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Keuper J, van Tuyl LHD, de Geit E, Rijpkema C, Vis E, Batenburg R, Verheij R. The impact of eHealth use on general practice workload in the pre-COVID-19 era: a systematic review. BMC Health Serv Res 2024; 24:1099. [PMID: 39300456 DOI: 10.1186/s12913-024-11524-9] [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] [Received: 10/11/2023] [Accepted: 09/02/2024] [Indexed: 09/22/2024] Open
Abstract
BACKGROUND In recent years, eHealth has received much attention as an opportunity to increase efficiency within healthcare organizations. Adoption of eHealth might consequently help to solve perceived health workforce challenges, including labor shortages and increasing workloads among primary care professionals, who serve as the first point of contact for healthcare in many countries. The purpose of this systematic review was to investigate the impact of general eHealth use and specific eHealth services use on general practice workload in the pre-COVID-19 era. METHODS The databases of CINAHL, Cochrane, Embase, IEEE Xplore, Medline ALL, PsycINFO, Web of Science, and Google Scholar were searched, using combinations of keywords including 'eHealth', 'workload', and 'general practice'. Data extraction and quality assessment of the included studies were independently performed by at least two reviewers. Publications were included for the period 2010 - 2020, before the start of the COVID-19 pandemic. RESULTS In total, 208 studies describing the impact of eHealth services use on general practice workload were identified. We found that two eHealth services were mainly investigated within this context, namely electronic health records and digital communication services, and that the largest share of the included studies used a qualitative study design. Overall, a small majority of the studies found that eHealth led to an increase in general practice workload. However, results differed between the various types of eHealth services, as a large share of the studies also reported a reduction or no change in workload. CONCLUSIONS The impact of eHealth services use on general practice workload is ambiguous. While a small majority of the effects indicated that eHealth increased workload in general practice, a large share of the effects also showed that eHealth use reduced workload or had no impact. These results do not imply a definitive conclusion, which underscores the need for further explanatory research. Various factors, including the study setting, system design, and the phase of implementation, may influence this impact and should be taken into account when general practices adopt new eHealth services. STUDY REGISTRATION NUMBER PROSPERO (International Prospective Register of Systematic Reviews) CRD42020199897; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=199897 .
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Affiliation(s)
- Jelle Keuper
- Netherlands Institute for Health Services Research (NIVEL), Otterstraat 118, Utrecht, 3513CR, Netherlands.
- Tranzo, Tilburg School of Social and Behavioral Sciences, Tilburg University, Professor Cobbenhagenlaan 125, Tilburg, 5037DB, Netherlands.
| | - Lilian H D van Tuyl
- Netherlands Institute for Health Services Research (NIVEL), Otterstraat 118, Utrecht, 3513CR, Netherlands
| | - Ellemarijn de Geit
- Netherlands Institute for Health Services Research (NIVEL), Otterstraat 118, Utrecht, 3513CR, Netherlands
| | - Corinne Rijpkema
- Netherlands Institute for Health Services Research (NIVEL), Otterstraat 118, Utrecht, 3513CR, Netherlands
- Tranzo, Tilburg School of Social and Behavioral Sciences, Tilburg University, Professor Cobbenhagenlaan 125, Tilburg, 5037DB, Netherlands
| | - Elize Vis
- Netherlands Institute for Health Services Research (NIVEL), Otterstraat 118, Utrecht, 3513CR, Netherlands
| | - Ronald Batenburg
- Netherlands Institute for Health Services Research (NIVEL), Otterstraat 118, Utrecht, 3513CR, Netherlands
- Department of Sociology, Radboud University Nijmegen, Thomas van Aquinostraat 4, Nijmegen, 6525GD, Netherlands
| | - Robert Verheij
- Netherlands Institute for Health Services Research (NIVEL), Otterstraat 118, Utrecht, 3513CR, Netherlands
- Tranzo, Tilburg School of Social and Behavioral Sciences, Tilburg University, Professor Cobbenhagenlaan 125, Tilburg, 5037DB, Netherlands
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Willer F, Chua D, Ball L. Patient aggression towards receptionists in general practice: a systematic review. Fam Med Community Health 2023; 11:e002171. [PMID: 37414572 PMCID: PMC10335458 DOI: 10.1136/fmch-2023-002171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023] Open
Abstract
OBJECTIVE General practice receptionists provide an essential function in the healthcare system but routinely encounter acts of incivility and aggression from patients, including hostility, abuse and violence. This study was conducted to summarise what is known about patient-initiated aggression towards general practice receptionists, including impacts on reception staff and existing mitigation strategies. DESIGN Systematic review with convergent integrated synthesis. ELIGIBILITY CRITERIA Studies published at any time in English that examine patient aggression experiences of reception staff in primary care settings. INFORMATION SOURCES Searches of five major databases were performed (CINAHL Complete, Scopus, PubMed, Healthcare Administration Database and Google Scholar) to August 2022. RESULTS Twenty studies of various designs were included, ranging from the late 1970s to 2022 and originating from five OECD countries. Twelve were assessed as high quality using a validated checklist. Reviewed articles represented 4107 participants; 21.5% were general practice receptionists. All studies reported that displays of aggression towards receptionists by patients were a frequent and routine occurrence in general practice, particularly verbal abuse such as shouting, cursing, accusations of malicious behaviour and use of racist, ablest and sexist insults. Although infrequent, physical violence was widely reported. Inefficient appointment scheduling systems, delayed access to doctors and prescription denial appeared common precipitators. Receptionists adapted their behaviour and demeanour to placate and please patients to avoid escalation of patient frustrations at the cost of their own well-being and clinic productivity. Training in patient aggression management increased receptionist confidence and appeared to decrease negative sequalae. Coordinated support for general practice reception staff who had experienced patient aggression was generally lacking, with a small proportion receiving professional counselling. CONCLUSIONS Patient aggression towards reception staff is a serious workplace safety concern for general practices and negatively affects healthcare sector function more broadly. Receptionists in general practice deserve evidence-based measures to improve their working conditions and well-being for their own benefit and that of the community. REGISTRATION Pre-registered in Open Science Framework (osf.io/42p85).
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Affiliation(s)
- Fiona Willer
- Centre for Community Health and Wellbeing, The University of Queensland, Saint Lucia, Queensland, Australia
- School of Exercise and Nutrition Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
| | - David Chua
- Centre for Community Health and Wellbeing, The University of Queensland, Saint Lucia, Queensland, Australia
| | - Lauren Ball
- Centre for Community Health and Wellbeing, The University of Queensland, Saint Lucia, Queensland, Australia
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Bowie P, de Wet C, Crickett T, McCulloch J, Young P, Freestone J, Watson P, Houston N, Gillies J, McNab D. User redesign, testing and evaluation of the Monitoring Risk and Improving System Safety (MoRISS) checklist for the general practice work environment. BMJ Open Qual 2020; 9:bmjoq-2020-000977. [PMID: 33184042 PMCID: PMC7662415 DOI: 10.1136/bmjoq-2020-000977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 08/11/2020] [Accepted: 10/03/2020] [Indexed: 11/21/2022] Open
Abstract
Background Inadequate checking of safety-critical issues can compromise care quality in general practice (GP) work settings. Adopting a systemic, methodical approach may lead to improved standardisation of processes and reliability of task performance, strengthening the safety systems concerned. This study aimed to revise, modify and test the content and relevance of a previously validated safety checklist to the current GP context. Methods A multimethod study was undertaken in Scottish GP involving: consensus building workshops with users and ‘experts’ to revise checklist content; regional testing of the modified checklist and follow-up usability evaluation survey of users. Quantitative data underwent descriptive statistical analyses and selected survey free-text comments are presented. Results A redesigned checklist tool consisting of eight themes (eg, medication safety) and 61 items (eg, out-of-date stock is appropriately disposed) was agreed by 53 users/experts with items reclassified as: mandatory (n=25), essential (n=24) and advisory (n=12). Totally 42/55 GPs tested the tool and submitted checklist data (76.4%). The mean aggregated results demonstrated 92.0% compliance with all 61 checklist items (range: 83.0%–98.0%) and 25/42 GP managers responded to the survey (59.5%) and reported high mean levels of agreement on the usefulness of the checklist (77.0%), ease of use (89.0%), learnability (94.0%) and satisfaction (78.4%). Conclusions The checklist was comprehensively redesigned as a practical safety monitoring and improvement tool for potential implementation in Scottish GP. Testing and evaluation demonstrated high levels of checklist content compliance and strong usability feedback, but some variation was evident indicating room for improvement in current safety-critical checking processes. The checklist should be of interest in similar GP settings internationally and to other areas of primary care practice.
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Affiliation(s)
- Paul Bowie
- Medical Directorate, NHS Education for Scotland West Region, Glasgow, UK .,Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Carl de Wet
- Healthcare Improvement Unit, Queensland Health, Brisbane, Queensland, Australia.,School of Medicine, Griffith University, Nathan, Queensland, Australia
| | - Tracey Crickett
- Medical Directorate, NHS Education for Scotland West Region, Glasgow, UK
| | | | | | | | - Paul Watson
- Medical Directorate, NHS Education for Scotland West Region, Glasgow, UK
| | | | | | - Duncan McNab
- Medical Directorate, NHS Education for Scotland West Region, Glasgow, UK
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Kristiansen BK, Andersen B, Bro F, Svanholm H, Vedsted P. Direct notification of cervical cytology results to women improves follow-up in cervical cancer screening - A cluster-randomised trial. Prev Med Rep 2018; 13:118-125. [PMID: 30568870 PMCID: PMC6296289 DOI: 10.1016/j.pmedr.2018.11.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 10/23/2018] [Accepted: 11/22/2018] [Indexed: 11/27/2022] Open
Abstract
Up to half of all women do not receive follow-up as recommended after cervical cytology testing and are thus at increased risk of dysplasia progression. Women from lower social positions are at increased risk of not receiving follow-up. Sample takers, often general practitioners, convey results to women, but communication problems constitute a challenge. We aimed to investigate the effect of direct notification of cervical cytology results on follow-up rates. In a 1:1 cluster-randomised controlled trial, we assessed if having the pathology department convey cervical cytology results directly to the investigated women improved timely follow-up, compared with conveying the results via the general practitioner as usual. All women with a cervical cytology performed in a general practice in the Central Denmark Region (2013-2014) and receiving follow-up recommendation were included (n = 11,833). The proportion of women without timely follow-up was lower in the group with direct notifications than in the control group of women receiving usual care, regardless of age, educational status, cohabitation status and ethnicity. Among the women with the most severe cervical cytology diagnoses who are recommended gynaecological follow-up within 3 months, the percentage without timely follow-up was 15.1% in the intervention group and 19.5% in the control group (prevalence difference: -0.04 (95%CI: -0.07; -0.02)). Improved timely follow-up was also observed for women with a recommendation to have follow-up performed at 3 and 12 months. Cervical cytology results conveyed directly by letter to women increased the proportion of women with timely follow-up without raising inequality in follow-up measured by social position. Trial registration: ClinicalTrials.gov (TRN: NCT02002468) 29 November 2013.
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Key Words
- AGC, Atypical Glandular Cells
- AIS, adenocarcinoma in situ
- ASC-H, atypical squamous cells cannot exclude HSIL
- ASC-US, Atypical Squamous Cells of Undetermined Significance
- CCU, cancer of the cervix uteri
- CDR, Central Denmark Region
- DPDB, Danish National Pathology Registry and Data Bank
- Early detection of cancer
- GP, general practitioner
- General practice
- HSIL, High-grade Squamous Intraepithelial Lesion
- ICC, intra-cluster correlation coefficient
- LSIL, Low-grade Squamous Intraepithelial Lesion
- Mass screening
- PD, prevalence differences
- PR, prevalence ratio
- Quality of health care
- SNOMED, Systematized Nomenclature of Medicine
- Socioeconomic factors
- Uterine cervical dysplasia
- hrHPV-pos., high-risk Human Papilloma Virus positive
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Affiliation(s)
- Bettina Kjær Kristiansen
- Research Unit for General Practice, Department of Public Health, Aarhus University, 8000 Aarhus, Denmark.,Department for Public Health Programmes, Randers Regional Hospital, 8930 Randers, Denmark
| | - Berit Andersen
- Department for Public Health Programmes, Randers Regional Hospital, 8930 Randers, Denmark
| | - Flemming Bro
- Research Unit for General Practice, Department of Public Health, Aarhus University, 8000 Aarhus, Denmark
| | - Hans Svanholm
- Department of Pathology, Randers Regional Hospital, 8930 Randers, Denmark
| | - Peter Vedsted
- Research Centre for Cancer Diagnosis in Primary Care (CaP), Department of Public Health, Aarhus University, 8000 Aarhus, Denmark
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Baylis D, Price J, Bowie P. Content analysis of 50 clinical negligence claims involving test results management systems in general practice. BMJ Open Qual 2018; 7:e000463. [PMID: 30555934 PMCID: PMC6267325 DOI: 10.1136/bmjoq-2018-000463] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 10/30/2018] [Accepted: 11/06/2018] [Indexed: 11/30/2022] Open
Abstract
Background and aims Laboratory test results management systems are a complex safety issue in primary care settings worldwide. Related failures lead to avoidable patient harm, medicolegal action, patient complaints and additional workload to problem solve identified issues. We aimed to review and learn from 50 clinical negligence cases involving system failures related to the management of test results. Methods The Medical Protection Society database was searched and a convenience sample of 50 claims identified from a 3-year period covering 2014–2016. A content analysis of documentation was undertaken to quantify and theme data, aided by a Risk Assessment Matrix and the Yorkshire Contributory Factors Framework. Quantitative data were subjected to simple descriptive statistical analysis. Results 14/50 cases (28%) involved a delay in diagnosis or treatment of a patient with cancer. 15 cases were judged to be ‘never events’ (30%) and 85 distinct system issues were identified. Just under half of cases involved a failure to notify patients of an abnormal test result (n=24, 48%), while 18 cases (36%) involved a test result not being actioned by a doctor. The most frequently occurring contributory factors (n=30, 60%) were related to local working conditions, for example, unclear professional responsibilities with regards to test result review or follow-up or lack of patient care continuity. Conclusion This small study highlights why test result management systems fail and contribute to future litigation, providing new insights in this area. Most claims involved avoidable harm to patients and preventable organisational risks. The findings point to the inadequate design of practice systems and the need for proactive strategies to improve the management of test results in order to reduce patient harm.
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Affiliation(s)
| | | | - Paul Bowie
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
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Litchfield I, Bentham L, Hill A, McManus RJ, Lilford R, Greenfield S. The impact of status and social context on health service co-design: an example from a collaborative improvement initiative in UK primary care. BMC Med Res Methodol 2018; 18:136. [PMID: 30445914 PMCID: PMC6240286 DOI: 10.1186/s12874-018-0608-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 11/02/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Increasingly, collaborative participatory methods requiring open and honest interaction between a range of stakeholders are being used to improve health service delivery. To be successful these methodologies must incorporate perspectives from a range of patients and staff. Yet, if unaccounted for, the complex relationships amongst staff groups and between patients and providers can affect the veracity and applicability of co-designed solutions. METHODS Two focus groups convened to discuss suggestions for the improvement of blood testing and result communication in primary care. The groups were mixed of patients and staff in various combinations drawn from the four participating study practices. Here we present a secondary mixed-method analysis of the interaction between participants in both groups using sociogrammatic and thematic analysis. RESULTS Despite a similar mix of practice staff and patients the two groups produced contrasting discussions, seemingly influenced by status and social context. The sociograms provided a useful insight into the flow of conversation and highlighted the dominance of the senior staff member in the first focus group. Within the three key themes of social context, the alliances formed between participants and the fluidity of the roles assumed manifested differently between groups apparently dictated by the different profile of the participants of each. CONCLUSIONS For primary care service improvement attention must be paid to the background of participants when convening collaborative service improvement groups as status and imported hierarchies can have significant connotations for the data produced.
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Affiliation(s)
- Ian Litchfield
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.
| | - Louise Bentham
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Ann Hill
- Worcestershire Acute Hospitals NHS Trust, Worcester, UK
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Richard Lilford
- Warwick Centre for Applied Health Research and Delivery, Warwick Medical School, University of Warwick, Coventry, UK
| | - Sheila Greenfield
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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Maillet É, Paré G, Currie LM, Raymond L, Ortiz de Guinea A, Trudel MC, Marsan J. Laboratory testing in primary care: A systematic review of health IT impacts. Int J Med Inform 2018; 116:52-69. [PMID: 29887235 DOI: 10.1016/j.ijmedinf.2018.05.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 05/07/2018] [Accepted: 05/20/2018] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Laboratory testing in primary care is a fundamental process that supports patient management and care. Any breakdown in the process may alter clinical information gathering and decision-making activities and can lead to medical errors and potential adverse outcomes for patients. Various information technologies are being used in primary care with the goal to support the process, maximize patient benefits and reduce medical errors. However, the overall impact of health information technologies on laboratory testing processes has not been evaluated. OBJECTIVES To synthesize the positive and negative impacts resulting from the use of health information technology in each phase of the laboratory 'total testing process' in primary care. METHODS We conducted a systematic review. Databases including Medline, PubMed, CINAHL, Web of Science and Google Scholar were searched. Studies eligible for inclusion reported empirical data on: 1) the use of a specific IT system, 2) the impacts of the systems to support the laboratory testing process, and were conducted in 3) primary care settings (including ambulatory care and primary care offices). Our final sample consisted of 22 empirical studies which were mapped to a framework that outlines the phases of the laboratory total testing process, focusing on phases where medical errors may occur. RESULTS Health information technology systems support several phases of the laboratory testing process, from ordering the test to following-up with patients. This is a growing field of research with most studies focusing on the use of information technology during the final phases of the laboratory total testing process. The findings were largely positive. Positive impacts included easier access to test results by primary care providers, reduced turnaround times, and increased prescribed tests based on best practice guidelines. Negative impacts were reported in several studies: paper-based processes employed in parallel to the electronic process increased the potential for medical errors due to clinicians' cognitive overload; systems deemed not reliable or user-friendly hampered clinicians' performance; and organizational issues arose when results tracking relied on the prescribers' memory. DISCUSSION The potential of health information technology lies not only in the exchange of health information, but also in knowledge sharing among clinicians. This review has underscored the important role played by cognitive factors, which are critical in the clinician's decision-making, the selection of the most appropriate tests, correct interpretation of the results and efficient interventions. CONCLUSIONS By providing the right information, at the right time to the right clinician, many IT solutions adequately support the laboratory testing process and help primary care clinicians make better decisions. However, several technological and organizational barriers require more attention to fully support the highly fragmented and error-prone process of laboratory testing.
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Affiliation(s)
- Éric Maillet
- Faculty of Medicine and Health Sciences, School of Nursing, University of Sherbrooke, 150, place Charles-Le Moyne, Longueuil, Québec, Canada, J4K 0A8.
| | - Guy Paré
- Information Technology Department, HEC Montréal, Montréal, Québec, Canada.
| | - Leanne M Currie
- School of Nursing University of British Columbia, Vancouver, British Columbia, Canada.
| | - Louis Raymond
- Institut de recherche sur les PME, Université du Québec à Trois-Rivières, Trois-Rivières, Québec, Canada.
| | - Ana Ortiz de Guinea
- Information Technology Department, HEC Montréal, Montréal, Québec, Canada; Department of Strategy and Information Systems Deusto Business School, Universidad de Deusto (Spain).
| | | | - Josianne Marsan
- Department of Management Information Systems, Université Laval, Québec, Canada.
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Gomes ATDL, Alves KYA, Bezerril MDS, Rodrigues CCFM, Ferreira Júnior MA, Santos VEP. Validação de protocolos gráficos para avaliação da segurança do paciente politraumatizado. ACTA PAUL ENFERM 2018. [DOI: 10.1590/1982-0194201800071] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Resumo Objetivo: Validar o conteúdo e a aparência dos protocolos gráficos para avaliação da estrutura, processo e resultado do cuidado seguro de enfermagem ao paciente politraumatizado em situação de emergência. Métodos: Estudo metodológico e quantitativo. Para a coleta de dados, aplicou-se a técnica de Delphi em duas rodadas (Delphi I e Delphi II). A amostra do Delphi I consistiu em 15 juízes e o Delphi II arrolou 13 juízes. Considerou-se válidos aqueles itens dos protocolos com Índice de Validação de Conteúdo (IVC) maior que 0.78 e consenso de mais de 70,0% na técnica de Delphi. Os dados foram analisados por meio de estatística descritiva e inferencial (Teste de Wilcoxon e Binomial). Adotou-se o ρ-valor ≤ 0,05 para a significância estatística. Além disso, aplicou-se o Alfa de Cronbach (α) para avaliar a consistência interna dos protocolos. Considerou-se confiável aquele item que apresentasse o α ≥ 0,7. Resultados: Todos os requisitos de avaliação dos protocolos alcançaram concordância entre os juízes superior a 80,0%, bem como todos os itens alcançaram níveis de avaliação estatisticamente significativos. Ao final do Delphi II, os três protocolos se apresentaram expressivamente válidos (estrutura [IVC = 0,92]; processo [IVC = 0,96]; e, resultado [IVC = 0,96]) e confiáveis (estrutura [α = 0,95]; processo [α = 0,95]; e, resultado [α = 0,89]). Conclusão: Atingiu-se a validação de conteúdo e de aparência dos protocolos integralmente, assim como, a validação interna com exímio.
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Grosset KA, Deary E, El-Farargy N. Patient-centred improvement to repeat prescribing using the Always Event concept. BMJ Open Qual 2017; 6:e000042. [PMID: 29450268 PMCID: PMC5717943 DOI: 10.1136/bmjoq-2017-000042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Revised: 10/20/2017] [Accepted: 11/01/2017] [Indexed: 11/04/2022] Open
Abstract
Repeat prescriptions are prescriptions issued to a patient for a second or subsequent time without requiring a consultation with a doctor. Repeat prescribing is common and an efficient system is necessary to deliver a high-quality service. Always Events can be used to drive patient-centred improvements in healthcare delivery. Our aim was to use the Always Event concept to improve our repeat prescribing system. This quality improvement project was carried out in a deprived, inner-city general practice setting in Glasgow, UK. 51 patients taking repeat medications completed short questionnaires, and the Always Event ‘Repeat prescriptions should be ready and available to collect’ was generated. We used the Plan-Do-Study-Act cycles to elucidate how our system could be improved and check if our intervention was effective. Over a 3-day period in July 2016, 269 out of 292 prescriptions (92.1%) were ready. We mapped out the repeat prescribing process and discovered that sometimes reception staff graded a request as inappropriate, for example, requested too early, and these requests were therefore not processed. Patients would then attend to collect a prescription that was not there. This was both inconvenient for the patient and time-consuming for the reception staff to investigate the reason. Our system was changed so that any request that was not being processed was recorded and the patient informed. In September 260 out of 267 (97.4%) prescriptions were ready, in November 350 out of 364 (96.2%), and in February 2017 314 out of 323 (97.2%) were ready. In conclusion, the Always Event approach allowed us to elicit important feedback from patients to identify a weakness in our repeat prescribing system, which was simple to rectify and led to an improved, more efficient service.
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Affiliation(s)
| | - Elaine Deary
- The Cairns Practice, Shettleston Health Centre, Glasgow, UK
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Abstract
In the second paper of this series, we provide a brief overview of the scientific discipline of human factors and ergonomics (HFE). Traditionally the HFE focus in healthcare has been in acute hospital settings which are perceived to exhibit characteristics more similar to other high-risk industries already applying related principles and methods. This paper argues that primary care is an area which could benefit extensively from an HFE approach, specifically in improving the performance and well-being of people and organisations. To this end, we define the purpose of HFE, outline its three specialist sub-domains (physical, cognitive and organisational HFE) and provide examples of guiding HFE principles and practices. Additionally, we describe HFE issues of significance to primary care education, improvement and research and outline early plans for building capacity and capability in this setting.
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Affiliation(s)
- Paul Bowie
- a Medical Directorate , NHS Education for Scotland , Glasgow , UK.,b Institute of Health and Well-Being, University of Glasgow , Glasgow , UK
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11
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Grant S, Checkland K, Bowie P, Guthrie B. The role of informal dimensions of safety in high-volume organisational routines: an ethnographic study of test results handling in UK general practice. Implement Sci 2017; 12:56. [PMID: 28449716 PMCID: PMC5408428 DOI: 10.1186/s13012-017-0586-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 04/21/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The handling of laboratory, imaging and other test results in UK general practice is a high-volume organisational routine that is both complex and high risk. Previous research in this area has focused on errors and harm, but a complementary approach is to better understand how safety is achieved in everyday practice. This paper ethnographically examines the role of informal dimensions of test results handling routines in the achievement of safety in UK general practice and how these findings can best be developed for wider application by policymakers and practitioners. METHODS Non-participant observation was conducted of high-volume organisational routines across eight UK general practices with diverse organisational characteristics. Sixty-two semi-structured interviews were also conducted with the key practice staff alongside the analysis of relevant documents. RESULTS While formal results handling routines were described similarly across the eight study practices, the everyday structure of how the routine should be enacted in practice was informally understood. Results handling safety took a range of local forms depending on how different aspects of safety were prioritised, with practices varying in terms of how they balanced thoroughness (i.e. ensuring the high-quality management of results by the most appropriate clinician) and efficiency (i.e. timely management of results) depending on a range of factors (e.g. practice history, team composition). Each approach adopted created its own potential risks, with demands for thoroughness reducing productivity and demands for efficiency reducing handling quality. Irrespective of the practice-level approach adopted, staff also regularly varied what they did for individual patients depending on the specific context (e.g. type of result, patient circumstances). CONCLUSIONS General practices variably prioritised a legitimate range of results handling safety processes and outcomes, each with differing strengths and trade-offs. Future safety improvement interventions should focus on how to maximise practice-level knowledge and understanding of the range of context-specific approaches available and the safeties and risks inherent in each within the context of wider complex system conditions and interactions. This in turn has the potential to inform new kinds of proactive, contextually appropriate approaches to intervention development and implementation focusing on the enhanced deliberation of the safety of existing high-volume routines.
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Affiliation(s)
- Suzanne Grant
- Population Health Sciences, School of Medicine, University of Dundee, The Mackenzie Building, Kirsty Semple Way, Dundee, DD2 4BF, UK.
| | - Katherine Checkland
- Health Policy, Politics and Organisation (HiPPO) Research Group, Centre for Primary Care, Institute of Population Health, University of Manchester, 5th Floor, Williamson Building, Oxford Road, Manchester, M13 9PL, UK
| | - Paul Bowie
- NHS Education for Scotland, 2 Central Quay, Glasgow, G3 8BW, UK
| | - Bruce Guthrie
- Population Health Sciences, School of Medicine, University of Dundee, The Mackenzie Building, Kirsty Semple Way, Dundee, DD2 4BF, UK
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Bowie P, Price J, Hepworth N, Dinwoodie M, McKay J. System hazards in managing laboratory test requests and results in primary care: medical protection database analysis and conceptual model. BMJ Open 2015; 5:e008968. [PMID: 26614621 PMCID: PMC4663465 DOI: 10.1136/bmjopen-2015-008968] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 08/04/2015] [Accepted: 08/18/2015] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVES To analyse a medical protection organisation's database to identify hazards related to general practice systems for ordering laboratory tests, managing test results and communicating test result outcomes to patients. To integrate these data with other published evidence sources to inform design of a systems-based conceptual model of related hazards. DESIGN A retrospective database analysis. SETTING General practices in the UK and Ireland. PARTICIPANTS 778 UK and Ireland general practices participating in a medical protection organisation's clinical risk self-assessment (CRSA) programme from January 2008 to December 2014. MAIN OUTCOME MEASURES Proportion of practices with system risks; categorisation of identified hazards; most frequently occurring hazards; development of a conceptual model of hazards; and potential impacts on health, well-being and organisational performance. RESULTS CRSA visits were undertaken to 778 UK and Ireland general practices of which a range of systems hazards were recorded across the laboratory test ordering and results management systems in 647 practices (83.2%). A total of 45 discrete hazard categories were identified with a mean of 3.6 per practice (SD=1.94). The most frequently occurring hazard was the inadequate process for matching test requests and results received (n=350, 54.1%). Of the 1604 instances where hazards were recorded, the most frequent was at the 'postanalytical test stage' (n=702, 43.8%), followed closely by 'communication outcomes issues' (n=628, 39.1%). CONCLUSIONS Based on arguably the largest data set currently available on the subject matter, our study findings shed new light on the scale and nature of hazards related to test results handling systems, which can inform future efforts to research and improve the design and reliability of these systems.
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Affiliation(s)
- Paul Bowie
- Department of Medicine, NHS Education for Scotland, Glasgow, UK
- Institute of Health and Wellbeing, University of Glasgow, UK
| | | | | | | | - John McKay
- Department of Medicine, NHS Education for Scotland, Glasgow, UK
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Abstract
BACKGROUND The use of checklists to minimise errors is well established in high reliability, safety-critical industries. In health care there is growing interest in checklists to standardise checking processes and ensure task completion, and so provide further systemic defences against error and patient harm. However, in UK general practice there is limited experience of safety checklist use. AIM To identify workplace hazards that impact on safety, health and wellbeing, and performance, and codesign a standardised checklist process. DESIGN AND SETTING Application of mixed methods to identify system hazards in Scottish general practices and develop a safety checklist based on human factors design principles. METHOD A multiprofessional 'expert' group (n = 7) and experienced front-line GPs, nurses, and practice managers (n = 18) identified system hazards and developed and validated a preliminary checklist using a combination of literature review, documentation review, consensus building workshops using a mini-Delphi process, and completion of content validity index exercise. RESULTS A prototype safety checklist was developed and validated consisting of six safety domains (for example, medicines management), 22 sub-categories (for example, emergency drug supplies) and 78 related items (for example, stock balancing, secure drug storage, and cold chain temperature recording). CONCLUSION Hazards in the general practice work system were prioritised that can potentially impact on the safety, health and wellbeing of patients, GP team members, and practice performance, and a necessary safety checklist prototype was designed. However, checklist efficacy in improving safety processes and outcomes is dependent on user commitment, and support from leaders and promotional champions. Although further usability development and testing is necessary, the concept should be of interest in the UK and internationally.
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Elder NC. Laboratory testing in general practice: a patient safety blind spot. BMJ Qual Saf 2015; 24:667-70. [PMID: 26286473 DOI: 10.1136/bmjqs-2015-004644] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2015] [Indexed: 11/03/2022]
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Litchfield I, Bentham L, Hill A, McManus RJ, Lilford R, Greenfield S. Routine failures in the process for blood testing and the communication of results to patients in primary care in the UK: a qualitative exploration of patient and provider perspectives. BMJ Qual Saf 2015; 24:681-90. [PMID: 26251507 PMCID: PMC4680130 DOI: 10.1136/bmjqs-2014-003690] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 06/18/2015] [Indexed: 11/04/2022]
Abstract
BACKGROUND The testing and result communication process in primary care is complex. Its successful completion relies on the coordinated efforts of a range of staff in primary care and external settings working together with patients. Despite the importance of diagnostic testing in provision of care, this complexity renders the process vulnerable in the face of increasing demand, stretched resources and a lack of supporting guidance. METHODS We conducted a series of focus groups with patients and staff across four primary care practices using process-improvement strategies to identify and understand areas where either unnecessary delay is introduced, or the process may fail entirely. We then worked with both patients and staff to arrive at practical strategies to improve the current system. RESULTS A total of six areas across the process were identified where improvements could be introduced. These were: (1) delay in phlebotomy, (2) lack of a fail-safe to ensure blood tests are returned to practices and patients, (3) difficulties in accessing results by telephone, (4) role of non-clinical staff in communicating results, (5) routine communication of normal results and (6) lack of a protocol for result communication. CONCLUSIONS A number of potential failures in testing and communicating results to patients were identified, and some specific ideas for improving existing systems emerged. These included same-day phlebotomy sessions, use of modern technology methods to proactively communicate routine results and targeted training for receptionists handling sensitive data. There remains an urgent need for further work to test these and other potential solutions.
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Affiliation(s)
- Ian Litchfield
- School of Health and Population Sciences, Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Louise Bentham
- School of Health and Population Sciences, Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Ann Hill
- Department of Transformation, Worcestershire Acute Hospitals, Worcestershire, UK
| | - Richard J McManus
- Nuffield Department Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Richard Lilford
- Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Sheila Greenfield
- School of Health and Population Sciences, Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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Litchfield I, Bentham L, Lilford R, McManus RJ, Hill A, Greenfield S. Test result communication in primary care: a survey of current practice. BMJ Qual Saf 2015; 24:691-9. [PMID: 26243888 PMCID: PMC4680128 DOI: 10.1136/bmjqs-2014-003712] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 06/18/2015] [Indexed: 11/21/2022]
Abstract
Background The number of blood tests ordered in primary care continues to increase and the timely and appropriate communication of results remains essential. However, the testing and result communication process includes a number of participants in a variety of settings and is both complicated to manage and vulnerable to human error. In the UK, guidelines for the process are absent and research in this area is surprisingly scarce; so before we can begin to address potential areas of weakness there is a need to more precisely understand the strengths and weaknesses of current systems used by general practices and testing facilities. Methods We conducted a telephone survey of practices across England to determine the methods of managing the testing and result communication process. In order to gain insight into the perspectives from staff at a large hospital laboratory we conducted paired interviews with senior managers, which we used to inform a service blueprint demonstrating the interaction between practices and laboratories and identifying potential sources of delay and failure. Results Staff at 80% of practices reported that the default method for communicating normal results required patients to telephone the practice and 40% of practices required that patients also call for abnormal results. Over 80% had no fail-safe system for ensuring that results had been returned to the practice from laboratories; practices would otherwise only be aware that results were missing or delayed when patients requested results. Persistent sources of missing results were identified by laboratory staff and included sample handling, misidentification of samples and the inefficient system for collating and resending misdirected results. Conclusions The success of the current system relies on patients both to retrieve results and in so doing alert staff to missing and delayed results. Practices appear slow to adopt available technological solutions despite their potential for reducing the impact of recurring errors in the handling of samples and the reporting of results. Our findings will inform our continuing work with patients and staff to develop, implement and evaluate improvements to existing systems of managing the testing and result communication process.
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Affiliation(s)
- Ian Litchfield
- School of Health and Population Sciences, Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Louise Bentham
- School of Health and Population Sciences, Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Richard Lilford
- Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ann Hill
- Department of Transformation, Worcestershire Acute Hospitals NHS Trust, Worcester, UK
| | - Sheila Greenfield
- School of Health and Population Sciences, Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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