Patient feedback for safety improvement in primary care: results from a feasibility study

Evaluation of the psychometric performance of the Spanish and Catalan versions of the patient reported experiences and Outcomes of Safety in Primary Care (PREOS-PC)-Compact questionnaire

BACKGROUND

Patients provide a unique, irreplaceable, and essential perspective in evaluating patient safety. The suite of Patient Reported Experiences and Outcomes of Safety in Primary Care (PREOS-PC) tools are a notable exception to the scarcity of patient-reported patient safety measures. Full evaluation of their performance has only been attempted for the English version, thereby limiting its international applicability.

OBJECTIVES

To assess the psychometric performance of the Spanish and Catalan versions of the PREOS-PC-Compact.

METHODS

Cross-sectional validation study. We used Classical Test Theory methods to examine scale score distribution, internal consistency, and construct validity; and Item Response Theory (IRT) methods to further explore construct validity.

RESULTS

3287 patients completed the Spanish version, and 1007 the Catalan version. Similar results were obtained for both versions. Confirmatory Factor Analysis supported a single construct for each scale. The correlations between PREOS-PC-Compact scales and known group analysis suggested adequate construct validity (inconclusive for known groups at the provider level). All four multi-item scales demonstrated adequate internal consistency reliability (α > 0.7), which was only confirmed for test-retest reliability for 'Practice activation.' A sample between 60-90 patients per practice was estimated sufficient to produce scores with reliability > 0.7 for all scales except for harm scales. IRT models showed disordered thresholds for 'Practice activation' and 'Harm burden' but showed excellent fit after reducing the response categories.

CONCLUSION

The Spanish and Catalan versions of the PREOS-PC-Compact are broadly valid and reliable tools to measure patient safety in Spanish primary care centres; confirmation of lower-than-expected test-rest reliability merits further examination .

Reconceptualizing Patient Safety Beyond Harm: Insights From a Mixed-Methods Qualitative Inquiry

BACKGROUND

Although patients' and care partners' perspectives on patient safety can guide health care learning and improvements, this information remains underutilized. Efforts to leverage this valuable data require challenging the narrow focus of safety as the absence of harm.

PURPOSE

The purpose of this study was to gain a broader insight into how patients and care partners perceive and experience safety.

METHODS

We used a mixed-methods approach that included a literature review and interviews and focus groups with patients, care partners, and health care providers. An emergent coding schema was developed from triangulation of the 2 data sets.

RESULTS

Two core themes-feeling unsafe and feeling safe-emerged that collectively represent a broader view of safety.

CONCLUSION

Knowledge from patients and care partners about feeling unsafe and safe needs to inform efforts to mitigate harm and promote safety, well-being, and positive outcomes and experiences.

Mapping Strategies for Strengthening Safety Culture: A Scoping Review

BACKGROUND

Twenty years after the "To Err Is Human" report, one in ten patients still suffer harm in hospitals in high-income countries, highlighting the need to strengthen the culture of safety in healthcare. This scoping review aims to map patient safety culture strengthening strategies described in the literature.

METHOD

This scoping review follows the JBI methodology. It adhered to all scoping review checklist items (PRISMA-ScR) with searches in the Lilacs, MedLine, IBECS, and PubMed databases and on the official websites of Brazilian and North American patient safety organizations. The research took place during the year 2023.

RESULTS

In total, 58 studies comprising 52 articles and 6 documents from health organizations were included. Various strategies were identified and grouped into seven categories based on similarity, highlighting the need for a comprehensive organizational approach to improve patient care. The most described strategies were communication (69%), followed by teamwork (58.6%) and active leadership (56.9%).

CONCLUSION

The identified strategies can promote the development of a culture in which an organization can achieve patient safety, involving practices and attitudes that reduce risks and errors in healthcare. However, the identification of strategies is limited because it is restricted to certain databases and websites of international organizations and does not cover a broader spectrum of sources. Furthermore, the effectiveness of these strategies in improving patient safety culture has not yet been evaluated.

Systematic review of feedback literacy instruments for health professions students

Successfully managing and utilizing feedback is a critical skill for self-improvement. Properly identifying feedback literacy level is crucial to facilitate teachers and learners especially in clinical learning to plan for better learning experience. The present review aimed to gather and examine the existing definitions and metrics used to assess feedback literacy (or parts of its concepts) for health professions education. A systematic search was conducted on six databases, together with a manual search in January 2023. Quality of the included studies were appraised using the COSMIN Checklist. Information on the psychometric properties and clinical utility of the accepted instruments were extracted. A total 2226 records of studies were identified, and 11 articles included in the final analysis extracting 13 instruments. These instruments can be administered easily, and most are readily accessible. However, 'appreciating feedback' was overrepresented compared to the other three features of feedback literacy and none of the instruments had sufficient quality across all COSMIN validity rating sections. Further research studies should focus on developing and refining feedback literacy instruments that can be adapted to many contexts within health professions education. Future research should apply a rigorous methodology to produce a valid and reliable student feedback literacy instrument.

A service-user digital intervention to collect real-time safety information on acute, adult mental health wards: the WardSonar mixed-methods study

Background

Acute inpatient mental health services report high levels of safety incidents. The application of patient safety theory has been sparse, particularly concerning interventions that proactively seek patient perspectives.

Objective(s)

Develop and evaluate a theoretically based, digital monitoring tool to collect real-time information from patients on acute adult mental health wards about their perceptions of ward safety.

Design

Theory-informed mixed-methods study. A prototype digital monitoring tool was developed from a co-design approach, implemented in hospital settings, and subjected to qualitative and quantitative evaluation.

Setting and methods

Phase 1: scoping review of the literature on patient involvement in safety interventions in acute mental health care; evidence scan of digital technology in mental health contexts; qualitative interviews with mental health patients and staff about perspectives on ward safety. This, alongside stakeholder engagement with advisory groups, service users and health professionals, informed the development processes. Most data collection was virtual. Phase 1 resulted in the technical development of a theoretically based digital monitoring tool that collected patient feedback for proactive safety monitoring. Phase 2: implementation of the tool in six adult acute mental health wards across two UK NHS trusts; evaluation via focused ethnography and qualitative interviews. Statistical analysis of WardSonar data and routine ward data involving construction of an hour-by-hour data set per ward, permitting detailed analysis of the use of the WardSonar tool.

Participants

A total of 8 patients and 13 mental health professionals participated in Phase 1 interviews; 33 staff and 34 patients participated in Phase 2 interviews.

Interventions

Patients could use a web application (the WardSonar tool) to record real-time perceptions of ward safety. Staff could access aggregated, anonymous data to inform timely interventions.

Results

Coronavirus disease 2019 restrictions greatly impacted the study. Stakeholder engagement permeated the project. Phase 1 delivered a theory-based, collaboratively designed digital tool for proactive patient safety monitoring. Phase 2 showed that the tool was user friendly and broadly acceptable to patients and staff. The aggregated safety data were infrequently used by staff. Feasibility depended on engaged staff and embedding use of the tool in ward routines. There is strong evidence that an incident leads to increased probability of further incidents within the next 4 hours. This puts a measure on the extent to which social/behavioural contagion persists. There is weak evidence to suggest that an incident leads to a greater use of the WardSonar tool in the following hour, but none to suggest that ward atmosphere predicts future incidents. Therefore, how often patients use the tool seems to send a stronger signal about potential incidents than patients' real-time reports about ward atmosphere.

Limitations

Implementation was limited to two NHS trusts. Coronavirus disease 2019 impacted design processes including stakeholder engagement; implementation; and evaluation of the monitoring tool in routine clinical practice. Higher uptake could enhance validity of the results.

Conclusions

WardSonar has the potential to provide a valuable route for patients to communicate safety concerns. The WardSonar monitoring tool has a strong patient perspective and uses proactive real-time safety monitoring rather than traditional retrospective data review.

Future work

The WardSonar tool can be refined and tested further in a post Coronavirus disease 2019 context.

Study registration

This study is registered as ISRCTN14470430.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128070) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 14. See the NIHR Funding and Awards website for further award information.

Promoting a Patient-Centered Understanding of Safety in Acute Mental Health Wards: A User-Centered Design Approach to Develop a Real-Time Digital Monitoring Tool

BACKGROUND

Acute mental health services report high levels of safety incidents that involve both patients and staff. The potential for patients to be involved in interventions to improve safety within a mental health setting is acknowledged, and there is a need for interventions that proactively seek the patient perspective of safety. Digital technologies may offer opportunities to address this need.

OBJECTIVE

This research sought to design and develop a digital real-time monitoring tool (WardSonar) to collect and collate daily information from patients in acute mental health wards about their perceptions of safety. We present the design and development process and underpinning logic model and programme theory.

METHODS

The first stage involved a synthesis of the findings from a systematic review and evidence scan, interviews with patients (n=8) and health professionals (n=17), and stakeholder engagement. Cycles of design activities and discussion followed with patients, staff, and stakeholder groups, to design and develop the prototype tool.

RESULTS

We drew on patient safety theory and the concepts of contagion and milieu. The data synthesis, design, and development process resulted in three prototype components of the digital monitoring tool (WardSonar): (1) a patient recording interface that asks patients to input their perceptions into a tablet computer, to assess how the ward feels and whether the direction is changing, that is, "getting worse" or "getting better"; (2) a staff dashboard and functionality to interrogate the data at different levels; and (3) a public-facing ward interface. The technology is available as open-source code.

CONCLUSIONS

Recent patient safety policy and research priorities encourage innovative approaches to measuring and monitoring safety. We developed a digital real-time monitoring tool to collect information from patients in acute mental health wards about perceived safety, to support staff to respond and intervene to changes in the clinical environment more proactively.

Evaluation of SINERGIAPS, an intervention to improve patient safety in primary healthcare centers in Spain based on patients' perceptions and experiences: a protocol for a hybrid type I randomized clinical trial

Background

Adverse events in the primary care setting result in a direct cost equivalent to at least 2.5% of total healthcare spending. Across OECD countries, they lead to more than seven million avoidable hospital admissions annually. In this manuscript, we describe the protocol of a trial aimed at evaluating the effectiveness of SinergiAPS (a patient-centered audit and feedback intervention) in reducing avoidable hospital admission and explore the factors that may affect its implementation.

Methods

We will conduct a 24-month, parallel, open-label, multicenter, pragmatic, hybrid type 1 randomized clinical trial. 118 primary healthcare centers with wide geographical distribution in Spain will be randomly assigned (ratio 1:1) to two groups. The intervention group will receive two audits (baseline and intermediate at 12 months) based on information collected through the administration of the PREOS-PC questionnaire (a measure of patient-reported patient safety) to a convenience sample of 100 patients per center. The intervention group will receive reports on the results of both audits, along with educational resources aimed at facilitating the design and implementation of safety improvement plans. The control group will receive care as usual. The primary outcome will be the rate of avoidable hospitalizations (administrative data). Secondary outcomes: patient-reported patient safety experiences and outcomes (PREOS-PC questionnaire); patient safety culture as perceived by professionals (MOSPSC questionnaire); adverse events reported by healthcare professionals (ad hoc questionnaire); the number of safety improvement actions which the re has implemented (ad hoc questionnaire). Outcome data will be collected at baseline and 24 months follow-up. For the evaluation of the implementation of the SinergiAPS intervention, we will draw on the Consolidated Framework for Implementation Research (CFIR). We will collect and analyze qualitative and quantitative data (30 individual interviews, implementation logbooks; questionnaires for professionals from intervention centers, and level of use of the SinergiAPS web tool).

Discussion

This study will expand the scarce body of evidence existing regarding the effects and implementation of interventions aimed at promoting patient and family engagement in primary healthcare, specifically for enhancing patient safety. The study has the potential to produce an impact on clinical practice, healthcare systems, and population health.Clinical Trial Registration: https://clinicaltrials.gov/study/NCT05958108?term=sinergiAPS&rank=1 (NCT05958108).

Safer Patients Empowered to Engage and Communicate about Health (SPEECH) in primary care: a feasibility study and process evaluation of an intervention for older people with multiple long-term conditions (multimorbidity)

BACKGROUND

Older people with multiple long-term conditions (multimorbidity) (MLTC-M) experience difficulties accessing and interacting with health and care services. Breakdowns in communication between patients and staff can threaten patient safety. To improve communication and reduce risks to patient safety in primary care, we developed an intervention: Safer Patients Empowered to Engage and Communicate about Health (SPEECH). SPEECH comprises a booklet for patients and an associated guide for staff. The booklet is designed to provide patients with information about staff and services, skills to prepare and explain, and confidence to speak up and ask.

METHODS

A single-arm mixed methods feasibility study with embedded process evaluation. General practices in the North West of England were recruited. Participating practices invited patients aged 65+ with MLTC-M who had an appointment scheduled during the study period. Patients were asked to complete questionnaires at baseline and follow-up (four to eight weeks after being sent the patient booklet), including the Consultation and Relational Empathy measure, Empowerment Scale, Multimorbidity Treatment Burden Questionnaire, and Primary Care Patient Measure of Safety. Staff completed questionnaires at the end of the study period. A sub-sample of patients and staff were interviewed about the study processes and intervention. Patients and the public were involved in all aspects of the study, from generation of the initial idea to interpretation of findings.

RESULTS

Our target of four general practices were recruited within 50 days of the study information being sent out. A fifth practice was recruited later to boost patient recruitment. We received expressions of interest from 55 patients (approx. 12% of those invited). Our target of 40 patient participants completed baseline questionnaires and were sent the SPEECH booklet. Of these, 38 (95%) completed follow-up. Patients found the intervention and study processes acceptable, and staff found the intervention acceptable and feasible to deliver.

CONCLUSIONS

Our findings suggest the intervention is acceptable, and it would be feasible to deliver a trial to assess effectiveness. Prior to further evaluation, study processes and the intervention will be updated to incorporate suggestions from participants.

TRIAL REGISTRATION

The study was registered on the ISRCTN registry (ISRCTN13196605: https://doi.org/10.1186/ISRCTN13196605 ).

How do hospital inpatients conceptualise patient safety? A qualitative interview study using constructivist grounded theory

BACKGROUND

Efforts to involve patients in patient safety continue to revolve around professionally derived notions of minimising clinical risk, yet evidence suggests that patients hold perspectives on patient safety that are distinct from clinicians and academics. This study aims to understand how hospital inpatients across three different specialties conceptualise patient safety and develop a conceptual model that reflects their perspectives.

METHODS

A qualitative semi-structured interview study was conducted with 24 inpatients across three clinical specialties (medicine for the elderly, elective surgery and maternity) at a large central London teaching hospital. An abbreviated form of constructivist grounded theory was employed to analyse interview transcripts. Constant comparative analysis and memo-writing using the clustering technique were used to develop a model of how patients conceptualise patient safety.

RESULTS

While some patients described patient safety using terms consistent with clinical/academic definitions, patients predominantly conceptualised patient safety in the context of what made them 'feel safe'. Patients' feelings of safety arose from a range of care experiences involving specific actors: hospital staff, the patient, their friends/family/carers, and the healthcare organisation. Four types of experiences contributed to how patients conceptualise safety: actions observed by patients; actions received by patients; actions performed by patients themselves; and shared actions involving patients and other actors in their care.

CONCLUSIONS

Our findings support the need for a patient safety paradigm that is meaningful to all stakeholders, incorporating what matters to patients to feel safe in hospital. Additional work should explore and test how the proposed conceptual model can be practically applied and implemented to incorporate the patient conceptualisation of patient safety into everyday clinical practice.

Feasibility of the SINERGIAPS ("Sinergias entre profesionales y pacientes para una Atención Primaria Segura") intervention for improving patient safety in primary care

AIM

The primary aim was to examine the feasibility of intervention delivery and of trial procedures. Secondary aims were to study the intervention uptake; its acceptability and perceived utility; and its potential to improve safety culture and avoidable hospital admissions.

METHODS

We conducted a 3-month, single-arm feasibility study in 10 primary care (PC) centres in Spain. Centres received information regarding patients' experiences of safety (through the Patient Reported Experiences and Outcomes of Safety in Primary Care [PREOS-PC] questionnaire), and were instructed to plan safety improvements based on that feedback. We used a bespoke online tool to recruit PC professionals, collect patient feedback, and deliver it to the centres, and to collect outcome data (patient safety culture [Medical Office Survey on Patient Safety Culture, MOSPSC questionnaire]). We measured recruitment and follow-up rates and intervention uptake (based on the number of safety improvement plans registered). We conducted semistructured interviews with 9 professionals to explore the intervention acceptability and perceived utility.

RESULTS

Of 256 professionals invited, 120 (47%) agreed to participate, and 97 completed baseline and postintervention measures. Of 780 patients invited, 585 (75%) completed the PREOS-PC questionnaire. Five of 10 centres (50%) designed an improvement plan, providing 27 plans in total (range per centre, 1-14). The intervention was perceived as a novel strategy for improving safety, although the healthcare professionals identified several factors limiting its acceptability and utility: lack of feedback at the individual professional level; potentially unrepresentative sample of patients providing feedback; and number of educational materials deemed overwhelming.

DISCUSSION

It is feasible to deliver the proposed intervention so long as the identified limitations are addressed.

Questionnaires Measuring Patient Participation in Patient Safety-a systematic review

AIM

The purpose of this review was to evaluate the content, validity and reliability of patient-reported questionnaires on patient participation in patient safety.

BACKGROUND

Patient participation in patient safety is one of the key strategies that are increasingly regarded as a critical intervention to improve the quality of safety care.

EVALUATION

A systematic review was conducted according to PRISMA guidelines. The content, reliability and validity of patient-reported questionnaires on patient participation in patient safety were assessed.

KEY ISSUES

Twenty-seven studies were included for data extraction and synthesis. The questionnaire contents most commonly used to describe patient participation in patient safety were 'attitudes and perceptions', 'experience', 'information and feedback' and 'willingness'. Internal consistency was evaluated for seventeen questionnaires, and test-retest reliability was tested for four questionnaires. Content validity was assessed among all included questionnaires, and structural validity was evaluated for twelve questionnaires.

CONCLUSIONS

Future research targeting the different safety issues is still indispensable for developing patient-reported questionnaires with great psychometric quality in validity, reliability, feasibility and usability in patient participation in patient safety.

IMPLICATIONS FOR NURSING MANAGEMENT

Clinical nurses should consider the internal consistency, test-retest reliability, content validity and structural validity of the questionnaires that have been positively appraised for methodological quality before use.

Nature and type of patient-reported safety incidents in primary care: cross-sectional survey of patients from Australia and England

BACKGROUND

Patient engagement in safety has shown positive effects in preventing or reducing adverse events and potential safety risks. Capturing and utilising patient-reported safety incident data can be used for service learning and improvement.

OBJECTIVE

The aim of this study was to characterise the nature of patient-reported safety incidents in primary care.

DESIGN

Secondary analysis of two cross sectional studies.

PARTICIPANTS

Adult patients from Australian and English primary care settings.

MEASURES

Patients' self-reported experiences of safety incidents were captured using the validated Primary Care Patient Measure of Safety questionnaire. Qualitative responses to survey items were analysed and categorised using the Primary Care Patient Safety Classification System. The frequency and type of safety incidents, contributory factors, and patient and system level outcomes are presented.

RESULTS

A total of 1329 patients (n=490, England; n=839, Australia) completed the questionnaire. Overall, 5.3% (n=69) of patients reported a safety incident over the preceding 12 months. The most common incident types were administration incidents (n=27, 31%) (mainly delays in accessing a physician) and incidents involving diagnosis and assessment (n=16, 18.4%). Organisation of care accounted for 27.6% (n=29) of the contributory factors identified in the safety incidents. Staff factors (n=13, 12.4%) was the second most commonly reported contributory factor. Where an outcome could be determined, patient inconvenience (n=24, 28.6%) and clinical harm (n=21, 25%) (psychological distress and unpleasant experience) were the most frequent.

CONCLUSIONS

The nature and outcomes of patient-reported incidents differ markedly from those identified in studies of staff-reported incidents. The findings from this study emphasise the importance of capturing patient-reported safety incidents in the primary care setting. The patient perspective can complement existing sources of safety intelligence with the potential for service improvement.