BMJ Open Quality最新文献

Objectives: Quality improvement (QI) is critical in facilitating advancements in patient outcomes, system efficiency and professional growth. This paper aimed to elucidate the underlying rationale and framework guiding JurongHealth Campus (JHC), a nascent Regional Health System, in developing its QI capacity and capability at all levels of the organisation.

Methods: An exhaustive analysis of high-performance management systems and effective improvement frameworks was conducted, and the principles were customised to suit the local context.A three-phased approach was applied: (1) developing the JHC QI framework; (2) building capacity through a dosing approach and (3) building capability through QI projects and initiatives using the model for improvement (MFI). Three components of the RE-AIM implementation strategy were assessed: (1) Reach-overall percentage of staff trained; (2) Effectiveness-outcomes from organisation-wide improvement projects and (3) Adoption-number of QI projects collated and presented.

Results: The percentage of staff trained in QI increased from 11.3% to 22.0% between January 2020 and March 2024, with over 350 projects documented in the central repository. The effectiveness of the MFI was demonstrated by improving inpatient discharges before 12pm performance from 21.52% to 25.84% and reducing the 30-day inpatient readmission rate from 13.92% to 12.96%.

Conclusion: Four critical factors for an effective QI framework were identified: (1) establishing a common language for improvement; (2) defining distinct roles and skills for improvement at different levels of the organisation; (3) adopting a dosing approach to QI training according to the defined roles and skills and (4) building a critical mass of committed staff trained in QI practice. The pragmatic approach to developing QI capability is both scalable and applicable to emerging healthcare institutions.

Background: Discussions about care decisions, including code status documentation and advance care planning, are crucial components of patient-centred care. However, due to numerous barriers, these discussions are often avoided by both physicians and patients. As a result, these discussions often take place at the emergency department (ED). We aimed to improve the quality of care decision conversations in the internal medicine ED.

Methods: This pre-post intervention study was conducted at the internal medicine ED of a tertiary hospital in the Netherlands. Two interventions were implemented simultaneously: physician training and patient education. Physician training included an e-learning module and simulated patient sessions. Patients received a leaflet providing information about care decisions. Primary outcome was patient satisfaction with the care decision discussions, assessed using the Quality of Communication questionnaire. Secondary outcomes included the percentage of patients recalling a care decision discussion, initiator of the discussion, leaflet recall, leaflet evaluation, prior care decision discussions and perceived appropriate timing for discussions.

Results: 333 patients participated, 149 before and 184 after the interventions. Postintervention, there were significant improvements in patient-reported quality of care decision communication (p<0.001) and more patients recalled having care decision discussions (63.7% vs 45.9%, p=0.001). However, only 12% of patients recalled receiving the leaflet.

Conclusions: Implementation of physician training and patient education significantly improved the quality of care decision conversations in our internal medicine ED. Despite low leaflet recall, the interventions demonstrated a notable impact on patient satisfaction with care decision discussions. Future research could explore alternative patient education methods and involve other healthcare professionals in initiating discussions. These findings underscore the importance of ongoing efforts to enhance communication in healthcare settings, particularly in emergency care.

Introduction: The transfer of patients between hospitals, known as interhospital transfer (IHT), is associated with higher rates of mortality, longer lengths of stay and greater resource utilisation compared with admissions from the emergency department. To characterise the IHT process and identify key barriers and facilitators to IHT care, we examined the experiences of physician and advanced practice provider (APP) hospital medicine clinicians who care for IHT patients transferred to their facility.

Methods: Qualitative descriptive study using semistructured interviews with adult medicine hospitalists from an academic acute care hospital that accepts approximately 4000 IHT patients annually. A combined inductive and deductive coding approach guided thematic analysis.

Results: We interviewed 30 hospitalists with a mean of 5.7 years of experience. Two-thirds of interviewees were physicians and one-third were APPs.They described IHTs as challenging when (1) exchanged information was incomplete, inaccurate, extraneous, and/or untimely, (2) uncertainty impacted care responsibilities and (3) healthcare team members and patients had differing care expectations. As a result, participants described patient safety issues such as delays in care and inappropriate triage of patients due to incomplete communication of clinical status changes.Recommended improvement strategies include (1) dedicated individuals performing IHT tasks to improve consistency of information exchanged and relationships with transferring clinicians, (2) standardised scripts and documentation, (3) bidirectional communication, (4) interdisciplinary training and (5) shared understanding of care needs and expectations.

Conclusions: Physicians and APP hospital medicine clinicians at an accepting hospital found information exchange, care responsibilities and expectation management challenging in IHT. In turn, hospitalists perceived a negative impact on IHT patient care and safety. Highly reliable and timely information transfer, standardisation of IHT processes and clear interdisciplinary communication may facilitate improved care for IHT patients.

Introduction: The management of healthcare waste is a crucial issue for public health and the environment. To minimise risks, it is essential to ensure that the management of healthcare waste is meticulously applied. Additionally, among the evaluation methods adopted by the hospital hygiene department to monitor the degree of compliance. The aim of this study was to assess the degree of compliance with healthcare waste management before and after a training and support programme.

Methods: This is a pre-experimental study based on two audits of healthcare waste management at Farhat Hached University Hospital in Sousse, Tunisia. All medical, surgical and laboratory departments were included. The first audit was carried out, followed by training of the responsible staff, which was carried out according to a cycle of training and coaching hygiene technicians, and finally, a second audit was conducted. The compliance rate is compared between 2021 and 2022.

Results: When comparing the averages of the compliance percentages for the four audit areas, there was a statistically significant improvement between the years 2021 and 2022 in the availability of equipment and consumables required for the management of infectious and sharp healthcare waste (p=0.029) as well as intramural transport (p=0.014).

Conclusion: The study highlights the central role of effective waste management training in promoting compliance, awareness and responsible practices. Constant attention and training are essential to maintain progress at Farhat Hached University Hospital. This helps create safer care environments, better public health outcomes and long-term sustainability.

Introduction: Service delivery networks, also called healthcare providers networks (HCPNs) have been used to address health inequities and promote universal healthcare (UHC). This study described the effect of instituting a mixed HCPN (partnership of public health facilities with a private pharmacy) on the provision of medications in the rural primary care pilot site of the Philippine Primary Care Studies (PPCS).

Methods: This is a case study of the mixed HCPN in the PPCS rural site. A mixed HCPN involving one private pharmacy was instituted to increase the supply of drugs. The total number of medications prescribed per month from April 2019 to October 2021, and the number of medications dispensed from the public sector (rural health unit or RHU) and from the partner private pharmacy in the same time period were obtained.

Results: Of the 101 031 medications prescribed in the first year (April 2019 to March 2020), 21.7% were dispensed at the RHU and 66.7% were dispensed in the partner private pharmacy. The remaining 11.5% were unrendered or dispensed in other private pharmacies. Of the 35 408 medications prescribed in the second year (April 2020 to March 2021), 5.6% were dispensed at the RHU and 32.2% were dispensed at the partner private pharmacy. Majority (62.1%) were unrendered or dispensed in other private pharmacies. From April to October 2021, of the 6448 medications prescribed, 2.3% were dispensed at the RHU, and 47.3% were dispensed at the partner private pharmacy. Majority (50.3%) were unrendered or dispensed in other private pharmacies.

Conclusion: Creation of a mixed HCPN in a rural primary care site augmented access to essential medications. The mixed HCPN model in the study showed potential in strengthening access to consultations and medications in a rural community. Improving essential primary care services can facilitate implementation of UHC in the Philippines.

Background: Admission notes are an important aspect of clinical practice and a vital means of communication among healthcare professionals. Incomplete or poor clinical documentation on admission can lead to delayed surgery.

Patients and methods: A retrospective analysis of 20 consecutive admission notes to our department was compared against the Royal College of Surgeons standards (GSP 2014). A new admission proforma was designed, and after the introductory period, two further retrospective cycles were performed.

Results: In total, 60 admission notes were analysed. Following the introduction of the proforma, there was an overall improvement in the documentation of the quality and quantity of notes studied.

Conclusion: Our study demonstrated that a well-structured admission protocol can improve the overall quality of admission notes.

Background: Over 95% of penicillin allergy labels are inaccurate and may be addressed in low-risk patients using direct oral penicillin challenge (DPC). This study explored the behaviour, attitudes and acceptability of patients, healthcare professionals (HCPs) and managers of using DPC in low-risk patients.

Methods: Mixed-method, investigation involving patient interviews and staff focus groups at three NHS acute hospitals. Transcripts were coded using inductive and deductive thematic analysis informed by the Theoretical Domains Framework.

Findings: Analysis of 43 patient interviews and three focus groups (28 HCPs: clinicians and managers) highlighted themes of 'knowledge', 'beliefs about capabilities and consequences', 'environmental context', 'resources', 'social influences', 'professional role and identity', 'behavioural regulation and reinforcement' and a cross-cutting theme of digital systems. Overall, study participants supported the DPC intervention. Patients expressed reassurance about being in a monitored, hospital setting. HCPs acknowledged the need for robust governance structures for ensuring clarity of roles and responsibilities and confidence.

Conclusion: There were high levels of acceptability among patients and HCPs. HCPs recognised the importance of DPC. Complexities of penicillin allergy (de)labelling were highlighted, and issues of knowledge, risk, governance and workforce were identified as key determinants. These should be considered in future planning and adoption strategies for DPC.

Postpartum maternal sepsis is a leading cause of maternal mortality and morbidity. A single dose of prophylactic antibiotics following assisted vaginal births has been shown to significantly reduce postpartum maternal infection in a landmark multicentre randomised controlled trial, which led to its national recommendation. This project aimed to improve the local implementation of prophylactic antibiotics following assisted vaginal births to reduce postnatal maternal infections.Using a prospectively collated birth register, data were collected retrospectively on prophylactic antibiotics administration and postnatal maternal infection rates after assisted vaginal births at the Sandwell and West Birmingham Hospitals National Health Service Trust in North-West Birmingham of the UK. The data were collected from routinely used electronic health records over three audit cycles (n=287) between 2020 and 2023.A mixed-method approach was used to improve the use of prophylactic antibiotics: (1) evidence-based journal clubs targeting doctors in training, (2) presentations of results after all three audit cycles at our and (3) expedited a formal change of local guidelines to support prophylactic antibiotics use.Prophylactic antibiotic administration increased from 13.2% (December 2021) to 90.7% (July 2023), associated with a reduction in maternal infection rates (18.2% when prophylaxis was given vs 22.2% when no prophylaxis was given). However, we observed a gradual increase in the overall postnatal maternal infection rates during the project period.Our repeat audit identified prophylactic antibiotics were regularly omitted after deliveries in labour ward rooms (59.3%), compared with 100% of those achieved in theatre. After further interventions, prophylactic antibiotics administration rates were comparable between these clinical areas (>90%) in 2023.Together, we have demonstrated a simple set of interventions that induced sustainable changes in practice. Further evaluation of other modifiable risk factors and infection rates following all deliveries is warranted in view of the gradual increase in the overall postnatal maternal infection rates.

Objective: Learning from adverse outcomes in health and social care is critical to advancing a culture of patient safety and reducing the likelihood of future preventable harm to service users. This review aims to present an overview of all clinical claims finalised in one calendar year involving publicly funded health and social care providers in Ireland.

Design: This is a retrospective observational study. The Clinical Risk Unit (CRU) of the State Claims Agency identified all service-user clinical claims finalised between 1 January 2017 and 31 December 2017 from Ireland's National Incident Management System (n=713). Claims that had incurred financial damages were considered for further analysis (n=356). 202 claims underwent an in-depth qualitative review. Of these, 57 related to maternity and gynaecology, 64 to surgery, 46 to medicine, 20 to community health and social care and 15 related to children's healthcare.

Results: The services of surgery and medicine ranked first and second, respectively, in terms of a number of claims. Claims in maternity services, despite ranking third in terms of claims numbers, resulted in the highest claims costs. Catastrophic injuries in babies resulting in cerebral palsy or other brain injury accounted for the majority of this cost.Diagnostic errors and inadequate or substandard communication, either with service users and/or interprofessional communication with colleagues, emerged as common issues across all clinical areas analysed. Quantitative analysis of contributory factors demonstrated that the complexity and seriousness of the service user's condition was a significant contributory factor in the occurrence of incidents leading to claims.

Conclusion: This national report identifies common issues resulting in claims. Targeting these issues could mitigate patient safety risks and reduce the cost of claims.