1
|
Mlaver E, Sweeney JF. Establishing a culture of highly reliable quality care. Surgery 2024; 175:1229-1231. [PMID: 37953142 DOI: 10.1016/j.surg.2023.09.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/26/2023] [Indexed: 11/14/2023]
Abstract
Reliability is the likelihood that a process will perform a required function without failure, consistent over time and personnel changes. In the rapidly evolving healthcare landscape, reliably delivering excellent surgical care demands a comprehensive and systematic approach. Accomplishing this task is beyond the reach of any individual clinician, administrator, or leader. The team must work together to establish a highly reliable quality care culture that serves as the foundation for safe, patient-centered practice. High reliability thus inherently relies on transdisciplinary collaboration, with every level of clinical, administrative, and regulatory team members actively communicating, supporting each other, and building trust in each other's expertise. Here, we discuss the fundamentals of establishing a highly reliable quality care culture. We outline the key principles of a highly reliable organization - preoccupation with failure, sensitivity to operations, reluctance to oversimplify, commitment to resilience, and deference to expertise - and the characteristics of teams that can effectively implement these principles. We discuss the importance of standardization, continuous process and outcome measurement, and setting collective goals. And finally, we exemplify these fundamentals through a brief case study. In outlining these foundational concepts for today's care, we also look forward to the impact of big data, artificial intelligence, and interconnectedness on our future continuous quality improvement efforts. Within the myriad complexities of surgical care, there are bound to be adverse outcomes, but by instilling a culture of highly reliable quality care, we can do our best to minimize their frequency, mitigate their harm, and optimize outcomes.
Collapse
Affiliation(s)
- Eli Mlaver
- Department of Surgery, Emory University School of Medicine, Atlanta, GA.
| | - John F Sweeney
- Department of Surgery, Emory University School of Medicine, Atlanta, GA. https://twitter.com/EmorySurgery
| |
Collapse
|
2
|
Fahy R, Corbett M, Crotty T, Chadwick L, Keogh I. Totally endoscopic cartilage tympanoplasty: a hierarchical task analysis. J Laryngol Otol 2023; 137:1326-1333. [PMID: 36093951 DOI: 10.1017/s0022215122001992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Totally endoscopic ear surgery is a novel method of conducting otological surgery. Hierarchical task analysis and the systematic human error reduction and prediction approach ('SHERPA') are valuable tools that can effectively deconstruct the technical and non-technical skills required to successfully complete a surgical procedure. METHODS Twenty-five endoscopic tragal cartilage tympanoplasties were observed, to identify the tasks and subtasks required for completion of totally endoscopic tragal cartilage tympanoplasty. The systematic human error reduction and prediction approach was used to identify the potential risks and methods, to reduce or remediate these risks. RESULTS A hierarchical task analysis was performed, identifying 8 tasks and 50 subtasks for a safe approach to completing totally endoscopic tragal cartilage tympanoplasty. A risk score for each subtask was calculated to produce a systematic human error reduction and prediction approach and to highlight potential errors. CONCLUSION This hierarchical task analysis allowed for quick reference to a correct method of endoscopic tympanoplasty. The systematic human error reduction and prediction approach was employed to reduce the risks associated with undergoing endoscopic tympanoplasty, to improve patient safety.
Collapse
Affiliation(s)
- R Fahy
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Galway, Galway, Ireland
- School of Medicine, National University of Ireland, Galway, Ireland
| | - M Corbett
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Galway, Galway, Ireland
- School of Medicine, National University of Ireland, Galway, Ireland
| | - T Crotty
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Galway, Galway, Ireland
- School of Medicine, National University of Ireland, Galway, Ireland
| | - L Chadwick
- Department of Mechanical and Biomedical Engineering, National University of Ireland, Galway, Ireland
| | - I Keogh
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Galway, Galway, Ireland
- School of Medicine, National University of Ireland, Galway, Ireland
| |
Collapse
|
3
|
Scott AL, Howe WT, Bisel R. Reviewing High Reliability Team (HRT) Scholarship: A 21st Century Approach to Safety. SMALL GROUP RESEARCH 2022. [DOI: 10.1177/10464964221116349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
High reliability team (HRT) theorizing emerged from high reliability organization (HRO) theory and now represents a distinct subset of HRO literature. Seeking to capture the development and range of HRT research, a comprehensive literature review was conducted. This systematic review of HRT scholarship, the first of its kind, provides a foundation from which small group and team scholars across disciplines may reflect on key lessons and chart future research. This review includes 71 articles across 21 disciplines and incorporates historical reflection on HRT theory foundations, existing empirical support, critiques and rivals, theory extensions, and ideas for future scholarship efforts.
Collapse
|
4
|
Loibner M, Barach P, Wolfgruber S, Langner C, Stangl V, Rieger J, Föderl-Höbenreich E, Hardt M, Kicker E, Groiss S, Zacharias M, Wurm P, Gorkiewicz G, Regitnig P, Zatloukal K. Resilience and Protection of Health Care and Research Laboratory Workers During the SARS-CoV-2 Pandemic: Analysis and Case Study From an Austrian High Security Laboratory. Front Psychol 2022; 13:901244. [PMID: 35936273 PMCID: PMC9353000 DOI: 10.3389/fpsyg.2022.901244] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/10/2022] [Indexed: 11/25/2022] Open
Abstract
The SARS-CoV-2 pandemic has highlighted the interdependency of healthcare systems and research organizations on manufacturers and suppliers of personnel protective equipment (PPE) and the need for well-trained personnel who can react quickly to changing working conditions. Reports on challenges faced by research laboratory workers (RLWs) are rare in contrast to the lived experience of hospital health care workers. We report on experiences gained by RLWs (e.g., molecular scientists, pathologists, autopsy assistants) who significantly contributed to combating the pandemic under particularly challenging conditions due to increased workload, sickness and interrupted PPE supply chains. RLWs perform a broad spectrum of work with SARS-CoV-2 such as autopsies, establishment of virus cultures and infection models, development and verification of diagnostics, performance of virus inactivation assays to investigate various antiviral agents including vaccines and evaluation of decontamination technologies in high containment biological laboratories (HCBL). Performance of autopsies and laboratory work increased substantially during the pandemic and thus led to highly demanding working conditions with working shifts of more than eight hours working in PPE that stressed individual limits and also the ergonomic and safety limits of PPE. We provide detailed insights into the challenges of the stressful daily laboratory routine since the pandemic began, lessons learned, and suggest solutions for better safety based on a case study of a newly established HCBL (i.e., BSL-3 laboratory) designed for autopsies and research laboratory work. Reduced personal risk, increased resilience, and stress resistance can be achieved by improved PPE components, better training, redundant safety measures, inculcating a culture of safety, and excellent teamwork.
Collapse
Affiliation(s)
- Martina Loibner
- Diagnostic and Research Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Paul Barach
- Diagnostic and Research Institute of Pathology, Medical University of Graz, Graz, Austria
- College of Population Health, Thomas Jefferson University, Philadelphia, PA, United States
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Stella Wolfgruber
- Diagnostic and Research Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Christine Langner
- Diagnostic and Research Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Verena Stangl
- Diagnostic and Research Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Julia Rieger
- Diagnostic and Research Institute of Pathology, Medical University of Graz, Graz, Austria
| | | | - Melina Hardt
- Diagnostic and Research Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Eva Kicker
- Diagnostic and Research Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Silvia Groiss
- Diagnostic and Research Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Martin Zacharias
- Diagnostic and Research Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Philipp Wurm
- Diagnostic and Research Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Gregor Gorkiewicz
- Diagnostic and Research Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Peter Regitnig
- Diagnostic and Research Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Kurt Zatloukal
- Diagnostic and Research Institute of Pathology, Medical University of Graz, Graz, Austria
| |
Collapse
|
5
|
BJS commission on surgery and perioperative care post-COVID-19. Br J Surg 2021; 108:1162-1180. [PMID: 34624081 DOI: 10.1093/bjs/znab307] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 07/26/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) was declared a pandemic by the WHO on 11 March 2020 and global surgical practice was compromised. This Commission aimed to document and reflect on the changes seen in the surgical environment during the pandemic, by reviewing colleagues' experiences and published evidence. METHODS In late 2020, BJS contacted colleagues across the global surgical community and asked them to describe how severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) had affected their practice. In addition to this, the Commission undertook a literature review on the impact of COVID-19 on surgery and perioperative care. A thematic analysis was performed to identify the issues most frequently encountered by the correspondents, as well as the solutions and ideas suggested to address them. RESULTS BJS received communications for this Commission from leading clinicians and academics across a variety of surgical specialties in every inhabited continent. The responses from all over the world provided insights into multiple facets of surgical practice from a governmental level to individual clinical practice and training. CONCLUSION The COVID-19 pandemic has uncovered a variety of problems in healthcare systems, including negative impacts on surgical practice. Global surgical multidisciplinary teams are working collaboratively to address research questions about the future of surgery in the post-COVID-19 era. The COVID-19 pandemic is severely damaging surgical training. The establishment of a multidisciplinary ethics committee should be encouraged at all surgical oncology centres. Innovative leadership and collaboration is vital in the post-COVID-19 era.
Collapse
MESH Headings
- Adult
- Biomedical Research/organization & administration
- COVID-19/diagnosis
- COVID-19/economics
- COVID-19/epidemiology
- COVID-19/prevention & control
- Education, Medical, Graduate/methods
- Education, Medical, Graduate/trends
- Female
- Global Health
- Health Resources/supply & distribution
- Health Services Accessibility/trends
- Humans
- Infection Control/economics
- Infection Control/methods
- Infection Control/standards
- International Cooperation
- Male
- Middle Aged
- Pandemics
- Perioperative Care/education
- Perioperative Care/methods
- Perioperative Care/standards
- Perioperative Care/trends
- Practice Patterns, Physicians'/standards
- Practice Patterns, Physicians'/trends
- Surgeons/education
- Surgeons/psychology
- Surgeons/trends
- Surgical Procedures, Operative/education
- Surgical Procedures, Operative/methods
- Surgical Procedures, Operative/standards
- Surgical Procedures, Operative/trends
Collapse
|
6
|
Warm EJ, Ahmad Y, Kinnear B, Kelleher M, Sall D, Wells A, Barach P. A Dynamic Risk Management Approach for Reducing Harm From Invasive Bedside Procedures Performed During Residency. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2021; 96:1268-1275. [PMID: 33735129 DOI: 10.1097/acm.0000000000004066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Internal medicine (IM) residents frequently perform invasive bedside procedures during residency training. Bedside procedure training in IM programs may compromise patient safety. Current evidence suggests that IM training programs rely heavily on the number of procedures completed during training as a proxy for resident competence instead of using objective postprocedure patient outcomes. The authors posit that the results of procedural training effectiveness should be reframed with outcome metrics rather than process measures alone. This article introduces the as low as reasonably achievable (ALARA) approach, which originated in the nuclear industry to increase safety margins, to help assess and reduce bedside procedural risks. Training program directors are encouraged to use ALARA calculations to define the risk trade-offs inherent in current procedural training and assess how best to reliably improve patient outcomes. The authors describe 5 options to consider: training all residents in bedside procedures, training only select residents in bedside procedures, training no residents in bedside procedures, deploying 24-hour procedure teams supervised by IM faculty, and deploying 24-hour procedure teams supervised by non-IM faculty. The authors explore how quality improvement approaches using process maps, fishbone diagrams, failure mode effects and analyses, and risk matrices can be effectively implemented to assess training resources, choices, and aims. Future research should address the drivers behind developing optimal training programs that support independent practice, correlations with patient outcomes, and methods that enable faculty to justify their supervisory decisions while adhering to ALARA risk management standards.
Collapse
Affiliation(s)
- Eric J Warm
- E.J. Warm is professor of medicine and program director, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio; ORCID: https://orcid.org/0000-0002-6088-2434
| | - Yousef Ahmad
- Y. Ahmad is an internal medicine resident, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Benjamin Kinnear
- B. Kinnear is associate professor of medicine and pediatrics and associate program director, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; ORCID: https://orcid.org/0000-0003-0052-4130
| | - Matthew Kelleher
- M. Kelleher is assistant professor of medicine and pediatrics and associate program director, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Dana Sall
- D. Sall is assistant professor of medicine, University of Arizona College of Medicine Phoenix, and program director, HonorHealth Scottsdale Thompson Peak Internal Medicine Residency Program, Scottsdale, Arizona
| | - Andrew Wells
- A. Wells is a cardiology fellow, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Paul Barach
- P. Barach is clinical professor, Department of Pediatrics, Wayne State University School of Medicine, Detroit, Michigan, and lecturer, Jefferson College of Population Health, Philadelphia, Pennsylvania; ORCID: https://orcid.org/0000-0002-7906-698X
| |
Collapse
|
7
|
Paredes AZ, Hyer JM, Tsilimigras DI, Sahara K, White S, Pawlik TM. Interaction of Surgeon Volume and Nurse-to-Patient Ratio on Post-operative Outcomes of Medicare Beneficiaries Following Pancreaticoduodenectomy. J Gastrointest Surg 2020; 24:2551-2559. [PMID: 31745895 DOI: 10.1007/s11605-019-04449-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 10/25/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND We sought to assess the effect of nurse-to-patient ratio on outcomes with a focus on defining whether nurse-to-patient ratio altered outcomes relative to pancreaticoduodenectomy (PD) surgeon specific volume. METHODS Medicare SAFs from 2013-2015 were used to identify patients who underwent PD. Nurse-to-patient ratio, PD specific surgeon volume were stratified. Association of factors associated with short term outcomes was evaluated. RESULTS Overall, 6668 patients (median age 73, IQR 68-77; 52.8% male) were identified. The median annual PD volume of surgeons in the highest volume tier was 24 (IQR 21-29), whereas surgeons in the lowest tier performed 2 PDs annually (IQR 1-3) (p < 0.001). Compared with hospitals that had the highest nurse-to-patient ratio tier, patients at hospitals with the lowest nurse-to-patient ratio tier were 26% more likely to have a complication (OR 1.26, 95% CI 1.02-1.55). Additionally, patients of surgeons in the lowest tier had 43% greater odds of suffering a complication compared to patients of surgeons in the highest tier (OR 1.43, 95% CI 1.11-1.84). However, patients who underwent a PD by a surgeon within the lowest tier had similar odds of a complication irrespective of nurse-to-patient ratio (OR 1.34, 95% CI 0.97-1.86). CONCLUSION Compared with patients who underwent an operation by a surgeon in highest PD volume tier, patients treated by surgeons in the lowest tier had higher odds of post-operative complications which was not mitigated by a higher nurse-to-patient ratio.
Collapse
Affiliation(s)
- Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Kota Sahara
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Susan White
- Division of Health Information Management and Systems, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA.
| |
Collapse
|
8
|
Barach P, Dadlani GH, Lipshultz SE. Evidence-based, safety management policies for pediatric cardiac care in New York State. PROGRESS IN PEDIATRIC CARDIOLOGY 2019. [DOI: 10.1016/j.ppedcard.2019.101139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
9
|
Bansal N, Barach P, Amdani SM, Lipshultz SE. When is early septal myectomy in children with hypertrophic cardiomyopathy justified? Transl Pediatr 2018; 7:362-366. [PMID: 30460188 PMCID: PMC6212380 DOI: 10.21037/tp.2018.09.08] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Neha Bansal
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, Bronx, NY, USA
| | - Paul Barach
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI, USA
| | - Shahnawaz M Amdani
- Division of Pediatric Cardiology, Saint Louis Children's Hospital, Washington University School of Medicine, Saint Louis, MO, USA
| | - Steven E Lipshultz
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI, USA
- Children's Research Center of Michigan, Children's Hospital of Michigan, Detroit, MI, USA
| |
Collapse
|
10
|
Clay-Williams R, Plumb J, Luscombe GM, Hawke C, Dalton H, Shannon G, Johnson J. Improving Teamwork and Patient Outcomes with Daily Structured Interdisciplinary Bedside Rounds: A Multimethod Evaluation. J Hosp Med 2018; 13:311-317. [PMID: 29698537 DOI: 10.12788/jhm.2850] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Previous research has shown that interdisciplinary ward rounds have the potential to improve team functioning and patient outcomes. DESIGN A convergent parallel multimethod approach to evaluate a hospital interdisciplinary ward round intervention and ward restructure. SETTING An acute medical unit in a large tertiary care hospital in regional Australia. PARTICIPANTS Thirty-two clinicians and inpatients aged 15 years and above, with acute episode of care, discharged during the year prior and the year of the intervention. INTERVENTION A daily structured interdisciplinary bedside round combined with a ward restructure. MEASUREMENTS Qualitative measures included contextual factors and measures of change and experiences of clinicians. Quantitative measures included length of stay (LOS), monthly "calls for clinical review," and cost of care delivery. RESULTS Clinicians reported improved teamwork, communication, and understanding between and within the clinical professions, and between clinicians and patients, after the intervention implementation. There was no statistically significant difference between the intervention and control wards in the change in LOS over time (Wald ?2 = 1.05; degrees of freedom [df] = 1; P = .31), but a statistically significant interaction for cost of stay, with a drop in cost over time, was observed in the intervention group, and an increase was observed in the control wards (Wald ?2 = 6.34; df = 1; P = .012). The medical wards and control wards differed significantly in how the number of monthly "calls for clinical review" changed from prestructured interdisciplinary bedside round (SIBR) to during SIBR (F (1,44) = 12.18; P = .001). CONCLUSIONS Multimethod evaluations are necessary to provide insight into the contextual factors that contribute to a successful intervention and improved clinical outcomes.
Collapse
Affiliation(s)
- Robyn Clay-Williams
- Centre for Healthcare Resilience & Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia.
| | - Jennifer Plumb
- Australian Commission on Safety and Quality in Health Care, Sydney, New South Wales, Australia
| | - Georgina M Luscombe
- The School of Rural Health, Sydney Medical School, The University of Sydney, Orange, New South Wales, Australia
| | - Catherine Hawke
- The School of Rural Health, Sydney Medical School, The University of Sydney, Orange, New South Wales, Australia
| | - Hazel Dalton
- Faculty of Health and Medicine, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Gabriel Shannon
- The School of Rural Health, Sydney Medical School, The University of Sydney, Orange, New South Wales, Australia
| | - Julie Johnson
- Department of Surgery, Center for Healthcare Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| |
Collapse
|
11
|
Carmona F, Manso PH, Ferreira MN, Ikari NM, Jatene MB, Amato L, Turquetto AL, Caneo LF. Collaborative Quality Improvement in the Congenital Heart Defects: Development of the ASSIST Consortium and a Preliminary Surgical Outcomes Report. Braz J Cardiovasc Surg 2017; 32:260-269. [PMID: 28977197 PMCID: PMC5613721 DOI: 10.21470/1678-9741-2016-0074] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 03/12/2017] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE ASSIST is the first Brazilian initiative in building a collaborative quality improvement program in pediatric cardiology and congenital heart disease. The purposes of this manuscript are: (a) to describe the development of the ASSIST project, including the historical, philosophical, organizational, and infrastructural components that will facilitate collaborative quality improvement in congenital heart disease care; (b) to report past and ongoing challenges faced; and (c) to report the first preliminary data analysis. METHODS A total of 614 operations were prospectively included in a comprehensive online database between September 2014 and December 2015 in two participating centers. Risk Adjustment for Congenital Heart Surgery (RACHS) 1 and Aristotle Basic Complexity (ABC) scores were obtained. Descriptive statistics were provided, and the predictive values of the two scores for mortality were calculated by multivariate logistic regression models. RESULTS Many barriers and challenges were faced and overcome. Overall mortality was 13.4%. Independent predictors of in-hospital death were: RACHS-1 categories (3, 4, and 5/6), ABC level 4, and age group (≤ 30 days, and 30 days - 1 year). CONCLUSION The ASSIST project was successfully created over a solid base of collaborative work. The main challenges faced, and overcome, were lack of institutional support, funding, computational infrastructure, dedicated staff, and trust. RACHS-1 and ABC scores performed well in our case mix. Our preliminary outcome analysis shows opportunities for improvement.
Collapse
Affiliation(s)
- Fabio Carmona
- Hospital das Clinicas of Faculdade de Medicina de Ribeirão Preto of Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | - Paulo Henrique Manso
- Hospital das Clinicas of Faculdade de Medicina de Ribeirão Preto of Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | - Mariana Nicoletti Ferreira
- Hospital das Clinicas of Faculdade de Medicina de Ribeirão Preto of Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
| | - Nana Miura Ikari
- Heart Institute of Hospital das Clínicas of Faculdade de Medicina of Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP, Brazil
| | - Marcelo Biscegli Jatene
- Heart Institute of Hospital das Clínicas of Faculdade de Medicina of Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP, Brazil
| | - Luciana Amato
- Heart Institute of Hospital das Clínicas of Faculdade de Medicina of Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP, Brazil
| | - Aida Luiza Turquetto
- Heart Institute of Hospital das Clínicas of Faculdade de Medicina of Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP, Brazil
| | - Luiz Fernando Caneo
- Heart Institute of Hospital das Clínicas of Faculdade de Medicina of Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP, Brazil
| |
Collapse
|
12
|
Sullivan JL, Rivard PE, Shin MH, Rosen AK. Applying the High Reliability Health Care Maturity Model to Assess Hospital Performance: A VA Case Study. Jt Comm J Qual Patient Saf 2017; 42:389-411. [PMID: 27535456 DOI: 10.1016/s1553-7250(16)42080-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND The lack of a tool for categorizing and differentiating hospitals according to their high reliability organization (HRO)-related characteristics has hindered progress toward implementing and sustaining evidence-based HRO practices. Hospitals would benefit both from an understanding of the organizational characteristics that support HRO practices and from knowledge about the steps necessary to achieve HRO status to reduce the risk of harm and improve outcomes. The High Reliability Health Care Maturity (HRHCM) model, a model for health care organizations' achievement of high reliability with zero patient harm, incorporates three major domains critical for promoting HROs-Leadership, Safety Culture, and Robust Process Improvement ®. A study was conducted to examine the content validity of the HRHCM model and evaluate whether it can differentiate hospitals' maturity levels for each of the model's components. METHODS Staff perceptions of patient safety at six US Department of Veterans Affairs (VA) hospitals were examined to determine whether all 14 HRHCM components were present and to characterize each hospital's level of organizational maturity. RESULTS Twelve of the 14 components from the HRHCM model were detected; two additional characteristics emerged that are present in the HRO literature but not represented in the model-teamwork culture and system-focused tools for learning and improvement. Each hospital's level of organizational maturity could be characterized for 9 of the 14 components. DISCUSSION The findings suggest the HRHCM model has good content validity and that there is differentiation between hospitals on model components. Additional research is needed to understand how these components can be used to build the infrastructure necessary for reaching high reliability.
Collapse
Affiliation(s)
- Jennifer L Sullivan
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, USA
| | | | | | | |
Collapse
|
13
|
|
14
|
Patient Safety Science in Cardiothoracic Surgery: An Overview. Ann Thorac Surg 2016; 101:426-33. [DOI: 10.1016/j.athoracsur.2015.12.034] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 12/15/2015] [Accepted: 12/15/2015] [Indexed: 11/21/2022]
|
15
|
Wakeam E, Hyder JA, Ashley SW, Weissman JS. Barriers and Strategies for Effective Patient Rescue: A Qualitative Study of Outliers. Jt Comm J Qual Patient Saf 2014; 40:503-6. [PMID: 26111368 DOI: 10.1016/s1553-7250(14)40065-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Organizational factors influencing failure-to-rescue (FTR)-or death after postoperative complications-are poorly understood. Case studies were conducted to generate hypotheses that could inform future FTR research and improvement strategies. METHODS Publicly reported 2009-2011 data were used to identify 144 outlier hospitals with statistically better or worse FTR performance than the national average. Of these 144 hospitals, 7 were selected for case studies in a purposive sample. Outliers enabled a focus on the organizational factors and processes at the extremes of performance. Semi-structured interviews were conducted in 2013 with key informants at each hospital, and transcripts were analyzed using the constant comparative method to identify emergent organizational behavioral themes. RESULTS The 7 hospitals-4 high- and 3 low-performing-yielded 106 interviews. Critical barriers to effective rescue were ineffective communication, lack of psychological safety, staffing discontinuity, imbalance of shared ownership and individual responsibility, lack of appropriate training and education, and difficulty using current metrics. Participants also identified strategies to overcome these barriers-rapid response teams, flattening the hierarchy, escalation strategies, health information technology, structured communication tools, constant team structures, standardized care pathways, and organizational learning. CONCLUSION FTR is a complex process that is viewed, defined, and acted on differently across and within organizations. Early recognition of patients deviating from normal recovery was enhanced in high-performing hospitals through the use of standardized postoperative recovery pathways and automated escalation protocols. Current FTR measures may be less actionable for the purposes of quality improvement.
Collapse
Affiliation(s)
- Elliot Wakeam
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, USA
| | | | | | | |
Collapse
|
16
|
Barach P, Phelps G. Clinical sensemaking: a systematic approach to reduce the impact of normalised deviance in the medical profession. J R Soc Med 2013; 106:387-90. [PMID: 24097963 DOI: 10.1177/0141076813505045] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Paul Barach
- School of Medicine, University College Cork, Ireland, District 1
| | | |
Collapse
|
17
|
Koch CG. The New Organizational Vital Sign. Anesth Analg 2013. [DOI: 10.1213/ane.0b013e3182982c7e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
18
|
Kleinman LC, Dougherty D. Assessing quality improvement in health care: theory for practice. Pediatrics 2013; 131 Suppl 1:S110-9. [PMID: 23457146 DOI: 10.1542/peds.2012-1427n] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To review the role of theory as a means to enhance the practice of quality improvement (QI) research and to propose a novel conceptual model focused on the operations of health care. METHODS Conceptual model, informed by literature review. RESULTS To optimize learning across QI studies requires the integration of small-scale theories (middle-range theories, theories of change) within the context of larger unifying theories. We propose that health care QI research would benefit from a theory that describes the operations of health care delivery, including the multiplicity of roles that interpersonal interactions play. The broadest constructs of the model are entry into the system, and assessment and management of the patient, with the subordinate operations of access; recognition, assessment, and diagnosis; and medical decision-making (developing a plan), coordination of care, execution of care, referral and reassessment, respectively. Interpersonal aspects of care recognize the patient/caregiver as a source of information, an individual in a cultural context, a complex human being, and a partner in their care. Impacts to any and all of these roles may impact the quality of care. CONCLUSIONS Such a theory can promote opportunities for moving the field forward and organizing the planning and interpretation of comparable studies. The articulation of such a theory may simultaneously provide guidance for the QI researcher and an opportunity for refinement and improvement.
Collapse
Affiliation(s)
- Lawrence C Kleinman
- Mount Sinai School of Medicine, Department of Health Evidence and Policy, One Gustave Levy Place, Box 1077, New York, NY 10029, USA.
| | | |
Collapse
|