Measurement of Quality and Assurance of Safety in the Critically Ill

Acting between guidelines and reality- an interview study exploring the strategies of first line managers in patient safety work

BACKGROUND

Safety culture can be described and understood through its manifestations in the organization as artefacts, espoused values and basic underlying assumptions and is strongly related to leadership-yet it remains elusive as a concept. Even if the literature points to leadership as an important factor for creating and sustaining a mature safety culture, little is known about how the safety work of first line managers' is done and how they balance the different and often conflicting organizational goals in everyday practice. The purpose of this study was to explore how health care first line managers perceive their role and how they promote patient safety and patient safety culture in their units.

METHODS

Interview study with first line managers in intensive care units in eight different hospitals located in the middle of Sweden. An inductive qualitative content analysis approach was used, this was then followed by a deductive analysis of the strategies informed by constructs from High reliability organizations.

RESULTS

We present how first line managers view their role in patient safety and exemplify concrete strategies by which managers promote patient safety in everyday work.

CONCLUSIONS

Our study shows the central role of front-line managers in organizing for safe care and creating a culture for patient safety. Although promoted widely in Swedish healthcare at the time for the interviews, the HSOPSC was not mentioned by the managers as a central source of information on the unit's safety culture.

Safety attitudes and working climate after organizational change in a major emergency department in Sweden

BACKGROUND

Medically complex patients present challenges to the health care system, particularly in the emergency department (ED) setting. Specifically, teamwork is thought to affect staff safety climate, which in turn impacts patient safety.

AIM

This study aimed to evaluate the effect of organizational changes to interprofessional team assessment processes on staff perception of teamwork and safety attitudes in the ED.

METHODS

This prospective observational study used cross-sectional design and measured ED staff perception of patient safety related domains at two time-points (before and after an organizational intervention), using the Safety Attitude Questionnaire.

RESULTS

Statistically significant changes were seen among the overall sample (n = 112 at time point one and n = 121 at time point two) for the safety climate, working conditions, and stress recognition domains. Nurses and doctors showed different baseline attitudes and different responses to the intervention between the two time points.

CONCLUSION

The results reflect improved positive attitudes overall though there were differences in responses between the nursing and medical professions. The findings highlight opportunities to improve attitudes among ED team members through defined organizational change and learning from one another. Organizational change can affect staff perceptions of the safety climate and interprofessional teamwork, which may improve the ED working environment.

Monitoring intensive care unit performance-impact of a novel individualised performance scorecard in critical care medicine: a mixed-methods study protocol

INTRODUCTION

Patients admitted to a critical care medicine (CCM) environment, including an intensive care unit (ICU), are susceptible to harm and significant resource utilisation. Therefore, a strategy to optimise provider performance is required. Performance scorecards are used by institutions for the purposes of driving quality improvement. There is no widely accepted or standardised scorecard that has been used for overall CCM performance. We aim to improve quality of care, patient safety and patient/family experience in CCM practice through the utilisation of a standardised, repeatable and multidimensional performance scorecard, designed to provide a continuous review of ICU physician and nurse practice, as well as departmental metrics.

METHODS AND ANALYSIS

This will be a mixed-methods, controlled before and after study to assess the impact of a CCM-specific quality scorecard. Scorecard metrics were developed through expert consensus and existing literature. The study will include 19 attending CCM physicians and approximately 300 CCM nurses. Patient data for scorecard compilation are collected daily from bedside flow sheets. Preintervention baseline data will be collected for 6 months for each participant. After this, each participant will receive their scorecard measures. Following a 3-month washout period, postintervention data will be collected for 6 months. The primary outcome will be change in performance metrics following the provision of scorecard feedback to subjects. A cost analysis will also be performed, with the purpose of comparing total ICU costs prior to implementation of the scorecard with total ICU costs following implementation of the scorecard. The qualitative portion will include interviews with participants following the intervention phase. Interviews will be analysed in order to identify recurrent themes and subthemes, for the purposes of driving scorecard improvement.

ETHICS AND DISSEMINATION

This protocol has been approved by the local research ethics board. Publication of results is anticipated in 2019. If this intervention is found to improve patient- and unit-directed outcomes, with evidence of cost-effectiveness, it would support the utilisation of such a scorecard as a quality standard in CCM.

Measurement of harms in community care: a qualitative study of use of the NHS Safety Thermometer

Objectives

Measurement is a vital part of improvement work. While it is known that the context of improvement work influences its success, less is known about how context affects measurement of underlying harms. We sought to explore the use of a harm measurement tool, the NHS Safety Thermometer (NHS-ST), designed for use across diverse healthcare settings in the particular context of community care.

Methods

This is a qualitative study of 19 National Health Service (NHS) organisations, 7 of which had community service provision. We conducted ethnographic observations of practice and interviews with front-line nursing and senior staff. Analysis was based on the constant comparison method.

Results

Measurement in community settings presents distinct challenges, calling into question the extent to which measures can be easily transferred. The NHS-ST was seen as more appropriate for acute care, not least because community nurses did not have the same access to information. Data collection requirements were in tension with maintaining a relationship of trust with patients. The aim to collect data across care settings acted to undermine perceptions of the representativeness of community data. Although the tool was designed to measure preventable harms, care providers questioned their preventability within a community setting. Different harms were seen as priorities for measurement and improvement within community settings.

Conclusions

Measurement tools are experienced by healthcare staff as socially situated. In the community setting, there are distinct challenges to improving care quality not experienced in the acute sector. Strategies to measure harms, and use of any resulting data for improvement work, need to be cognisant of the complexity of an environment where healthcare staff often have little opportunity to monitor and influence patients.

Quality Improvement in Critical Care: Selection and Development of Quality Indicators

Background. Caring for critically ill patients is complex and resource intensive. An approach to monitor and compare the function of different intensive care units (ICUs) is needed to optimize outcomes for patients and the health system as a whole. Objective. To develop and implement quality indicators for comparing ICU characteristics and performance within and between ICUs and regions over time. Methods. Canadian jurisdictions with established ICU clinical databases were invited to participate in an iterative series of face-to-face meetings, teleconferences, and web conferences. Eighteen adult intensive care units across 14 hospitals and 5 provinces participated in the process. Results. Six domains of ICU function were identified: safe, timely, efficient, effective, patient/family satisfaction, and staff work life. Detailed operational definitions were developed for 22 quality indicators. The feasibility was demonstrated with the collection of 3.5 years of data. Statistical process control charts and graphs of composite measures were used for data display and comparisons. Medical and nursing leaders as well as administrators found the system to be an improvement over prior methods. Conclusions. Our process resulted in the selection and development of 22 indicators representing 6 domains of ICU function. We have demonstrated the feasibility of such a reporting system. This type of reporting system will demonstrate variation between units and jurisdictions to help identify and prioritize improvement efforts.

Comparison of a Trigger Tool and Voluntary Reporting to Identify Adverse Events in a Paediatric Intensive Care Unit

Reduction of adverse events depends on accurate detection. The utility of a Trigger Tool to detect and classify severity of adverse events in an intensive care unit of a paediatric university hospital was compared to voluntary reporting. Sixty patient records were randomly selected from 314 admissions over three months. Events detected by the Trigger Tool were classified by two independent investigators as insignificant, minor, moderate, major or catastrophic. Examination of each record required, on average, 40 minutes. Ninety-eight adverse events (1.66/patient) were detected in 59 available records. Mean admission was 2.77 days. The incidence of adverse events was 59.9 per 100 patient days or 0.60 events per patient per day. The number of events detected by the Trigger Tool was related to duration of admission (r=0.70, P < 0.0001) and risk of mortality on admission (r=0.50, P=0.0001) but not to age. The inter-rater agreement on detection of adverse events was good. Investigator One detected 66 adverse events while Investigator Two detected 93 events (kappa 0.63). Of the 61 events detected by both investigators, the agreement of classification of severity was very good (kappa 0.89). Of the 56 events rated similarly by both investigators, 13 (23%) were insignificant, 19 (34%) were minor, 17 (30%) were moderate, 4 (7%) were major and 3 (6%) were catastrophic. Only four adverse events had been reported voluntarily, of which two were detected using the Trigger Tool. Whereas the Trigger Tool is a simple, efficient and robust method, voluntary reporting is inadequate and captures very few adverse events in the intensive care unit environment.

Human factors in critical care: towards standardized integrated human-centred systems of work

PURPOSE OF REVIEW

Improvements in safety and quality benefit from a systems approach. Human factors is the study and practice of the relationship between humans and systems. This review examines recent advances in human factors in healthcare.

RECENT FINDINGS

Early studies focused on understanding incidents, and on the translation of principles from aviation to healthcare, which demonstrated a useful but limited application of the human factors approach. More recent studies have begun to address the complexity of the relationship between human behaviour and technology, tasks, environment and organization. Human factors frameworks have been usefully applied that aid in these complex considerations, providing a better understanding of the healthcare system, and a much broader range of solutions to problems than checklists, protocols or training. In particular, in improving equipment design and procurement; improving job design by understanding the demands and tasks of individual healthcare practitioners; in improving what and when training is delivered; and the integration of these complex system components into a coherent whole.

SUMMARY

The human factors approach is not yet mature in healthcare, but the importance is being increasingly recognized, and the breadth of application continually expanded.

Is preventable harm the right patient safety metric?

Despite increasing attention and discussion, patient harm remains an important issue in health care. Defining and identifying harm remains challenging, and little standardization in approach exists. This summary describes an approach to identifying hospital-wide preventable harm with focused safety efforts using the Preventable Harm Index as a measure of progress and as a metric to motivate improvement. Our hospital's significant decrease in serious safety events, mortality, and preventable harm is outlined.

The effect of two different electronic health record user interfaces on intensive care provider task load, errors of cognition, and performance

OBJECTIVES

The care of critically ill patients generates large quantities of data. Increasingly, these data are presented to the provider within an electronic medical record. The manner in which data are organized and presented can impact on the ability of users to synthesis that data into meaningful information. The objective of this study was to test the hypothesis that novel user interfaces, which prioritize the display of high-value data to providers within system-based packages, reduce task load, and result in fewer errors of cognition compared with established user interfaces that do not.

DESIGN

Randomized crossover study.

SETTING

Academic tertiary referral center.

SUBJECTS

Attending, resident and fellow critical care physicians.

INTERVENTIONS

Novel health care record user interface.

MEASUREMENT

Subjects randomly assigned to either a standard electronic medical record or a novel user interface, were asked to perform a structured task. The task required the subjects to use the assigned electronic environment to review the medical record of an intensive care unit patient said to be actively bleeding for data that formed the basis of answers to clinical questions posed in the form of a structured questionnaire. The primary outcome was task load, measured using the paper version of the NASA-task load index. Secondary outcome measures included time to task completion, number of errors of cognition measured by comparison of subject to post hoc gold standard questionnaire responses, and the quantity of information presented to subjects by each environment.

MAIN RESULTS

Twenty subjects completed the task on eight patients, resulting in 160 patient-provider encounters (80 in each group). The standard electronic medical record contained a much larger data volume with a median (interquartile range) number of data points per patient of 1008 (895-1183) compared with 102 (77-112) contained within the novel user interface. The median (interquartile range) NASA-task load index values were 38.8 (32-45) and 58 (45-65) for the novel user interface compared with the standard electronic medical record (p < .001). The median (interquartile range) times in seconds taken to complete the task for four consecutive patients were 93 (57-132), 60 (48-71), 68 (48-80), and 54 (42-64) for the novel user interface compared with 145 (109-201), 125 (113-162), 129 (100-145), and 112 (92-123) for the standard interface (p < .0001), respectively. The median (interquartile range) number of errors per provider was 0.5 (0-1) and two (0.25-3) for the novel user interface and standard electronic medical record interface, respectively (p = .007).

CONCLUSIONS

A novel user interface was designed based on the information needs of intensive care unit providers with a specific goal of development being the reduction of task load and errors of cognition associated with filtering, extracting, and using medical data contained within a comprehensive electronic medical record. The results of this simulated clinical experiment suggest that the configuration of the intensive care unit user interface contributes significantly to the task load, time to task completion, and number of errors of cognition associated with the identification, and subsequent use, of relevant patient data. Task-specific user interfaces, developed from an understanding of provider information requirements, offer advantages over interfaces currently available within a standard electronic medical record.

Relation between hospital orthopaedic specialisation and outcomes in patients aged 65 and older: retrospective analysis of US Medicare data

OBJECTIVE

To explore the relation between hospital orthopaedic specialisation and postoperative outcomes after total hip or knee replacement surgery.

DESIGN

Retrospective analysis of US Medicare data, 2001-5.

SETTING

3818 US hospitals carrying out total joint replacement. Population 1 273 081 Medicare beneficiaries age 65 and older who underwent primary or revision hip or knee replacement.

MAIN OUTCOME MEASURES

Hospitals were stratified into fifths on the basis of their degree of orthopaedic specialisation (lowest fifth, least specialised; highest fifth, most specialised). The primary outcome was defined as a composite representing the occurrence of one or more of pulmonary embolism, deep vein thrombosis, haemorrhage, infection, myocardial infarction, or death within 90 days of the index surgery.

RESULTS

As hospital orthopaedic specialisation increased from the lowest fifth to highest fifth, the proportion of people admitted who were women or black, or who had diabetes or heart failure progressively decreased (P<0.001), whereas procedural volume increased. Compared with the most specialised hospitals (highest fifth), after adjustment for patient characteristics and hospital volume, the odds of adverse outcomes increased progressively with decreased hospital specialisation: lowest fifth (odds ratio 1.59, 95% confidence interval 1.53 to 1.65), second fifth (1.32, 1.28 to 1.36), third fifth (1.24, 1.21 to 1.28), and fourth fifth (1.10, 1.07 to 1.13).

CONCLUSIONS

Increased hospital orthopaedic specialisation is associated with improved patient outcomes after adjusting for both patient characteristics and hospital procedural volume. These results should be interpreted with caution because the possibility that other unmeasured confounders related to socioeconomic status or different factors are responsible for the improved patient outcomes rather than hospital specialisation can not be excluded. The findings suggest that hospital specialisation may capture different components of hospital quality than the components captured by hospital volume.

Quality and safety in intensive care-A means to an end is critical

BACKGROUND

To achieve improvement in healthcare quality and safety, all four domains (outcome, process, structure and culture) must be considered in conjunction with the best available clinical evidence to improve patient care and reduce harm. A range of improvement initiatives have targeted processes of care in recognition of: (1) complexities of patient care and (2) evidence that a large portion of adverse events are preventable, occur during ongoing care, and result in poorer patient outcomes.

PURPOSE

The aims of this paper are to: (1) outline national and international quality and safety initiatives; (2) identify evidence-based processes of care applicable to the general adult ICU patient population; (3) summarise the literature on relevant quality improvement strategies.

METHODS

An integrative literature review was conducted by: (1) database search of Ovid Medline, CINAHL, EMBASE and Cochrane for articles published between 1996 and October 2009; (2) identification of additional studies from articles obtained; (3) purposive internet search identifying relevant quality and safety initiatives.

FINDINGS

Quality improvement initiatives across the globe were identified, with ensuing focus on how the development, implementation and evaluation of evidence-based processes of care can lead to improvements in the delivery and outcomes of intensive care practice. Variation in practice and methodological limitations of existing studies were also noted, highlighting the need for innovative approaches to improving processes in the ICU.

CONCLUSION

This integrative review has outlined potential for achieving practice improvements in intensive care and highlighted the need for further evaluative research to improve patient care at the bedside.

Health care-associated infection reporting: the need for ongoing reliability and validity assessment

Government-mandated reporting of health care-associated infections (HAIs) and new reimbursement regulations place a premium on accurate and reliable detection of HAIs. This commentary addresses the challenges and opportunities of having consistent, well-defined, and continuous methods in place to ensure the reliability and validity of HAI detection and reporting. In addition, such procedures could support the development and expertise of infection preventionists. A Web-based clinical vignette model is suggested for improving HAI reporting for hospitals participating in the Centers for Disease Control and Prevention's National Healthcare Safety Network.