Getting going together: can clinical teams and managers collaborate to identify problems and initiate improvement?

Understanding how and why audits work in improving the quality of hospital care: A systematic realist review

BACKGROUND

Several types of audits have been used to promote quality improvement (QI) in hospital care. However, in-depth studies into the mechanisms responsible for the effectiveness of audits in a given context is scarce. We sought to understand the mechanisms and contextual factors that determine why audits might, or might not, lead to improved quality of hospital care.

METHODS

A realist review was conducted to systematically search and synthesise the literature on audits. Data from individual papers were synthesised by coding, iteratively testing and supplementing initial programme theories, and refining these theories into a set of context-mechanism-outcome configurations (CMOcs).

RESULTS

From our synthesis of 85 papers, seven CMOcs were identified that explain how audits work: (1) externally initiated audits create QI awareness although their impact on improvement diminishes over time; (2) a sense of urgency felt by healthcare professionals triggers engagement with an audit; (3) champions are vital for an audit to be perceived by healthcare professionals as worth the effort; (4) bottom-up initiated audits are more likely to bring about sustained change; (5) knowledge-sharing within externally mandated audits triggers participation by healthcare professionals; (6) audit data support healthcare professionals in raising issues in their dialogues with those in leadership positions; and (7) audits legitimise the provision of feedback to colleagues, which flattens the perceived hierarchy and encourages constructive collaboration.

CONCLUSIONS

This realist review has identified seven CMOcs that should be taken into account when seeking to optimise the design and usage of audits. These CMOcs can provide policy makers and practice leaders with an adequate conceptual grounding to design contextually sensitive audits in diverse settings and advance the audit research agenda for various contexts.

PROSPERO REGISTRATION

CRD42016039882.

Insights into physician scheduling: a case study of public hospital departments in Sweden

PURPOSE

The purpose of this paper is to describe current physician scheduling and concomitant opportunities for improvement in public hospital departments in Sweden.

DESIGN/METHODOLOGY/APPROACH

A total of 13 departments spread geographically across Sweden covering seven different specialties participated in the study. Data were collected through interviews with individuals involved in creating physician schedules. All departments investigated provided copies of the documents necessary for physician scheduling.

FINDINGS

Physician scheduling required the temporal coordination of patients, physicians, non-physician staff, rooms and equipment. A six-step process for creating physician schedules could be distinguished: capacity and demand overview, demand goal and schedule setting, vacation and leave requests, schedule creation, schedule revision, and schedule execution. Several opportunities for improvement could be outlined; e.g. overreliance on memory, lacking coordination of resources, and redundant data entering.

RESEARCH LIMITATIONS/IMPLICATIONS

The paucity of previous studies on physician scheduling lends an exploratory character to this study and calls for a more thorough evaluation of the feasibility and effects of the approaches proposed. The study excluded the scheduling of non-physician staff.

PRACTICAL IMPLICATIONS

To improve physician scheduling and enable timeliness, three approaches are proposed: reinforcing centralisation, creating learning opportunities, and improving integration.

ORIGINALITY/VALUE

This paper is among the few to investigate physician scheduling, which is essential for delivering high quality care, particularly concerning timeliness. Several opportunities for improvement identified in this study are not exclusive to physician scheduling but are pervasive in healthcare processes in general.

Context challenges the champion: improving hip fracture care in a Swedish university hospital

PURPOSE

The purpose of this paper is to describe and explain a clinician-led improvement of a hip fracture care process in a university hospital, and to assess the results and factors helping and hindering change implementation.

DESIGN/METHODOLOGY/APPROACH

The paper has a mixed methods case study design. Data collection was guided by a framework directing attention to the content and process of the change, its context and outcomes.

FINDINGS

Using a multiprofessional project team, beneficial changes in the early parts of the care process were achieved, but inability to change surgical staff work practices meant that the original goal of operating patients within 24 hours was not reached. After three years, top management introduced a hospital-wide process improvement programme, which "took over" the responsibility for improving hip fracture care.

RESEARCH IMPLICATIONS/LIMITATIONS

A clear vision why change is needed and what needs to be done, which is well communicated by a respected clinical leader, can motivate personnel, but other influences are also needed to bring about change. Without a plan agreed and supported by top management, changes are likely to be limited to parts of the process and improvements to patient care may be minimal. These and other findings may be applicable to similar situations in other services.

ORIGINALITY/VALUE

This case study is an illustration of both the strengths and the weaknesses of a "bottom-up, clinician-champion-led improvement initiative" in a complex university hospital.

How does lean work in emergency care? A case study of a lean-inspired intervention at the Astrid Lindgren Children's hospital, Stockholm, Sweden

Background

There is growing interest in applying lean thinking in healthcare, yet, there is still limited knowledge of how and why lean interventions succeed (or fail). To address this gap, this in-depth case study examines a lean-inspired intervention in a Swedish pediatric Accident and Emergency department.

Methods

We used a mixed methods explanatory single case study design. Hospital performance data were analyzed using analysis of variance (ANOVA) and statistical process control techniques to assess changes in performance one year before and two years after the intervention. We collected qualitative data through non-participant observations, semi-structured interviews, and internal documents to describe the process and content of the lean intervention. We then analyzed empirical findings using four theoretical lean principles (Spear and Bowen 1999) to understand how and why the intervention worked in its local context as well as to identify its strengths and weaknesses.

Results

Improvements in waiting and lead times (19-24%) were achieved and sustained in the two years following lean-inspired changes to employee roles, staffing and scheduling, communication and coordination, expertise, workspace layout, and problem solving. These changes resulted in improvement because they: (a) standardized work and reduced ambiguity, (b) connected people who were dependent on one another, (c) enhanced seamless, uninterrupted flow through the process, and (d) empowered staff to investigate problems and to develop countermeasures using a "scientific method". Contextual factors that may explain why not even greater improvement was achieved included: a mismatch between job tasks, licensing constraints, and competence; a perception of being monitored, and discomfort with inter-professional collaboration.

Conclusions

Drawing on Spear and Bowen's theoretical propositions, this study explains how a package of lean-like changes translated into better care process management. It adds new knowledge regarding how lean principles can be beneficially applied in healthcare and identifies changes to professional roles as a potential challenge when introducing lean thinking there. This knowledge may enable health care organizations and managers in other settings to configure their own lean program and to better understand the reasons behind lean's success (or failure).

Patient safety in elderly hip fracture patients: design of a randomised controlled trial

Background

The clinical environment in which health care providers have to work everyday is highly complex; this increases the risk for the occurrence of unintended events. The aim of this randomised controlled trial is to improve patient safety for a vulnerable group of patients that have to go through a complex care chain, namely elderly hip fracture patients.

Methods/design

A randomised controlled trial that consists of three interventions; these will be implemented in three surgical wards in Dutch hospitals. One surgical ward in another hospital will be the control group. The first intervention is aimed at improving communication between care providers using the SBAR communication tool. The second intervention is directed at stimulating the role of the patient within the care process with a patient safety card. The third intervention consists of a leaflet for patients with information on the most common complications for the period after discharge. The primary outcome measures in this study are the incidence of complications and adverse events, mortality rate within six months after discharge and functional mobility six months after discharge. Secondary outcome measures are length of hospital stay, quality and completeness of information transfer and patient satisfaction with the instruments.

Discussion

The results will give insight into the nature and scale of complications and adverse events that occur in elderly hip fracture patients. Also, the implementation of three interventions aimed at improving the communication and information transfer provides valuable possibilities for improving patient safety in this increasing patient group. This study combines the use of three interventions, which is an innovative aspect of the study.

Trial registration

The Netherlands National Trial Register NTR1562

Commitment of project participants to developing health care services based on the internet technology

BACKGROUND

When developing Information and Communication Technology (ICT), such as services for the decision-making process, skilled health care professionals with their comprehensive knowledge of patients/clients are essential contributors to the project. Careful evaluation is needed to assess the effectiveness of project management as well as to analyze the commitment of the personnel to goal attainment.

OBJECTIVE

In the course of the development of integrated maternity care services, the commitment of project participants (n=48) was evaluated. What factors enhanced or impaired their commitment to the project work?

METHODS

Questionnaire (n=80, response rate 60%) with quantitative analysis as well as open-ended questions with qualitative content analysis.

RESULTS

Positive commitment was related to a confidential and open atmosphere during the project. The utilization of personal skills and experience was appreciated. Differences in the working principles and cultures between the participating organizations complicated fluent collaboration. To encourage commitment, a lot of attention should be paid to internal communication as well as the effective realization of project tasks.

CONCLUSION

The strength of the project was the highly innovative and confidential atmosphere. The well-established project goals, the highly inspired project team, and the effective co-operation between the project manager and the core group helped to deepen overall commitment in the project.