Translating concerns into action: a detailed qualitative evaluation of an interdisciplinary intervention on medical wards

Enhancing capability for continuous organisational improvement and learning in healthcare organisations: a systematic review of the literature 2013-2022

BACKGROUND

Healthcare organisations strive to meet their current and future challenges and need to increase their capacity for continuous organisational improvement and learning (COIL). A key aspect of this capacity is the development of COIL capability among employees.

OBJECTIVE

This systematic review aims to explore common attributes of interventions that contribute to the development of COIL capability in healthcare organisations and to explore possible facilitating and hindering factors.

METHODS

A comprehensive search was conducted in Scopus, MEDLINE and Business Source Complete for primary research studies in English or Swedish, in peer-reviewed journals, focusing on organisational improvements and learning in healthcare organisations. Studies were included if they were published between 2013 and 23 November 2022, reported outcomes on COIL capability, included organisations or groups, and were conducted in high-income countries. The included articles were analysed to identify themes related to successful interventions and factors influencing COIL capability.

RESULTS

Thirty-six articles were included, with two studies reporting unsuccessful attempts at increasing COIL capability. The studies were conducted in nine different countries, encompassing diverse units, with the timeframes varying from 15 weeks to 8 years, and they employed quantitative (n=10), qualitative (n=11) and mixed methods (n=15). Analysis of the included articles identified four themes for both attributes of interventions and the factors that facilitated or hindered successful interventions: (1) engaged managers with a strategic approach, (2) external training and guidance to develop internal knowledge, skills and confidence, (3) process and structure to achieve improvements and learning and (4) individuals and teams with autonomy, accountability, and safety.

CONCLUSION

This review provides insights into the intervention attributes that are associated with increasing COIL capability in healthcare organisations as well as factors that can have hindering or facilitating effects. Strategic management, external support, structured processes and empowered teams emerged as key elements for enhancing COIL capability.

Towards diagnostic excellence on academic ward teams: building a conceptual model of team dynamics in the diagnostic process

OBJECTIVES

Achieving diagnostic excellence on medical wards requires teamwork and effective team dynamics. However, the study of ward team dynamics in teaching hospitals is relatively underdeveloped. We aim to enhance understanding of how ward team members interact in the diagnostic process and of the underlying behavioral, psychological, and cognitive mechanisms driving team interactions.

METHODS

We used mixed-methods to develop and refine a conceptual model of how ward team dynamics in an academic medical center influence the diagnostic process. First, we systematically searched existing literature for conceptual models and empirical studies of team dynamics. Then, we conducted field observations with thematic analysis to refine our model.

RESULTS

We present a conceptual model of how medical ward team dynamics influence the diagnostic process, which serves as a roadmap for future research and interventions in this area. We identified three underexplored areas of team dynamics that are relevant to diagnostic excellence and that merit future investigation (1): ward team structures (e.g., team roles, responsibilities) (2); contextual factors (e.g., time constraints, location of team members, culture, diversity); and (3) emergent states (shared mental models, psychological safety, team trust, and team emotions).

CONCLUSIONS

Optimizing the diagnostic process to achieve diagnostic excellence is likely to depend on addressing all of the potential barriers and facilitators to ward team dynamics presented in our model.

Employee-Driven Innovation in Health Organizations: Insights From a Scoping Review

BACKGROUND

Employee-driven innovation (EDI) occurs when frontline actors in health organizations use their firsthand experience to spur new ideas to transform care. Despite its increasing prevalence in health organizations, the organizational conditions under which EDI is operationalized have received little scholarly attention.

METHODS

This scoping review identifies gaps and assembles existing knowledge on four questions: What is EDI in health organizations and which frontline actors are involved? What are the characteristics of the EDI process? What contextual factors enable or impede EDI? And what benefits does EDI bring to health organizations? We searched seven databases with keywords related to EDI in health organizations. After screening 1580 studies by title and abstract, we undertook full-text review of 453 articles, retaining 60 for analysis. We performed a descriptive and an inductive thematic analysis guided by the four questions.

RESULTS

Findings reveal an heterogeneous literature. Most articles are descriptive (n = 41). Few studies are conceptual and empirical (n = 15) and four are conference papers. EDI was often described as a participatory, learning innovation process involving frontline clinical and non-clinical staff and managers. Majority EDI were top-down, often driven by the organization's focus on participatory improvement and innovation and research-based initiatives. Five categories of methods is used in top-down EDI, two thirds of which includes a learning, a team and/or a digital component. Hybrid EDI often involves a team-based component. Bottom-up EDI emerged spontaneously from the work of frontline actors. Enablers, barriers, and benefits of EDI are seen at macro, organizational, team and individual levels; some benefits spread to other health organizations and health systems.

CONCLUSION

This scoping review provides a comprehensive understanding of the organizational conditions under which EDI is operationalized. It offers insights for researchers, health organizations, and policy-makers about how and why frontline actors' involvement is crucial for the transformation of care.

A qualitative systematic review on the application of the normalization of deviance phenomenon within high-risk industries

INTRODUCTION

The concept of normalization of deviance describes the gradual acceptance of deviant observations and practices. It is founded upon the gradual desensitization to risk experienced by individuals or groups who recurrently deviate from standard operating procedures without encountering negative consequences. Since its inception, normalization of deviance has seen extensive, but segmented, application across numerous high-risk industrial contexts. The current paper describes a systematic review of the existing literature on the topic of normalization of deviance within high-risk industrial settings.

METHOD

Four major databases were searched in order to identify relevant academic literature, with 33 academic papers meeting all inclusion criteria. Directed content analysis was used to analyze the texts.

RESULTS

Based on the review, an initial conceptual framework was developed to encapsulate identified themes and their interactions; key themes linked to the normalization of deviance included risk normalization, production pressure, culture, and a lack of negative consequences.

CONCLUSIONS

While preliminary, the present framework offers relevant insights into the phenomenon that may help guide future analysis using primary data sources and aid in the development of intervention methods.

PRACTICAL APPLICATIONS

Normalization of deviance is an insidious phenomenon that has been noted in several high-profile disasters across a variety of industrial settings. A number of organizational factors allow for and/or propagate this process, and as such, the phenomenon should be considered as an aspect of safety evaluations and interventions.

An evaluation of the implementation of interventions to reduce postoperative infections and optimise antibiotic use across the surgical pathway in India: a mixed-methods exploratory study protocol

INTRODUCTION

Postoperative infections represent a significant burden of disease, demanding antibiotic prescriptions, and are contributing to antimicrobial resistance. The burden of infection as a surgical complication is greater in low- and middle-income countries (LMICs). We report the protocol of a pilot study for the co-design, implementation and evaluation of two infection prevention and control (IPC) and antimicrobial stewardship (AMS) interventions across the surgical pathway in a teaching hospital in India.

METHODS AND ANALYSIS

The two interventions developed following in-depth qualitative enquiry are (i) surveillance and feedback of postoperative infections to optimise the use of antibiotics in two surgical departments (gastrointestinal and cardiovascular and thoracic surgery) and (ii) raising awareness amongst patients, carers and members of public about IPC and AMS. We will conduct a prospective study, formatively evaluating the implementation process of delivering the two co-designed interventions using implementation science frameworks. The study will systematically assess the context of intervention delivery, so that implementation support for the interventions may be adapted to the needs of stakeholders throughout the study. Analysis of implementation logs and interviews with stakeholders upon completion of the implementation period, will offer insights into the perceived acceptability, appropriateness, feasibility and sustainability of the interventions and their implementation support. Implementation costs will be captured descriptively. Feasibility of clinical data collection to investigate effectiveness of interventions will also be assessed for a future larger study. Thematic framework analysis and descriptive statistics will be used to report the qualitative and quantitative data, respectively.

STRENGTHS AND LIMITATIONS OF THIS STUDY

• The paired interventions have been co-designed from their inception with involvement of stakeholders at different stages in the surgical pathway. • Simultaneous evaluation of implementation and clinical outcomes will inform the development of a future larger study to enable/assess the scalability of interventions • The study offers a novel combination of implementation theory-informed, stakeholder-driven and clinically relevant evaluation, carried out in the context of a middle-income country hospital. • The project may not be applicable to every low-resource setting and surgical context due to differences in healthcare systems and cultures. However, the application of implementation science concepts may facilitate transferability and adaptation to other settings.

Huddles and their effectiveness at the frontlines of clinical care: a scoping review

BACKGROUND

Brief, stand-up meetings known as huddles may improve clinical care, but knowledge about huddle implementation and effectiveness at the frontlines is fragmented and setting specific. This work provides a comprehensive overview of huddles used in diverse health care settings, examines the empirical support for huddle effectiveness, and identifies knowledge gaps and opportunities for future research.

METHODS

A scoping review was completed by searching the databases PubMed, EBSCOhost, ProQuest, and OvidSP for studies published in English from inception to May 31, 2019. Eligible studies described huddles that (1) took place in a clinical or medical setting providing health care patient services, (2) included frontline staff members, (3) were used to improve care quality, and (4) were studied empirically. Two reviewers independently screened abstracts and full texts; seven reviewers independently abstracted data from full texts.

RESULTS

Of 2,185 identified studies, 158 met inclusion criteria. The majority (67.7%) of studies described huddles used to improve team communication, collaboration, and/or coordination. Huddles positively impacted team process outcomes in 67.7% of studies, including improvements in efficiency, process-based functioning, and communication across clinical roles (64.4%); situational awareness and staff perceptions of safety and safety climate (44.6%); and staff satisfaction and engagement (29.7%). Almost half of studies (44.3%) reported huddles positively impacting clinical care outcomes such as patients receiving timely and/or evidence-based assessments and care (31.4%); decreased medical errors and adverse drug events (24.3%); and decreased rates of other negative outcomes (20.0%).

DISCUSSION

Huddles involving frontline staff are an increasingly prevalent practice across diverse health care settings. Huddles are generally interdisciplinary and aimed at improving team communication, collaboration, and/or coordination. Data from the scoping review point to the effectiveness of huddles at improving work and team process outcomes and indicate the positive impact of huddles can extend beyond processes to include improvements in clinical outcomes.

STUDY REGISTRATION

This scoping review was registered with the Open Science Framework on 18 January 2019 ( https://osf.io/bdj2x/ ).

Interventions promoting employee "speaking-up" within healthcare workplaces: A systematic narrative review of the international literature

BACKGROUND

Healthcare systems worldwide increasingly value the contribution of employee voice in ensuring the quality of patient care. Although employees' concerns are often dealt with satisfactorily, considerable evidence suggests that some employees may feel unable to speak-up, and even when they do their concerns may be ignored. As a result, in addition to trans-national and national policies, workplace interventions that support employees to speak-up about their concerns have recently increased.

METHODS

A systematic narrative review, informed by complex systems perspectives addresses the question: "What workplace strategies and/or interventions have been implemented to promote speaking-up by employees"?

RESULTS

Thirty-four studies were included in the review. Most studies reported inconclusive results. Researchers explanations for the successful implementation, or otherwise, of speak-up interventions were synthesised into two narrative themes (Braithwaite et al., 2018 (a)) hierarchical, interdisciplinary and cultural relationships and (Francis, 2015 (b)) psychological safety.

CONCLUSIONS

We strengthen the existing evidence base by providing an in-depth critique of the complex system factors influencing the implementation of speak-up interventions within the healthcare workforce. Although many of the studies were locally unique, there were international similarities in workplace cultures and norms that created contexts inimical to speaking-up interventions. Changing communication behaviours and creating a climate that supports speaking-up is immensely challenging. Interventions can be usurped in practice by complex, emergent and contextual issues, such as pre-existing socio-cultural relationships and workplace hierarchies.

Translating staff experience into organisational improvement: the HEADS-UP stepped wedge, cluster controlled, non-randomised trial

OBJECTIVES

Frontline insights into care delivery correlate with patients' clinical outcomes. These outcomes might be improved through near-real time identification and mitigation of staff concerns. We evaluated the effects of a prospective frontline surveillance system on patient and team outcomes.

DESIGN

Prospective, stepped wedge, non-randomised, cluster controlled trial; prespecified per protocol analysis for high-fidelity intervention delivery.

PARTICIPANTS

Seven interdisciplinary medical ward teams from two hospitals in the UK.

INTERVENTION

Prospective clinical team surveillance (PCTS): structured daily interdisciplinary briefings to capture staff concerns, with organisational facilitation and feedback.

MAIN MEASURES

The primary outcome was excess length of stay (eLOS): an admission more than 24 hours above the local average for comparable patients. Secondary outcomes included safety and teamwork climates, and incident reporting. Mixed-effects models adjusted for time effects, age, comorbidity, palliation status and ward admissions. Safety and teamwork climates were measured with the Safety Attitudes Questionnaire. High-fidelity PCTS delivery comprised high engagement and high briefing frequency.

RESULTS

Implementation fidelity was variable, both in briefing frequency (median 80% working days/month, IQR 65%-90%) and engagement (median 70 issues/ward/month, IQR 34-113). 1714/6518 (26.3%) intervention admissions had eLOS versus 1279/4927 (26.0%) control admissions, an absolute risk increase of 0.3%. PCTS increased eLOS in the adjusted intention-to-treat model (OR 1.32, 95% CI 1.10 to 1.58, p=0.003). Conversely, high-fidelity PCTS reduced eLOS (OR 0.79, 95% CI 0.67 to 0.94, p=0.006). High-fidelity PCTS also increased total, high-yield and non-nurse incident reports (incidence rate ratios 1.28-1.79, all p<0.002). Sustained PCTS significantly improved safety and teamwork climates over time.

CONCLUSIONS

This study highlighted the potential benefits and pitfalls of ward-level interdisciplinary interventions. While these interventions can improve care delivery in complex, fluid environments, the manner of their implementation is paramount. Suboptimal implementation may have an unexpectedly negative impact on performance.

TRIAL REGISTRATION NUMBER

ISRCTN 34806867 (http://www.isrctn.com/ISRCTN34806867).