Towards safer, better healthcare: harnessing the natural properties of complex sociotechnical systems

Strengthening open disclosure in maternity services in the English NHS: the DISCERN realist evaluation study

Background

There is a policy drive in NHS maternity services to improve open disclosure with harmed families and limited information on how better practice can be achieved.

Objectives

To identify critical factors for improving open disclosure from the perspectives of families, doctors, midwives and services and to produce actionable evidence for service improvement.

Design

A three-phased, qualitative study using realist methodology. Phase 1: two literature reviews: scoping review of post-2013 NHS policy and realist synthesis of initial programme theories for improvement; an interview study with national stakeholders in NHS maternity safety and families. Phase 2: in-depth ethnographic case studies within three NHS maternity services in England. Phase 3: interpretive forums with study participants. A patient and public involvement strategy underpinned all study phases.

Setting

National recruitment (study phases 1 and 3); three English maternity services (study phase 2).

Participants

We completed n = 142 interviews, including 27 with families; 93 hours of ethnographic observations, including 52 service and family meetings over 9 months; and interpretive forums with approximately 69 people, including 11 families.

Results

The policy review identified a shift from viewing injured families as passive recipients to active contributors of post-incident learning, but a lack of actionable guidance for improving family involvement. The realist synthesis found weak evidence of the effectiveness of open disclosure interventions in the international maternity literature, but some improvements with organisation-wide interventions. Recent evidence was predominantly from the United Kingdom. The research identified and explored five key mechanisms for open disclosure: meaningful acknowledgement of harm; involvement of those affected in reviews/investigations; support for families' own sense-making; psychological safely of skilled clinicians (doctors and midwives); and knowing that improvements to care have happened. The need for each family to make sense of the incident in their own terms is noted. The selective initiatives of some clinicians to be more open with some families is identified. The challenges of an adversarial medicolegal landscape and limited support for meeting incentivised targets is evidenced.

Limitations

Research was conducted after the pandemic, with exceptional pressure on services. Case-study ethnography was of three higher performing services: generalisation from case-study findings is limited. No observations of Health Safety Investigation Branch investigations were possible without researcher access. Family recruitment did not reflect population diversity with limited representation of non-white families, families with disabilities and other socially marginalised groups and disadvantaged groups.

Conclusions

We identify the need for service-wide systems to ensure that injured families are positioned at the centre of post-incident events, ensure appropriate training and post-incident care of clinicians, and foster ongoing engagement with families beyond the individual efforts made by some clinicians for some families. The need for legislative revisions to promote openness with families across NHS organisations, and wider changes in organisational family engagement practices, is indicated. Examination of how far the study's findings apply to different English maternity services, and a wider rethinking of how family diversity can be encouraged in maternity services research.

Study registration

This study is registered as PROSPERO CRD42020164061. The study has been assessed following RAMESES realist guidelines.

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: 17/99/85) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 22. See the NIHR Funding and Awards website for further award information.

Top Ten Tips Palliative Care Clinicians Should Know About Dignity-Conserving Practice

The acknowledgment and promotion of dignity is commonly viewed as the cornerstone of person-centered care. Although the preservation of dignity is often highlighted as a key tenet of palliative care provision, the concept of dignity and its implications for practice remain nebulous to many clinicians. Dignity in care encompasses a series of theories describing different forms of dignity, the factors that impact them, and strategies to encourage dignity-conserving care. Different modalities and validated instruments of dignity in care have been shown to lessen existential distress at the end of life and promote patient-clinician understanding. It is essential that palliative care clinicians be aware of the impacts of dignity-related distress, how it manifests, and common solutions that can easily be adapted, applied, and integrated into practice settings. Dignity-based constructs can be learned as a component of postgraduate or continuing education. Implemented as a routine component of palliative care, they can provide a means of enhancing patient-clinician relationships, reducing bias, and reinforcing patient agency across the span of serious illness. Palliative care clinicians-often engaging patients, families, and communities in times of serious illness and end of life-wield significant influence on whether dignity is intentionally integrated into the experience of health care delivery. Thus, dignity can be a tangible, actionable, and measurable palliative care goal and outcome. This article, written by a team of palliative care specialists and dignity researchers, offers 10 tips to facilitate the implementation of dignity-centered care in serious illness.

Risk Management and Patient Safety in the Artificial Intelligence Era: A Systematic Review

BACKGROUND

Healthcare systems represent complex organizations within which multiple factors (physical environment, human factor, technological devices, quality of care) interconnect to form a dense network whose imbalance is potentially able to compromise patient safety. In this scenario, the need for hospitals to expand reactive and proactive clinical risk management programs is easily understood, and artificial intelligence fits well in this context. This systematic review aims to investigate the state of the art regarding the impact of AI on clinical risk management processes. To simplify the analysis of the review outcomes and to motivate future standardized comparisons with any subsequent studies, the findings of the present review will be grouped according to the possibility of applying AI in the prevention of the different incident type groups as defined by the ICPS.

MATERIALS AND METHODS

On 3 November 2023, a systematic review of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was carried out using the SCOPUS and Medline (via PubMed) databases. A total of 297 articles were identified. After the selection process, 36 articles were included in the present systematic review.

RESULTS AND DISCUSSION

The studies included in this review allowed for the identification of three main "incident type" domains: clinical process, healthcare-associated infection, and medication. Another relevant application of AI in clinical risk management concerns the topic of incident reporting.

CONCLUSIONS

This review highlighted that AI can be applied transversely in various clinical contexts to enhance patient safety and facilitate the identification of errors. It appears to be a promising tool to improve clinical risk management, although its use requires human supervision and cannot completely replace human skills. To facilitate the analysis of the present review outcome and to enable comparison with future systematic reviews, it was deemed useful to refer to a pre-existing taxonomy for the identification of adverse events. However, the results of the present study highlighted the usefulness of AI not only for risk prevention in clinical practice, but also in improving the use of an essential risk identification tool, which is incident reporting. For this reason, the taxonomy of the areas of application of AI to clinical risk processes should include an additional class relating to risk identification and analysis tools. For this purpose, it was considered convenient to use ICPS classification.

A novel framework for human factors analysis and classification system for medical errors (HFACS-MES)-A Delphi study and causality analysis

The healthcare system (HCS) is one of the most crucial and essential systems for humanity. Currently, supplying the patients' safety and preventing the medical adverse events (MAEs) in HCS is a global issue. Human and organizational factors (HOFs) are the primary causes of MAEs. However, there are limited analytical methods to investigate the role of these factors in medical errors (MEs). The aim of present study was to introduce a new and applicable framework for the causation of MAEs based on the original HFACS. In this descriptive-analytical study, HOFs related to MEs were initially extracted through a comprehensive literature review. Subsequently, a Delphi study was employed to develop a new human factors analysis and classification system for medical errors (HFACS-MEs) framework. To validate this framework in the causation and analysis of MEs, 180 MAEs were analyzed by using HFACS-MEs. The results showed that the new HFACS-MEs model comprised 5 causal levels and 25 causal categories. The most significant changes in HFACS-MEs compared to the original HFACS included adding a fifth causal level, named "extra-organizational issues", adding the causal categories "management of change" (MOC) and "patient safety culture" (PSC) to fourth causal level", adding "patient-related factors (PRF)" and "task elements" to second causal level and finally, appending "situational violations" to first causal level. Causality analyses among categories in the HFACS-MEs framework showed that the new added causal level (extra-organizational issues) have statistically significant relationships with causal factors of lower levels (Φc≤0.41, p-value≤0.038). Other new causal category including MOC, PSC, PRF and situational violations significantly influenced by the causal categories of higher levels and had an statistically significant effect on the lower-level causal categories (Φc>0.2, p-value<0.05). The framework developed in this study serves as a valuable tool in identifying the causes and causal pathways of MAEs, facilitating a comprehensive analysis of the human factors that significantly impact patient safety within HCS.

Exploring value creation in a virtual community of practice: a framework analysis for knowledge and skills development among primary care professionals

BACKGROUND

Healthcare professionals traditional education reflects constraints to face the complex needs of people with chronic diseases in primary care settings. Since more innovative and practical solutions are required, Virtual Community of Practices (vCoP) seem to better respond to learning updates, improving professional and organizational knowledge. However, little is known about the value created in vCoPs as social learning environments. The objective of this project was to explore the value creation process of a gamified vCoP ("e-mpodera vCoP") aimed at improving the knowledge and attitudes of primary healthcare professionals (PCPs) (nurses and general practitioners) to the empowerment of people with chronic conditions.

METHODS

A framework analysis assessed the value creation process using a mixed methods approach. The framework provided awareness about knowledge and usefulness in a learning community through five cycles: (1) immediate value, (2) potential value, (3) applied value, (4) realized value, and (5) reframing value. Quantitative data included vCoP analytics such as logins, contributions, points, badges, and performance metrics. Qualitative data consisted of PCPs' forum contributions from Madrid, Catalonia, and Canary Islands over 14 months.

RESULTS

A total of 185 PCPs had access to the e-mpodera vCoPs. The vCoP showed the dynamic participation of 146 PCPs, along 63 content activities posted, including a total of 3,571 contributions (including text, images, links to webpages, and other files). Regarding the value creation process, the e-mpodera vCoP seems to encompass a broad spectrum of value cycles, with indicators mostly related to cycle 1 (immediate value - activities and interactions) and cycle 2 (potential value - knowledge capital); and to a lesser extent for cycle 3 (applied value - changes in practice) and for cycle 4 (realized value - performance improvement). The presence of indicators related to cycle 5 (reframing value), was minimal, due to few individual redefinitions of success.

CONCLUSION

To reach a wider range of value possibilities, a combination of learning objectives, competence framework, challenged-based gamified platform, and pathway model of skill development seems crucial. However, additional research is required to gain clearer insights into organizational values, professionals' lifelong educational needs in healthcare, and the long-term sustainability of performance improvement.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02757781. Registered on 02/05/2016.

The Role of Clinical Audits in Advancing Quality and Safety in Healthcare Services: A Multiproject Analysis From a Jordanian Hospital

Introduction Clinical audits have become essential instruments for evaluating and improving the standard of patient care in healthcare services. While individual clinical audits focus on particular aspects of care, multiple clinical audits across various domains, specialties, or departments provide a more comprehensive understanding of clinical practice and encourage systemic improvements. Methodology This study employed a mixed-methods approach to review and assess various clinical audits and quality improvement initiatives conducted at Al-Karak Governmental Hospital in southern Jordan. The study aimed to identify obstacles and possibilities of conducting clinical audits and provide suggestions for enhancing audit procedures and results. Data were collected from both retrospective and prospective sources and analyzed using descriptive and inferential statistics. Results The study comprised 11 audits conducted in three medical departments, namely surgery, obstetrics and gynecology (OB/GYN), and pediatrics, with a total of 618 participants. The improvements in adherence to guidelines after the second loop of all the audits were significant and showed significant improvements in adherence to guidelines, demonstrating the efficacy of clinical audits in improving clinical practice and outcomes. Conclusions Clinical audits are essential for maintaining and improving quality and safety in healthcare services, particularly in developing nations where emergency obstetric care is lacking. Multiple clinical audits provide a comprehensive understanding of clinical practice and encourage systemic improvements. The findings of our study suggest that clinical audits can lead to significant improvements in adherence to guidelines and better clinical outcomes. Future research should focus on identifying best practices for conducting clinical audits and evaluating their long-term viability and expandability.

Nurses' Experience Implementing an Automated Video Monitoring System to Decrease the Risk of Patient Falls during a Global Pandemic

Healthcare is a complex sociotechnical system where information systems (IS) and information technology (IT) intersect to solve problems experienced by patients and providers alike. One example of IS/IT in hospitals is the Ocuvera automated video monitoring system (AVMS), which has been implemented in more than 30 hospitals. The purpose of this study was to evaluate nurses' attitudes toward AVMS implementation over time as they received the training program developed for this intervention. Consistent with the job demands-resources (JDR) model, we found that perceptions of AVMS usefulness increased over time and were positively associated with perceptions of social influence and behavioral control. These results were consistent with our finding that there was a significant decrease in the risk of unassisted falls from the bed from baseline to intervention. Leaders in hospital systems and healthcare organizations may want to consider implementing an AVMS as researchers continue to test, verify, and demonstrate the effectiveness of these interventions for improving patient well-being.

Bridging the gap: Study protocol for development of an implementation strategy for evidence-informed reablement and rehabilitation for community-dwelling people with dementia

BACKGROUND

Extensive research supports the use of goal-directed reablement and rehabilitation interventions to address a range of physical, functional, cognitive and behavioural needs of people living with dementia. Despite this, evidence-informed multidisciplinary reablement and rehabilitation interventions are not being offered in usual dementia care across Australia. An examination is needed of how best to implement reablement and rehabilitation interventions within the community-based dementia care sector.

METHODS

Drawing on implementation science, this study uses a four-phase mixed-methods retrospective and prospective approach: (1) clinical audit to evaluate current clinical practice, and through focus groups with practitioners, identify practitioner-led goals and targets for practice change; (2) Delphi survey to converge opinions from the diverse stakeholders involved in reablement in dementia, to reach national consensus around an implementation strategy; (3) hybrid pragmatic effectiveness-implementation pilot will facilitate testing of the implementation strategy in parallel with exploring effectiveness of the reablement intervention specifically within a real-world Australian community aged care context; (4) implementation capacity building.

DISCUSSION

This study will result in a freely available, nationally relevant implementation protocol, designed and tailored via input from key stakeholders over a series of iterative project activities. By testing this protocol via a pilot implementation-effectiveness study, we will generate national information about effectiveness of evidence-informed reablement programs for people living with dementia across various community aged care settings. Outcomes have potential to influence policy and drive widespread practice change, increasing access to evidence-informed reablement and rehabilitation for people living with dementia across Australia.

Why Is Patient Safety a Challenge? Insights From the Professionalism Opinions of Medical Students' Research

OBJECTIVES

Despite increased emphasis on education and training for patient safety in medical schools, there is little known about factors influencing decision making regarding patient safety behaviors. This study examined the nature and magnitude of factors that may influence opinions around patient safety-related behaviors as a means of providing insights into how Australian doctors and medical students view these issues relative to members of the public.

METHODS

A national, multicenter, prospective, cross-sectional survey was conducted using responses to hypothetical patient safety scenarios involving the following: fabricating results, personal protective equipment, presenteeism, and reporting concerns.Australian enrolled medical students, medical doctors, and members of the public were surveyed.Participant responses were compared for the different contextual variables within the scenarios and the participants' demographic characteristics.

RESULTS

In total, 2602 medical student, 809 doctors, and 503 members of the Australian public participated. The 3 demographic groups had significantly differing opinions on many of the patient safety dilemmas. Doctors were more tolerant of medical students not reporting concerning behaviors and attending placements despite recent illness. Medical students' opinions frequently demonstrated a "transition effect," bridging between the doctors and publics' attitudes, consistent with professional identity formation.

CONCLUSIONS

Opinions on the acceptability of medical students' patient safety-related behaviors were influenced by the demographics of the cohort and the contextual complexity of the scenario. Although the survey used hypothetical scenarios, doctors and medical students' opinions seem to be influenced by cognitive dissonances, biases, and heuristics, which may negatively affect patient safety.

Government Actions and Their Relation to Resilience in Healthcare During the COVID-19 Pandemic in New South Wales, Australia and Ontario, Canada

BACKGROUND

Resilience, a system's ability to maintain a desired level of performance when circumstances disturb its functioning, is an increasingly important concept in healthcare. However, empirical investigations of resilience in healthcare (RiH) remain uncommon, particularly those that examine how government actions contribute to the capacity for resilient performance in the healthcare setting. We sought to investigate how governmental actions during the coronavirus disease 2019 (COVID-19) pandemic related to the concept of resilience, how these actions contributed to the potential for resilient performance in healthcare, and what opportunities exist for governments to foster resilience within healthcare systems.

METHODS

We conducted case studies of government actions pertaining to the COVID-19 pandemic in New South Wales, Australia and Ontario, Canada. Using media releases issued by each government between December 2019 and August 2020, we performed qualitative content analysis to identify themes relevant to the resilience potentials (anticipate, monitor, respond, learn) and RiH.

RESULTS

Direct references to the term 'resilience' appeared in the media releases of both governments. However, these references focused on the reactive aspects of resilience. While actions that constitute the resilience potentials were evident, the media releases also revealed opportunities to enhance learning (eg, a need to capitalize on opportunities for double-loop learning and identify strategies appropriate for complex systems) and anticipating (eg, incorporating the concept of hedging into frameworks of RiH).

CONCLUSION

Though fostering RiH through government action remains a challenge, this study suggests opportunities to realize this goal. Articulating a proactive vision of resilience and recognizing the complex nature of current systems could enhance governments' ability to coordinate resilient performance in healthcare. Reflection on how anticipation relates to resilience appears necessary at both the practical and conceptual levels to further develop the capacity for RiH.

Sociotechnical Intervention for Improved Delivery of Preventive Cardiovascular Care to Rural Communities: Participatory Design Approach

Background

Clinical practice guidelines recommend antiplatelet and statin therapies as well as blood pressure control and tobacco cessation for secondary prevention in patients with established atherosclerotic cardiovascular diseases (ASCVDs). However, these strategies for risk modification are underused, especially in rural communities. Moreover, resources to support the delivery of preventive care to rural patients are fewer than those for their urban counterparts. Transformative interventions for the delivery of tailored preventive cardiovascular care to rural patients are needed.

Objective

A multidisciplinary team developed a rural-specific, team-based model of care intervention assisted by clinical decision support (CDS) technology using participatory design in a sociotechnical conceptual framework. The model of care intervention included redesigned workflows and a novel CDS technology for the coordination and delivery of guideline recommendations by primary care teams in a rural clinic.

Methods

The design of the model of care intervention comprised 3 phases: problem identification, experimentation, and testing. Input from team members (n=35) required 150 hours, including observations of clinical encounters, provider workshops, and interviews with patients and health care professionals. The intervention was prototyped, iteratively refined, and tested with user feedback. In a 3-month pilot trial, 369 patients with ASCVDs were randomized into the control or intervention arm.

Results

New workflows and a novel CDS tool were created to identify patients with ASCVDs who had gaps in preventive care and assign the right care team member for delivery of tailored recommendations. During the pilot, the intervention prototype was iteratively refined and tested. The pilot demonstrated feasibility for successful implementation of the sociotechnical intervention as the proportion of patients who had encounters with advanced practice providers (nurse practitioners and physician assistants), pharmacists, or tobacco cessation coaches for the delivery of guideline recommendations in the intervention arm was greater than that in the control arm.

Conclusions

Participatory design and a sociotechnical conceptual framework enabled the development of a rural-specific, team-based model of care intervention assisted by CDS technology for the transformation of preventive health care delivery for ASCVDs.

Using network analysis to model the effects of the SARS Cov2 pandemic on acute patient care within a healthcare system

Consolidation of healthcare in the US has resulted in integrated organizations, encompassing large geographic areas, with varying services and complex patient flows. Profound changes in patient volumes and behavior have occurred during the SARS Cov2 pandemic, but understanding these across organizations is challenging. Network analysis provides a novel approach to address this. We retrospectively evaluated hospital-based encounters with an index emergency department visit in a healthcare system comprising 18 hospitals, using patient transfer as a marker of unmet clinical need. We developed quantitative models of transfers using network analysis incorporating the level of care provided (ward, progressive care, intensive care) during pre-pandemic (May 25, 2018 to March 16, 2020) and mid-pandemic (March 17, 2020 to March 8, 2021) time periods. 829,455 encounters were evaluated. The system functioned as a non-small-world, non-scale-free, dissociative network. Our models reflected transfer destination diversification and variations in volume between the two time points - results of intentional efforts during the pandemic. Known hub-spoke architecture correlated with quantitative analysis. Applying network analysis in an integrated US healthcare organization demonstrates changing patterns of care and the emergence of bottlenecks in response to the SARS Cov2 pandemic, consistent with clinical experience, providing a degree of face validity. The modelling of multiple influences can identify susceptibility to stress and opportunities to strengthen the system where patient movement is common and voluminous. The technique provides a mechanism to analyze the effects of intentional and contextual changes on system behavior.

A taxonomy of knowledge risks for healthcare organizations

Purpose

Knowledge is a critical factor for health-care organizations’ sustainability in today’s hyperconnected and technology reliant environment, which presents additional challenges and responsibilities for managing knowledge and its risks in medical practices. This paper aims at developing a taxonomy of knowledge risks (KR) within a health-care context, with relevant descriptions and discussion of their possible impact on health-care organizations.

Design/methodology/approach

As KRs have not been discussed yet within a health-care context, the authors reviewed relevant literature on KRs and challenges to knowledge practices in general contexts and in other industries. In addition, the authors reviewed literature on knowledge management (KM) in health care. The authors synthesized their findings and combined it with authors’ insights based on their experience in the health-care and KM fields to develop the taxonomy of KR, with contextual explanations and expounded on their potential effects on health-care organizations.

Findings

The authors propose and explain 25 types of KRs in health-care organizations and organized them into three categories: human, operational and technology.

Practical implications

Proper identification of clinical and administrative KRs plays a critical role in their effective management and remediation, thus improving the quality of care, promoting efficiency savings and ensuring health-care organizations’ sustainability. This paper will raise the awareness of KR among health-care professionals and offer researchers solid ground for more rigorous research in the field of KR and their management, within the health-care context in specific.

Originality/value

To the best of the authors’ knowledge, this paper is the first to comprehensively discuss issues of KRs within a health-care context.

The biopsychosociotechnical model: a systems-based framework for human-centered health improvement

The biopsychosocial model is among the most influential frameworks for human-centered health improvement but has faced significant criticism- both conceptual and pragmatic. This paper extends and fundamentally re-structures the biopsychosocial model by combining it with sociotechnical systems theory. The resulting biopsychosociotechnical model addresses key critiques of the biopsychosocial model, providing a more "practical theory" for human-centered health improvement. It depicts the determinants of health as complex adaptive system of systems; includes the the artificial world (technology); and provides a roadmap for systems improvement by: differentiating between "health status" and "health and needs assessment", [promoting problem framing]; explaining health as an emergent property of the biopsychosociotechnical context [imposing a systems orientation]; focusing on "interventions" vs. "treatments" to modify the biopsychosociotechnical determinants of health, [expanding the solution space]; calling for a participatory design process [supporting systems awareness and goal-orientation]; and including intervention management to support the full lifecycle of health improvement.

Digital Health Testbeds in Sweden: An exploratory study

Objective

This study explored the Swedish digital health testbeds through the lens of complexity science.

Methods

The purposive sampling was used to identify 38 digital health testbed organizations to conduct interviews in written or audio-conferencing. The interview responses were aggregated and analyzed using thematic analysis. The themes were mainly generated through complexity theory and the principles of complex adaptive systems.

Results

Fifteen testbed organizations responded, comprising 13 written responses and two audio-conferencing. Five main theoretical themes were generated: agents and diversity, connections and communication, adaptation and learning, perturbations, and path dependence. Agents and diversity depicted different types of testbeds, stakeholders and innovation, and the primary function and purpose of the testbeds. Various factors enhancing connections and communications among multiple stakeholders were identified, such as the quality of e-health solutions and the 2030 Agenda for Sustainable Development. Some adaptation and learning factors, such as internal reorganization, sharing and creating learning opportunities, and additional funding, guaranteed the sustainability of testbeds. Perturbations were characterized by two factors: non-linear interactions – lack of commitment and transparency in stakeholders' engagement, and uncertainty about testbed definitions and concepts. Path dependence highlighted the importance of history, such as previous positive and negative experiences.

Conclusion

This study provided insights into testbeds' organization, their functions, how various aspects were challenged, and how they adapted to overcome and improve the system issues. Identifying the stakeholders and relevant factors, commissioning an evaluation, backing up with a contingency plan, securing adequate funding, and disseminating the findings can improve the testbeds' design and implementation.

A science of collaborative learning health systems

INTRODUCTION

Improving the U.S. healthcare system and health outcomes is one of the most pressing public health challenges of our time. Previously described Collaborative Learning Health Systems (CLHSs) are a promising approach to outcomes improvement. In order to fully realize this promise, a deeper understanding of this phenomenon is necessary.

METHODS

We drew on our experience over the past decade with CLHSs as well as qualitative literature review to answer three questions: What kind of phenomena are CLHSs? and what is an appropriate scientific approach? How might we frame CLHSs conceptually? What are potential mechanisms of action?

RESULTS

CLHSs are complex adaptive systems in which all stakeholders are able to collaborate, at scale, to create and share resources to satisfy a variety of needs. This is accomplished by providing infrastructure and services that enable stakeholders to act on their inherent motivations. This framing has implications for both research and practice.

CONCLUSION

Articulating this framework and potential mechanisms of action should facilitate research to test and refine hypotheses as well as guide practice to develop and optimize this promising approach to improving healthcare systems.

Patient experience data as enacted: Sociomaterial perspectives and 'singular-multiples' in health care quality improvement research

Over the last three decades, sociomaterial approaches to the study of health care practices have made an important contribution to the sociology of health care. Significant attention has been paid to the role of technology and artefacts in health care and the operation of actor-networks but less space has been given to questions of ontological multiplicity in health care practices. In this paper, we draw upon our study of patient experience data in five acute hospitals in England to illustrate how treating patient experience data as 'singular-multiples' can enable useful insights into patient experience data work in health care organisations. Our data was generated during 12 months of fieldwork at five participating hospitals and included organisational documents, field notes, informal and formal interviews with frontline and managerial staff and patient representatives at the study sites. We use the examples of the Friends and Family Test (FFT) and the National Cancer Patient Experience Survey (NCPES) in England to consider the multiple nature of data as it is enacted in practice and the work data does when coordinated as an entity in the singular. We argue that, and discuss how, the sociomaterial insights we discuss here are relevant to health care quality and improvement research and practice.

Understanding how and why audits work in improving the quality of hospital care: A systematic realist review

BACKGROUND

Several types of audits have been used to promote quality improvement (QI) in hospital care. However, in-depth studies into the mechanisms responsible for the effectiveness of audits in a given context is scarce. We sought to understand the mechanisms and contextual factors that determine why audits might, or might not, lead to improved quality of hospital care.

METHODS

A realist review was conducted to systematically search and synthesise the literature on audits. Data from individual papers were synthesised by coding, iteratively testing and supplementing initial programme theories, and refining these theories into a set of context-mechanism-outcome configurations (CMOcs).

RESULTS

From our synthesis of 85 papers, seven CMOcs were identified that explain how audits work: (1) externally initiated audits create QI awareness although their impact on improvement diminishes over time; (2) a sense of urgency felt by healthcare professionals triggers engagement with an audit; (3) champions are vital for an audit to be perceived by healthcare professionals as worth the effort; (4) bottom-up initiated audits are more likely to bring about sustained change; (5) knowledge-sharing within externally mandated audits triggers participation by healthcare professionals; (6) audit data support healthcare professionals in raising issues in their dialogues with those in leadership positions; and (7) audits legitimise the provision of feedback to colleagues, which flattens the perceived hierarchy and encourages constructive collaboration.

CONCLUSIONS

This realist review has identified seven CMOcs that should be taken into account when seeking to optimise the design and usage of audits. These CMOcs can provide policy makers and practice leaders with an adequate conceptual grounding to design contextually sensitive audits in diverse settings and advance the audit research agenda for various contexts.

PROSPERO REGISTRATION

CRD42016039882.

Implementing large-system, value-based healthcare initiatives: a realist study protocol for seven natural experiments

INTRODUCTION

Value-based healthcare delivery models have emerged to address the unprecedented pressure on long-term health system performance and sustainability and to respond to the changing needs and expectations of patients. Implementing and scaling the benefits from these care delivery models to achieve large-system transformation are challenging and require consideration of complexity and context. Realist studies enable researchers to explore factors beyond 'what works' towards more nuanced understanding of 'what tends to work for whom under which circumstances'. This research proposes a realist study of the implementation approach for seven large-system, value-based healthcare initiatives in New South Wales, Australia, to elucidate how different implementation strategies and processes stimulate the uptake, adoption, fidelity and adherence of initiatives to achieve sustainable impacts across a variety of contexts.

METHODS AND ANALYSIS

This exploratory, sequential, mixed methods realist study followed RAMESES II (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) reporting standards for realist studies. Stage 1 will formulate initial programme theories from review of existing literature, analysis of programme documents and qualitative interviews with programme designers, implementation support staff and evaluators. Stage 2 envisages testing and refining these hypothesised programme theories through qualitative interviews with local hospital network staff running initiatives, and analyses of quantitative data from the programme evaluation, hospital administrative systems and an implementation outcome survey. Stage 3 proposes to produce generalisable middle-range theories by synthesising data from context-mechanism-outcome configurations across initiatives. Qualitative data will be analysed retroductively and quantitative data will be analysed to identify relationships between the implementation strategies and processes, and implementation and programme outcomes. Mixed methods triangulation will be performed.

ETHICS AND DISSEMINATION

Ethical approval has been granted by Macquarie University (Project ID 23816) and Hunter New England (Project ID 2020/ETH02186) Human Research Ethics Committees. The findings will be published in peer-reviewed journals. Results will be fed back to partner organisations and roundtable discussions with other health jurisdictions will be held, to share learnings.

Opportunities and Challenges Surrounding the Use of Data From Wearable Sensor Devices in Health Care: Qualitative Interview Study

BACKGROUND

Wearable sensors connected via networked devices have the potential to generate data that may help to automate processes of care, engage patients, and increase health care efficiency. The evidence of effectiveness of such technologies is, however, nascent and little is known about unintended consequences.

OBJECTIVE

Our objective was to explore the opportunities and challenges surrounding the use of data from wearable sensor devices in health care.

METHODS

We conducted a qualitative, theoretically informed, interview-based study to purposefully sample international experts in health care, technology, business, innovation, and social sciences, drawing on sociotechnical systems theory. We used in-depth interviews to capture perspectives on development, design, and use of data from wearable sensor devices in health care, and employed thematic analysis of interview transcripts with NVivo to facilitate coding.

RESULTS

We interviewed 16 experts. Although the use of data from wearable sensor devices in health and care has significant potential in improving patient engagement, there are a number of issues that stakeholders need to negotiate to realize these benefits. These issues include the current gap between data created and meaningful interpretation in health and care contexts, integration of data into health care professional decision making, negotiation of blurring lines between consumer and medical care, and pervasive monitoring of health across previously disconnected contexts.

CONCLUSIONS

Stakeholders need to actively negotiate existing challenges to realize the integration of data from wearable sensor devices into electronic health records. Viewing wearables as active parts of a connected digital health and care infrastructure, in which various business, personal, professional, and health system interests align, may help to achieve this.

Avoiding unnecessary hospitalisation for patients with chronic conditions: a systematic review of implementation determinants for hospital avoidance programmes

Background

Studies of clinical effectiveness have demonstrated the many benefits of programmes that avoid unnecessary hospitalisations. Therefore, it is imperative to examine the factors influencing implementation of these programmes to ensure these benefits are realised across different healthcare contexts and settings. Numerous factors may act as determinants of implementation success or failure (facilitators and barriers), by either obstructing or enabling changes in healthcare delivery. Understanding the relationships between these determinants is needed to design and tailor strategies that integrate effective programmes into routine practice. Our aims were to describe the implementation determinants for hospital avoidance programmes for people with chronic conditions and the relationships between these determinants.

Methods

An electronic search of four databases was conducted from inception to October 2019, supplemented by snowballing for additional articles. Data were extracted using a structured data extraction tool and risk of bias assessed using the Hawker Tool. Thematic synthesis was undertaken to identify determinants of implementation success or failure for hospital avoidance programmes for people with chronic conditions, which were categorised according to the Consolidated Framework for Implementation Research (CFIR). The relationships between these determinants were also mapped.

Results

The initial search returned 3537 articles after duplicates were removed. After title and abstract screening, 123 articles underwent full-text review. Thirteen articles (14 studies) met the inclusion criteria. Thematic synthesis yielded 23 determinants of implementation across the five CFIR domains. ‘Availability of resources’, ‘compatibility and fit’, and ‘engagement of interprofessional team’ emerged as the most prominent determinants across the included studies. The most interconnected implementation determinants were the ‘compatibility and fit’ of interventions and ‘leadership influence’ factors.

Conclusions

Evidence is emerging for how chronic condition hospital avoidance programmes can be successfully implemented and scaled across different settings and contexts. This review provides a summary of key implementation determinants and their relationships. We propose a hypothesised causal loop diagram to represent the relationship between determinants within a complex adaptive system.

Trial registration

PROSPERO 162812 

The three numbers you need to know about healthcare: the 60-30-10 Challenge

BACKGROUND

Healthcare represents a paradox. While change is everywhere, performance has flatlined: 60% of care on average is in line with evidence- or consensus-based guidelines, 30% is some form of waste or of low value, and 10% is harm. The 60-30-10 Challenge has persisted for three decades.

MAIN BODY

Current top-down or chain-logic strategies to address this problem, based essentially on linear models of change and relying on policies, hierarchies, and standardisation, have proven insufficient. Instead, we need to marry ideas drawn from complexity science and continuous improvement with proposals for creating a deep learning health system. This dynamic learning model has the potential to assemble relevant information including patients' histories, and clinical, patient, laboratory, and cost data for improved decision-making in real time, or close to real time. If we get it right, the learning health system will contribute to care being more evidence-based and less wasteful and harmful. It will need a purpose-designed digital backbone and infrastructure, apply artificial intelligence to support diagnosis and treatment options, harness genomic and other new data types, and create informed discussions of options between patients, families, and clinicians. While there will be many variants of the model, learning health systems will need to spread, and be encouraged to do so, principally through diffusion of innovation models and local adaptations.

CONCLUSION

Deep learning systems can enable us to better exploit expanding health datasets including traditional and newer forms of big and smaller-scale data, e.g. genomics and cost information, and incorporate patient preferences into decision-making. As we envisage it, a deep learning system will support healthcare's desire to continually improve, and make gains on the 60-30-10 dimensions. All modern health systems are awash with data, but it is only recently that we have been able to bring this together, operationalised, and turned into useful information by which to make more intelligent, timely decisions than in the past.

Organizational diagnostics: a systematic approach to identifying technology and workflow issues in clinical settings

Objectives

Healthcare organizations need to rapidly adapt to new technology, policy changes, evolving payment strategies, and other environmental changes. We report on the development and application of a structured methodology to support technology and process improvement in healthcare organizations, Systematic Iterative Organizational Diagnostics (SIOD). SIOD was designed to evaluate clinical work practices, diagnose technology and workflow issues, and recommend potential solutions.

Materials and Methods

SIOD consists of five stages: (1) Background Scan, (2) Engagement Building, (3) Data Acquisition, (4) Data Analysis, and (5) Reporting and Debriefing. Our team applied the SIOD approach in two ambulatory clinics and an integrated ambulatory care center and used SIOD components during an evaluation of a large-scale health information technology transition.

Results

During the initial SIOD application in two ambulatory clinics, five major analysis themes were identified, grounded in the data: putting patients first, reducing the chaos, matching space to function, technology making work harder, and staffing is more than numbers. Additional themes were identified based on SIOD application to a multidisciplinary clinical center. The team also developed contextually grounded recommendations to address issues identified through applying SIOD.

Discussion

The SIOD methodology fills a problem identification gap in existing process improvement systems through an emphasis on issue discovery, holistic clinic functionality, and inclusion of diverse perspectives. SIOD can diagnose issues where approaches as Lean, Six Sigma, and other organizational interventions can be applied.

Conclusion

The complex structure of work and technology in healthcare requires specialized diagnostic strategies to identify and resolve issues, and SIOD fills this need.

Beyond ‘find and fix’: improving quality and safety through resilient healthcare systems

Objective

The aim was to develop a method based on resilient healthcare principles to proactively identify system vulnerabilities and quality improvement interventions.

Design

Ethnographic methods to understand work as it is done in practice using concepts from resilient healthcare, the Concepts for Applying Resilience Engineering model and the four key activities that are proposed to underpin resilient performance—anticipating, monitoring, responding and learning.

Setting

Accident and Emergency Department (ED) and the Older People’s Unit (OPU) of a large teaching hospital in central London.

Participants

ED—observations 104 h, and 14 staff interviews. OPU—observations 60 h, and 15 staff interviews.

Results

Data were analysed to identify targets for quality improvement. In the OPU, discharge was a complex and variable process that was difficult to monitor. A system to integrate information and clearly show progress towards discharge was needed. In the ED, patient flow was identified as a complex high-intensity activity that was not supported by the existing data systems. The need for a system to integrate and display information about both patient and organizational factors was identified. In both settings, adaptive capacity was limited by the absence of systems to monitor the work environment.

Conclusions

The study showed that using resilient healthcare principles to inform quality improvement was feasible and focused attention on challenges that had not been addressed by traditional quality improvement practices. Monitoring patient and workflow in both the ED and the OPU was identified as a priority for supporting staff to manage the complexity of the work.

Intravenous infusion practices across England and their impact on patient safety: a mixed-methods observational study

Background

Intravenous (IV) medication administration has traditionally been regarded to be error-prone with high potential for harm. A recent US multisite study revealed surprisingly few potentially harmful errors despite a high overall error rate. However, there is limited evidence about infusion practices in England and how they relate to prevalence and types of error.

Objectives

To determine the prevalence, types and severity of errors and discrepancies in infusion administration in English hospitals, and to explore sources of variation in errors, discrepancies and practices, including the contribution of smart pumps.

Design

Phase 1 comprised an observational point-prevalence study of IV infusions, with debrief interviews and focus groups. Observers compared each infusion against the medication order and local policy. Deviations were classified as either errors or discrepancies based on their potential for patient harm. Contextual issues and reasons for deviations were explored qualitatively during observer debriefs, and analytically in supplementary analyses. Phase 2 comprised in-depth observational studies at five of the participating sites to better understand causes of error and how safety is maintained. Workshops were held with key stakeholder groups, including health professionals and policy-makers, the public and industry.

Setting

Sixteen English NHS hospital trusts.

Results

Point-prevalence data were collected from 1326 patients and 2008 infusions. In total, 240 errors were observed in 231 infusions and 1489 discrepancies were observed in 1065 infusions. Twenty-three errors (1.1% of all infusions) were considered potentially harmful; one might have resulted in short-term patient harm had it not been intercepted, but none was judged likely to prolong hospital stay or result in long-term harm. Types and prevalence of deviations varied widely among trusts, as did local policies. Deviations from medication orders and local policies were sometimes made for efficiency or to respond to patient need. Smart pumps, as currently implemented, had little effect. Staff had developed practices to manage efficiency and safety pragmatically by working around systemic challenges.

Limitations

Local observers may have assessed errors differently across sites, although steps were taken to minimise differences through observer training, debriefs, and review and cleaning of data. Each in-depth study involved a single researcher, and these were limited in scale and scope.

Conclusions

Errors and discrepancies are common in everyday infusion administration but most have low potential for patient harm. Findings are best understood by viewing IV infusion administration as a complex adaptive system. Better understanding of performance variability to strategically manage risk may be more helpful for improving patient safety than striving to eliminate all deviations.

Future work

There is potential value in reviewing policy around IV infusion administration to reduce unnecessary variability, manage staff workload and engage patients, while retaining the principle that policy has to be fit for purpose, contextualised to the particular ward situation and treatment protocol, and sensitive to the risks of different medications. Further work on understanding infusion administration as a complex adaptive system might deliver new insights into managing patient safety.

Funding

This project was funded by the NIHR Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 7. See the NIHR Journals Library website for further project information.

A realist evaluation to identify contexts and mechanisms that enabled and hindered implementation and had an effect on sustainability of a lean intervention in pediatric healthcare

BACKGROUND

In 2012, the Saskatchewan Ministry for Health mandated a system-wide Lean transformation. Research has been conducted on the implementation processes of this system-wide Lean implementation. However, no research has been done on the sustainability of these Lean efforts. We conducted a realist evaluation on the sustainability of Lean in pediatric healthcare. We used the context (C) + mechanism (M) = outcome (O) configurations (CMOcs) heuristic to explain under what contexts, for whom, how and why Lean efforts are sustained or not sustained in pediatric healthcare.

METHODS

We employed a case study research design. Guided by a realist evaluation framework, we conducted qualitative realist interviews with various stakeholder groups across four pediatric hospital units 'cases' at one acute hospital. Interview data was analyzed using an integrated approach of CMOc categorization coding, CMOc connecting and pattern matching.

RESULTS

We conducted thirty-two interviews across the four cases. Five CMOcs emerged from our realist interview data. These configurations illustrated a 'ripple-effect' from implementation outcomes to contexts for sustainability. Sense-making and staff engagement were prominent mechanisms to the sustainment of Lean efforts. Failure to trigger these mechanisms resulted in resistance. The implementation approach used influenced mechanisms and outcomes for sustainability, more so than Lean itself. Specifically, the language, messaging and training approaches used triggered mechanisms of innovation fatigue, poor 'sense-making' and a lack of engagement for frontline staff. The mandated, top-down, externally led nature of implementation and lack of customization to context served as potential pitfalls. Overall, there was variation between leadership and frontline staff's perceptions on how embedded Lean was in their contexts, and the degree to which participants supported Lean sustainability.

CONCLUSIONS

This research illuminates important contextual factors and mechanisms to the process of Lean sustainment that can be applicable to those implementing systems changes. Future work is needed to continue to develop the science on the sustainability of interventions for healthcare improvement.

Towards a safer culture: implementing multidisciplinary simulation-based team training in New Zealand operating theatres - a framework analysis

AIM

NetworkZ is a simulation-based multidisciplinary team-training programme designed to enhance patient safety by improving communication and teamwork in operating theatres (OTs). In partnership with the Accident Compensation Corporation, its implementation across New Zealand (NZ) began in 2017. Our aim was to explore the experiences of staff - including the challenges they faced - in implementing NetworkZ in NZ hospitals, so that we could improve the processes necessary for subsequent implementation.

METHOD

We interviewed staff from five hospitals involved in the initial implementation of NetworkZ, using the Organising for Quality model as the framework for analysis. This model describes embedding successful quality improvement as a process of overcoming six universal challenges: structure, infrastructure, politics, culture, motivation and learning.

RESULTS

Thirty-one people participated. Structural support within the hospital was considered essential to maintain staff enthusiasm, momentum and to embed the programme. The multidisciplinary, simulation-based approach to team training was deemed a fundamental infrastructure for learning, with participants especially valuing the realistic in situ simulations and educational support. Participants reported positive changes to the OT culture as a result of NetworkZ and this realisation motivated its implementation. In sites with good structural support, NetworkZ implementation proceeded quickly and participants reported rapid cultural change towards improved teamwork and communication in their OTs.

CONCLUSION

Implementation challenges exist and strategies to overcome these are informing future implementation of NetworkZ. Embedding the programme as business as usual across a nation requires significant and sustained support at all levels. However, the potential gains in patient safety and workplace culture from widespread multidisciplinary team training are substantial. Trial registration number ACTRN12617000017325.

The impact of post-fall huddles on repeat fall rates and perceptions of safety culture: a quasi-experimental evaluation of a patient safety demonstration project

BACKGROUND

Conducting post-fall huddles is considered an integral component of a fall-risk-reduction program. However, there is no evidence linking post-fall huddles to patient outcomes or perceptions of teamwork and safety culture. The purpose of this study is to determine associations between conducting post-fall huddles and repeat fall rates and between post-fall huddle participation and perceptions of teamwork and safety culture.

METHODS

During a two-year demonstration project, we developed a system for 16 small rural hospitals to report, benchmark, and learn from fall events, and we trained them to conduct post-fall huddles. To calculate a hospital's repeat fall rate, we divided the total number of falls reported by the hospital by the number of unique medical record numbers associated with each fall. We used Spearman correlations with exact P values to determine the association between the proportion of falls followed by a huddle and the repeat fall rate. At study end, we used the TeamSTEPPS® Teamwork Perceptions Questionnaire (T-TPQ) to assess perceptions of teamwork support for fall-risk reduction and the Hospital Survey on Patient Safety Culture (HSOPS) to assess perceptions of safety culture. We added an item to the T-TPQ for respondents to indicate the number of post-fall huddles in which they had participated. We used a binary logistic regression with a logit link to examine the effect of participation in post-fall huddles on respondent-level percent positive T-TPQ and HSOPS scores. We accounted for clustering of respondents within hospitals with random effects using the GLIMMIX procedure in SAS/STAT.

RESULT

Repeat fall rates were negatively associated with the proportion of falls followed by a huddle. As compared to hospital staff who did not participate in huddles, those who participated in huddles had more positive perceptions of four domains of safety culture and how team structure, team leadership, and situation monitoring supported fall-risk reduction.

CONCLUSIONS

Post-fall huddles may reduce the risk of repeat falls. Staff who participate in post-fall huddles are likely to have positive perceptions of teamwork support for fall-risk reduction and safety culture because huddles are a team-based approach to reporting, adapting, and learning.

How coping can hide larger systems problems: the routine immunisation supply chain in Bihar, India

Introduction

Coping occurs when health system personnel must make additional, often undocumented efforts to compensate for existing system and management deficiencies. While such efforts may be done with good intentions, few studies evaluate the broader impact of coping.

Methods

We developed a computational simulation model of Bihar, India’s routine immunisation supply chain where coping (ie, making additional vaccine shipments above stated policy) occurs. We simulated the impact of coping by allowing extra trips to occur as needed up to one time per day and then limiting coping to two times per week and three times per month before completely eliminating coping.

Results

Coping as needed resulted in 3754 extra vaccine shipments over stated policy resulting in 56% total vaccine availability and INR 2.52 logistics cost per dose administered. Limiting vaccine shipments to two times per week reduced shipments by 1224 trips, resulting in a 7% vaccine availability decrease to 49% and an 8% logistics cost per dose administered increase to INR 2.73. Limiting shipments to three times per month reduced vaccine shipments by 2635 trips, which decreased vaccine availability by 19% to 37% and increased logistics costs per dose administered by 34% to INR 3.38. Completely eliminating coping further reduced shipments by 1119 trips, decreasing total vaccine availability an additional 24% to 13% and increasing logistics cost per dose administered by 169% to INR 9.08.

Conclusion

Our results show how coping can hide major system design deficiencies and how restricting coping can improve problem diagnosis and potentially lead to enhanced system design.

A Network Approach to Stroke Systems of Care

The landscape of stroke systems of care is evolving as patients are increasingly transferred between hospitals for access to higher levels of care. This is driven by time-sensitive disability-reducing interventions such as mechanical thrombectomy. However, coordination and triage of patients for such treatment remain a challenge worldwide, particularly given complex eligibility criteria and varying time windows for treatment. Network analysis is an approach that may be applied to this problem. Hospital networks interlinked by patients moved from facility to facility can be studied using network modeling that respects the interdependent nature of the system. This allows understanding of the central hubs, the change of network structure over time, and the diffusion of innovations. This topical review introduces the basic principles of network science and provides an overview on the applications and potential interventions in stroke systems of care.

The stipulation-stimulation spiral: A model of system change

This paper proposes a general model, based on what is known about the nature of (complex) systems, of how systems-in particular, health care systems-respond to attempted change. Inferences are drawn from a critical literature review and reinterpretation of two primary studies. The two fundamental system-change approaches are "stipulation" and "stimulation": stip(ulation) attempts to elicit a specific response from the system; stim(ulation) encourages the system to generate diverse responses. Each has a unique strength: stip's is precision, the ability to directly impact the desired outcome and only that outcome; stim's is resonance, the ability to take advantage of behavior already present within the system. Each approach's inherent strength is its complement's inherent weakness; thus, stip and stim often clash if attempted simultaneously but can reinforce each other if applied in alternation. Opposite patterns (the "stip-stim spiral" vs "stip-stim stalemate") are observed to underpin successful vs failed system change: The crucial difference is whether decision-makers respond to a need for precision/resonance by strengthening the appropriate approach (stipulation/stimulation, respectively), or merely by weakening its complement. With further validation, the model has the potential to yield a more fundamental understanding of why system-change efforts fail and how they can succeed.

Determinants of health and wellbeing in refractory epilepsy and surgery: The Patient Reported, ImpleMentation sciEnce (PRIME) model

This paper offers a new way of understanding the course of a chronic, neurological condition through a comprehensive model of patient-reported determinants of health and wellbeing: The Patient Reported ImpleMentation sciEnce (PRIME) model is the first model of its kind to be based on patient-driven insights for the design and implementation of initiatives that could improve tertiary, primary, and community healthcare services for patients with refractory epilepsy, and has broad implications for other disorders; PRIME focuses on: patient-reported determinants of health and wellbeing, pathways through care, gaps in treatment and other system delays, patient need and expectation, and barriers and facilitators to high-quality care provision; PRIME highlights that in the context of refractory epilepsy, patients value appropriate, clear, and speedy referrals from primary care practitioners and community neurologists to specialist healthcare professionals based in tertiary epilepsy centers. Many patients also want to share in decisions around treatment and care, and gain a greater understanding of their debilitating disease, so as to find ways to self-manage their illness more effectively and plan for the future. Here, PRIME is presented using refractory epilepsy as the exemplar case, while the model remains flexible, suitable for adaptation to other settings, patient populations, and conditions; PRIME comprises six critical levels: 1) The Individual Patient Model; 2) The Patient Relationships Model; 3) The Patient Care Pathways Model; 4) The Patient Transitions Model; 5) The Pre- and Postintervention Model; and 6) The Comprehensive Patient Model. Each level is dealt with in detail, while Levels 5 and 6 are presented in terms of where the gaps lie in our current knowledge, in particular in relation to patients' journeys through healthcare, system intersections, and individuals adaptive behavior following resective surgery, as well as others' views of the disease, such as family members.

Care bundles for acute kidney injury: a balanced accounting of the impact of implementation in an acute medical unit

In 2009, a National Confidential Enquiry into Patient Outcome and Death report detailed significant shortcomings in recognition and management of patients with acute kidney injury (AKI). As part of a national collaborative to reduce harm from AKI, the Scottish Patient Safety Programme developed two care bundles to improve response ('SHOUT') and review ('BUMP') of AKI. Baseline data from eight patients with AKI on the acute medical unit (AMU) in Ninewells Hospital showed 62% compliance with SHOUT. However, most patients were transferred from AMU within 24 hours so BUMP could not be assessed. Our aim was to achieve >95% compliance with SHOUT on AMU within 2 months. The content of the SHOUT bundle was condensed onto a sticker for the case notes, which was implemented using Plan-Do-Study-Act cycles. Compliance was assessed weekly and feedback obtained from stakeholders concerning their opinion of the sticker, SHOUT bundle and care bundles in general. Use of the sticker was 27% in week 1 but fell to 5% by week 4. Compliance with the bundle varied from 45% to 60% and was only slightly improved by use of the sticker (OR 1.58, 95% CI 0.39 to 6.42). Staff found the sticker burdensome and did not agree that all elements of SHOUT were equally important. This opinion was supported by finding that their compliance with sepsis and hypovolaemia recommendations was 91%-100% throughout, whereas urinalysis was documented in only 55%-63% of patients. Several staff mentioned 'bundle fatigue' and on one day we identified 22 other care bundles or structured improvement forms in AMU. We concluded that the AMU staff had legitimate concerns about the SHOUT care bundle and that our intervention was demotivating. Overcoming bundle fatigue will not be a simple task. We plan to work with staff on integrating AKI into patient safety huddles and on using modelling and recognition of good practice to improve motivation.

Primary care networks and team effectiveness: the case of a large-scale quality improvement disparity reduction program

Documentation of primary care teams' involvement in disparity reduction efforts exists, yet little is known about how teams interact or perceive their effectiveness. We investigated how the social network and structural ties among primary-care-clinic team members relate to their perceived team effectiveness (TE), in a large-scale disparity reduction intervention in Israel's largest insurer and provider of services. A mixed-method design of Social Network Analysis and qualitative data collection was employed. 108 interviews with medical, nursing, and administrative teams of 26 clinics and their respective managerial units were performed and information on the organizational ties, analyzing density and centrality, collected. Pearson correlations examined association between network measures and perceived TE. Clinics with strong intra-clinic density and high clinic-subregional-management density were positively correlated with perceived TE. Clinic in-degree centrality was also positively associated with perceived TE. Qualitative analyses support these findings with teamwork emerging as a factor which can impede or facilitate teams' ability to design and implement disparity reduction interventions. The study demonstrates that in an organization-wide disparity reduction initiative, cohesive intra-network structure and close relations with mid-level management increase the likelihood that teams perceive themselves as possessing the skills and resources needed to lead and implement disparity reduction efforts. List of abbreviations Team Effectiveness (TE); Clalit Health Services (Clalit); Social Network Analysis (SNA); Quality Improvement (QI); National Health Care Collaborative (NHPC); Tampa Bay Community Cancer Network (TBCCN).

Mixed-methods study of reported clinical cases of undesirable events, medical errors, and near misses in health care

RATIONALE, AIMS, AND OBJECTIVES

Patient safety is recognized as a key indicator of quality of medical care. International experience has shown that all efforts should focus on the delivery of a safer work environment and health care system as a whole in order to reduce or mitigate medical errors and their impact on society. The aim of this study is to investigate and classify the most common incidents regarding patient safety as well as their contributory factors, based on personal real-life experiences and situations in medical care reported by health care professionals.

METHODS

A mixed-methods study design was used. Sixty-five respondents participated (aged from 23 to 58 y). Reported cases of undesirable events (UE), medical errors (ME), and near misses (NM) were collected, processed, and analysed based on our original conceptual framework. A qualitative content analysis and descriptive statistics were conducted on the narratives in all 34 reported valid case files. Intercoder reliability was measured through the kappa statistics (κ = .69). The overall agreement of judgments on all codes was excellent (95%).

RESULTS

A total of 29 MEs in 34 cases were reported. In 85% of them, an average of 1.83 contributory factors were identified. The most common contributory factors were "Incompetence," "Neglect," "Severe work overload," and "Shortage of staff."

DISCUSSION

Important steps to prevent medical errors are their identification and reporting.

CONCLUSION

Health care professionals appear able to report UEs, MEs, and NMs occurring in medical care practice. They seem more willing to report and distinguish incidents related to MEs than to UEs and NMs.

Linguistic Validation and Cultural Adaptation of Bulgarian Version of Hospital Survey on Patient Safety Culture (HSOPSC)

BACKGROUND:

Patient safety (PS) is one of the essential elements of health care quality and a priority of healthcare systems in most countries. Thus the creation of validated instruments and the implementation of systems that measure patient safety are considered to be of great importance worldwide.

AIM:

The present paper aims to illustrate the process of linguistic validation, cross-cultural verification and adaptation of the Bulgarian version of the Hospital Survey on Patient Safety Culture (B-HSOPSC) and its test-retest reliability.

METHODS:

The study design is cross-sectional. The HSOPSC questionnaire consists of 42 questions, grouped in 12 different subscales that measure patient safety culture. Internal con­sistency was assessed using Cronbach’s alpha. The Wilcoxon signed-rank test and the split-half method were used; the Spear­man-Brown coefficient was calculated.

RESULTS:

The overall Cronbach’s alpha for B-HSOPSC is 0.918. Subscales 7 Staffing and 12 Overall perceptions of safety had the lowest coefficients. The high reliability of the instrument was confirmed by the Split-half method (0.97) and ICC-coefficient (0.95). The lowest values of Spearmen-Broun coefficients were found in items A13 and A14.

CONCLUSION:

The study offers an analysis of the results of the linguistic validation of the B-HSOPSC and its test-retest reliability. The psychometric characteristics of the questions revealed good validity and reliability, except two questions. In the future, the instrument will be administered to the target population in the main study so that the psychometric properties of the instrument can be verified.

Changing how we think about healthcare improvement

Complexity science offers ways to change our collective mindset about healthcare systems, enabling us to improve performance that is otherwise stagnant, argues Jeffrey Braithwaite

When complexity science meets implementation science: a theoretical and empirical analysis of systems change

BACKGROUND

Implementation science has a core aim - to get evidence into practice. Early in the evidence-based medicine movement, this task was construed in linear terms, wherein the knowledge pipeline moved from evidence created in the laboratory through to clinical trials and, finally, via new tests, drugs, equipment, or procedures, into clinical practice. We now know that this straight-line thinking was naïve at best, and little more than an idealization, with multiple fractures appearing in the pipeline.

DISCUSSION

The knowledge pipeline derives from a mechanistic and linear approach to science, which, while delivering huge advances in medicine over the last two centuries, is limited in its application to complex social systems such as healthcare. Instead, complexity science, a theoretical approach to understanding interconnections among agents and how they give rise to emergent, dynamic, systems-level behaviors, represents an increasingly useful conceptual framework for change. Herein, we discuss what implementation science can learn from complexity science, and tease out some of the properties of healthcare systems that enable or constrain the goals we have for better, more effective, more evidence-based care. Two Australian examples, one largely top-down, predicated on applying new standards across the country, and the other largely bottom-up, adopting medical emergency teams in over 200 hospitals, provide empirical support for a complexity-informed approach to implementation. The key lessons are that change can be stimulated in many ways, but a triggering mechanism is needed, such as legislation or widespread stakeholder agreement; that feedback loops are crucial to continue change momentum; that extended sweeps of time are involved, typically much longer than believed at the outset; and that taking a systems-informed, complexity approach, having regard for existing networks and socio-technical characteristics, is beneficial.

CONCLUSION

Construing healthcare as a complex adaptive system implies that getting evidence into routine practice through a step-by-step model is not feasible. Complexity science forces us to consider the dynamic properties of systems and the varying characteristics that are deeply enmeshed in social practices, whilst indicating that multiple forces, variables, and influences must be factored into any change process, and that unpredictability and uncertainty are normal properties of multi-part, intricate systems.

How does leadership influence incident reporting intention in healthcare? A dual process model of leader–member exchange

Building on social exchange and social identity theory, we examined how leader–member exchange (LMX) influences intention to report incidents in healthcare organizations through two different mechanisms. Using survey data of 15 hospitals in Germany ( N = 480) and multilevel structural equation modelling, we found as expected that LMX positively related to reporting-specific trust and organizational identification of employees. However, only reporting-specific trust but not organizational identification was directly related to incident reporting intention. Furthermore, top management support for patient safety moderated the link between LMX and reporting-specific trust, indicating a compensatory mechanism of top management support for followers with a low-quality leadership relationship. In addition, codification of patient safety regulations moderated the link between organizational identification and incident reporting intention. As expected, the institutionalization of patient safety norms through a strong follow-through of the organization is related to increased reporting only for employees with high organizational identification. Results are discussed in terms of how safety leadership can be enacted at both the supervisory and top management level in order to promote safety behaviour in healthcare organizations.

The struggle of translating science into action: Foundational concepts of implementation science

RATIONALE, AIMS, AND OBJECTIVES: "Implementation science," the scientific study of methods translating research findings into practical, useful outcomes, is contested and complex, with unpredictable use of results from routine clinical practice and different levels of continuing assessment of implementable interventions. The authors aim to reveal how implementation science is presented and understood in health services research contexts and clarify the foundational concepts: diffusion, dissemination, implementation, adoption, and sustainability, to progress knowledge in the field.

METHOD

Implementation science models, theories, and frameworks are critiqued, and their value for laying the groundwork from which to implement a study's findings is emphasised. The paper highlights the challenges of turning research findings into practical outcomes that can be successfully implemented and the need for support from change agents, to ensure improvements to health care provision, health systems, and policy. The paper examines how researchers create implementation plans and what needs to be considered for study outputs to lead to sustainable interventions. This aspect needs clear planning, underpinned by appropriate theoretical paradigms that rigorously respond to a study's aims and objectives.

CONCLUSION

Researchers might benefit from a return to first principles in implementation science, whereby applications that result from research endeavours are both effective and readily disseminated and where interventions can be supported by appropriate health care personnel. These should be people specifically identified to promote change in service organisation, delivery, and policy that can be systematically evaluated over time, to ensure high-quality, long-term improvements to patients' health.

Learning from high risk industries may not be straightforward: a qualitative study of the hierarchy of risk controls approach in healthcare

OBJECTIVE

Though healthcare is often exhorted to learn from 'high-reliability' industries, adopting tools and techniques from those sectors may not be straightforward. We sought to examine the hierarchies of risk controls approach, used in high-risk industries to rank interventions according to supposed effectiveness in reducing risk, and widely advocated as appropriate for healthcare.

DESIGN

Classification of risk controls proposed by clinical teams following proactive detection of hazards in their clinical systems. Classification was based on a widely used hierarchy of controls developed by the US National Institute for Occupational Safety and Health (NIOSH).

SETTING AND PARTICIPANTS

A range of clinical settings in four English NHS hospitals.

RESULTS

The four clinical teams in our study planned a total of 42 risk controls aimed at addressing safety hazards. Most (n = 35) could be classed as administrative controls, thus qualifying among the weakest type of interventions according to the HoC approach. Six risk controls qualified as 'engineering' controls, i.e. the intermediate level of the hierarchy. Only risk control qualified as 'substitution', classified as the strongest type of intervention by the HoC.

CONCLUSIONS

Many risk controls introduced by clinical teams may cluster towards the apparently weaker end of an established hierarchy of controls. Less clear is whether the HoC approach as currently formulated is useful for the specifics of healthcare. Valuable opportunities for safety improvement may be lost if inappropriate hierarchical models are used to guide the selection of patient safety improvement interventions. Though learning from other industries may be useful, caution is needed.

False Dawns and New Horizons in Patient Safety Research and Practice

In response to a weight of evidence that patients are frequently harmed as a result of their care, there have been concerted efforts to make healthcare safer, with health systems across the globe investing significant resources in policies and programmes designed to reduce adverse events. Yet, despite extensive efforts, improvements in safety have proved difficult to sustain and spread, with studies confirming there has been no measurable, systems-level improvement in the overall rates of preventable harm. Here, we highlight the limitations of the thinking which underpins current efforts to make healthcare systems safer and point to new and emerging approaches to understanding and addressing patient safety in complex, dynamic health systems.

Efficiency and thoroughness trade-offs in high-volume organisational routines: an ethnographic study of prescribing safety in primary care

Background

Prescribing is a high-volume primary care routine where both speed and attention to detail are required. One approach to examining how organisations approach quality and safety in the face of high workloads is Hollnagel’s Efficiency and Thoroughness Trade-Off (ETTO). Hollnagel argues that safety is aligned with thoroughness and that a choice is required between efficiency and thoroughness as it is not usually possible to maximise both. This study aimed to ethnographically examine the efficiency and thoroughness trade-offs made by different UK general practices in the achievement of prescribing safety.

Methods

Non-participant observation was conducted of prescribing routines across eight purposively sampled UK general practices. Sixty-two semistructured interviews were also conducted with key practice staff alongside the analysis of relevant practice documents.

Results

The eight practices in this study adopted different context-specific approaches to safely handling prescription requests by variably prioritising speed of processing by receptionists (efficiency) or general practitioner (GP) clinical judgement (thoroughness). While it was not possible to maximise both at the same time, practices situated themselves at various points on an efficiency-thoroughness spectrum where one approach was prioritised at particular stages of the routine. Both approaches carried strengths and risks, with thoroughness-focused approaches considered safer but more challenging to implement in practice due to GP workload issues. Most practices adopting efficiency-focused approaches did so out of necessity as a result of their high workload due to their patient population (eg, older, socioeconomically deprived).

Conclusions

Hollnagel’s ETTO presents a useful way for healthcare organisations to optimise their own high-volume processes through reflection on where they currently prioritise efficiency and thoroughness, the stages that are particularly risky and improved ways of balancing competing priorities.

Effectiveness of a virtual intervention for primary healthcare professionals aimed at improving attitudes towards the empowerment of patients with chronic diseases: study protocol for a cluster randomized controlled trial (e-MPODERA project)

BACKGROUND

Communities of practice are based on the idea that learning involves a group of people exchanging experiences and knowledge. The e-MPODERA project aims to assess the effectiveness of a virtual community of practice aimed at improving primary healthcare professional attitudes to the empowerment of patients with chronic diseases.

METHODS

This paper describes the protocol for a cluster randomized controlled trial. We will randomly assign 18 primary-care practices per participating region of Spain (Catalonia, Madrid and Canary Islands) to a virtual community of practice or to usual training. The primary-care practice will be the randomization unit and the primary healthcare professional will be the unit of analysis. We will need a sample of 270 primary healthcare professionals (general practitioners and nurses) and 1382 patients. We will perform randomization after professionals and patients are selected. We will ask the intervention group to participate for 12 months in a virtual community of practice based on a web 2.0 platform. We will measure the primary outcome using the Patient-Provider Orientation Scale questionnaire administered at baseline and after 12 months. Secondary outcomes will be the sociodemographic characteristics of health professionals, sociodemographic and clinical characteristics of patients, the Patient Activation Measure questionnaire for patient activation and outcomes regarding use of the virtual community of practice. We will calculate a linear mixed-effects regression to estimate the effect of participating in the virtual community of practice.

DISCUSSION

This cluster randomized controlled trial will show whether a virtual intervention for primary healthcare professionals improves attitudes to the empowerment of patients with chronic diseases.

TRIAL REGISTRATION

ClicalTrials.gov, NCT02757781 . Registered on 25 April 2016. Protocol Version. PI15.01 22 January 2016.

A qualitative study on the implementation of quality systems in Australian hospitals

Public hospitals are required to have quality systems in place to meet accreditation standards, achieve government performance expectations and continually improve care. However, previous study suggests that there has been limited success in the implementation of effective quality systems. Using document review, self-evaluation and qualitative data from interviews and focus groups of 270 board members, managers and staff we explored the implementation of quality systems in eight Australian public hospitals. Using normalisation process theory, we found that the hospitals took a technical, top-down approach to quality system implementation and did not provide staff with opportunities for socialization of the technology that enabled them to normalise the quality work. 'Quality' was consistently described as an 'extra' set of tasks to do, rather than a means to creating sustained, safe, quality care. Despite enormous goodwill and positive intent, a lack of understanding of how to effect change in the complexity of hospitals has led the boards and senior managers in our sample to execute a technical, top-down approach based on compliance and reactive risk.

Mental health services conceptualised as complex adaptive systems: what can be learned?

Despite many attempts at promoting systems integration, seamless care, and partnerships among service providers and users, mental health services internationally continue to be fragmented and piecemeal. We exploit recent ideas from complexity science to conceptualise mental health services as complex adaptive systems (CASs). The core features of CASs are described and Australia's headspace initiative is used as an example of the kinds of problems currently being faced. We argue that adopting a CAS lens can transform services, creating more connected care for service users with mental health conditions.