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Brummell Z, Braun D, Hussein Z, Moonesinghe SR, Vindrola-Padros C. National statutory reporting: not even ticking the boxes? The quality of 'Learning from Deaths' reporting in quality accounts within the NHS in England 2017-2020. BMJ Open Qual 2023; 12:bmjoq-2022-002092. [PMID: 36764733 PMCID: PMC9923336 DOI: 10.1136/bmjoq-2022-002092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 01/24/2023] [Indexed: 02/12/2023] Open
Abstract
INTRODUCTION Regulation through statutory reporting is used in healthcare internationally to improve accountability, quality of care and patient safety. Since 2017, within the National Health Service (NHS) in England, NHS Secondary Care Trusts (NSCTs) are legally required to report annually both quantitative and qualitative information related to patient deaths within their care within their publicly available Quality Accounts as part of a countrywide patient safety programme: The Learning from Deaths (LfDs) programme. METHOD All LfDs reports published between 2017 (programme inception) and 2020 were reviewed and evaluated through a critical realist lens, quantitatively reported using descriptive statistics and qualitatively using reflexive thematic analysis. RESULTS In 2017/2018, 44% of NSCTs reported all six statutory elements of the LfDs reporting regulations, in 2019/2020 35% of NSCTs were reporting this information. A small number of NSCTs did not report any parts of the LfDs regulatory requirements between 2017 and 2020. Multiple qualitative themes arose from this study suggesting problematic engagement with the LfDs programme, erroneous reporting accuracy and errors in written communication. CONCLUSIONS The LfDs programme has, to some extent, reduced variation and improved consistency to the way that NSCTs identify, report and investigate deaths. However, 3 years into the LfDs programme, the majority of NSCTs are not reporting as required by law. This makes the validity of National statutory reporting in Quality Accounts within the NHS in England questionable as a regulatory process.
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Affiliation(s)
- Zoe Brummell
- Department of Targeted Intervention, University College London, London, UK
| | | | - Zainab Hussein
- Department of Targeted Intervention, University College London, London, UK
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Robinson LJ, Butler HV, Hackett KL. Identifying and prioritising the key components of a Quality Improvement Network for allied health professionals and psychological therapists: a group concept mapping project. BMJ Open Qual 2023; 12:bmjoq-2022-002039. [PMID: 36717182 PMCID: PMC9887700 DOI: 10.1136/bmjoq-2022-002039] [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: 07/05/2022] [Accepted: 01/11/2023] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Despite growing enthusiasm for quality improvement (QI), the complexities of modern healthcare continue to create gaps in our ability to consistently deliver the most effective and efficient care for patients, and improvement activities often fail to achieve widespread uptake even when there is robust evidence of their benefits. METHODS We undertook a novel, mixed methods evaluation and planning project using group concept mapping (GCM) methodology to identify and prioritise the ways in which our recently established Quality Improvement Network (QIN) could support allied health professionals, psychological therapists and administrative staff in their daily work to improve patient outcomes and experience. Mid-level leaders across our therapy services department contributed towards a statement generation activity and individually sorted these statements into themes. Each statement was rated for perceived importance and current success. Multidimensional scaling and hierarchical cluster analysis were applied to the sorted data to produce themed clusters of ideas within concept maps. Priority values were applied to these maps to identify key areas for future QIN activity. RESULTS Overall, 34 participants took part in ideas generation, 20 in sorting and 30 in the rating activity. A five-item cluster map was agreed on, containing the following named clusters: data support; practical skills and training; time and resources; embedding a QI culture; and sharing ideas and working together. Statements contained within each of the five clusters highlight the importance of supporting a range of activities spanning the technical and human aspects of QI at an individual, group/team, organisation and wider systems level. CONCLUSION GCM provided a structured and systematic approach for identifying the perceived support needs of allied health professionals, psychological therapists and administrative support staff in relation to QI. The findings from this project provide a useful benchmark from which to track targeted QI support in an applied healthcare setting.
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Affiliation(s)
- Lisa J Robinson
- Rehabilitation Department, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, UK
| | - Hannah V Butler
- Rehabilitation Department, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, UK
| | - Kate L Hackett
- Department of Social Work, Education and Community Wellbeing, Northumbria University, Newcastle upon Tyne, Tyne and Wear, UK
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Vindrola-Padros C, Ledger J, Hill M, Tomini S, Spencer J, Fulop NJ. The Special Measures for Quality and Challenged Provider Regimes in the English NHS: A Rapid Evaluation of a National Improvement Initiative for Failing Healthcare Organisations. Int J Health Policy Manag 2022; 11:2917-2926. [PMID: 35490260 PMCID: PMC10105181 DOI: 10.34172/ijhpm.2022.6619] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 04/10/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND There is limited knowledge about interventions used for the improvement of low-performing healthcare organisations and their unintended consequences. Our evaluation sought to understand how healthcare organisations in the National Health Service (NHS) in England responded to a national improvement initiative (the Special Measures for Quality [SMQ] and challenged provider [CP] regimes) and its perceived impact on achieving quality improvements (QIs). METHODS Our evaluation included national-level interviews with key stakeholders involved in the delivery of SMQ (n=6); documentary analysis (n=20); and a qualitative study based on interviews (n=60), observations (n=8) and documentary analysis (n=291) in eight NHS case study sites. The analysis was informed by literature on failure, turnaround and QI in organisations in the public sector. RESULTS At the policy level, SMQ/CP regimes were intended to be "support" programmes, but perceptions of the interventions at hospital level were mixed. The SMQ/CP regimes tended to consider failure at an organisational level and turnaround was visualised as a linear process. There was a negative emotional impact reported by staff, especially in the short-term. Key drivers of change included: engaged senior leadership teams, strong clinical input and supportive external partnerships within local health systems. Trusts focused efforts to improve across multiple domains with particular investment in improving overall staff engagement, developing an open, listening organisational culture and better governance to ensure clinical safety and reporting. CONCLUSION Organisational improvement in healthcare requires substantial time to embed and requires investment in staff to drive change and cultivate QI capabilities at different tiers. The time this takes may be underestimated by external 'turn-around' interventions and performance regimes designed to improve quality in the short-term and which come at an emotional cost for staff. Shifting an improvement focus to the health system or regional level may promote sustainable improvement across multiple organisations over the long-term.
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Affiliation(s)
- Cecilia Vindrola-Padros
- Department of Applied Health Research, University College London, London, UK
- Department of Targeted Intervention, University College London, London, UK
| | - Jean Ledger
- Department of Applied Health Research, University College London, London, UK
| | - Melissa Hill
- NHS North Thames Genomic Laboratory Hub, Great Ormond Street Hospital, London, UK
| | - Sonila Tomini
- Department of Applied Health Research, University College London, London, UK
| | | | - Naomi J. Fulop
- Department of Applied Health Research, University College London, London, UK
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Jones L. Including a wider range of values in healthcare policy: how can public value evaluation help? Future Healthc J 2022; 9:222-225. [PMID: 36561824 PMCID: PMC9761455 DOI: 10.7861/fhj.2022-0109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
To meet future healthcare challenges a broader range of values need to be included in analysis, debate and policy. Different modes of governance foreground and facilitate different values. Collaboration, the governing principle of the newly formed integrated care systems, values the contribution of diverse stakeholders in discussions and decisions, to foster creativity and produce durable solutions to complex problems. Approaches to evaluation reinforce particular values, as captured in the adage 'what's measured is what matters'. New approaches are needed to support the collaborative aims of integrated care systems. Public value evaluation proceeds through values inquiry, establishing what is important to different stakeholders (including policy makers, healthcare staff, patients and communities) as a backdrop to understanding the effects of policies and programmes.
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Affiliation(s)
- Lorelei Jones
- ABangor University, Bangor, UK,Address for correspondence: Dr Lorelei Jones, School of Medical and Health Sciences, Bangor University, Fron Heulog LL57 2EF, UK. Twitter: @dr_loreleijones
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Vindrola-Padros C, Ledger J, Barbosa EC, Fulop NJ. The Implementation of Improvement Interventions for "Low Performing" and "High Performing" Organisations in Health, Education and Local Government: A Phased Literature Review. Int J Health Policy Manag 2022; 11:874-882. [PMID: 33160292 PMCID: PMC9808185 DOI: 10.34172/ijhpm.2020.197] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 10/04/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND There is limited understanding about whether and how improvement interventions are effective in supporting failing healthcare organisations and improving the quality of care in high-performing organisations. The aim of this review was to examine the underlying concepts guiding the design of interventions aimed at low and high performing healthcare organisations, processes of implementation, unintended consequences, and their impact on costs and quality of care. The review includes articles in the healthcare sector and other sectors such as education and local government. METHODS We carried out a phased rapid systematic review of the literature. Phase one was used to develop a theoretical framework of organisational failure and turnaround, and the types of interventions implemented to improve quality. The framework was used to inform phase 2, which was targeted and focused on organisational failure and turnaround in healthcare, education and local government settings. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement to guide the reporting of the methods and findings and the Mixed Methods Appraisal Tool (MMAT) as a quality assessment tool. The review protocol was registered with PROSPERO (CRD: 42019131024). RESULTS Failure is frequently defined as the inability of organisations to meet pre-established performance standards and turnaround as a linear process. Improvement interventions are designed accordingly and are focused on the organisation, with limited system-level thinking. Successful interventions included restructuring senior leadership teams, inspections, and organisational restructuring by external organisations. Limited attention was paid to the potential negative consequences of the interventions and their costs. CONCLUSION Dominant definitions of success/failure and turnaround have led to the reduced scope of improvement interventions, the linear perception of turnaround, and lack of consideration of organisations within the wider system in which they operate. Future areas of research include an analysis of the costs of delivering these interventions in relation to their impact on quality of care.
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Affiliation(s)
| | - Jean Ledger
- Department of Applied Health Research, University College London, London, UK
| | | | - Naomi J. Fulop
- Department of Applied Health Research, University College London, London, UK
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Aase I, Ree E, Strømme T, Wiig S. Behind the Scenes of a Patient Safety Leadership Intervention in Nursing Homes and Homecare: Researchers' Tips for Success. J Patient Saf 2022; 18:e368-e372. [PMID: 33009183 PMCID: PMC8719495 DOI: 10.1097/pts.0000000000000786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
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Martin J, Flynn MA, Khurshid Z, Fitzsimons JJ, Moore G, Crowley P. Board level “Picture-Understanding-Action”: a new way of looking at quality. INTERNATIONAL JOURNAL OF HEALTH GOVERNANCE 2021. [DOI: 10.1108/ijhg-05-2021-0047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeThe purpose of this study is to present a quality improvement approach titled “Picture-Understanding-Action” used in Ireland to enhance the role of healthcare boards in the oversight of healthcare quality and its improvement.Design/methodology/approachThe novel and practical “Picture-Understanding-Action” approach was implemented using the Model for Improvement to iteratively introduce changes across three quality improvement projects. This approach outlines the concepts and activities used at each step to support planning and implementation of processes that allow a board to effectively achieve its role in overseeing and improving quality. This approach matured over three quality improvement projects.FindingsThe “Picture” included quantitative and qualitative aspects. The quantitative “Picture” consisted of a quality dashboard/profile of board selected outcome indicators representative of the health system using statistical process control (SPC) charts to focus discussion on real signals of change. The qualitative picture was based on the experience of people who use and work in health services which “people-ised” the numbers. Probing this “Picture” with collective grounding, curiosity and expert training/facilitation developed a shared “Understanding”. This led to “Action(s)” from board members to improve the “Picture” and “Understanding” (feedback action), to ask better questions and make better decisions and recommendations to the executive (feed-forward action). The Model for Improvement, Plan-Do-Study-Act cycles and a co-design approach in design and implementation were key to success.Originality/valueTo the authors’ knowledge, this is the first time a board has undertaken a quality improvement (QI) project to enhance its own processes. It addresses a gap in research by outlining actions that boards can take to improve their oversight of quality of care.
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Wiig S, Aase K, Bal R. Reflexive Spaces: Leveraging Resilience Into Healthcare Regulation and Management. J Patient Saf 2021; 17:e1681-e1684. [PMID: 32011428 PMCID: PMC8612922 DOI: 10.1097/pts.0000000000000658] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Siri Wiig
- From the SHARE-Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Stavanger
| | - Karina Aase
- From the SHARE-Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Stavanger
| | - Roland Bal
- School of Health Policy & Management, Erasmus University, Rotterdam, the Netherlands
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Johannessen T, Ree E, Aase I, Bal R, Wiig S. Exploring managers' response to a quality and safety leadership intervention: findings from a multiple case study in Norwegian nursing homes and homecare services. BMJ Open Qual 2021; 10:bmjoq-2021-001494. [PMID: 34373250 PMCID: PMC8354257 DOI: 10.1136/bmjoq-2021-001494] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 07/25/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Improvement interventions would be easier to treat if they were stable and uninfluenced by their environment, but in practice, contextual factors may create difficulties in implementing and sustaining changes. Managers of healthcare organisations play an important role in quality and safety improvement. We need more research in the nursing home and homecare settings to support managers in their quality and safety improvement work. The aim of this study was to explore managers' response to a leadership intervention on quality and safety improvement. METHODS This study reports findings from the SAFE-LEAD intervention undertaken from April 2018 to March 2019. The research design was a multiple case study of two nursing homes and two homecare services in four municipalities in Norway. We used a combination of qualitative methods including interviews, workshops, observations, site visits and document analysis in our data collection that took place over a 1-year period. RESULTS Management continuity was key for the implementation process of the quality and safety leadership intervention. In the units where stable management teams were in place, the intervention was more rooted in the units, and changes in quality and safety practice occurred. The intervention served as an arena for managers to work with quality and safety improvement. We found that the workshops and use of the leadership guide contributed to a common understanding and commitment to quality and safety improvement among the managers. CONCLUSIONS This is a longitudinal study of managers' response to a leadership intervention targeted to improve quality and safety work in nursing home and homecare settings. Our research demonstrates how the mechanisms of stable management and established structures are crucial for quality and safety improvement activities. Management continuity is key for participating in interventions and for using the leadership guide in quality and safety work.
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Affiliation(s)
- Terese Johannessen
- SHARE- Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Eline Ree
- SHARE- Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Ingunn Aase
- SHARE- Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Roland Bal
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Siri Wiig
- SHARE- Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
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Bion J, Aldridge C, Beet C, Boyal A, Chen YF, Clancy M, Girling A, Hofer T, Lord J, Mannion R, Rees P, Roseveare C, Rowan L, Rudge G, Sun J, Sutton E, Tarrant C, Temple M, Watson S, Willars J, Lilford R. Increasing specialist intensity at weekends to improve outcomes for patients undergoing emergency hospital admission: the HiSLAC two-phase mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background
NHS England’s 7-day services policy comprised 10 standards to improve access to quality health care across all days of the week. Six standards targeted hospital specialists on the assumption that their absence caused the higher mortality associated with weekend hospital admission: the ‘weekend effect’. The High-intensity Specialist-Led Acute Care (HiSLAC) collaboration investigated this using the implementation of 7-day services as a ‘natural experiment’.
Objectives
The objectives were to determine whether or not increasing specialist intensity at weekends improves outcomes for patients undergoing emergency hospital admission, and to explore mechanisms and cost-effectiveness.
Design
This was a two-phase mixed-methods observational study. Year 1 focused on developing the methodology. Years 2–5 included longitudinal research using quantitative and qualitative methods, and health economics.
Methods
A Bayesian systematic literature review from 2000 to 2017 quantified the weekend effect. Specialist intensity measured over 5 years used self-reported annual point prevalence surveys of all specialists in English acute hospital trusts, expressed as the weekend-to-weekday ratio of specialist hours per 10 emergency admissions. Hospital Episode Statistics from 2007 to 2018 provided trends in weekend-to-weekday mortality ratios. Mechanisms for the weekend effect were explored qualitatively through focus groups and on-site observations by qualitative researchers, and a two-epoch case record review across 20 trusts. Case-mix differences were examined in a single trust. Health economics modelling estimated costs and outcomes associated with increased specialist provision.
Results
Of 141 acute trusts, 115 submitted data to the survey, and 20 contributed 4000 case records for review and participated in qualitative research (involving interviews, and observations using elements of an ethnographic approach). Emergency department attendances and admissions have increased every year, outstripping the increase in specialist numbers; numbers of beds and lengths of stay have decreased. The reduction in mortality has plateaued; the proportion of patients dying after discharge from hospital has increased. Specialist hours increased between 2012/13 and 2017/18. Weekend specialist intensity is half that of weekdays, but there is no relationship with admission mortality. Patients admitted on weekends are sicker (they have more comorbid disease and more of them require palliative care); adjustment for severity of acute illness annuls the weekend effect. In-hospital care processes are slightly more efficient at weekends; care quality (errors, adverse events, global quality) is as good at weekends as on weekdays and has improved with time. Qualitative researcher assessments of hospital weekend quality concurred with case record reviewers at trust level. General practitioner referrals at weekends are one-third of those during weekdays and have declined further with time.
Limitations
Observational research, variable survey response rates and subjective assessments of care quality were compensated for by using a difference-in-difference analysis over time.
Conclusions
Hospital care is improving. The weekend effect is associated with factors in the community that precede hospital admission. Post-discharge mortality is increasing. Policy-makers should focus their efforts on improving acute and emergency care on a ‘whole-system’ 7-day approach that integrates social, community and secondary health care.
Future work
Future work should evaluate the role of doctors in hospital and community emergency care and investigate pathways to emergency admission and quality of care following hospital discharge.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 13. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Julian Bion
- University Department of Anaesthesia & Critical Care, University of Birmingham, Birmingham, UK
| | - Cassie Aldridge
- University Department of Anaesthesia & Critical Care, University of Birmingham, Birmingham, UK
| | - Chris Beet
- Intensive Care Medicine, Royal Derby Hospital NHS Trust, Derby, UK
| | - Amunpreet Boyal
- Research & Development, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Yen-Fu Chen
- Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Michael Clancy
- Emergency Medicine, University of Southampton, Southampton, UK
| | - Alan Girling
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Timothy Hofer
- Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Joanne Lord
- Southampton Health Technology Assessments Centre, University of Southampton, Southampton, UK
| | - Russell Mannion
- Health Services Management Centre, University of Birmingham, Birmingham, UK
| | - Peter Rees
- Patient & Lay Committee, Academy of Medical Royal Colleges, London, UK
| | - Chris Roseveare
- General Internal Medicine, Southern Health NHS Foundation Trust, Southampton, UK
| | - Louise Rowan
- University Department of Anaesthesia & Critical Care, University of Birmingham, Birmingham, UK
| | - Gavin Rudge
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Jianxia Sun
- Informatics, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | | | | | - Mark Temple
- Nephrology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Sam Watson
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Janet Willars
- Health Sciences, University of Leicester, Leicester, UK
| | - Richard Lilford
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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Sutton E, Bion J, Mannion R, Willars J, Shaw E, Tarrant C. A qualitative study of organisational response to national quality standards for 7-day services in English hospitals. BMC Health Serv Res 2021; 21:205. [PMID: 33676507 PMCID: PMC7937294 DOI: 10.1186/s12913-021-06213-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 02/24/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND National standards are commonly used as an improvement strategy in healthcare, but organisations may respond in diverse and sometimes negative ways to external quality demands. This paper describes how a sample of NHS hospital trusts in England responded to the introduction of national standards for 7-day services (7DS), from an organisational behaviour perspective. METHODS We conducted 43 semi-structured interviews with executive/director level and clinical staff, in eight NHS trusts that varied in size, location, and levels of specialist staffing at weekends. We explored approaches to implementing standards locally, and the impact of organisational culture and local context on organisational response. RESULTS Senior staff in the majority of trusts described a focus on hitting targets and achieving compliance with the standards. Compliance-based responses were associated with a hierarchical organisational culture and focus on external performance. In a minority of trusts senior staff described mobilising commitment-based strategies. In these trusts senior staff reframed the external standards in terms of organisational values, and used co-operative strategies for achieving change. Trusts that took a commitment-based approach tended to be described as having a developmental organisational culture and a history of higher performance across the board. Audit data on 7DS showed improvement against standards for most trusts, but commitment-focused trusts were less likely to demonstrate improvements on the 7DS audit. The ability of trusts to respond to external standards was limited when they were under pressure due to a history of overall poor performance or resource limitations. CONCLUSIONS National standards and audit for service-level improvement generate different types of response in different local settings. Approaches to driving improvement nationally need to be accompanied by resources and tailored support for improvement, taking into account local context and organisational culture.
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Affiliation(s)
- Elizabeth Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Julian Bion
- Intensive Care Medicine, University Department of Anaesthesia & Critical Care, University of Birmingham, Birmingham, UK.
| | - Russell Mannion
- Health Services Management Centre, University of Birmingham, Birmingham, UK
| | - Janet Willars
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Elizabeth Shaw
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Carolyn Tarrant
- Department of Health Sciences, University of Leicester, Leicester, UK
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Abstract
Background In hospital cancer care, there is no set standard for next-of-kin involvement in improving the quality of care and patient safety. There is therefore a growing need for tools and methods that can guide this complex area. Objective The aim of this study was to present the results from a consensus-based participatory process of designing a guide for next-of-kin involvement in hospital cancer care. Method A consensus process based on a modified Nominal group technique was applied with 20 stakeholder participants from 2 Norwegian university hospitals. Result The participants agreed on the 5 most important priorities for hospital cancer care services when involving next-of-kin. The results showed that next-of-kin stakeholders, when proactively involved, are important resources for the patient and healthcare professionals in terms of contribution to quality and safety in hospitals. Suggested means of involving next-of-kin were closer interaction with external support bodies, integration in clinical pathways, adjusted information, and training healthcare professionals. Conclusion In this study, we identified topics and elements to include in a next-of-kin involvement guide to support quality and safety in hospital cancer care. The study raises awareness of the complex area of next-of-kin involvement and contributes with theory development and knowledge translation in an involvement guide tailored for use by healthcare professionals and managers in everyday clinical practice. Implications for Practice Service providers can use the guide to formulate intentions and make decisions with suggestions and priorities or as a reflexive tool for organizational improvement.
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Latif A, Gulzar N, Gohil S, Ansong T. Quality improvement in community pharmacy: a qualitative investigation of the impact of a postgraduate quality improvement educational module on pharmacists understanding and practice. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2020; 29:84-89. [PMID: 32797686 DOI: 10.1111/ijpp.12663] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 07/12/2020] [Accepted: 07/14/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Quality improvement (QI) is increasingly featuring in the United Kingdom (UK) National Health Service (NHS) agenda to promote safety, effectiveness and patient experience. However, the use of QI techniques by healthcare professionals appears limited and constrained with only isolated examples of good practice. This study explores QI within the pharmacy context. Focusing on the community pharmacy 'Healthy Living Pharmacy scheme', this study aims to explore changes in QI understanding resulting from a postgraduate QI educational intervention. METHODS Four focus groups were held involving 13 community pharmacists enrolled onto a newly developed postgraduate QI educational module. Two focus groups were held before and two after the module's completion. Knowledge of QI and practical applications following the learning was explored. KEY FINDINGS Three themes emerged: pharmacists' motivation for learning about QI, conceptual understanding and translation into practice. Pharmacists expressed positive views about learning new skills but expressed logistical concerns about how they would accommodate the extra learning. Prior knowledge of QI was found to be lacking and its application in practice ineffectual. Following completion of the QI module, significant improvements in comprehension and application were seen. Pharmacists considered it too soon to make an assessment on patient outcomes as their improvements required time to effectively embed changes in practice. CONCLUSIONS Quality improvement forms an important part of the NHS quality and safety agenda; however, community pharmacists may not currently have adequate knowledge of QI principles. The postgraduate educational intervention showed promising results in pharmacist's knowledge, organisational culture and application in practice.
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Affiliation(s)
- Asam Latif
- School of Health Sciences, Faculty of Medicine and Health Sciences, Queen's Medical Centre, University of Nottingham, Nottingham, UK
| | - Nargis Gulzar
- Leicester School of Pharmacy, Faculty of Health and Life Sciences, De Montfort University, Leicester, UK
| | - Sejal Gohil
- Leicester School of Pharmacy, Faculty of Health and Life Sciences, De Montfort University, Leicester, UK
| | - Theo Ansong
- Leicester School of Pharmacy, Faculty of Health and Life Sciences, De Montfort University, Leicester, UK
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Fowler Davis S, Hinde S, Ariss S. Complex programme evaluation of a 'new care model' vanguard: a shared commitment to quality improvement in an integrated health and care context. BMJ Open 2020; 10:e029174. [PMID: 32152152 PMCID: PMC7064121 DOI: 10.1136/bmjopen-2019-029174] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
NHS vanguards, under-pressure to perform, required better contracting and data management arrangements with evaluation teams, to ensure that integrated service outcomes could be reported effectively. This communication reflects the experience of evaluating an NHS vanguard and suggests how academic teams can improve capacity for complex programme evaluation of rapid improvements in integrated services. This should be based on a shared commitment to data collection and management. Also, robust knowledge exchange processes can enable systems change and sustainability. The identifying features of the particular site have been withheld.
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Affiliation(s)
- Sally Fowler Davis
- College of Health, Wellbeing and Life Sciences, Sheffield Hallam University, Sheffield, UK
- CCA Care Group, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Sebastian Hinde
- Centre for Health Economics, York University, Heslington, UK
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Anderson JE, Robert G, Nunes F, Bal R, Burnett S, Karltun A, Sanne J, Aase K, Wiig S, Fulop NJ. Translating research on quality improvement in five European countries into a reflective guide for hospital leaders: the 'QUASER Hospital Guide'. Int J Qual Health Care 2019; 31:G87-G96. [PMID: 31187862 DOI: 10.1093/intqhc/mzz055] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 02/26/2019] [Accepted: 05/06/2019] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE The aim was to translate the findings of the QUASER study into a reflective, dialogic guide to help senior hospital leaders develop an organization wide QI strategy. DESIGN The QUASER study involved in depth ethnographic research into QI work and practices in two hospitals in each of five European countries. Three translational stakeholder workshops were held to review research findings and advise on the design of the Guide. An extended iterative process involving researchers from each participant country was then used to populate the Guide. SETTING The research was carried out in two hospitals in each of five European countries. PARTICIPANTS In total, 389 interviews with healthcare practitioners and 803 hours of observations. INTERVENTION None. MAIN OUTCOME MEASURE None. RESULTS The QUASER Hospital Guide was designed for leadership teams to diagnose their organization's strengths and weaknesses in the eight QI challenges. The Guide supports organizational dialogue about QI challenges, enables leaders to share perspectives, and helps teams to develop solutions to their situated problems. The Guide includes extensive examples of QI strategies drawn from the data and is published online and on paper. CONCLUSIONS The QUASER Hospital Guide is empirically based, draws on a dialogical approach to Organizational Development and complexity science and can facilitate hospital leadership teams to identify the best solutions for their organization.
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Affiliation(s)
- Janet E Anderson
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London, UK
| | - Glenn Robert
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London, UK
| | - Francisco Nunes
- Department of Human Resources and Organizational Behavior, ISCTE-IUL, Lisbon, Portugal
| | - Roland Bal
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Netherlands
| | - Susan Burnett
- Honorary Research Fellow, Faculty of Medicine, Department of Surgery & Cancer, Imperial College, UK
| | - Anette Karltun
- Department of Industrial Engineering and Management, Jönköping University Sweden and The Jönköping Academy for Improvement of Healthcare and Welfare, Sweden
| | - Johan Sanne
- IVL Swedish Environmental Research Institute, Sweden
| | - Karina Aase
- SHARE-Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Norway
| | - Siri Wiig
- SHARE-Centre for Resilience in Healthcare, Faculty of Health Sciences, University of Stavanger, Norway
| | - Naomi J Fulop
- Department of Applied Health Research, University College London, UK
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Donetto S, Desai A, Zoccatelli G, Robert G, Allen D, Brearley S, Rafferty AM. Organisational strategies and practices to improve care using patient experience data in acute NHS hospital trusts: an ethnographic study. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07340] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Although NHS organisations have access to a wealth of patient experience data in various formats (e.g. surveys, complaints and compliments, patient stories and online feedback), not enough attention has been paid to understanding how patient experience data translate into improvements in the quality of care.
Objectives
The main aim was to explore and enhance the organisational strategies and practices through which patient experience data are collected, interpreted and translated into quality improvements in acute NHS hospital trusts in England. The secondary aim was to understand and optimise the involvement and responsibilities of nurses in senior managerial and front-line roles with respect to such data.
Design
The study comprised two phases. Phase 1 consisted of an actor–network theory-informed ethnographic study of the ‘journeys’ of patient experience data in five acute NHS hospital trusts, particularly in cancer and dementia services. Phase 2 comprised a series of Joint Interpretive Forums (one cross-site and one at each trust) bringing together different stakeholders (e.g. members of staff, national policy-makers, patient/carer representatives) to distil generalisable principles to optimise the use of patient experience data.
Setting
Five purposively sampled acute NHS hospital trusts in England.
Results
The analysis points to five key themes: (1) each type of data takes multiple forms and can generate improvements in care at different stages in its complex ‘journey’ through an organisation; (2) where patient experience data participate in interactions (with human and/or non-human actors) characterised by the qualities of autonomy (to act/trigger action), authority (to ensure that action is seen as legitimate) and contextualisation (to act meaningfully in a given situation), quality improvements can take place in response to the data; (3) nurses largely have ultimate responsibility for the way in which data are collected, interpreted and used to improve care, but other professionals also have important roles that could be explored further; (4) formalised quality improvement can confer authority to patient experience data work, but the data also lead to action for improvement in ways that are not formally identified as quality improvement; (5) sense-making exercises with study participants can support organisational learning.
Limitations
Patient experience data practices at trusts performing ‘worse than others’ on the Care Quality Commission scores were not examined. Although attention was paid to the views of patients and carers, the study focused largely on organisational processes and practices. Finally, the processes and practices around other types of data were not examined, such as patient safety and clinical outcomes data, or how these interact with patient experience data.
Conclusions
NHS organisations may find it useful to identify the local roles and processes that bring about autonomy, authority and contextualisation in patient experience data work. The composition and expertise of patient experience teams could better complement the largely invisible nursing work that currently accounts for a large part of the translation of data into care improvements.
Future work
To date, future work has not been planned.
Study registration
NIHR 188882.
Funding
The National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Sara Donetto
- Department of Adult Nursing, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College London, London, UK
| | - Amit Desai
- Department of Adult Nursing, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College London, London, UK
| | - Giulia Zoccatelli
- Department of Adult Nursing, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College London, London, UK
| | - Glenn Robert
- Department of Adult Nursing, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College London, London, UK
| | - Davina Allen
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - Sally Brearley
- Independent patient and public involvement advisor, Sutton, UK
| | - Anne Marie Rafferty
- Department of Adult Nursing, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College London, London, UK
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Robert G, Sarre S, Maben J, Griffiths P, Chable R. Exploring the sustainability of quality improvement interventions in healthcare organisations: a multiple methods study of the 10-year impact of the 'Productive Ward: Releasing Time to Care' programme in English acute hospitals. BMJ Qual Saf 2019; 29:31-40. [PMID: 31358685 PMCID: PMC6934234 DOI: 10.1136/bmjqs-2019-009457] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 07/09/2019] [Accepted: 07/10/2019] [Indexed: 12/03/2022]
Abstract
Background The ‘Productive Ward: Releasing Time to Care’ programme is a quality improvement (QI) intervention introduced in English acute hospitals a decade ago to: (1) Increase time nurses spend in direct patient care. (2) Improve safety and reliability of care. (3) Improve experience for staff and patients. (4) Make changes to physical environments to improve efficiency. Objective To explore how timing of adoption, local implementation strategies and processes of assimilation into day-to-day practice relate to one another and shape any sustained impact and wider legacies of a large-scale QI intervention. Design Multiple methods within six hospitals including 88 interviews (with Productive Ward leads, ward staff, Patient and Public Involvement representatives and senior managers), 10 ward manager questionnaires and structured observations on 12 randomly selected wards. Results Resource constraints and a managerial desire for standardisation meant that, over time, there was a shift away from the original vision of empowering ward staff to take ownership of Productive Ward towards a range of implementation ‘short cuts’. Nonetheless, material legacies (eg, displaying metrics data; storage systems) have remained in place for up to a decade after initial implementation as have some specific practices (eg, protected mealtimes). Variations in timing of adoption, local implementation strategies and contextual changes influenced assimilation into routine practice and subsequent legacies. Productive Ward has informed wider organisational QI strategies that remain in place today and developed lasting QI capabilities among those meaningfully involved in its implementation. Conclusions As an ongoing QI approach Productive Ward has not been sustained but has informed contemporary organisational QI practices and strategies. Judgements about the long-term sustainability of QI interventions should consider the evolutionary and adaptive nature of change processes.
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Affiliation(s)
- Glenn Robert
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Sophie Sarre
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Jill Maben
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Peter Griffiths
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Rosemary Chable
- Training, Development & Workforce, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Johannessen T, Ree E, Strømme T, Aase I, Bal R, Wiig S. Designing and pilot testing of a leadership intervention to improve quality and safety in nursing homes and home care (the SAFE-LEAD intervention). BMJ Open 2019; 9:e027790. [PMID: 31213451 PMCID: PMC6597165 DOI: 10.1136/bmjopen-2018-027790] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE To describe the design of a leadership intervention for nursing home and home care, including a leadership guide for managers to use in their quality and safety improvement work. The paper reports results from the pilot test of the intervention and describes the final intervention programme. DESIGN Qualitative design, using the participation of stakeholders. METHODS The leadership guide and intervention were designed in collaboration with researchers, coresearchers and managers in nursing homes and home care organisations, through workshops and focus group interviews. The pilot test consisted of three workshops with managers working on the leadership guide, facilitated and observed by researchers, and evaluated by means of observation and focus group interviews with the participants. The analysis combined the integration of data from interviews and observations with directed content analysis. SETTING Norwegian nursing homes and home care services. PARTICIPANTS Managers at different levels in three nursing homes and two home care services, coresearchers, and patient and next-of-kin representatives. RESULTS The managers and coresearchers suggested some revisions to the leadership guide, such as making it shorter, and tailoring the terminology to their setting. Based on their suggestions, we modified the intervention and developed learning resources, such as videos demonstrating the practical use of the guide. Evaluation of the pilot test study showed that all managers supported the use of the guide. They adapted the guide to their organisational needs, but found it difficult to involve patients in the intervention. CONCLUSIONS A participatory approach with stakeholders is useful in designing a leadership intervention to improve quality and safety in nursing homes and home care, although patient participation in its implementation remains difficult. The participatory approach made it easier for managers to adapt the intervention to their context and to everyday quality and safety work practice.
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Affiliation(s)
- Terese Johannessen
- Faculty of Health Sciences, SHARE - Centre for Resilience in Healthcare, University of Stavanger, Stavanger, Norway
| | - Eline Ree
- Faculty of Health Sciences, SHARE - Centre for Resilience in Healthcare, University of Stavanger, Stavanger, Norway
| | - Torunn Strømme
- Faculty of Health Sciences, SHARE - Centre for Resilience in Healthcare, University of Stavanger, Stavanger, Norway
| | - Ingunn Aase
- Faculty of Health Sciences, SHARE - Centre for Resilience in Healthcare, University of Stavanger, Stavanger, Norway
| | - Roland Bal
- School of Health Policy & Management, Erasmus University, Rotterdam, The Netherlands
| | - Siri Wiig
- Faculty of Health Sciences, SHARE - Centre for Resilience in Healthcare, University of Stavanger, Stavanger, Norway
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Abstract
Naomi Fulop and Angus Ramsay argue that we should focus more on how organisations and organisational leaders can contribute to improving the quality of healthcare
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Affiliation(s)
- Naomi J Fulop
- UCL Department of Applied Health Research, London, UK
- Correspondence to: N J Fulop
| | - Angus I G Ramsay
- UCL Department of Applied Health Research, London, UK
- Correspondence to: N J Fulop
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Kislov R. Engaging with theory: from theoretically informed to theoretically informative improvement research. BMJ Qual Saf 2018; 28:177-179. [PMID: 30429207 DOI: 10.1136/bmjqs-2018-009036] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2018] [Indexed: 11/04/2022]
Affiliation(s)
- Roman Kislov
- Alliance Manchester Business School, University of Manchester, Manchester, UK
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