How safe is the safety paradigm?

Exploring the role of managers in the development of a safety culture in seven French healthcare facilities: a qualitative study

BACKGROUND

Numerous studies have been conducted over the past 15 years to assess safety culture within healthcare facilities; in general, these studies have shown the pivotal role that managers play in its development. However, little is known about what healthcare managers actually do to support this development, and how caregivers and managers represent managers'role. Thus the objectives of this study were to explore: i) caregivers and managers' perceptions and representations of safety, ii) the role of managers in the development of safety culture as perceived by themselves and by caregivers, iii) managers' activities related to the development of safety culture.

METHODS

An exploratory, multicentre, qualitative study was conducted from May 2014 to March 2015 in seven healthcare facilities in France. Semi-structured interviews were conducted with managers (frontline, middle and top level) and caregivers (doctors, nurses and nurse assistants) and on-site observations of two managers were carried out in all facilities. A thematic analysis of semi-structured interviews was performed. Observed activities were categorised using Luthans' typology of managerial activities.

RESULTS

Participants in semi-structured interviews (44 managers and 21 caregivers) expressed positive perceptions of the level of safety in their facility. Support from frontline management was particularly appreciated, while support from top managers was identified as an area for improvement. Six main categories of safety-related activities were both observed among managers and regularly expressed by participants. However, caregivers' expectations of their managers and managerial perceptions of these expectations only partially overlapped.

CONCLUSIONS

The present study highlights current categories of managerial activities that foster safety culture, and points out an important gap between caregivers' expectations of their managers, and managerial perceptions of these expectations. The findings underline the need to allow more time for managers and caregivers to talk about safety issues. The results could be used to develop training programs to help healthcare managers to understand their role in the development of safety culture.

Patient Experience Shows Little Relationship with Hospital Quality Management Strategies

OBJECTIVES

Patient-reported experience measures are increasingly being used to routinely monitor the quality of care. With the increasing attention on such measures, hospital managers seek ways to systematically improve patient experience across hospital departments, in particular where outcomes are used for public reporting or reimbursement. However, it is currently unclear whether hospitals with more mature quality management systems or stronger focus on patient involvement and patient-centered care strategies perform better on patient-reported experience. We assessed the effect of such strategies on a range of patient-reported experience measures.

MATERIALS AND METHODS

We employed a cross-sectional, multi-level study design randomly recruiting hospitals from the Czech Republic, France, Germany, Poland, Portugal, Spain, and Turkey between May 2011 and January 2012. Each hospital contributed patient level data for four conditions/pathways: acute myocardial infarction, stroke, hip fracture and deliveries. The outcome variables in this study were a set of patient-reported experience measures including a generic 6-item measure of patient experience (NORPEQ), a 3-item measure of patient-perceived discharge preparation (Health Care Transition Measure) and two single item measures of perceived involvement in care and hospital recommendation. Predictor variables included three hospital management strategies: maturity of the hospital quality management system, patient involvement in quality management functions and patient-centered care strategies. We used directed acyclic graphs to detail and guide the modeling of the complex relationships between predictor variables and outcome variables, and fitted multivariable linear mixed models with random intercept by hospital, and adjusted for fixed effects at the country level, hospital level and patient level.

RESULTS

Overall, 74 hospitals and 276 hospital departments contributed data on 6,536 patients to this study (acute myocardial infarction n = 1,379, hip fracture n = 1,503, deliveries n = 2,088, stroke n = 1,566). Patients admitted for hip fracture and stroke had the lowest scores across the four patient-reported experience measures throughout. Patients admitted after acute myocardial infarction reported highest scores on patient experience and hospital recommendation; women after delivery reported highest scores for patient involvement and health care transition. We found no substantial associations between hospital-wide quality management strategies, patient involvement in quality management, or patient-centered care strategies with any of the patient-reported experience measures.

CONCLUSION

This is the largest study so far to assess the complex relationship between quality management strategies and patient experience with care. Our findings suggest absence of and wide variations in the institutionalization of strategies to engage patients in quality management, or implement strategies to improve patient-centeredness of care. Seemingly counterintuitive inverse associations could be capturing a scenario where hospitals with poorer quality management were beginning to improve their patient experience. The former suggests that patient-centered care is not yet sufficiently integrated in quality management, while the latter warrants a nuanced assessment of the motivation and impact of involving patients in the design and assessment of services.

Advantages and Disadvantages of Health Care Accreditation Mod-els

BACKGROUND

This systematic review seeks to define the general advantages and disadvan-tages of accreditation programs to assist in choosing the most appropriate approach.

METHOD

Systematic search of SID, Ovid Medline & PubMed databases was conducted by the keywords of accreditation, hospital, medical practice, clinic, accreditation models, health care and Persian meanings. From 2379 initial articles, 83 articles met the full inclusion criteria. From initial analysis, 23 attributes were identified which appeared to define advantages and disadvantages of different accreditation approaches and the available systems were compared on these.

RESULTS

Six systems were identified in the international literature including the JCAHO from USA, the Canadian program of CCHSA, and the accreditation programs of UK, Australia, New Zealand and France. The main distinguishing attributes among them were: quality improve-ment, patient and staff safety, improving health services integration, public's confi-dence, effectiveness and efficiency of health services, innovation, influence global standards, information management, breadth of activity, history, effective relationship with stakeholders, agreement with AGIL attributes and independence from government.

CONCLUSION

Based on 23 attributes of comprehensive accreditation systems we have defined from a systematic review, the JCAHO accreditation program of USA and then CCHSA of Can-ada offered the most comprehensive systems with the least disadvantages. Other programs such as the ACHS of Australia, ANAES of France, QHNZ of New Zealand and UK accredita-tion programs were fairly comparable according to these criteria. However the decision for any country or health system should be based on an assessment weighing up their specific objec-tives and needs.

Health system outcomes and determinants amenable to public health in industrialized countries: a pooled, cross-sectional time series analysis

BACKGROUND

Few studies have tried to assess the combined cross-sectional and temporal contributions of a more comprehensive set of amenable factors to population health outcomes for wealthy countries during the last 30 years of the 20th century. We assessed the overall ecological associations between mortality and factors amenable to public health. These amenable factors included addictive and nutritional lifestyle, air quality, public health spending, healthcare coverage, and immunizations.

METHODS

We used a pooled cross-sectional, time series analysis with corrected fixed effects regression models in an ecological design involving eighteen member countries of the Organisation for Economic Cooperation and Development during the period 1970 to 1999.

RESULTS

Alcohol, tobacco, and fat consumption, and sometimes, air pollution were significantly associated with higher all-cause mortality and premature death. Immunizations, health care coverage, fruit/vegetable and protein consumption, and collective health expenditure had negative effects on mortality and premature death, even after controlling for the elderly, density of practicing physicians, doctor visits and per capita GDP. However, tobacco, air pollution, and fruit/vegetable intake were sometimes sensitive to adjustments.

CONCLUSION

Mortality and premature deaths could be improved by focusing on factors that are amenable to public health policies. Tackling these issues should be reflected in the ongoing assessments of health system performance.

Implementing a national strategy for patient safety: lessons from the National Health Service in England

Improving patient safety has become a core issue for many modern healthcare systems. However, knowledge of the best ways for government initiated efforts to improve patient safety is still evolving, although there is considerable commonality in the challenges faced by countries. Actions to improve patient safety must operate at multiple levels of the healthcare system simultaneously. Using the example of the NHS in England, this article highlights the importance of a strategic analysis of the policy process and the prevailing policy context in the design of the national patient safety strategy. The paper identifies a range of policy "levers" (forces for change) that can be used to support the implementation of the national safety initiative and, in particular, discusses the strengths and limitations of the "business case" approach that has attracted recent interest. The paper offers insights into the implementation of national patient safety goals that should provide learning for other countries.