BMJ Quality & Safety最新文献

Background: The 2017 Paediatric Research in Emergency Departments International Collaborative (PREDICT) Bronchiolitis Knowledge Translation (KT) Study, a cluster randomised trial in 26 Australasian hospitals, found targeted interventions provided over one bronchiolitis season effectively de-implemented five low-value practices (salbutamol, glucocorticoids, chest radiography, antibiotics and epinephrine) by 14.1% (adjusted risk difference, 95% CI 6.5% to 21.7%; p<0.001). A 2-year follow-up study found de-implementation was sustained. This process evaluation aimed to identify factors that influenced sustainability of de-implementation of these five low-value practices in PREDICT Bronchiolitis KT Study intervention hospitals and examine fidelity and/or adaptation of the targeted interventions over 4 years post intervention delivery (sustainment).

Methods: Semistructured qualitative interviews were conducted, over 2021 and 2022, with a purposive sample of emergency department (ED) and paediatric inpatient clinicians. Data were analysed thematically into facilitators and barriers using the Consolidated Framework for Sustainability Constructs in Healthcare (CFSCH). The Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies was used to explore fidelity and adaptation.

Results: 50 clinicians (nurses: n=26; doctors: n=24) from 12 intervention hospitals were interviewed. Eight themes were identified and mapped to three CFSCH domains: (1) organisational setting; (2) initiative design and delivery and (3) people involved. Facilitators were a culture of evidence-based practice, ongoing multimodal education, strong clinical leadership as unofficial champions and the previous effectiveness of the PREDICT Bronchiolitis KT Study interventions. Barriers were lack of paediatric trained ED staff, assumptions by senior clinicians that junior doctors can provide evidence-based bronchiolitis management, bronchiolitis not a current improvement priority and lack of bronchiolitis education sessions. Use of the targeted interventions reduced over time and, when used, was adapted locally.

Conclusion: This study provides insights into factors influencing the sustainability of de-implementation of low-value care in acute care settings. Fostering an evidence-based practice culture, supported by senior leadership and ongoing multimodal education, supports sustainability of improvements in this setting.

Trial registration number: Australian and New Zealand Clinical Trials Registry No: ACTRN12621001287820.

Background: Collaborative quality initiatives (CQIs), such as the Michigan Surgical Quality Collaborative (MSQC), have invested significant resources to improve surgical outcomes over time. This study aimed to assess whether CQI efforts translated to equitable improvements for vulnerable and non-vulnerable patients alike.

Methods: We performed a retrospective observational study of patients who underwent an operation at one of 73 MSQC hospitals between 2014 and 2023. The coprimary exposures were the Distressed Communities Index (DCI), race and payer. DCI is a community index at the zip code level ranging from prosperous to distressed based on socioeconomic variables. Outcomes included 30-day complications, emergency department (ED) visits and readmissions, estimated using a logistic regression model adjusting for patient and hospital characteristics.

Results: Among 344 135 patients, the mean age (SD) was 54.7 (17.6) years and 50.7% were female. From 2014 to 2023, 30-day complications decreased for all groups stratified by DCI, race and payer. There was a disparity in complications between public versus privately insured patients (11.4% vs 9.2%, p<0.001) that significantly narrowed by the end of the study period (7.3% vs 6.6%, p=0.01). ED visits demonstrated baseline disparities by DCI (10.5% vs 7.5%, p<0.001), payer (11.1% vs 6.7%, p<0.001) and race (11.0% vs 8.2%, p<0.001). The disparity significantly narrowed by payer only (9.5% vs 6.4%, p<0.001). Readmissions decreased for all groups stratified by DCI, race and payer, but there were no significant changes in the disparities over time.

Conclusions: Our study examining surgical outcomes for a statewide CQI found that disparities in outcomes narrowed over time. Quality collaboratives may effectively improve equity in surgical outcomes, but specific attention to persistent disparities is needed to close remaining gaps.

Background: Medical safety huddles are short, structured meetings for physicians to proactively discuss and respond to profession-specific patient safety concerns, with the goal of decreasing future adverse events. Prior observational studies found associations with improved patient safety outcomes, but no randomised controlled studies have been conducted.

Objective: The primary objective was to determine the impact of medical safety huddles on adverse events. Secondary objectives included the fidelity of huddle implementation and the impact on patient safety culture among physicians.

Design: Stepped-wedge cluster randomised trial with four sequences, and each hospital site was a cluster.

Setting: Inpatient oncology, surgery and rehabilitation programmes in four academic hospitals.

Participants: Physicians in participating programmes.

Intervention: Medical safety huddles were adapted for local context and implemented sequentially based on a computer-generated random sequence every 2 months after a 4-month control period. All sites remained in the intervention phase for at least 9 months.

Main outcome and measures: The primary outcome was the rate of adverse events, as determined through blinded chart audits of 912 randomly selected patients. The fidelity of implementation was assessed through the huddle attendance rate, number of safety issues raised in the huddles and number of actions taken in response. Patient safety culture was assessed using the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety.

Results: The adjusted rate of adverse events (per 1000 patient days) in the postintervention phase was 12% lower compared with preintervention (RR: 0.88; 95% CI: 0.80 to 0.98; p=0.016). The odds of having adverse events posthuddle implementation were 17% lower in the postintervention period compared with preintervention (OR intervention vs control: 0.83; 95% CI: 0.80 to 0.87; p<0.001). The mean huddle attendance rate at each site ranged from 30% to 85%, and the mean number of issues raised per huddle and the mean number of actions taken per huddle ranged from 1.6 to 3.1. The mean (SD) overall patient safety rating increased from 2.3 (0.53) to 2.8 (0.88), p=0.010. The mean per cent (SD) positive score for the composite measures of 'Organisational learning' increased significantly from 35% (26%) to 54% (23%), p=0.00, 'Response to error' 37% (24%) to 52% (22%), p=0.025 and 'Communication about error' 36% (28%) to 64% (42%), p=0.016 after implementation.

Conclusions and relevance: Medical safety huddles decreased adverse events and may improve patient safety culture through engaging physicians.

Trial registration number: NCT05365516.

Objective: Because physician burnout negatively affects patients, organisations and those impacted, we aimed to identify and evaluate factors contributing to burnout among internal medicine physicians in the USA.

Design: Cross-sectional survey conducted between 23 June 2023 and 8 May 2024.

Setting: A national multicentre study conducted in the USA.

Participants: Random sample of non-subspecialty internal medicine physicians identified through Physician Professional Data, a database maintained by the American Medical Association. Of 1421 eligible physicians, 629 (44.3%) responded.

Main outcome measures: The 42-item survey collected data on multiple factors-professional environment, community and personal-hypothesised to influence well-being. Burnout domains, including emotional exhaustion, depersonalisation and reduced personal accomplishment, were measured using the Maslach Burnout Inventory-Human Services Survey.

Results: A total of 9.8% (61/622) participants had extreme burnout as defined by meeting thresholds for all three burnout domains. In multivariable regression analysis, several aspects of the professional environment (eg, workload, lack of autonomy) were statistically significantly associated with elevated odds of burnout. Community factors statistically significantly associated with reduced odds of burnout included a supervisor who empowers and treats the physician with respect and dignity and greater support from organisational leaders. Mindful awareness and a sense of purpose were statistically significantly inversely associated with odds of burnout.

Conclusion: Burnout among US internal medicine physicians is common and influenced by many factors. Interventions to elevate well-being should be multi-faceted and seek to reduce workload, augment autonomy, bolster support and perceptions of value from leaders and co-workers and foster environments conducive to mindful practice and sense of purpose.

Background: The Patient Reported Indicator Surveys (PaRIS) initiative of the Organisation for Economic Co-operation and Development aimed to develop a valid and reliable instrument for self-reported assessment of health outcomes and experiences in primary and ambulatory care for people living with chronic conditions. This paper reports on the development and evaluation of the PaRIS Patient Questionnaire (PaRIS-PQ) in an 18-country field trial.

Methods: Following systematic reviews of instruments measuring core domains in the PaRIS conceptual framework (outcomes, experiences, health and healthcare capabilities and health behaviours), four instruments for each domain were shortlisted, and their psychometric performance was assessed using the Evaluating the Measurement of Patient-Reported Outcomes tool. In a modified Delphi procedure, one instrument was selected for each domain, along with additional relevant items. The preliminary English questionnaire was translated and cognitively tested. Psychometric evaluation was conducted on field trial data at item (missingness, distribution, ceiling/floor effects) and scale level (reliability, structure, construct validity).

Findings: 217 instruments were identified measuring one or more of the domains of the conceptual framework. Following mapping and prioritisation, the first draft of the PaRIS-PQ included 118 items. In the field trial (18 countries, 10 894 patients) median completion time ranged 24-33 minutes. PaRIS-PQ performed well at item and scale level. Reliability was ≥0.70 for most relevant measures at patient level, but not at practice and country level. Validity was adequate overall. Removal of additional items (3) resulted in the final PaRIS-PQ (115 items).

Interpretation: PaRIS-PQ demonstrates adequate psychometric performance for measuring experiences and outcomes of primary care for people living with chronic conditions. The instrument facilitates the collection of essential information for health policy and systems decision-making.

Background: A substantial number of people experiencing self-harm or suicidal ideation present to hospital emergency departments (EDs). In 2014, a National Clinical Programme was introduced in EDs in Ireland to standardise care provision. Internationally, there has been limited research on the factors affecting the implementation of care for people who present with mental health crises in EDs.

Methods: This qualitative study examined factors influencing the implementation of the National Clinical Programme for Self-harm and Suicide-related Ideation in 15 hospitals in Ireland from early (2015-2017) through to later implementation (2019-2022). Semi-structured interviews were conducted with staff involved in programme delivery, with the topic guide and thematic analysis informed by the Consolidated Framework for Implementation Research.

Results: A total of 30 participants completed interviews: nurse specialists (n=16), consultant psychiatrists (n=6), nursing managers (n=2), emergency medicine staff (n=2) and members of the national programme team (n=4). Enablers of implementation included the introduction of national, standardised guidance for EDs; implementation strategies led by the national programme team; and training and support for nurse specialists. The following inner-setting factors were perceived as barriers to implementation in some hospitals: limited access to a designated assessment room, delayed access to clinical input and poor collaboration with ED staff. Overall, these barriers dissipated over time, owing to implementation strategies at national and local levels. The varied availability of aftercare impacted providers' ability to deliver the programme and the adaptability of programme delivery had a mixed impact across hospitals.

Conclusions: The perceived value of the programme and national leadership helped to advance implementation. Strategies related to ongoing training and education, developing stakeholder interrelationships and evaluation and monitoring have helped address implementation barriers and promote continued sustainment of the programme. Continued efforts are needed to support nurse specialists delivering the programme and foster partnerships with community providers to improve the transition to aftercare.

Background: Patient-reported experience measures (PREMs) are valuable tools to evaluate patient-centredness (PC) from the patients' perspective. Despite their utility, a comprehensive PREM addressing PC has been lacking. To bridge this gap, we developed the preliminary version of the Experienced Patient-Centeredness Questionnaire (EPAT), a disease-generic tool based on the integrative model of PC comprising 16 dimensions. It demonstrated content validity. This study aimed to test its psychometric properties and to develop a final 64-item version (EPAT-64).

Methods: In this cross-sectional study, we included adult patients treated for cardiovascular diseases, cancer, musculoskeletal diseases and mental disorders in inpatient or outpatient settings in Germany. For each dimension of PC, we selected four items based on item characteristics such as item difficulty and corrected item-total correlation. We tested structural validity using confirmatory factor analysis, examined reliability by McDonald's Omega and tested construct validity by examining correlations with general health status and satisfaction with care.

Results: Analysis of data from 2.024 patients showed excellent acceptance and acceptable item-total correlations for all EPAT-64 items, with few items demonstrating ceiling effects. The confirmatory factor analysis indicated the best fit for a bifactor model, where each item loaded on both a general factor and a dimension-specific factor. Omega showed high reliability for the general factor, while varying for specific dimensions. Construct validity was confirmed by absence of strong correlations with general health status and a strong correlation of the general factor with satisfaction with care.

Conclusions: EPAT-64 demonstrated commendable psychometric properties. This tool allows comprehensive assessment of PC, offering flexibility to users who can measure each dimension with a four-item module or choose modules based on their needs. EPAT-64 serves multiple purposes, including quality improvement and evaluation of interventions aiming to enhance PC. Its versatility empowers users in diverse healthcare settings.

Many successful implementation studies fail to be sustained and spread after the publication. We aimed to spread a successful deimplementation strategy that reduced inappropriate peripheral venous catheter and urinary catheter use and evaluated the spread, adoption and effects of this strategy in clinical practice.We adapted the original successful study into a more accessible project, creating a toolkit called Better without catheter We recruited 39 hospitals (more than half of all Dutch hospitals) across the Netherlands, which participated in regular online meetings. After 21 months, we sent an online survey to the project leaders of the participating hospitals to assess progress, barriers and facilitators to adopting the project.Widespread promotion and targeted emails were key factors in spreading Better without catheter There was considerable variation in the hospitals' progress; five had not yet started, six had completed the project and the others were at various stages in between. Major barriers included lack of time and resources, organisational facilities and the composition of local project teams. Key facilitators were organisational support and the involvement of physicians and nurse leaders. Project leaders valued the toolkit, the flexibility to tailor the project and the online meetings.Overall, the spread and adoption of this deimplementation strategy showed encouraging results, with 39 hospitals joining the network within 2 years. Although reach and engagement were high, the hospitals' progress in the project was frequently hindered by organisational and management factors. Four elements supported the uptake: widespread promotion, the translation of the original study into an accessible improvement project with practical tools, the flexibility to tailor the approach locally and participation in a peer network.

Objective: To assess the association of county-level bias about black and white people with patient experience, influenza immunisation, and quality of clinical care for black and white older US adults (age 65+ years).

Design: Linear multivariable regression measured the cross-sectional association of county-level estimates of implicit and explicit bias about black and white people with patient experiences, influenza immunisation, and clinical quality-of-care for black and white older US adults.

Participants: We used data from 1.9 million white adults who completed implicit and explicit bias measures during 2003-2018, patient experience and influenza immunisation data from respondents to the 2009-2017 Medicare Consumer Assessment of Healthcare Providers and Systems (MCAHPS) Surveys, and clinical quality-of-care data from patients whose records were included in 2009-2017 Healthcare Effectiveness Data and Information Set (HEDIS) submissions (n=0.8-2.9 million per measure).

Main outcome measures: Three patient experience measures and patient-reported influenza immunisation from the MCAHPS Survey; five HEDIS measures.

Results: In county-level models, higher pro-white implicit bias was associated with lower immunisation rates and worse scores for some patient experience measures for black and white adults as well as larger-magnitude black-white disparities. Higher pro-white implicit bias was associated with worse scores for some HEDIS measures for black and white adults but not with black-white disparities in clinical quality of care. Most significant associations were small in magnitude (effect sizes of 0.2-0.3 or less).

Conclusions: To the extent that county-level pro-white implicit bias is indicative of bias among healthcare providers, there may be a need for interventions designed to prevent such bias from adversely affecting the experiences and preventive care of black patients and the clinical quality of care for all patients.

Background: Handoffs are a weak link in the chain of clinical care of inpatients. Within-unit handoffs are increasing in frequency due to changes in duty hours. There are strong rationales for standardising the reporting of critical information between providers, and such practices have been adopted by other industries.

Objectives: As part of Making Healthcare Safer IV we reviewed the evidence from the last 10 years that the use of structured handoff protocols influences patient safety outcomes within acute care hospital units.

Methods: We searched four databases for systematic reviews and original research studies of any design that assessed structured handoff protocols and reported patient safety outcomes. Screening and eligibility were done in duplicate, while data extraction was done by one reviewer and checked by a second reviewer. The synthesis of results is narrative. Certainty of evidence was based on the Grading of Recommendations Assessment, Development and Evaluation framework as modified for Making Healthcare Safer IV.

Results: We searched for evidence on 12 handoff tools. Two systematic reviews of Situation, Background, Assessment, Recommendation (SBAR) (including 11 and 28 original research studies; 5 and 15 were about the use in handoffs) and two newer original research studies provided low certainty evidence that the SBAR tool improves patient safety outcomes. Ten original research studies (about nine implementations) provided moderate certainty evidence that the I-PASS tool (Illness severity, Patient summary, Action list, Situation awareness, Synthesis to receiver) reduces medical errors and adverse events. No other structured handoff tool was assessed in more than one study or one setting.

Conclusion: The SBAR and I-PASS structured tools for within-unit handoffs probably improve patient safety, with I-PASS having a stronger certainty of evidence. Other published tools lack sufficient evidence to draw conclusions.

Prospero registration number: CRD42024576324.