P) psychiatric care for adults 18 to 64 years. In the context of sub-optimal physician resources and the COVID-19 pandemic, there was an accumulation of 812 non-urgent referrals in March 2021. Manual review of the number of incoming referrals and processing timelines estimated a wait time of 9 to 12 months to see a psychiatrist. This quality improvement project was conducted to resolve the backlog of referrals and to reduce the wait times for the incoming non-urgent referrals.

Methods: This project was developed and implemented by the core team of a programme manager, an administrative assistant (AA) and a psychiatrist. It was achieved without any additional funding for project management. Process mapping of various components of GAAMHS was completed and an Ishikawa diagram was created to identify factors contributing to the backlog. Quality improvement change ideas were proposed and tested using Plan-Do-Study-Act cycles. The interventions included reassessment of patient needs, implementation of an electronic data capture tool and team-based model of care, refining the referral triage process and standardising the service delivery practices of psychiatrists.

Results: The 812 backlogged referrals were resolved in a median of 5.3 months. The average number of new consultations and total O-P visits per full-time psychiatrist per month was 10.3 ±3.6 and 74.5±15.9, respectively, in 2020; it increased to 17.1±7.9 and 80.8±21.6 in 2022 and 18.8±8.9 and 90.0±20.2 in 2023. The wait times for the new incoming referrals have continued to decrease with the median wait times in December 2023 being 102 days and the wait times for the 75th percentile being 145 days.

Conclusion: A combination of strategies helped resolve the backlog and reduce wait times to access acute O-P mental health.

Background: Clinical guidelines recommend a biopsychosocial approach to low back pain (LBP) management, with physiotherapists playing a key role in occupational health primary care (OHPC). However, little is known about how their clinical behaviours at the first visit align with guideline-oriented biopsychosocial principles. Therefore, we evaluated LBP management quality in OHPC by applying predefined criteria to physiotherapists' documentation.

Methods: Based on a cluster-randomised implementation study data (ISRCTN11875357) we analysed 98 electronic patient records (EPRs) documented by 28 physiotherapists across diverse OHPC units. The intervention arm had received 3-7 days of biopsychosocial training. A stratified random sample of EPRs from individuals with LBP was reviewed using a structured researcher's evaluation tool. Each item was scored dichotomously (yes/no) and evaluated against predefined quality criteria with stepwise thresholds for different work disability risk groups.

Results: Step I, multidimensional biopsychosocial assessment of LBP, was documented in fewer than half of the records (36.5% in the intervention vs 16.7% in the control arm, p=0.081). The biological dimension was well documented in both arms (100% vs 95.8%, p=0.245), while psychological (58.1% vs 25%, p=0.009) and social (54.1% vs 29.2%, p=0.038) dimensions were more frequently documented in the intervention arm.Step II quality criteria (low-risk patients) were met in 58.1% of intervention versus 4.2% of control records (p<0.001), and step III (medium-risk) in 55.4% versus 4.2% (p<0.001). No EPRs met step IV (high-risk) quality criteria.The intervention arm more often documented psychosocial assessments, risk stratification, behavioural strategies and advice to stay active. Person-centredness (ie, goals, values, resources, expectations) was rarely documented (36.5% vs 0%, p<0.001).

Conclusion: Training in guideline-oriented biopsychosocial approach was associated with more frequent documentation of behaviours aligned with high-quality LBP management. However, overall quality varied, and person-centred aspects remained underreported. Complementary implementation strategies are required to ensure consistent delivery and documentation of biopsychosocial clinical practice in OHPC.

Background: Rapid response systems (RRSs) are designed to detect and treat physiological deterioration before cardiac arrest occurs. Since 2020, Japan has seen a rapid increase in RRS adoption; however, most new team members have not received formal training in critical care. This review synthesises international and Japanese evidence supporting implementation and training for new members.

Methods: PubMed, Web of Science and Ichushi Web were searched for English or Japanese studies evaluating adult RRSs (January 2010-April 2025). We included 47 records (43 comparative and 4 systematic reviews); the national guideline was not included.

Results: Mature RRSs were associated with a 35% relative reduction in unexpected in-hospital cardiac arrests and a 12% decrease in all-cause hospital mortality. However, the evidence is not uniformly positive-systematic reviews and multicentre analyses reported no significant mortality benefit-and outcome heterogeneity limits comparability. Effective programmes share three key features: (1) single-parameter activation criteria augmented by early-warning scores; (2) tiered response models for advanced practice nurses and (3) audit-feedback cycles with dashboards. Crew resource management, in situ simulation and mindfulness-based self-leadership approaches may be associated with reduced decision latency. Emerging tools like deep-learning prediction algorithms, continuous wearable monitoring and tele-support systems may expand coverage but require governance. Common barriers include limited night-time staffing, cultural reluctance to escalate care and medicolegal ambiguity; targeted education and registry-driven feedback mitigate challenges.

Conclusions: Well-structured RRSs improve outcomes beyond traditional code-blue models. Aligning activation thresholds, multidisciplinary competencies and data-driven quality improvement cycles with local resources may help new Japanese rapid response team members develop resilient, high-performing services.

Background: Hospital standardised mortality ratio (HSMR) is a simple ratio that is plagued by sparsity, dimensionality, overdispersion, exclusions and controversy.

Objective: Describe Hospital Outcome Prediction Equation V.7 (HOPE-7) methodology.

Setting: State of Victoria (Australia), population 6.8 million.

Methods: Multiphase process: (a) principal diagnoses aggregated into 406 clinical diagnosis groups (CDGs); (b) low case fatality rate (CFR<0.02%) CDGs set aside; (c) remaining CDGs ranked according to predicted risk; (d) final generalised linear model fitted to (75%) training dataset; (e) low-risk cases reinserted and allocated zero risk; (e) model performance in validation dataset assessed for calibration (Hosmer-Lemeshow goodness-of-fit (H₁₀), Brier score, calibration plot), discrimination (area under the receiver operator characteristic (AUCROC) and area under the precision recall (AUCPRC) curves) and classification (dispersion value (φ), SD random effect (τ)). Ideal model: Brier score~0, H₁₀ p value>0.05, AUCROC>0.80, AUCPRC>0.30, φ~1 and τ~0. Classification assessed by proportion of outlier CFR reclassified as inlier HSMR.

Results: 315 hospitals treated 12.97 million adult separations and 152 (48.3%) reported 63 806 in-hospital deaths, 0.49 (95% CI 0.48 to 0.50) per 100 separations. 10 722 principal diagnoses allocated to 198 non-significant CDGs, 45 low-risk CDGs (5.05 million cases) assigned zero risk and 163 significant CDGs aggregated to 20 risk ranks. Final model (development cohort 9.73 million) included demographic variables (age, birth sex, emergency, aged-care resident, hospital transfer, relationship status), one interaction term (emergency transfer) and 20 diagnosis-risk categories. Validation metrics (cohort 3.24 million): Brier score 0.015; H₁₀ p value 0.09; AUCROC 0.90 (95% CI 0.87 to 0.92); AUCPRC 0.28 (95% CI 0.25 to 0.31); φ=4.31 and τ=0.24. Study hospitals generated 2192 hospital quarters with 2053 (95.7%) outlier CFR values, of which 1975 (96.2%) reclassified as HSMR inliers.

Conclusions: HOPE-7 is a parsimonious and pragmatic HSMR model based on administrative data common to many jurisdictions that displayed satisfactory calibration, classification and discrimination metrics and addressed frequent HSMR limitations.

Unmet social needs in paediatric patients contribute to poor health outcomes and increased healthcare utilisation. In order to identify unmet social needs, we aimed to improve social determinant of health (SDoH) screening of children admitted to the general paediatrics teams at our institution. Between September 2021 and September 2024, we conducted a quality improvement project by a multidisciplinary stakeholder team to improve identification of unmet social needs at our institution. We set two aims: (1) develop a screening process acceptable to families and (2) increase the percentage of children admitted to general paediatrics with SDoH screening documented across four domains, including food insecurity, transportation barriers, housing insecurity and financial strain from 0% to 60%. During the project period, 4229 patients were eligible for screening. Screening was found to be acceptable by a pilot group of patients and their families (n=22). Rates of screening improved from 0% to 56.7% after various interventions, including nursing education and feedback, providing meal trays from the cafeteria to families in need, and integration of the screening questionnaire into the electronic health record. Food insecurity screening positively correlated with SDoH screening across all four domains. This multidisciplinary quality improvement project implemented SDoH screening on general paediatrics which was found acceptable by patients, and rates of screening improved by addressing identified needs. Tangible resources, such as providing meal trays during the hospitalisation, were a unique aspect of this project that helped families and alleviated distress of the screeners.

Background: Adverse drug events are a significant cause of morbidity, mortality, and healthcare costs. The Best Possible Medication History (BPMH) is a systematic compilation of a patient's medications derived using at least two sources of information including a patient interview. We sought to update the BPMH interview guide developed by the Institute for Safe Medication Practices (ISMP) Canada to reflect the evolving healthcare landscape.

Objectives: We conducted a rapid scoping review to develop questions and a standardised procedure for completing a BPMH, and to understand patient, caregiver, and healthcare professional preferences or perceptions regarding the BPMH interview.

Methods: We searched Medline, the Joanna Briggs Institute Evidence-Based Practice Database, the Evidence-Based Medicine Reviews database, and grey literature. We included peer-reviewed quantitative literature (randomised/non-randomised controlled trials, observational studies), qualitative studies, systematic reviews, and grey literature (including guidelines, quality improvement initiatives, patient experiences, health technology assessments). Following pilot testing to ensure inter-rater reliability, articles were screened and data extracted in duplicate using the Covidence platform. INPLASY registration protocol INPLASY2024110033.

Results: Our search identified 5424 records, and after removing duplicates and screening, we extracted data from 95 articles. Identified studies provided additional questions and procedural steps for assessing adherence, use of non-prescription medications and substances (eg, alcohol, smoking, cannabis, recreational use), and integration of virtual care into the BPMH guide. Perceived facilitators and barriers to conducting a BPMH included clinical leadership support for trained healthcare professionals to perform a BPMH, virtual care, access to technology, and intact hearing for patients or interviewed caregivers.

Conclusions: This review identified additional questions and approaches for updating the ISMP Canada BPMH interview guide. Additional feedback from users of the existing interview guide, and patients and caregivers who have participated in a BPMH interview should be integrated through codesign into the new updated ISMP Canada BPMH guide.

Trial registration number: INPLASY2024110033.

Modern breast cancer care is multimodal and multidisciplinary, and a lack of structured communication between members in different disciplines can introduce obstacles in a patient's journey, resulting in potential treatment delays. In this study, we aimed to increase the percentage of more complex breast cancer cases reviewed pretreatment in a multidisciplinary setting in order to improve breast cancer management at our breast programme. We first started by examining cases of a lower volume complex procedure, oncoplastic breast reconstruction, and aimed to increase the number reviewed preoperatively from 0% to 50% by May 2023. We then expanded the process to include all cases categorised as 'complex', aiming to increase the number reviewed from 0% to 50% by April 2024. We prospectively collected data on all triaged cancer cases to track the number of cases reviewed, with the conclusion that both aims were achieved. Feedback surveys were distributed to conference members at three study time points to assess benefits, challenges, perceptions of the process and ideas for department-specific sustainability. Our findings emphasise that pretreatment review is effective, with 23% of cases resulting in management changes directly as a result of review.